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Coronal approach

Subperiosteal Exposure of the orbits and upper midface

The anterior fibrous and muscular components of the medial canthal tendon fan out medially and insert into the nasofrontal maxillary process (left side of anatomic specimen).

The anterior branch of the medial canthal tendon is identified as a firm fibrous strand (right side of anatomic specimen) that should be left intact during the subperiosteal medial rim dissection. The dissection is stopped at the upper end of the nasolacrimal sac within the lacrimal fossa. The anterior branch of the medial canthal tendon is then reflected anterolaterally, to elevate the lacrimal sac out of the fossa.
The posterior branch of the medial canthal tendon passes to the posterior lacrimal crest and is only rarely detached from the bone. If detached, it must be reattached prior to closure.