The Importance of Lacrimal Diaphragm and Periosteum Suturation in External Dacryocystorhinostomy

Purpose: To evaluate retrospectively the cosmetic and functional effects on success of lacrimal diaphragm and periosteum suturation after the anastamosis of anterior flaps before skin closure in external dacryocystorhinostomy (ext-DCR). Methods: During ext-DCR, lacrimal diaphragm was separated from periosteum over anterior lacrimal crest before entering lacrimal fossa. At the end of ext-DCR, the separated periosteum and lacrimal diaphragm were sutured in the study group (270 patients) and were left unsutured in the age-matched control group (96 patients). The effects of this approach on postoperative appearance of incision area at the 6-month postoperative controls, and functional success (assessed by fluorescein disappearing test) and anatomical success rates (assessed by lacrimal syringing) at the 12-month postoperative controls were evaluated. Results: The anatomic success rate between the 2 groups were found to be similar (94.8% and 92.7% in the study and control groups, respectively, p = 0.447). Fluorescein disappearing test was detected to be normal in 246 patients (91.1%) and 78 patients (81.2%) in the study and control groups, respectively (p = 0.009). Postoperative skin scar was found to develop significantly greater in the control group (p = 0.001). Significant hypertrophic scar was seen in 3 patients (1.1%) and 8 patients (8.3%) in the study and control groups, respectively. No epicanthal fold or webbing occurred in the study group. Conclusion: The preservation of the lacrimal sac wall's attachments at the end of ext-DCR to the medial canthal tendon, orbicularis oculi muscle, and lacrimal diaphragm allows the lacrimal pump to function more effectively. Ext-DCR with suturation of the periosteum and lacrimal diphragm method may provide an excellent functional and aesthetic outcome in the majority of patients.