Anatomy of the noe complex.

Bony anatomy the NOE complex is vulnerable to injury because of its

prominent position at the junction of the upper and middle thirds of the face.
Like the midface, it is a wedge-shaped structure oriented so that the narrow
portion faces anteriorly and the broader base lies posteriorly between the two
orbits. This arrangement compensates for the inherent weakness created by
large underlying sinus spaces (the ethmoidal sinuses). Additional strength is
sprovided by the organization of the complex into a lattice with individual
bones oriented at different angles to one another. The NOE complex is
composed of our paired bones: the lateral nasal bones, the frontal processes
of the maxilla, the lamina papyraceae of the ethmoid bone, and the lacrimal
bones. The perpendicular and cribirform plates of the ethmoid bone, the
nasal process of the frontal bone, and the sphenoid bone complete the bony
skeleton in the midline. The area between the two medial orbital walls and
below the anterior cranial fossa is sometimes referred to as the interorbital
space. Within the upper portion of the nasal cavity lie the superior and
middle turbinates, but these structures do not contribute to the structural
support of the complex.
Medial Canthal Anatomy. The medial aspects of the upper and lower
eyelids converge into an acute angle and form the medial canthus. Here,
deep and superficial extensions of the apreseptal and pretarsal orbicularis
oculi converge into a common tendon. The tendon, which functions as the
origin of the orbicularis oculi muscle, divides into anterior and posterior
bands before attaching to the bone. The anterior limb is the larger and more
significant of the two. It inserts broadly into the frontal process of the
maxilla, the anterior lacrimal crest (part of the maxillary bone), and the
lateralmost aspect of the nasal bone. If disrupted by injury, restoration of
this attachment is essential to the successful reconstruction of the NOE
complex. The smaller posterior limb of the medial canthal tendon is poorly
defined and inserts into the posterior lacrimal crest, which is part of the
lacrima l bone. It is composed of the deep head of the pretarsal orbicularis
oculi (horner’s muscle) and is generally ignored during reconstruction.
Between the anterior and posterior canthal limbs lie the lacrimal punctum,
superior and inferior canaliculi, and superior one third of the lacrimal sac,
which projects 1 to 2mm above the level of the tendon. The superior and
inferior canaliculi travel for a shaort distance vertically (approximately
2mm) before assuming a more horizontal orientation (approximately 2mm)
before assuming a more horizontal orientation (approximately 10mm). They
converage and form a common canaliculus that enters the nasolacrimal sac
at its posteroinferior third. The nasolacrimal duct, which is approximately
20mm in length, travels vertically within the maxilla to open into the inferior
meatus of the nose at the anteriorly located lacrimal fold. Together, these
structures are responsible for the collelction and drainage of tears from the
conjunctival fornices into the inferior meatus of the nose. Damage to any
portion of the system may lead to excessive tearing from the eye, a condition
known as epiphora.