Can Whitnall’s tubercle be localized using palpable landmarks around the orbit?

Year 2021, Volume: 15 Issue: 2, 121 - 126, 31.08.2021

Ali Can Korkmaz , Necati Salman , Aysun Uz

Abstract

Objectives: Whitnall’s tubercle (WT) is located deep in the lateral canthus and on the lateral orbital wall and has crucial structures attach to it. We aimed to define the location of WT using the palpable bone landmarks which can be used as reliable landmarks in eyelid and orbital surgery to prevent the damage of stuctures associated with WT.
Methods: Forty-four adult skulls (22 right, 22 left) were included to the study. The skulls were divided into two groups according to the apparancy of the WT. The distances from WT to the frontozygomatic suture, the marginal tubercle, the anterior point of the zygomatic arch, and the lateral margin of the orbit were measured. The clock positions of WT according to the marginal tubercle and the anterior point of the zygomatic arc were determined.
Results: The distances of the WT to the marginal tubercle, the anterior point of the zygomatic arch, the lateral margin of the orbit, and the frontozygomatic suture were 9.92±1.65 mm, 16.48±1.86 mm, 2.32±0.53 mm and 9.66±1.44 mm, respectively. WT was at 8 and 9 o’clock positions on the left, and at 4, 3, and 2 o’clock positions on the right according to the marginal tubercle. WT was at 10 o’clock position on the left, and 2 and 1 o’clock positions on the right according to the anterior point of the zygomatic arch.
Conclusion: The marginal tubercle, the lateral margin of the orbit, and the anterior point of the zygomatic arch can be used as standart bony landmarks in eyelid and orbital surgery to prevent the soft tissue damage relevant to WT. The high kappa values of the interclass and intraclass correlations suggest that these parameters are reliable and repeatable for clinical use. Out of these parameters, the anterior point of the zygomatic arch is more beneficial to locate the WT because of the standard clock positions. The WT is typically located at 10 o’clock position on the left and 2 o’clock position on the right according to the anterior point of the zygomatic arch.

Keywords

lateral canthus, marginal tubercle, orbita, Whitnall's tubercle, zygomatic arch

References

• Whitnall SE. On a tubercle on the malar bone, and on the lateral attachments of the tarsal plates. J Anat Physiol 1911;45:426–32.
• Mojallal A, Cotofana S. Anatomy of lower eyelid and eyelid–cheek junction. Ann Chir Plast Esthet 2017;62:365–74.
• Rosenstein T, Talebzadeh N, Pogrel MA. Anatomy of the lateral canthal tendon. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:24–8.
• Hwang K, Nam YS, Kim DJ, Han SH, Hwang SH. Anatomic study of the lateral palpebral raphe and lateral palpebral ligament. Ann Plast Surg 2009;62:232–6.
• Kang H, Takahashi Y, Ichinose A, Nakano T, Asamoto K, Ikeda H, Iwaki M, Kazizaki H. Lateral canthal anatomy: a review. Orbit 2012;31:279–85.
• Zoumalan CI, Roostaeian J. Simplifying blepharoplasty. Plast Reconstr Surg 2016;137:196e–213e.
• Whitnall SE. Osteology. In: Whitnall SE, editor. The anatomy of the human orbit and accessory organs of vision. London: Henry Frowde and Hodder & Stoughton; 1921. p. 13–4.
• Fries FN, Youssef P, Irwin PA, Tubbs RI, Loukas M, Tubbs RS. Comparing the left and right Whitnall’s tubercles and their relation to the frontozygomatic suture: application to symmetry following lateral orbital surgery. Orbit 2016;35:305–8.
• Didio LJ. The presence of the eminentia orbitalis in the os zygomaticum of Hindu skulls. Anat Rec 1962;142:31–9.
• Kakizaki H, Zako M, Nakano T, Asamoto K, Miyaishi O, Miyagawa T, Iwaki M. Lateral canthal support system in Japanese. Okajimas Folia Anat Jpn 2006;83:85–90.
• Ono R. Untersuchungen ueber die Orbita von Japaner. Japanese Journal of Medical Sciences. 1. Anatomy 1928;1:307–8.
• Kangas T. Das vorkommen des “tuberculum orbitale” in menschlichen Schaedel, insbesondere bei Finnen und Lappen. Duodecim (Helsinki) 1928;1:307–88.
• Buschkowitsch WJ. Ueber das “tuberculum orbitale” des Jochbeins des Menschen. Anat Anz 1927;63:353–7.
• Kakizaki H, Malhotra R, Madge SN, Selva D. Lower eyelid anatomy: an update. Ann Plast Surg 2009;63:344–51.
• Rizvi M, Lypka M, Gaon M, Kovacev T, Eisemann B, Eisemann M. Minimally invasive lateral canthopexy (MILC). J Plast Reconstr Aesthetic Surg 2010;63:1434–6.
• Hamed-Azzam S, Verity DH, Rose GE. Lateral canthotomy orbitotomy: a rapid approach to the orbit. Eye 2018;32:333–7.
• Moe KS, Jothi S, Stern R, Gassner HG. Lateral retrocanthal orbitotomy. Arch Facial Plast Surg 2007;9:419–26.
• Pascali M, Avantaggiato A, Brinci L, Cervelli V, Carinci F. Lateral canthal support in prevention of lower eyelid malpositioning in blepharoplasty: the tarsal sling. J Craniofac Surg 2015;26:e339–e342.
• Ousterhout DK, Weil RB. The role of the lateral canthal tendon in lower eyelid laxity. Plast Reconstr Surg 1982;69:620–2.
• Sukhija J, Singh M, Singh U. Profound weakening of the lateral rectus muscle with attachment to lateral canthal tendon for treatment of exotropic Duane syndrome. J AAPOS 2012;16:298–300.
• Tomita S. On the tuberculum orbitale of the zygomatic bone in the Japanese. Kanazawa Daigaku Igakubu Kaibogaku Kyoshitsu Gyoseki 1935;20:149–54.
• Gleeson M, Tunstall R. Head and neck: overview and surface anatomy. In: Standring S, editor. Gray’s anatomy: the anatomical basis of clinical practice. 41st ed. New York (NY): Elsevier; 2016. p. 410.
• Anastassov GE, Van Damme PA. Evaluation of the anatomical position of the lateral canthal ligament: clinical implications and guidelines. J Craniofac Surg 1996;7:429–36.
• Lira J, Langelier N, Lepsch A, Cypen SG, Ranjit-Reeves R, Woodward J. Facial and orbital asymmetry in oculofacial surgery patients. Cutis 2018;101:E22–3.
• Seiji F, Moreira RS, De Angelis MA, Smith Chairman RL. Orbital asymmetry in development: an anatomical study. Orbit 2009;28:342–6.