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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 60  |  Issue : 4  |  Page : 301-306

Comparison of surgical outcome between anterior-posterior flap with anterior suspended flap in external dacryocystorhinostomy


Department of Ophthalmology, JPM Rotary Club of Cuttack Eye Hospital and Research Institute, Cuttack, Trichy SRM Medical College Hospital and Research Centre, Trichy, Chennai, India

Date of Submission05-Jan-2022
Date of Decision25-Jul-2022
Date of Acceptance15-Aug-2022
Date of Web Publication19-Dec-2022

Correspondence Address:
K Meena Devi
Trichy SRM Medical College Hospital and Research Center SRM Nagar, Trichy-Chennai Highway Irungalur Village, Tiruchirapalli - 621105, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_1_22

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  Abstract 


Aim: To compare the surgical outcome between anterior-posterior flap (APF) and anterior suspended flap (ASF) in external dacryocystorhinostomy (DCR). Settings and Design: This was a prospective, non-randomized, comparative, interventional, clinical study, done in J. P. M Rotary Club of Cuttack Eye Hospital and Research Institute, Cuttack. Materials and Methods: This was a single-centre hospital-based study on patients with primary nasolacrimal duct obstruction who underwent external DCR conducted during a period of 18 months. The patients were selected into either of the two procedures, that is, anterior-posterior flap external dacryocystorhinostomy (APF-DCR) or anterior suspended flap external dacryocystorhinostomy (ASF-DCR) and were reviewed at day 1, day 7, 1 month, 3 months, and 6 months postoperatively. Absence of epiphora was considered as the subjective success rate, whereas patent sac was considered as an objective success rate. Statistical Analysis Used: Statistical analysis was done using the Statistical Package for the Social Sciences (SPSS) version 13 software. Results: In our study, 131 patients underwent APF-DCR, whereas 133 underwent ASF-DCR. At the final follow-up, the subjective success rate was 88.3% and 87.7%, respectively, while the objective success rate at 6 months was 85.8% and 87.7% in the APF-DCR group and ASF-DCR group, respectively. However, there was no statistically significant difference between the groups, both subjectively and objectively. Intraoperative haemorrhage and other postoperative complications were very few in both the groups. Conclusions: We recommend performing ASF-DCR, as the suspension of anterior flaps prevents the possibility of granulation tissue formation at the rhinostomy site. Again, simultaneous suturing of the anterior flaps along with excision of the posterior flaps speeds up the procedure.

Keywords: Anterior-posterior flap, anterior suspended Flap, external dacryocystorhinostomy, primary nasolacrimal duct obstruction


How to cite this article:
Agrawal A, Dinesh P, Sonkamble A, Devi K M, Dhyan S. Comparison of surgical outcome between anterior-posterior flap with anterior suspended flap in external dacryocystorhinostomy. TNOA J Ophthalmic Sci Res 2022;60:301-6

How to cite this URL:
Agrawal A, Dinesh P, Sonkamble A, Devi K M, Dhyan S. Comparison of surgical outcome between anterior-posterior flap with anterior suspended flap in external dacryocystorhinostomy. TNOA J Ophthalmic Sci Res [serial online] 2022 [cited 2023 Feb 8];60:301-6. Available from: https://www.tnoajosr.com/text.asp?2022/60/4/301/364233




  Introduction Top


Nasolacrimal duct obstruction (NLDO) is a common disorder in adults.[1] Chronic tear stasis and secondary infection frequently lead to acute exacerbations of dacryocystitis, mucocele, chronic conjunctivitis and corneal ulcer, orbital cellulitis in untreated cases, and pan-ophthalmitis in cases having undergone intraocular surgeries.[2] Dacryocystorhinostomy (DCR) has proven to be a reliable surgery for obstruction beyond the common canalicular opening. Its success rate ranges from 80% to 90%, according to different patient and surgeon factors.[3–7] Several techniques are available to surgically treat NLDO such as endoscopic,[8],[9] non-endoscopic endonasal DCR,[10] endonasal or transcanalicular laser DCR.[11] External DCR remains the gold standard surgical treatment for NLDO[3],[4],[12] and remains the method of choice for most oculoplastic surgeons.[13],[14] Since the description of the modern external DCR by Addeo Toti in 1904, various modifications have been made in order to increase the success rate and/or to decrease complications.[15] With a variation to the conventional anterior-posterior flap DCR, an approach known as anterior flap dacryocystorhinostomy (AF-DCR) was performed. Having comparable success rate with respect to the previous one with an easier technique, it is more favoured by most of the surgeons.[11] Another change in the technique came, which is known as anterior suspended flap dacryocystorhinostomy (ASF-DCR). The decision to opt between the two procedures should be taken during the surgery depending upon the anatomy of the nasolacrimal area, condition of the posterior flaps, and the surgeon's experience.[11] In this prospective study, we share our experience of the surgical outcomes between the two external DCR techniques.


  Subjects and Methods Top


Materials and Methods

This was a prospective study conducted in J. P. M. Rotary Club of Cuttack Eye Hospital & Research Institute, Cuttack, for a period of 18 months. The study was approved by the institutional ethics committee and adhered to the tenets of the Declaration of Helsinki. Informed consent was obtained from all patients and their parents/guardians if under the age of 18 years before undergoing the procedure. The confidentiality of patients was maintained at all the stages of data analysis.

Study population

All patients over the age of 15 years attending the hospital outpatient department (OPD) diagnosed with primary acquired NLDO, chronic dacryocystitis, mucocele or acute on chronic dacryocystitis were included in the study (These cases were treated with systemic antibiotic first, followed by surgery after a month from the resolution of acute phase.). Primary acquired NLDO was confirmed with probing and syringing. Complete ENT evaluation was done by an ENT surgeon to rule out any nasal pathology. The assessment was mainly clinical due to lack of dacrocystography facility at our centre. All surgeries were performed by a single surgeon. Exclusion criteria included canalicular or common canalicular obstruction, noticeable lid laxity, previous lacrimal surgery including previous failed DCR, patient being younger than 15 years, suspected malignancy, radiation therapy, post-traumatic lids, bony deformity, entropion/ectropion and punctal stenosis.

Surgical technique

External DCR was carried out under Local Anaesthesia (LA) with a mixture of 2% lidocaine and 0.5% bupivacaine in equal parts injected subcutaneously into the part anterior to anterior lacrimal crest. An incision of 1–3 cm was given 10–11 mm medial to medial canthus below the medial canthal tendon along the anterior lacrimal crest with a No. 11 Bard Parker (BP) blade; the soft tissue was dissected, exposing the periosteum. The periosteum anterior to anterior lacrimal crest was incised and elevated using the periosteal elevator. The lacrimal sac was reflected laterally to expose the lacrimal sac fossa and the lacrimal bone. A thin portion of the lacrimal bone was fractured with the help of the periosteal elevator; a bony window up to 1 cm diameter was created with the Kerrison Rongeur. Thereafter the technique of the external DCR was switched over to either of the two procedures. In case of the APF-DCR a No. 2 Bowman probe was introduced into the lacrimal sac through the upper punctum after dilating the punctum with punctum dilator. An incision to the lacrimal sac was given over the tented portion with the help of No. 11 BP blade and was extended in superior-inferior direction. Incision at the extremes of the wound created two flaps. A large anterior and a small, posterior, nasal mucosal flap were created with No. 11 BP blade. The posterior flaps of the sac and the nasal mucosa were sutured with 6-0 [Figure 1] vicryl followed by suturing of the anterior flaps [Figure 2]. In case of the ASF-DCR, after entering probe into the sac, an anterior sac flap was created by giving incision over the tented portion of the sac with No. 11 BP blade with further enlargement. A single nasal mucosal flap was created with No. 11 BP blade. Then both of the flaps were sutured with 6-0 vicryl suture at the superior and the inferior angles of the flaps [Figure 3], and through the orbicularis muscle and closed. Thus the flaps are elevated.
Figure 1: Anastomosis of posterior flaps in APF-DCR

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Figure 2: Anastomosis of anterior flaps in APF-DCR

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Figure 3: Anterior flaps of sac and nasal mucosa in ASF-DCR

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Data collection

Preoperative data included previous history of trauma, lacrimal surgery, or any radiation therapy. The postoperative data was collected on day 1, day 7, day 30, day 90, and day 180. Any intraoperative complications were also noted.

Outcome measures

In the primary outcomes, success rate was determined both subjectively and objectively by the absence of epiphora and by patency on syringing, respectively. Probing was done in cases with partial patent or blocked duct to know the site of obstruction. Secondary outcomes consisted of bleeding, oozing, and gapping from the wound, haemorrhage intraoperative or postoperative, wound infection or dehiscence, and any other complication.

Statistical analysis

Data collected was subjected to statistical analysis with the help of the Statistical Package for the Social Sciences (SPSS) version 13 software. Distribution of the study subjects according to age, sex, laterality, etc., was done following cross tabulation procedure. Matching of the treatment groups by age and sex was done following Chi-squared test of association. Comparison of subjective and objective success rate and complications by treatment groups and their test of association were done following the Chi-squared test of association. Descriptive statistics like mean age and standard error of mean age were computed with the help of descriptive procedure in SPSS. For better appreciation of the result, graphic illustration such as percentage bar diagrams, multiple bar diagrams and pie diagrams were used.


  Results Top


[Table 1] shows the demographic data of the study population. In the subjective success rate displayed in [Table 2], epiphora was absent in 98.5% and 97% at postoperative day 1 in APF-DCR and ASF-DCR, respectively (P = 0.420). At day 7, it was 97.7% and 95.5%, respectively (P = 0.320), for APF-DCR and ASF-DCR, whereas at 1 month it was 97.6% and 88.8% respectively (P = 0.006). Epiphora was absent in 91.7% and 88.6% of cases (P = 0.430) in APF-DCR and ASF-DCR groups, respectively, at 3-month follow-up, while at final follow up it was 88.3% and 87.7% respectively in both the groups (P = 0.885). At each follow-up, success rate was more in APF-DCR group that indicated a better trend of success for that group. However, the difference in the success rate was not statistically significant except at 1 month postoperatively (P = 0.006).
Table 1: Demographic characteristics of the study population

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Table 2: Subjective success rate treatment groups

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In APF-DCR group, the overall objective success rate displayed in [Table 3] ranged from 97.7% to 96.0% from postoperative day 1 to 1 month. At postoperative 3 months and 6 months this dropped to 90% and 85.8% respectively. In ASF-DCR group, the overall objective success rate at postoperative day 1 was 96.2% and thereafter, it reduced steadily and at 6 month, it was 87.7%. The comparison of the success rate at each follow-up reveals APF-DCR performance was slightly better than ASF-DCR except at 6 month. The difference was statistically significant only at 1 month postoperatively (P = 0.033). In other follow-ups, there was no statistical significance. Therefore, the objective success rate between the two groups may be considered as more or less similar.
Table 3: Objective success rate in treatment group

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Intraoperative bleeding was found in 3.8% and 5.3% of cases in APF-DCR and ASF-DCR, respectively (P = 0.573). Postoperative bleeding was found in 0% and 0.8% of cases in APF-DCR and ASF-DCR, respectively, on day 1 (P = 0.320). There was no bleeding in the rest of the follow-ups. Thus, bleeding was reported slightly more in ASF-DCR, but there was no statistically significant difference in both the groups. At day 1, none of the cases in both the groups presented with abscess. At day 7, two cases in APF-DCR presented with abscess while none with ASF-DCR (P = 0.154). At 1 month, one case in each group presented with abscess (P = 0.334). The difference was not statistically significant in both the groups. Again at 3 and 6 months, no case of abscess was found in both the groups. At days 1 and 7, none of the cases in both the groups presented with suture granuloma. At 1 month, 2.4% and 0.86% of cases of APF-DCR and ASF-DCR presented with suture granuloma, respectively (P = 0.350) while 0.83% and 0.43% of APF-DCR and ASF-DCR, respectively, at 3 and 6 months (P = 0.329). The difference was not statistically significant in both the groups at any follow-up period.


  Discussion Top


The subjective success rate in both the groups was around 98% at day 1 postoperatively. At 6 months, 88.3% of cases presented with no epiphora in APF-DCR group while 88% in ASF-DCR. At each follow-up, APF-DCR was found to have slightly better outcome. However, the difference was statistically not significant except at 1 month. Thus, the final interpretation on the subjective success rate is that both the procedures are more or less similar with regards to absence of epiphora.

In terms of patency, the success rate in APF-DCR group was 97.7% at day 1, followed by 96.9% at day 7, and 96% at 1 month. This declined to 90% at 3 months and 85.8% at 6 months. Meanwhile in the ASF-DCR group, a success rate of 96.2% was found at day 1, 91.7% at day 7, followed by 88.8% at 1 month. Thereafter, there was little decrease till 6 months. APF-DCR presented as a slightly better procedure than ASF-DCR, with the difference between the two groups being statistically not significant except at 1 month. However, at 6 months, ASF-DCR showed a better trend of success, though not significant statistically. Thus, both the groups having almost similar success rates, with shift of trend from APF-DCR to ASF-DCR at 6 months, is the final inference of this study. While exploring the cause of such a change, we found that in APF-DCR, nine patients had patent passage at 1 month but came with failed DCR at 3 months. Obstruction at the site of anastomosis was found in eight cases, while in one case canalicular obstruction was observed. Similarly at 6 months, six patients presented with failed DCR, with patent sac at 3 months. Out of them, five were found to have obstruction at the anastomosis site. Thus, there may be a possibility of delayed onset adhesion between the anterior and posterior flaps leading to failure of the surgery. The success rate of APF-DCR found by Elwan et al.[16] in 2003 was almost similar to our results, whereas that shown by Türkcü et al.[17] in 2012 as well as Katuwal et al.[18] in 2013 was slightly higher than our findings. But Dareshani et al.[19] in 1996, Serin et al.[20] in 2007, and Khan et al.[21] in 2010 demonstrated a much better trend of success than us. However the sample size in all of these studies ranged from 31 to 42, while 79 patients underwent APF-DCR in the study by Türkcü et al.[17] Thus. the sample size might be a factor in these studies, leading to the discrepancy in the success rate in our study. Again the total period of follow-up by Dareshani et al.,[19] Khan et al.,[21] and Katuwal et al.[18] was more or less equal to ours. Meanwhile intubation was done by Dareshani et al.,[19] Katuwal et al.,[8] and Khan et al.[21] which might be the cause of such high success rate. The success rate of ASF-DCR was 87.7%, which is less than what was found by previous authors. The sample size of Baldeschi et al.[9] was 45 while that of Dutta et al.[22] was 87, but in our study this was 114. Thus, the sample size may be a factor for variability of results in our study. Meanwhile the sample size of Evereklioglu et al.[23] was 112 with success rate of 99.1%. But the anastomosis of the flaps was done using figure of eight (8) mattress suture. This might have been the cause of high success rate in their study. Deka et al.[24] also found a very good success rate, but their approach was a little different. They had sutured the posterior flaps instead of the excision. To the best of our knowledge, no study has been published comparing APF-DCR with ASF-DCR. Thus, we correlated our findings with previous studies comparing APF-DCR with ASF-DCR, which is shown in [Table 4]. In our study, ASF-DCR was found to be slightly better than APF-DCR at the end of 6 months. However, the difference was not statistically significant. Elwan et al.,[16] Serin et al.,[20] and Pandya et al.[25] demonstrated anterior flap DCR as a slightly better technique than APF-DCR, whereas in studies by Dareshani et al.,[19] Khan et al.,[21] Türkcü et al.,[17] and Katuwal et al.,[18] APF-DCR was presented as a little better procedure than anterior flap DCR. But in none of the above studies the difference in the success rates was statistically significant. The conclusion made by most of the authors was that the success rates of both the procedures were more or less similar, and suturing of the posterior flaps was not an advantageous procedure with the probability of adhesion between the flaps. The technique of anterior flap DCR is a simpler one and speeds up the surgery. Suspension of the anterior flaps has an added advantage of prevention of formation of fibrous adhesion. Thus, this technique might be a better option than APF-DCR.
Table 4: Correlation of APF-DCR with Anterior Flap DCR

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Complications encountered were very few in both the groups, with no statistically significant difference between the groups. Intraoperative bleeding was found in 3.8% and 5.3% of cases in APF-DCR and ASF-DCR, respectively. Khan et al.[21] had demonstrated bleeding in 2.9% of cases while Katuwal et al.[18] in 12% of cases and Deka et al.[24] in 1% of cases, whereas bleeding was seen in 11.66% and 12.5% of cases by Zaman et al.[26] and Evereklioglu et al.,[23] respectively. To analyse the cause of failure, re-exploration of the lacrimal passage and/or imaging study like dacryocystostography, endoscopic ultrasound, computed tomography is required. But in our study, only one patient agreed for repeat DCR; also imaging facilities were not available within the premises. However, we were able to find out the site of obstruction from syringing and probing, though the exact cause could not be elicited. In most of the failed DCRs, the site of obstruction in both the groups was at the level of anastomosis which was 88% and 86% in APF-DCR and ASF-DCR groups, respectively. Only 12% of patients in APF-DCR and 14% in ASF-DCR were found to have obstruction at the level of common canaliculus. Serin et al.[20] found the presence of larger posterior flaps in one patient, but adhesion between the anterior and posterior flaps in others on nasal endoscopy in the two failed cases. Obstruction at the level of anastomosis was shown by Khan et al.[21] Zaman et al.[26] demonstrated collapse of bridge between the flaps in one case and previously unidentified canalicular stenosis in the other, resulting in failure of surgery in these two patients who had undergone ASF-DCR. Thus, the above studies on both APF-DCR and ASF-DCR show that the site of obstruction was mostly at the level of anastomosis, which correlates with our results.

Only one patient out of all the failed DCR cases was willing for re-DCR. ASF-DCR was previously done in this case. On syringing, DCR SITE it was found to be blocked with regurgitation of fluid through the opposite punctum. Hard stop was found on probing. This patient underwent re-DCR with intubation. On exploration, the flap was found to be well tented-up with bony window of adequate size. On probing, a bony spur just in front of the opening of the common canaliculus was found, which might be the reason for the hard stop. Again on further exploration, hypertrophied, fibrosed nasal mucosa was seen, which might be another reason for failure of the surgery.

Limitations of our study

  1. To know the cause of failure of the surgery, imaging facilities like dacryocystostography, endoscopic ultrasound, and computed tomography are required; these facilities were unavailable at our eye institute.
  2. Exploration of the lacrimal passage in failed cases is necessary, which we lacked in our study as except one patient of all the failed cases was willing for repeat DCR.



  Conclusion Top


Though the success rates of both the groups were more or less similar, we recommend ASF-DCR over APF-DCR due to the following reasons:

  1. Anastomosis of anterior flaps with overlying orbicularis muscle suspends the flaps from the rhinostomy site, thus preventing the formation of fibrous adhesion and thereby decreasing the possibility of failure of the procedure.
  2. Simultaneous suturing of the anterior flaps speeds up the procedure.
  3. ASF-DCR is easier to perform as there is no need to suture the posterior flaps.
  4. Excision of the posterior flaps decreases the duration of surgery as well as simplifies it and prevents the formation of granulation tissue.
  5. Suturing of the posterior flaps may be cumbersome in the presence of bleeding, leading to failure of the surgery.


Acknowledgements

The authors would like to express their deepest gratitude to Dr. Naresh Desinayak, Dr. Suwarn Chetan, and Dr. Sukhada Mishra for their immense guidance throughout the study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ali MJ. Lacrimal disorders and surgery: Historical perspectives. In: Ali MJ, editor. Principles and Practice of Lacrimal Surgery. New Delhi: Springer; 2015. p. 1–8.  Back to cited text no. 1
    
2.
Duke-Elder S, MacFaul PA. Diseases of the lacrimal passages. Syst Ophthalmol 1974;13:675-724.  Back to cited text no. 2
    
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Picó G. A modified technique of external dacryocystorhinostomy. Am J Ophthalmol 1971;72:679-90.  Back to cited text no. 3
    
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Rosen N, Sharir M, Moverman DC, Rosner M. Dacryocystorhinostomy with silicone tubes: Evaluation of 253 cases. Ophthalmic Surg 1989;20:115-9.  Back to cited text no. 4
    
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Shams PN, Chen PG, Wormald PJ, Sloan B, Wilcsek G, McNab A, et al. Management of functional epiphora in patients with an anatomically patent dacryocystorhinostomy. JAMA Ophthalmol 2014;132:1127.  Back to cited text no. 5
    
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Allen K, Berlin AJ. Dacryocystorhinostomy failure: Association with nasolacrimal silicone intubation. Ophthalmic Surg 1989;20:486-9.  Back to cited text no. 6
    
7.
Qidwai N, Jafri Raza H. Comparison of dacryocystorhinostomy with mitomycin C against Dacryocysto- rhinostomy with intubation. Pakistan J Ophthalmol 2012;28:214-8.  Back to cited text no. 7
    
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Ben Simon GJ, Joseph J, Lee S, Schwarcz RM, McCann JD, Goldberg RA. External versus endoscopic dacryocystorhinostomy for acquired nasolacrimal ductobstruction in a tertiary referral center. Ophthalmology 2005;112:1463-8.  Back to cited text no. 8
    
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Baldeschi L, Nardi M, Hintschich CR, Koornneef L. Anterior suspended flaps: A modified approach for external dacryocystorhinostomy. Br J Ophthalmol 1998;82:790-2.  Back to cited text no. 9
    
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Dolman PJ. Comparison of external dacryocystorhinostomy with nonlaser endonasal dacryocystorhinostomy. Ophthalmology 2003;110:78-84.  Back to cited text no. 10
    
11.
Piaton JM, Limon S, Ounnas N, Keller P. Transcanalicular endodacryocystorhinostomy using Neodymium: YAGlaser. J Fr Ophthalmol 1994;17:555-67.  Back to cited text no. 11
    
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Qian Z, Zhang Y, Fan X. Clinical outcomes of dacryocystorhinostomy with or without intraoperative use of mitomycin C: A systematic review and meta-analysis. J Ocul Pharmacol Ther 2014;30:615-24.  Back to cited text no. 12
    
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Burns JA, Cahill KV. Modified Kinosian dacryocystorhinostomy: A review of 122 cases. Opthalmic Surg 1985;16:710-6.  Back to cited text no. 13
    
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Zhang WQ, Zhou X, Zhou HZ. Clinical management of dacryocystorhinostomy in treatment of chronic dacryocystitis. Int J Ophthalmol 2006;6:953-4.  Back to cited text no. 14
    
15.
John P, Evans GRD. Soft-Tissue Surgery of the Craniofacial Region. New York: Informa Healthcare; 2007.  Back to cited text no. 15
    
16.
Elwan S. A randomized study comparing DCR with and without excision of the posterior mucosal flap. Orbit 2003;22:7-13.  Back to cited text no. 16
    
17.
Türkcü FM, Öner V, Taş M, Alakuş F, İşcan Y. Anastomosis of both posterior and anterior flaps or only anterior flaps in external dacryocystorhinostomy. Orbit 2012;31:383-5.  Back to cited text no. 17
    
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Katuwal S, Aujla JS, Limbu B, Saiju R, Ruit S. External dacryocystorhinostomy: Do we really need to repair the posterior flap? Orbit 2013;32:102-6.  Back to cited text no. 18
    
19.
Dareshani S, Niazi JH, Mahmood Saeed M, M Saleh Memon MS, Tariq Mahmood T. Dacryocystorhinostomy: Importance of anastomosis between anterior and posterior flaps. Pak J Ophthalmol 1996;12:129-31.  Back to cited text no. 19
    
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Serin D, Alagoz G, Karsloglu S, Celebi S, Kukner S. External dacryocystorhinostomy: Double-flap anastomosis or excision of the posterior flaps. Ophthal Plast Reconstr Surg 2007;23:28-31.  Back to cited text no. 20
    
21.
Khan FA, Yaqub MA, Fayyaz M. The importance of excising or suturing the posterior mucosal flaps in external dacryocystorhinostomy. Pak J Ophthalmol 2010;26:69-73.  Back to cited text no. 21
    
22.
Dutta D, Kundu A, Singhal PK, Sanyal S, Hazra TK. Failure rate of dacryocystorhinostomy is 10 to 15%. is it really so dissapointing? 2009.   Back to cited text no. 22
    
23.
Deka A, Saikia SP, Bhuyan SK. Combined posterior flap and anterior suspended flap dacryocystorhinostomy: A modification of external dacryocystorhinostomy. Oman J Ophthal 2010;3:18-20.  Back to cited text no. 23
    
24.
Zaman M, Babar TF, Saeed N. A review of 120 cases of dacryocystorhinostomies (Dupuy Dutemps and Bourguet technique). J Ayub Med Coll Abbottabad 2003;15:10-2.  Back to cited text no. 24
    
25.
Pandya VB, Lee S, Benger R, Danks JJ, Kourt G, Martin PA, et al. The role of mucosal flaps in external dacryocystorhinostomy. Orbit 2010;29:324-7.  Back to cited text no. 25
    
26.
Evereklioglu C, Oner A, Somdas MA, Ketenci I, Dogan H, Mirza E, et al. Figure of- eight vertical mattress suture technique for anterior flap suspension to overlying tissues in external dacryocystorhinostomy. Am J Ophthalmol 2007;143:328-33.  Back to cited text no. 26
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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