The patient was operated by me 27-August-2009 for severe head injury with laceration of the brain and complete destruction of the bony alignments of the forehead and she survived.

The patient then came 08-October-2009 and she was neurologically free, but has slight disfigurement of the left naso-lacrimal area. The patient was sent for neuroradiologic investigations, but she disappeared.

The patient then came 08-August-2010 and the father claiming that the tears of the left eye are coming out and the bony disfigurement became more pronounced. CT-scan of the orbits was done 09-August-2010 and she was sent for ophthalmological consultation.

On examination: the patient is neurologically free and there is closure of the left lacrimal ducts with bony disfigurement of the left naso-lacrimal area.

Limited Lynch incision was performed over the most prominent bony elevation in the deformed left naso-lacrimal area. The medial canthal ligament identified and dissected off the deformed bony prominences. All the bony deformities were corrected and the lacrimal sac was decompressed of all bony compression. The lacrimal canal of the left maxillary bone was partially opened to ensure that it is free. The posterior wall of the canal was pushed posterior. Inspection for any bony prominences was negative and the comparison with the contralateral side showed complete symmetry. The medial canthal tendon was sutured to the periosteum and routine closure of the wound.

Routine closure of the wound. Smooth postoperative recovery.

The transcaruncular approach is not appropriate for this case, because the aim of surgery is not only cosmetic, but also to decompress the lacrimal duct, caused by the bony elements. This approach is ideal for the medial wall of the orbit to lesions behind the lacrimal duct.

The Lynch approach has its disadvantages, but in this case it was the most appropriate one, to resolve all the problems of the patient.