Though various incisions have been described, the authors prefer the commonly used curvilinear incision of about 10–12 mm in length, 3–4 mm from the medial canthus along the anterior lacrimal crest (Fig. 17.2).

Blunt dissection is carried on to reach the periosteum. A freer elevator is used to separate the periosteum from the bone and reflect it laterally along with the lacrimal sac to expose the lacrimal fossa. It is preferable to preserve the medial canthal tendon and dissect only when needed (Fig. 17.3).

Once the lacrimal fossa is exposed, bone punching should be started at the junction of the lamina papyracea of the ethmoid and lacrimal bone. The kerrison bone punch should be gently inserted between the bone and the nasal mucosa and the ostium sequentially enlarged (Figs. 17.4 and 17.5). The extent of the ostium which the authors follow is:

The first step is to create sac flaps. To do this a Bowman’s probe is passed through the lower punctum and bent in such a way to tent the sac as posterior as possible to create a large anterior and small posterior flap. Alternatively, fluorescein-stained viscoelastic can be injected from the upper punctum to dilate the sac and help in creating flaps. Using the probe as guide, an “H”-shaped incision is made with the help of a number 11 or 15 blade right across the sac from the fundus to the nasolacrimal duct. Flaps are raised and the posterior one is cut (Fig. 17.6).

The second step is to fashion the nasal mucosal flaps. With the help of a number 11 blade, incisions are made in the nasal mucosa along the bony ostium except anteriorly to have a hinged flap. The large anterior flap is raised and the posterior small residual flap is cut (Fig. 17.7). Alternatively both the flaps can be sutured, but no significant difference in the success has been noted in doing this either way [6, 7].

It is important to appose the nasal mucosal and sac flaps edge to edge. Excess nasal mucosa can be excised in a controlled manner so as to avoid sagging of the flaps that may compromise the tear drainage later (Fig. 17.8). In case of overriding, the nasal mucosal overriding is preferable or alternatively one can tent the flaps and suture to the overlying orbicularis.

Once flaps are secured, the orbicularis is sutured back with 6-0 Vicryl followed by the skin with 6-0 silk (Fig. 17.9).