Spontaneous reformation of upper eyelid.

Twenty-six patients with lesions of upper eyelids were treated with simple surgical excision under local anaesthesia as day cases. Three other patients with eyelid injuries had full-thickness margin-inclusive lacerations of upper eyelids. In all these 29 patients the upper eyelid wounds were allowed to heal solely by spontaneous repair. The cautious study began with small extramarginal skin excisions and progressed gradually via moderate sized juxtamarginal excisions of skin and orbicularis lamella to full-thickness margin-inclusive excisions. The wounds healed satisfactorily in all the 29 patients without ocular or palpebral complications. The functional results were normal. Cosmetic results were excellent in 27 patients and acceptable in 2, one of whom subsequently underwent a secondary oculoplastic repair. This study demonstrates that, for upper eyelids, full-thickness margin-inclusive excisions of up to 10 mm in horizontal extent and 5-6 mm in height, and moderate sized 13 X 10 mm juxtamarginal excisions of the skin and orbicularis lamella, yield near normal results with solely spontaneous repair. Immediate surgical reconstruction of such wounds is assumed to be mandatory by current tenets of oculoplastic surgery.     

Spontaneous reformation of lower eyelid.

Eleven consecutive patients with tumours involving the lower eyelid margin were treated with margin-including full-thickness excision of the eyelid and suturing of bleeding vessels as the sole primary surgical procedure, needing less than 10 minutes. The resulting defects of 2/5 to 7/8 of the horizontal extent of the eyelid and varying in height from 4 to 7 mm were allowed to heal spontaneously. In all the 11 patients the wounds healed, without ocular or palpebral complications in about 6 weeks and underwent further cosmetic improvement for the ensuing 6--8 weeks. Cosmetic results were excellent in 8 patients with excisions of 2/5 to 1/2 of the eyelid. All procedures including the secondary reconstructions were carried out on day-case basis under local anaesthesia. Histology confirmed complete tumour clearance in all the patients. Apart from being the first report of a planned study of spontaneous repair of full-thickness surgical wounds of the lower eyelid this study shows that the conventional method of dressing such wounds can be replaced by the less expensive and convenient 'dressing' of a cartella shield with an improvised central hole.     

Lateral canthoplasty with acellular cadaveric dermal matrix graft (AlloDerm) reinforcement

Lateral canthal dystopia can lead to lower eyelid malposition, abnormal lateral eyelid fissure appearance, and lagophthalmos. In most cases, the lateral canthus can be repaired with a standard lateral canthopexy or canthoplasty. In a fraction of cases, especially when recurrent, the surgical repair may require additional lateral canthal reinforcement.     

Eyelid Basal cell carcinoma arising on the site of a congenital port wine hemangioma

 Purpose: Only one previous case of eyelid basal cell carcinoma arising in a facial port wine stain without previous local radiotherapy has been reported. We now report a second case. Methods: A 42-year-old female patient with eyelid basal cell carcinoma developing within a facial port wine stain underwent incisional biopsy, surgical excision and repair. Results: The patient had a mass at the inner canthus of the left eye for two years. She had a left facial congenital port wine hemangioma involving the left eyelid, for which no topical treatment had been given. Clinical examination disclosed a 1.5×1.2 cm ulcerated skin mass with irregular borders in the medial canthal region involving the medial aspect of both upper and lower left eyelids. Incisional biopsy revealed basal cell carcinoma. She underwent surgical excision by Mohs’ technique and subsequent reconstructive eyelid surgery. The wound healed well postoperatively. At 2 years of follow up the patient showed no recurrence. Conclusion: Patients with congenital facial port wine stain may develop basal cell carcinoma, and should be regularly monitored.     

The use of forehead flaps in the management of large basal cell carcinomas of the medial canthus/medial lower eyelid in Saudi patients

PurposeBasal cell carcinoma (BCC) is the most common skin cancer worldwide. BCC represents 90–95% of all malignant eyelid tumors with lower eyelid/medial canthus lesions being more common than lower eyelid/lateral canthus lesions. Although various local flaps have been used for the reconstruction of medial canthus/adjacent eyelid defects, we find the forehead flap to be the most suited for these cases.Materials and methodsWe are reporting a clinical series of BCC involving the medial canthus and adjacent medial lower eyelid through a retrospective review of 18 patients who underwent surgical excision of the lesion followed by primary reconstruction using forehead flaps. Patients who underwent reconstruction without forehead flaps were excluded. All cases were Saudis and underwent this type of reconstruction. Indications, results, and complications were reviewed with special emphasis on the acceptance of the obvious forehead donor site scar in Saudi patients.ResultsAll flaps survived completely Follow-up ranged from 2 to 10 years (mean of 5 years). Tumor recurrence was not seen in any of the patients. Functionally, there was no ectropion and the eyelid margin was well aligned and stable. However, epiphora was evident since lacrimal system reconstruction was not performed.ConclusionWe are presenting the first Saudi series of large medical canthus/lower eyelid defects that underwent reconstruction using forehead flaps. The outcome was satisfactory and there were no cases of tumor recurrence. The only disadvantage is the donor scar which seems to be acceptable in the Saudi population because of their traditional head cover.     

Epidemiologic characteristics and clinical course of patients with malignant eyelid tumors in an incidence cohort in Olmsted County, Minnesota

OBJECTIVE: To determine the epidemiologic and clinical characteristics of patients with malignant eyelid tumors in an incidence cohort. DESIGN: Cohort series. PARTICIPANTS: A computerized retrieval system was used to identify all patients residing in Olmsted County, Minnesota, who had a newly diagnosed malignant eyelid tumor during the 15-year interval from 1976 through 1990. The patients' medical records were reviewed for demographic and clinical data. INTERVENTION: Surgical excision with frozen-section histopathologic analysis, Mohs' micrographic excision, and electrodesiccation and curettage were the primary methods of treatment. MAIN OUTCOME MEASURES: Survivorship free of tumor. RESULTS: The incidence cohort included 174 patients who each had 1 tumor; men and women were equally affected, and all patients were white. Tumors developed most commonly on the lower eyelid (n = 85; 48.9%) and in the medial canthal region (n = 48; 27.6%) but involved the right and left sides with equal frequency. Of the 174 tumors, 158 were basal cell carcinomas (90.8%), 15 were squamous cell carcinomas (8.6%), and 1 (0.6%) was a malignant melanoma. The age- and gender-adjusted incidence rates for basal cell carcinoma, squamous cell carcinoma, and malignant melanoma were 14.35, 1.37, and 0.08 per 100,000 individuals per year, respectively. No cases of sebaceous gland carcinoma were identified. The 5- and 10-year recurrence rates for all tumors on the eyelid were 2% and 3%, respectively. The probability of an unrelated malignancy developing elsewhere in the body was approximately 9% at 5 years and 15% at 10 years. CONCLUSIONS: Basal cell carcinoma is the most common malignant eyelid tumor in whites. The lower eyelid and medial canthus are the most frequent sites of origin. Men and women are equally affected. Recurrence after surgical excision is uncommon.     

Periocular keratoacanthoma: clinical features,pathology, and management

PURPOSE: To review the clinical features and results of surgical treatment of keratoacanthoma of the eyelids. DESIGN: Retrospective, interventional case series. PARTICIPANTS: Ten patients. METHODS: Chart review of all eyelid keratoacanthomas treated between 1992 and 2001. MAIN OUTCOME MEASURES: Adequate excision, recurrence rate, and complications. RESULTS: Patient ages ranged from 27 to 78 years, with a mean age of 59 years. Six patients were male and four were female. The lesion was found on the lower lid in five patients, upper lid in two, medial canthus in two, and lateral canthus in one. The maximum diameter of the lesion varied from 2 to 25 mm, with a mean of 7.2 mm. All lesions were treated by surgical excision, with frozen-section control of margins in five cases. All lesions were excised completely with clear resection margins, and there were no cases of recurrence. The only complication was a minor wound infection in one patient. Mean follow-up was 34.5 months. CONCLUSIONS: Because of the aggressive nature and uncertain relationship to squamous cell carcinoma, we recommend excision of periocular keratoacanthoma. Surgical excision of eyelid keratoacanthoma provides good results and a very low risk of recurrence. Frozen-section control of margins should be used in selected cases to ensure complete excision.     

Clinical factors influencing periocular surgical defects after Mohs micrographic surgery

PURPOSE: To determine if the surgical defect after excision of periocular skin cancers can be predicted preoperatively. METHODS: Review of medical records of patients who underwent excision of periocular skin cancers between 1990 and 1995. RESULTS: Two hundred sixty-four patients (157 men, 107 women) with a total of 281 malignant tumors were treated. Basal cell carcinoma accounted for 92.2% of the tumors, whereas squamous cell carcinoma constituted 6.4% of lesions. The lower eyelid and medial canthus were the most frequent sites of involvement. Data analysis was conducted on tumor size, cell type, location, and the Mohs stages and sections that were required for cure. Morpheaform basal cell carcinomas required the most Mohs stages and sections and resulted in the largest excisional defects when compared with clinical tumor dimensions. The lateral canthus had the fewest tumors, but lesions in this area resulted in the largest excisional defects (mean, 9.5 cm2) when compared with lesions of the medial eyelid (p = 0.35). The average size of the defect after Mohs excision of basal cell carcinoma was 4.2 to 4.6 times the original clinical tumor size. For morpheaform basal cell carcinoma, however, the average excisional defect was 6.1 times larger. Conversely, the average defect after excision of squamous cell carcinoma was only 2.6 times as large as the original clinical tumor size. CONCLUSIONS: These data are useful in predicting the size of a defect after Mohs excision of periocular skin cancer, based on the original clinical tumor size.     

Bipalpebral sliding flap in the repair of inner or outer canthal defects.

Seven patients were successfully treated with a bipalpebral sliding flap for the repair of medial or lateral canthal defects. In our experience this technique minimises the size of the associated surgical repair-a skin graft for the inner canthus or a cheek rotation flap for the outer canthus.     

Eyelid Surgery in Ocular Myopathies

Introduction: Lid defects created by removal of tumors are conventionally repaired by lid reconstruction. An alternative to surgical repair is wound healing by secondary intention. This technique, laissez-faire, as used in the periorbital region, was first described in 1957. Purpose: This report considers how effective this technique is for defects of various sizes and different locations in the periorbital region. Methods: Defects following excision of periocular tumors in 10 Caucasian patients were allowed to heal by laissez-faire. The locations of the defects were the medial canthus (n = 4), lower eyelid (n = 4), lateral canthus (n = 1), and upper lid (n = 1). The functional and cosmetic outcome of the healing process was noted. Results: A good functional and cosmetic outcome were obtained after healing by laissez-faire in 8 of the 10 patients. Of the 2 remaining patients one patient had a large medial canthal and lower lid defect which extended onto the cheek, which healed with residual scarring and medial ectropion. The second patient had a lower lid defect, which healed with a cicatricial ectropion. Of the 2 patients, only one required further surgery. Conclusions: This report shows the technique of healing by laissez-faire can be extended for relatively large defects with good results. The medial canthal region and full-thickness lower lid defects remain the favored locations for healing by secondary intention. In large defects particularly with extension onto the cheek, there is a significant risk of cicatrization, and the possibility of a second corrective operation should be discussed with the patient prior to tumor excision.     

Reconstructive options for the medial canthus and eyelids following tumor excision

General principles provide the framework for eyelid and periorbital reconstruction following tumor excision. Eyelid tumors involving the medial canthus region and/or lacrimal system add to the complexity of reconstructive planning. The nature of the tumor, patient and tissue factors, and surgeon preference guide repair design choices. Reconstructive considerations and options following medial canthal tumor resection are described.     

Glabellar transposition flap for medial canthal reconstruction after tumour excision

BACKGROUND: We focussed on the suitability of a glabellar transposition flap for repairing medial canthal defects after tumour excision and also on a satisfactory cosmetic result. PATIENTS AND METHOD: Between July 1994 and November 1999 we supplied 11 patients with a glabellar transposition flap to repair a soft tissue defect in the medial canthal area. 4 patients with a histologically proven basalioma. 5 patients had a recurrence of basalioma, who had first been operated on elsewhere. One patient was suffering from a squamous cell carcinoma and one patient showed a scar epicanthus. In the following we describe the glabellar transposition flap. This method is available for the reconstruction of the medial canthus. We also mention other methods and combinations. RESULTS: No patient required a further operation. Good postoperative cosmetic and functional results were seen in all patients. CONCLUSIONS: The glabellar transposition flap is suitable for reconstructing the medial canthus. Our results suggested that this flap can be applied for the repair of defects measuring up to 30 x 25 mm. This method is also appropriate for deeper defects in this area. The flap is suitable if a patient has a recurrence of tumour.     

The horizontal dynamic of the medial and lateral canthus

PURPOSE: To identify and quantify the horizontal dynamic movement of the medial and lateral canthus in subjects without previous eyelid surgery. METHODS: Prospective, experimental study. RESULTS: Seventy-two eyes in 36 normal subjects were studied. Frontal view lateral canthal movement with abduction of the globe averaged -0.4 mm (negative numbers mean the canthus moves in the opposite direction of the globe), with a range of -3.8 to 2.1. Profile view lateral canthal movement with abduction of the globe averaged 1.6 mm, with a range of -2.2 to 4.7 mm. Frontal view lateral canthal movement with adduction of the globe averaged -0.3 mm, with a range of -3.7 to 3.9 mm. Profile view lateral canthal movement with adduction of the globe averaged 0.5 mm, with a range of -2.4 to 3.9 mm. Frontal view medial canthal movement with abduction of the globe averaged -0.4 mm, with a range of -3.9 to 1.5 mm. Frontal view medial canthal movement with adduction of the globe averaged 0.1 mm, with a range of -5.2 to 4.6 mm. Intrasubject variation was observed for all measurements. CONCLUSIONS: The medial canthus and the lateral canthus are dynamic structures that move with horizontal eye movements in patients who have not undergone canthoplasty. The measured movement of the lateral canthus differed, based on the position from which the measurements were made, and was not always in the direction of the globe. The movement of the lateral canthus and the medial canthus differed on the right and left sides of the same subject.     

Atypical oculoplastic surgery in children (author's transl)]

The problems of restorative surgery for inborn eyelid-alterations are indicated here with examples. The following experiences result. 1. Inborn eyelid colobomas without disfigurement of the inner canthus are in general readily correctable. 2. Inborn eyelid colobomas with a disfigured inner canthus and atresia of the canaliculi hardly ever permit the production of a cosmetically satisfactory inner canthus, and never permit a functionally satisfactory one. The use of lacoductorhinostomy, according to L. Jones, is problematic here. 3. The correction of inborn eyelid colobomas in the case of Goldenhar's syndrome is difficult because, due to additional dermoids and fibromas, irregular excisions become necessary. Thus, the lid margin becomes significantly deformed. A considerable temporal displacement of the skin cannot be avoided. 4. Any plastic correction of an inborn, genuine eyelid tumor is difficult, if the important structures of the eyelid--especially the tarsus and levator muscles--are only fragmentarily developed. In the case of the large, soft fibroma of the upper eyelid in neurofibromatosis, only a static eyelid in middle position can be accomplished. 5. Very often, motility problems arise in this connection. Both in Goldenhar's disease and in Recklinghausen's disease, primary dysplasis of the rectus externus muscle occurs.     

下睑内翻和上睑肥厚性单睑及内眦赘皮一期手术观察

目的 探讨下睑内翻和上睑肥厚性单睑及内眦赘皮一期进行的手术方法和美容效果.方法 先进行睑裂横径和内眦间距的测量,根据测量值设计新内眦点,采用睫毛周边切口矫治内眦赘皮.平行上下睑缘剪开内眦赘皮达新内眦点,分离上下皮瓣与眼轮匝肌,将原内眦点的皮肤与新内眦点皮肤缝合.下睑睫毛下1.5 mm横贯切口与内眦皮瓣相连,分离皮肤达眶下缘,白睑缘下2 mm分出宽4 mm肌肉瓣,在近外眦处将其缩短3～4 mm,7-0尼龙线间断缝合皮肤.上睑沿重睑设计线切开,下唇分离至睫毛根部,剪除其下多余组织,上唇去除一窄条皮肤直达内眦皮瓣并将其多余处剪除,打开眶隔剪除脱出脂肪组织,中间挂提上睑肌腱膜后间断缝合皮肤.结果 本组16例32只眼,上、下睑内翻均得到矫正,重睑自然,睑裂明显变长开大,内眦赘皮消失.结论 采用此种联合手术方法做出的眼睛,不但治疗了疾病,而且达到了美容的目的,值的推广应用.     

Canthus-sparing ectropion repair

PURPOSE: To describe a novel surgical technique for lower eyelid ectropion repair that avoids canthotomy and cantholysis and can be used in combination with external levator repair and/or in combination with blepharoplasty. METHODS: A retrospective analysis of lower eyelid procedures with the use of the canthus-sparing technique between January 1, 1998, and December 31, 1999, was performed. The canthus-sparing approach was used in 198 eyelid procedures for the correction of lower eyelid ectropion. Seventy-four (37.4%) procedures involved the correction of lower eyelid ectropion alone and 25 (12.6%) procedures involved the correction of lower eyelid ectropion during upper eyelid small-incision external levator repair. In these cases, an incision was made lateral to the lateral canthus and a periosteal flap was created at the lateral orbital rim. The inferior crus of the lateral canthal tendon was then attached to this full-thickness elevated periosteum. Twenty (10.1%) procedures involved the correction of ectropion during upper blepharoplasty and 79 (39.9%) procedures involved the correction of ectropion during combined upper eyelid ptosis repair and blepharoplasty. In these cases, the inferior crus of the lateral canthal tendon was attached to a periosteal flap created through the lateral portion of the blepharoplasty incision. RESULTS: The mean age of patients undergoing ectropion repair was 74.3+/-9.3 years (range, 42-93 years). The average duration of symptoms (most commonly tearing and/or ocular irritation) was 20+/-14 months (range, 3-84 months). Recurrences of lower eyelid ectropion or symptoms occurred in 4 (2%) eyelids. The average follow-up interval was 54+/-65 days (range, 3-330 days). CONCLUSIONS: The canthus-sparing approach to ectropion repair promotes a secure adhesion to the lateral orbital wall with minimal violation of normal anatomic structures and relations. It is time-efficient and reduces postoperative morbidity.     

Miniplate reconstruction of the lateral orbital rim after orbital decompression for Graves disease.

BACKGROUND: Removal of lateral orbital bone with or without simultaneous removal of the lateral orbital rim is an accepted method of orbital decompression for Graves disease. Once removed, the bone is no longer available for reconstruction and secondary complications such as rounding of the canthal angle, canthal dystopia, and globe dystopia may result. METHODS: The authors replaced the excised bone with a titanium miniplate to protect the globe and fixate the lateral canthal tendon in 18 patients (33 orbits). The orbital rim and lateral orbital wall were completely removed, and the inner aspect of the orbit was enlarged with a cutting burr. A standard titanium miniplate was then anchored to remaining bone, and soft tissue was secured to the miniplate to reconstruct the lateral canthus. RESULTS: The results, as manifest by appearance of the lateral canthus and position of the eyelid in apposition to the globe, were graded as excellent in all patients and orbits. There were no early or late complications. CONCLUSION: Miniplate reconstruction of the lateral orbital rim after decompression for Graves disease allows the beneficial affect of lateral decompression and preserves the functional aspect of the lateral orbital wall.     

老年性上睑皮肤松弛症成形术术式的研究

目的 探讨预防上睑整形术后睑闭合不全,同时纠正下睑退缩及老年性睑外翻的手术方法。方法 传统上睑重睑切口线,平视状态下确定皮肤去除量,缩短上睑提肌腱膜,内外眦韧带悬吊,恢复睑裂横径。结果 术后上睑下垂及眼睑皮肤松弛同时得到纠正。提紧下睑及上提外眦水平,舒平外眦皱纹,术后恢复快,形态自然。结论 此术式更加符合老年人生理特点和心理状态,既改善了眼睑功能又达到美容效果。     

Use of Temporalis Fascia in Eyelid Reconstruction

Full-thickness eyelid defects, as a result of trauma, continue to present a dilemma to the reconstructive surgeon. The authors present a technique of utilizing a temporalis fascia graft to hammock and support a nasal septal cartilage graft as part of reconstruction of the lower eyelid and the lateral canthus after traumatic avulsion. The static suspension afforded by the fascia helps produce proper apposition of the lower eyelid to the globe and provides lateral canthal support. This tissue implant is well tolerated in the eyelid and is readily available in the ophthalmic surgical field.     

Malignant hidradenoma of the medial canthus with orbital and intracranial extension

A 70-year-old woman presented with signs and symptoms consistent with nasolacrimal duct obstruction. MRI revealed a medial canthal mass with orbital and intracranial extension. The patient was treated with wide surgical excision, chemotherapy, and radiation. A diagnosis of malignant hidradenoma of the medial canthus was confirmed by histopathology. Despite aggressive therapy, the patient developed metastatic disease and died within 1 year.