Appraisal of a modified medial canthal plication for treating laxity of the medial lower eyelid.

PURPOSE: The purpose of this study was to evaluate the efficacy of modified medial canthal tendon plication technique for correcting laxity of the medial end of the lower eyelid. MATERIAL AND METHODS: Eleven patients (9 males and 2 females, 21 eyes), with an age range of 31-80 years, having laxity of the medial end of the lower lid of varying degrees were enrolled in this study. These patients presented with complaints of watering, recurrent redness, photophobia and foreign body sensation. After grading the amount of lower lid laxity, plication was performed. In patients in whom laxity was associated with ectropion, the severity of lower lid ectropion was also graded. In patients with ectropion of Grade II or more, additional procedures for its correction were performed before undertaking plication. The patients were followed up 6 months post-operatively and re-assessed for laxity, recurrence of symptoms and complications of plication. RESULTS: All the lids were evaluated for the amount and extent of laxity of lower lid. Twelve (57%) eyes had Grade I, 9 (43%) had Grade II (and none Grade III) laxity of the lower lid. Twelve eyes had laxity restricted to the medial end and 9 eyes had laxity of the entire length of the lower lid. Some eyes also had an associated ectropion. Among the 21 eyes, 4 eyes (22%) had Grade 1, 11 (61%) had Grade 2, 6 (17%) Grade 3 and none Grade 4 ectropion. In the lids with associated ectropion, additional procedures had been performed. In 1 eye, the medial canthus was anchored to the tendon and this patient had poor apposition of the lower lid to the globe. Hence, in the remaining 20 eyes, the medial canthus was anchored to the orbital periosteum. The mean change in eyelid length was 2.6 mm (measured from medial to lateral canthus) from pre-operative status (33+/-3.4 mm) to the post-operative status (30+/-2.9 mm) this being statistically significant. An overriding of the lower lid was seen in 2 eyes (10%), and a residual gap between the lower lid and globe was noticed in 15 (71%) eyes. Some eyes had uncorrected symptoms including epiphora (3 eyes; 14%), redness (2 eyes; 10%), and photophobia (1 eye; 5%). All were those in which the lateral end was lax. None had a recurrence of foreign body sensation. CONCLUSION: Plication is easy, effective and quick for correcting laxity of the lower lid when restricted predominantly to the medial end. Correct identification of anatomical landmarks and appropriate tension of sutures is vital to achieve proper apposition of the lower lid to the globe.     

Cicatricial iatrogenic lower eyelid malposition in skin cancer surgery: results of a combined approach

PurposeMalposition of the lower lid, including rounding of the lateral canthal angle, lower eyelid retraction with inferior scleral show, and ectropion, is a relatively frequent complication in the surgical treatment of skin cancer of the cheek and zygomatic areas. The tarsal strip technique, in association with a vertical vector cheek lift, is a reliable method for correcting lower lid malposition.Materials and patientsFrom January 2008 to January 2010, we treated 19 patients with lower eyelid malposition after skin cancer surgery of the cheek and zygomatic areas. To correct lower eyelid malposition, we used the tarsal strip technique and a vertical vector cheek lift in all patients.ResultsEleven patients had scleral show and eight patients had ectropion. Sixteen patients obtained satisfactory correction of the eyelid malposition in a single surgical procedure, while three patients required a second surgical step to correct the remaining scleral show. Good esthetic and functional results were achieved in all cases.ConclusionsThe surgical treatment of skin cancer of the cheek and zygomatic areas has the potential for postoperative sequelae. The tarsal strip technique, in association with a vertical vector cheek lift, is a relatively simple technique for correcting scleral show and ectropion.     

Comparison of the two techniques for involutional lower eyelid entropion: A retrospective study

Evaluation of the surgical outcome and the patient satisfaction between the modified Wies technique and the Jones retractor plication technique for involutional lower eyelid entropion without horizontal eyelid laxity.Patients who underwent the modified Wies technique (group 1) and the Jones retractor plication technique (group 2) for correction of involutional lower eyelid entropion without horizontal eyelid laxity between January 2014 and January 2020 were retrospectively reviewed. Patients with horizontal eyelid laxity; cicatricial, congenital or iatrogenic entropion; and less than 6 months of follow-up time were excluded. The main outcome measures were the recurrence rate, correct anatomical position of the eyelid, symptom relief, and postoperative complications for both groups.37 patients (41 eyes) in Group 1 and 34 patients (34 eyes) in Group 2 were enrolled in the study. Mean age ± SD was 75.6 ± 8.5 years in Group 1 and 73.4 ± 7.9 years in Group 2 (p:0.255). The mean follow-up time (range) was 24.3 (6–80) months in group 1 and 25.3 (6–78) months in group 2 (p:0.818). Two patients in Group 1 and seven patients in Group 2 had a recurrence during the follow-up period (p:0.07).Based on the results of the study, it seems that the modified Wies technique may be a good alternative in suitable patients, as it has satisfactory surgical results.     

Redraping of the fat and eye lift for the correction of the tear trough

IntroductionTear trough deformity is very difficult to correct. It can appear at relatively young age and it deepens over the years due to laxity and loss of structural support.We describe a technique for the correction of tear trough deformity and mid-face laxity by means of redraping blepharoplasty and lateral “eye lift”.Materials and methodsUpper lid markings were made and removal of the excess skin was employed. The herniated fat was removed from the nasal fat pad.Using a subciliary incision the dissection was completed at the level of the orbital rim and the fat was repositioned with 5-0 Monocryl (poliglecaprone 25, Ethicon) sutures at the inner canthus to correct the tear trough. Subsequently, a canthopexy performed to secure the lower eyelid. We then dissected the cheek over the periosteum of the zygomatic bone-arch and the flap was suspended through a tunnel at the periosteum of the upper-lateral orbit by 5-0 Monocryl (poliglecaprone 25, Ethicon) suture.ResultsThirty-five procedures were performed between 2009 and 2013. Patients were followed for at least one year. Successful correction of the tear trough deformity with middle face elevation was achieved in all patients. Sclera show was noted in 7 patients but resolved over 3–6 months period with no surgical intervention. Diplopia was noted in 1 patient probably due to oedema and was released 4 weeks after the operation. The oedema was prolonged (more than 1.5 month) in 10 patients probably due to the lymphatic stasis. Conjunctivitis was also noted in 2 patients and was released by conservative treatment.ConclusionOur technique of redraping blepharoplasty and mid-face lift describes a relatively new approach for the correction of the tear trough deformity and middle face laxity. It shows stable results for up to 4 years although longer follow-up is needed to confirm the stability of the correction.     

Open loop fascial sling for severe congenital blepharoptosis

PurposeSevere congenital eyelid ptosis present as a functional and aesthetic problem. The choices of procedures depend mainly on providing an additional elevator force to the upper lid to elevate it, and maintain a reasonable eye opening and vision. We describe a simple open loop fascia lata suspension sling to the frontalis muscle to treat patients with sever eyelid ptosis and poor levator function.MethodsSixty nine lids in 51 patients, were enrolled in this study, all had sever eyelid ptosis and had autogenous fascial sling used for the correction of the ptosis.ResultsThe final lid level and contour was evaluated after the follow-up period and showed that the results were satisfactory in 77% of the patients. The unsatisfactory results were due to under correction in 10%, poor lid crease in 6%, lid notch in 4%, and entropion in 3% of the operated lids.ConclusionsThe accurate evaluation and implementation of this technique can correct the problem of ptosis provided that the patients exercises the frontalis muscle in order to accomplish the desired lid level.     

Tarsal strip technique for correction of malposition of the lower eyelid after treatment of orbital trauma

Purpose

The transconjunctival, subciliary, subtarsal, and subpalpebral approaches for accessing the infraorbital rim and orbital floor have both advantages and disadvantages. The most common complications include rounding of the lateral canthal angle, lower eyelid retraction with inferior scleral show, and frank ectropion.

Materials and patients

From 2000 to 2007, we treated 29 patients with lower eyelid malposition after surgery to manage the floor and infraorbital trauma (22 subciliary approaches, five transconjunctival approaches and lateral canthotomies, and two transconjunctival approaches). To correct lower eyelid malposition, we applied the tarsal strip technique in all patients.

Results

Twenty-five patients had scleral show and four patients had ectropion: three were previous treated using transconjunctival access and one using subciliary access. Twenty-six patients obtained satisfactory correction of eyelid malposition in a single-step surgical procedure, while three patients required a second surgical step to correct the remaining scleral show. Good aesthetic and functional results were achieved in all cases.

Conclusions

All approaches to the infraorbital rim or orbital floor have the potential for postoperative sequelae. The tarsal strip technique is a relatively simple technique that oral and maxillofacial surgeons can use to manage lower lid malposition, such as scleral show and ectropion.     

Lower eyelid ectropion as a sequela of different underlying diseases in maxillo-facial surgery: Diagnostics and treatment approaches

PurposeThis study investigated the outcome of lower eyelid ectropion (LEE) treatment in patients with another primary periorbital or mid-facial pathology.Materials and methodsThis 18-year monocentric retrospective cohort study included patients admitted for various leading mid-facial pathologies and presenting with a LEE. The primary diagnosis, surgical pretreatment, ectropion type, ectropion severity score (ESS), and surgical techniques were recorded. The primary endpoint was the postoperative ESS score.ResultsOverall, 40 patients (female n = 16, male n = 24, average age 70.8 years), primarily with periorbital skin cancer (n = 21, 52.5%), facial palsy (n = 7, 17%), trauma (n = 6, 15%), or other pathologies (n = 6, 15%), were included. Surgical procedures mostly addressed a correction of anterior and posterior lamellae (n = 22, 55%), with isolated anterior lamellae in only a few cases (n = 10, 25%). The ESS score significantly decreased from 4.8 ± 1.8 to 1.3 ± 1.3 (paired t-test, p < 0.001) after a mean follow-up of 23.8 months.ConclusionLEE constitutes a relevant problem. Due to preexisting canthal ligament laxity in patients undergoing oncologic or traumatic midface surgery, the risk of ectropion has so far been underestimated. Bilamellar approaches in elderly patients are likely to be obligatory in any case.     

Cheek rotation flap reconstruction—an anthropometric appraisal of surgical outcomes

Objectives

Cheek rotation flaps are an established surgical procedure for coverage of facial skin defects especially of the cheek and infraorbital region. A comparison of pre- and postoperative anthropometric measurements may help to objectify intraoperative estimations with regards to postoperative appearance.

Materials and methods

We present an evaluation of 31 patients undergoing periorbital reconstruction by a cheek rotation flap on standardized photographs based on reference anthropometric data. Analysis included intercanthal, binocular and eye fissure width, eye fissure, lid sulcus and upper lid height, upper and lower iris coverage, position of cornea to palpebra inferior, scleral show, ectropion, and canthal tilt. Furthermore, it was clearly differentiated whether the defect to cover included eyelid skin or not.

Results

Ectropion showed a significant association to surgery (p?=?0.03) and time (p?=?0.03). If the defect to cover included lower eyelid skin, lower iris coverage values decreased significantly (p?=?0.02), meanwhile the rate of scleral show increased significantly (p?<?0.01), indicating pre- to postoperative lower eyelid retraction.

Conclusions

In all patients analyzed, indices were reproducible and reliable. An association between surgery and ectropion was detectable. Whenever lower eyelid skin is involved in the defect to be covered, the significantly decreased lower iris coverage and increased rate of scleral show indicate an increased risk of lower lid retraction.

Clinical relevance

Whenever eyelid skin is involved in a defect to be covered by a cheek rotation flap, there is an increased risk of postoperative lower lid distortion. Special care has to be taken to perform techniques preventing lower lid retraction.     

Transconjunctival versus subciliary approach for orbital fracture repair—an anthropometric evaluation of 221 cases

Objectives

In the literature, there is an ongoing discussion about the influence of orbital fractures and the surgical approach on the rate of eyelid deformities of the lower eyelid.

Materials and methods

We present an evaluation of a series of 221 patients 9 months after zygomaticomaxillary complex fracture repair that underwent implant removal. Reference anthropometric data were measured on standardized pre- and postoperative photographs. Analysis included eye fissure width and height, lid sulcus and upper lid height, upper and lower iris coverage, position of cornea to palpebra inferior, canthal tilt, scleral show, ectropion, and entropion. Both operated and contralateral eyelids were evaluated as well as whether a transconjunctival or a subciliary approach was performed.

Results

Time, surgery, and surgical approach presented significant effects on eye fissure index and lower iris coverage. Scleral show was significantly influenced by the surgical procedure itself as well as by the type of incision. The rate of ectropion increased significantly pre- to postoperative.

Conclusions

The subciliary approach included the highest risk of lower lid retraction. The low pre- to postoperative increase of scleral show and ectropion compared to recent studies gives us an idea about the influence of the underlying trauma on the rate of lower lid retraction. The standardized measurements described are accurately and objective to evaluate postoperative results.

Clinical relevance

The transconjunctival approach is preferable in orbital fracture repair.     

Efficacy of pre-expanded forehead flap based on the superficial temporal artery in correction of cicatricial ectropion of the lower eyelid

Lower eyelid retraction or ectropion bring suffering to the patients both physically and mentally. Efforts to explore pertinent surgical treatments are still needed. Here we have described our preferred surgical technique for lower eyelid ectropion repair with pre-expanded island forehead flaps or pedicled forehead flaps. Between July 2007 and March 2017, a retrospective review of 12 patients who suffered from cicatricial lower eyelid ectropion as a result of trauma, surgery, or infection was conducted. Forehead skin flap based on the superficial temporal artery was expanded depending on the area of defect of the lower eyelid. Tissue expansion, flap transfer, pedicle delaying and division were involved in this process. There were no major complications, such as expander exposure, infection, haematoma or large skin flap necrosis in all the 12 patients. Venous congestion was reported in two patients. No recurrent ectropion was noted in any patient. During the three-month to two-year follow-up all patients were satisfied with the results in terms of the skin texture, colour, and flexibility after the treatment with an expanded forehead skin flap. This study suggests that expanded forehead skin flaps are effective for correction of cicatricial lower eyelid ectropion.     

Subcuticular Suture Technique: Alternative to Frost Suture to Prevent Ectropion After Transcutaneous Incision of Lower Eyelid

Introduction

An ectropion is a complication that can arise from reconstruction in the infraorbital region. Often, this complication occurs despite proper positioning of the lower lid at the time of closure. Various transcutaneous approaches to orbit skeleton have investigated in view of complication arising from them. A subtarsal approach with a postoperative Frost suture gives an advantage to reduce the occurrence of ectropion especially after treatment of orbital floor fractures.

Material and methods

This case describes a method of subcuticular suturing technique for subtarsal incision of lower lid which can be used to support the lid during healing period, thus decreasing the rate of ectropion.

Conclusion

The technique described here is an alterative method for frost suturing with certain advantages.

     

The isolated orbital floor fracture from a transconjunctival or subciliary perspective-A standardized anthropometric evaluation

Background

The influence of orbital fractures and their repair on the rate of deformities of the lower eyelid is an ongoing source of discussion in the literature. Most of the present studies include isolated blowout as well as combined orbital fractures.

Material and Methods

We present a retrospective evaluation of a series of 100 patients after isolated blowout fracture repair using reference anthropometric data on standardized photographs. Analysis included eye fissure width and height, lid sulcus height, upper lid height, upper and lower iris coverage, position of cornea to palpebra inferior, canthal tilt, scleral show, ectropion and entropion. It was clearly distinguished between operated and contralateral eyelid, whether a transconjunctival or a subciliary approach was performed and amount of fracture. Our main interests were changes of the aforementioned parameters with regards to eyelid deformities.

Results

Surgery per se did not significantly influence eyelid deformities. However, the surgical approach selected significantly affected eye fissure index, lower iris coverage and rate of scleral show, indicating retraction of the lower eyelid.

Conclusions

The standardized measurements described here are accurate and objective to evaluate postoperative results. The subciliary approach included the highest risk of lower lid retraction as compared to transconjunctival approaches. Key words:Transconjunctical approach, subciliary approach, orbital floor fracture.     

Objective anthropometric analysis of eyelid reconstruction procedures

Before undergoing facial tumour resection and reconstruction, especially of the eyelids, patients are worried about their postoperative appearance. “Eye-balling” of postoperative results may not be sufficient to adequately judge surgical results. Reference anthropometric measurements for the eyelids are available.We present an evaluation of a series of tumour resection and reconstructive procedures of the eyelids on standardized photographs based on reference anthropometric data. 51 patients underwent eyelid reconstruction with different established techniques after resection of local eyelid tumours. Analysis included intercanthal width, biocular width, eye fissure width, eye fissure height, lid sulcus height, upper lid height, upper iris coverage, lower iris coverage, position of cornea to palpebra inferior, scleral show, ectropion, and canthal tilt. We clearly differentiated between resections including eyelid margin or not.Time (p = 0.04) and surgery (p = 0.03) showed a significant association with decreased values of lower eyelid coverage. Resection of the eyelid margin showed no significant influence on the values investigated.In all the patients analysed the indices were reproducible and reliable. Not surprisingly an association between surgery and lower eyelid retraction was found. Resection of the eyelid margin does not seem to cause a greater risk of eyelid deformity. The standard measurements described are accurate and objective to evaluate postoperative results.     

Long-term surgical outcomes of Quickert sutures for involutional lower eyelid entropion

ObjectivesTo determine the long-term surgical outcomes associated with the use of Quickert sutures (Q-sutures) for involutional entropion and elucidate the risk factors for postoperative recurrences.MethodsThis is a retrospective, interventional case series. We recruited patients suffering from involutional entropion who were treated with Q-sutures during the period from January 2008 to August 2010. Preoperative clinical characteristics and surgical outcomes including recurrence at 1, 6, 12, and 24 months were investigated by reviewing the medical charts.ResultsOf 85 patients, 69 attended each follow-up visit and were included in the analysis. Thirty-four patients (49.3%) experienced recurrences within 2 years. The recurrence rate was 5 of 69 (7.2%) at 1 month, 15 of 64 (21.6%) at 6 months, 9 of 49 (13%) at 12 months, and 5 of 40 (7.2%) at 2 years. Multiple logistic regression analysis showed that men and patients with lower-lid laxity (OR = 2.852 [95% CI: 1.005–8.092] and OR = 3.780 [95% CI: 1.231–11.614], respectively) were susceptible to postoperative recurrences.ConclusionsThe recurrence rate among patients treated with Q-sutures was highest at the 6-month follow-up visit. Alternative surgical options should be considered in males and those with lower-lid laxity in order to prevent recurrences.     

A modified tarsorrhaphy in patients with facial nerve palsy

PurposeWe report our experience with a modified tarsorrhaphy (MT) technique in patients with facial nerve palsy (FNP).MethodsThis study involved a retrospective chart review of patients with FNP undergoing MT over a 10-year period in one Medical Center. Patient demographics, presence of lagophthalmos, occurrence of eyelid malpositions, recurrent retraction, and repeat procedures were noted from medical records.ResultsTwenty patients (11 females, mean age 38 years) were included. Mean follow-up was 41 months (range 6–132). All patients had lagophthalmos prior to surgery compared with four on last follow-up. The number of patients with punctate epithelial erosions (PEEs) reduced from nine preoperatively to five postoperatively. While seven patients used lubricating drops prior to surgery, two stopped lubrication completely and five reduced the amount after surgery. No patients developed a new-onset lower eyelid malposition. No recurrence or postoperative complications were noted.ConclusionThis MT technique avoids grey line split and excision of orbicularis muscle or skin. It improves lower eyelid retraction and reduces lagophthalmos in FNP.     

The zygomaticomaxillary complex fracture – An anthropometric appraisal of surgical outcomes

Before undergoing repair of zygomaticomaxillary complex fractures, most patients are worried about their postoperative appearance. Furthermore, there is an ongoing discussion about the selection of the surgical approach to the inferior orbita and resulting eyelid deformities.We present a photo-assisted postoperative evaluation of zygomaticomaxillary complex fracture repair based on reference anthropometric data.Two hundred and twenty-one patients underwent zygomaticomaxillary complex fracture repair. An analysis of standardized postoperative photographs included measurements of eye fissure width and height, lid sulcus height, upper lid height, upper and lower coverage, position of cornea to palpebra inferior, canthal tilt, scleral show, ectropion and entropion. It was clearly distinguished between operated and contralateral eyelid, and whether a transconjunctival or a subciliary approach was performed.Surgery per se significantly influenced eyelid deformities as measured by its impact on eye fissure index, lower iris coverage and rate of scleral show and ectropion. The surgical approach selected significantly affected eye fissure index, lower iris coverage and rate of scleral show, indicating distortion of the lower eyelid.Investigations regarding orbital fractures should clearly differentiate the type of fracture. The subciliary approach included the highest risk of postoperative lower eyelid deformity in zygomaticomaxillary complex fracture repair. The standardized measurements described here are accurate and objective to evaluate postoperative results.     

Transconjunctival incision for total maxillectomy—an alternative for subciliary incision

A subciliary incision may be associated with various complications of the lower eyelid when it is used during a total maxillectomy. The use of the transconjunctival incision instead is an alternative in suitable patients. The records of 17 patients were reviewed in whom a transconjunctival incision was used during total maxillectomy. These included 13 in whom the Weber-Ferguson incision was used, and 4 who had a sublabial incision. There was mild conjunctival oedema in all the cases during the immediate postoperative period but it did not last for more than two days. Four patients had mild to moderate oedema of the lid that resolved within two days. One had mild ectropion with transient epiphora, which was caused by early removal of the medial canthal sutures. We found the approach to be cosmetically acceptable as it avoids a scar in the subciliary region. The transconjunctival incision can be used in place of the subciliary incision for lateral exposure during total maxillectomy. There are few complications associated with the lower lid, and it has good cosmetic results; if it is combined with a sublabial incision in suitable patients, the maxillectomy is virtually scar-free.     

Traumatology of the facial skeleton in octogenarian patients: A retrospective analysis of 96 cases

AimThe aim of this retrospective study was to evaluate the frequency and distribution of maxillofacial trauma patients over 80 years, with regard to type and environment of accidents as well as treatment and complications.Patients and methodsData for 94 patients (96 cases; aged 80–94 years) with maxillofacial fractures were retrospectively analysed.ResultsData of 30 male and 64 female patients with an average age of 85 years were analysed. In 90% of the study population, the cause of fractures was a fall, followed by traffic accidents (9%) and assault (1%). Seventy-two patients had fractures of the midface, 10 had factures of the mandible, 9 had fractures of both the midface and mandible and 5 had fractures of the neurocranium and midface. Surgical intervention was required in 57% of the patients. Post-operative complications were: four cases of diplopia, two cases of infected plates, four cases of lower eyelid ectropion and in one case a retrobulbar haematoma.ConclusionFacial trauma in the elderly can often be treated conservatively unless the patient complains of functional problems. Due to co-morbidities, special attention should be paid to hypertension, anticoagulant agents and the surgical approach.     

小切口配合提骨钩用于颧骨复合体骨折治疗的临床总结

目的:探讨提骨钩、小切口在颧骨复合体骨折三维复位中的临床效果。方法:32例颧骨复合体骨折患者,经术前X线片或三维CT成像等影像学检查确诊后,手术取眉弓外、下睑结膜内及同侧上颌磨牙区前庭沟切口,配合提骨钩行三维复位后,分别用小型钛板进行颧额缝、眶下缘、颧上颌缝3点的坚强内固定。结果:所有患者切口均一期愈合,颧面部外形满意,张口度正常,无复视、眼睑外翻、面部麻木等并发症。结论:小切口配合提骨钩可减少手术损伤,并能达到骨折三维复位的目的,具有一定的临床推广价值。