Medial canthal reconstruction by a modified glabellar flap

AIMS: To present a modified technique for the preparation of glabellar skin flaps to reconstruct medial canthal defects. METHODS: Ten consecutively treated patients were included who had skin defects after resection of skin tumours like basal cell carcinomas in the medial canthal area of a medium vertical diameter of 2.5 cm. The defects were closed by preparation of a modified glabellar flap. The pedicle of the flap was guided through a skin tunnel prepared diagonally at the root of the nose. The pedicle was resected 4 weeks after the initial surgery. RESULTS: In all 10 cases, the procedure was adequate for reconstruction of the defect. There were no flap necroses and the cosmetic results were favourable in all cases. The resection of the pedicle could be performed easily in an out-patient procedure 4 weeks after the operation. CONCLUSION: Glabellar flaps are established procedures to reconstruct medium to large defects of the medial canthus. Skin distortion in the area of the flap pedicle leading to a skin bulge and visible scars at the root of the nose and medial transposition of the eye brows can be reduced by a modification of the surgical technique preparing a skin tunnel for the flap pedicle. In our hands, the cosmetic results are better with the modified technique in comparison to the original procedure.     

Glabellar flap technique in oculoplastic surgery

Facial skin defect reconstruction in medial-canthal area of the lids can be a challenge even when performed by a skilled surgeon. The excision of large tumors in this area leads to significant surgical defects that cannot be repaired by merely closing the wound. The glabellar area provides a source of redundant skin with similar characteristics to that of the medial-canthal lid area. The purpose show the possibility of the glabellar flap technique surgery in patients after tumor excision in the medial canthal area with the formation of a large surgical defect and especially those with defect under the medial canthal tendon. We selected 15 well-documented retrospective cases of patients operated over 2 years and followed up for a minimum of 36 months, who underwent surgery with a glabellar flap technique. Patients were operated with V-Y glabellar rotation, advancement, or combined transposition flap techniques. According to the defect’s location, we divided the patients into three groups: upper, medial, and lower surgical defects. A satisfactory functional result was obtained in all the patients. In most of them, the cosmetic results were also good. No additional surgical procedures were required in any of the patients. Our experience showed excellent results with the glabellar flap technique in all three types of lesions in the medial canthal zone—upper, medial, and especially lower which until recently was thought to be inappropriate.     

Infraglabellar transnasal bilobed flap in the reconstruction of medial canthal defects

We investigated the effectiveness of reconstruction using an infraglabellar bilobed flap of transnasal skin and subcutaneous tissue for patients with medial canthal defects. Our noncomparative interventional case series involved 11 consecutive patients with medial canthal defects following Mohs micrographic excision of basal cell carcinoma. The medial canthal area was divided into 3 zones: zone 1, just above the medial canthal tendon; zone 2, centered on the medial canthal tendon; and zone 3, just below the medial canthal tendon. Primary closure was achieved easily with a good cosmetic result for all 3 zones. There were no complications or further procedures required. The outcome measures documented clinically and photographically included complete closure of the defect, cosmetic appearance, complications, and further surgery.     

The rhomboid flap in medial canthal reconstruction

AIM: To describe a series of patients who have undergone a medial canthal reconstruction with a rhomboid flap. METHODS: A non-comparative interventional case series of 27 patients with medial canthal defects after Mohs excision of medial canthal basal cell carcinomas who underwent reconstruction using a rhomboid-shaped transpositional flap of adjoining skin and subcutaneous tissue. 25 cases were performed under local anaesthesia. The remaining two cases were combined with major lid reconstruction and performed under general anaesthesia. The outcome measures were closure of the defect, the cosmetic result, complications, and re-operations. RESULTS: Primary closure of the defect was achieved in all cases. The cosmetic result was highly satisfactory in all cases. There were no major complications or re-operations. Two cases had minor webbing of the medial upper lid. CONCLUSIONS: The rhomboid flap is an effective, quick, and simple technique for medial canthal reconstruction. It provides excellent cosmesis and is associated with minimal complications. It can be modified according to the nature of the periorbital skin and the location, size, and depth of the defect.     

Rekonstruktion von Hautdefekten in der Lid- und Periorbitalregion mittels vier Dreiecksverschiebelappen

PURPOSE: This report presents a procedure as an alternative to free skin grafts for reconstruction of rhomboid skin defects in the lid region. METHOD: Ten consecutively treated patients were included who had skin defects after resection of eyelid tumors such as basaliomas. The skin defects were rhomboid and had the same horizontal and vertical diameter (medium 1.5 cm) and were therefore too large for a horizontal advancement flap. The defects were closed by preparation of four triangular skin flaps that were sutured crosswise into the defect. RESULTS: The procedure was adequate for reconstruction of the defect in all ten cases. There were no lid malpositions and the cosmetic results were favorable in all cases. The medium operation time was significantly shorter in comparison to free skin grafts. CONCLUSIONS: Application of free skin grafts is a standard procedure for reconstruction of anterior lamellar lid defects. Triangular transposition flaps can be a timesaving alternative with good cosmetic results.     

The bilobed flap in medial canthal reconstruction

Background: Although several techniques for repair of medial canthal defects have been described, most have shortcomings which prevent satisfactory repair. We describe the use of a bilobed flap which allows for optimal reconstruction in this area.
Surgical Technique: A bilobed flap was used to repair 36 medial canthal defects in 35 patients. The primary lobe is usually slightly smaller than the defect. The secondary lobe is smaller than the primary though of equal length, fashioned so that its axis lies within the relaxed skin tension lines of the face to allow direct closure with minimal tension. All patients achieved a satisfactory cosmetic and functional repair.
Conclusions: We recommend this technique as an excellent means of repairing all types of medial canthal defect. The technique allows reconstruction to be performed in a single stage with rapid rehabilitation and minimal morbidity.     

Use of the pericranial flap in medial canthal reconstruction: another application for this versatile flap

PURPOSE: To describe the use and outcomes of a versatile surgical technique in the reconstruction of deep soft tissue and bony defects of the medial canthus. METHODS: A retrospective review of consecutive cases requiring reconstruction of medial canthal defects involving loss of periosteum or bone by a median forehead pericranial flap and full-thickness skin grafting in a tertiary referral hospital setting. Two techniques were used: an open technique, using a midline forehead incision; and an endoscopic technique, using 2 incisions behind the hairline. RESULTS: Twenty-one cases were identified: 19 open and 2 endoscopic. The average length of follow-up was 13 months (range, 6-50 months). Ten cases required additional oculoplastic procedures including local periosteal flaps and mucous membrane grafts. Two cases (10%) had complete flap failure; one of these was caused by infection. Five (24%) had partial (< 50%) skin graft necrosis. Two cases (10%) have required further surgery. CONCLUSIONS: Our experience shows the pericranial flap to be versatile, robust, and easy to manipulate, offering advantages over alternative techniques when used for the repair of deep medial canthal defects. It is a valuable reconstructive technique that can yield good cosmetic and functional results.     

Simultaneous spontaneous and primary surgical repair of eyelids.

Fifteen patients with suspected malignant lesions of the lower eyelids or inner canthal region, needing large excisions, were managed as day cases with spontaneous repair and simultaneous subtotal primary surgical reconstruction under local anaesthesia. For lesions confined to the lower eyelid, only those patients requiring full-thickness margin-inclusive (FTMI) excisions of more than half the horizontal extent of the eyelid are included in this study-the largest excision being 21 x 6 mm. For malignant lesions of the inner canthus, only those patients needing moderate to large excision of inner canthal skin and orbicularis with simultaneous FTMI excision of the medial one-third (8 x 5 mm) of the upper as well as the lower eyelid are included. The 16th patient had traumatic loss of inner canthal tissue. The final cosmetic and functional results in all 16 patients were satisfactory and comparable with the results of competent and in-toto primary surgical reconstructions. For large excisions at the inner canthus spontaneous with partial primary surgical repair allows the use of a less extensive and less elaborate surgical procedure that is within the capabilities of most ophthalmic surgeons.     

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.     

Medial canthal defects following tumour excision: To reconstruct or not to reconstruct?

Laissez-faire following excision of peri-ocular tumours has been described, but is not universally well established. We describe our experience with laissez-faire for managing medial canthal defects following tumour excision and compare our outcomes with full thickness skin grafts. Retrospective comparative case series of 68 patients who underwent reconstruction of a medial canthal defect using laissez-faire with sutured Sorbsan (LFS) (n = 36) or a full thickness skin graft (FTSG) (n = 32) at the same centre. Tumour diagnosis, defect size, time taken to epithelialise, functional and cosmetic outcomes, complications, follow-up duration and any secondary interventions were recorded. Basal call carcinoma was the most common neoplasm excised (63/68, 93%). Defect size ranged from 7 × 5 mm to 25 × 10 mm. Mean time for wound epithelialisation in LFS group was 33 days. Mean duration of follow-up was 32 months (range 1–80 months) for LFS and 30 months (range 6–60 months) for FTSG. Good functional and cosmetic outcomes were achieved in all 68 patients. Review of clinical photographs showed epicanthic fold in 2 patients and visible scar in 1 patient in the LFS group and 3 cases of hypopigmented scar and 7 hypertrophic scars in the FTSG group. No cases required secondary intervention. There were no cases of postoperative infection. LFS in the medial canthal region is less likely to lead to hypertrophic scarring or cicatricial sequelae compared to FTSG (p = 0.02). Both techniques are associated with excellent functional and aesthetic outcomes even for larger defects.     

Management of peri-ocular skin tumours by laissez-faire technique: analysis of functional and cosmetic results

AIM: The role of wound healing by secondary intention in the treatment of peri-ocular skin tumours is not well established. The object of this retrospective analysis was to evaluate the functional and cosmetic outcome of patients treated by the Laissez-faire technique in situations where primary closure would not have been possible. METHODS: Skin defects following excision of lid and peri-ocular tumours in 24 Caucasian patients were allowed to heal by granulation. The locations included lower eyelid (n = 10), upper lid (n = 6), medial canthus (n = 5), nasojugal fold (n = 2), lateral canthus (n = 1) and brow (n = 1). Four patients had lid margin involvement. The size of the initial defect, time taken to heal, discomfort during healing, the functional and cosmetic results-both from the surgeon and patient perspective, complications, secondary intervention if any and patient satisfaction were studied. RESULTS: A good functional and cosmetic result was obtained in 23 of the 25 lesions (92%). Of these 23 patients, two patients had slightly hypertrophied scars, which responded well to massage and two patients had some degree of ectropion. Of the two patients who did not have a good cosmetic result, only one needed secondary intervention. One had an exuberant granulation tissue, which responded to topical steroids and massage, but left behind a distorted lateral canthus. CONCLUSION: Healing by secondary intention of large defects following excision of peri-ocular tumours is an effective alternative to primary or staged reconstruction in selected cases.     

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 transnasal advancement flap: A technique for medial canthal area defects

AIM. To illustrate an alternative technique for reconstructing defects in the medial canthal area following tumour removal. MATERIALS AND METHODS. Eight consecutive patients who underwent Mohs(1) micrographic surgery for removal of a basal cell carcinoma in the medial canthal area were prospectively recruited. An experienced dermatologist trained in Mohs(1) micrographic surgery removed the tumour, and subsequently an oculoplastic surgeon reconstructed the defect. An incision is made from the superior end of the defect superomedially towards the midline of the dorsum of the nose following one of the natural lines of the skin (spec name). The incision runs in arcuate fashion just medial to the eyebrow and then reaches the dorsum of the nose and extends on the contralateral aspect of the nose towards the medial canthal area. The skin is then undermined to free up the newly formed flap. The flap is advanced towards the lesion and fixed intra-dermally with Vicryl Rapide(R) sutures to ensure anchoring into the concavity of the medial canthal region. The skin is then sutured with prolene sutures. RESULTS. The defects presented were oval or round in shape with diameters ranging from 0.5 to 2 cm. In all cases the transnasal flap covered the entire area and the defect was successfully reconstructed. Mean follow-up is 10.8 months (+/-4.5 SD) (range 4-17 months); all patients had an excellent cosmetic result and were subjectively satisfied. CONCLUSIONS. The transnasal advancement flap seems to have some advantages over the usual reconstruction techniques in use to repair medium defects in the medial canthal area. These are the avoidance of vertical scars in the glabellar area, eyebrow hair is not transposed into the medial canthal area, the skin match is excellent, both in colour and thickness, and surgical scars are hidden within the natural lines of the nasal bridge. We advocate the use of this technique for all minor to medium skin defects.     

The transnasal advancement flap: A technique for medial canthal area defects

AIM . To illustrate an alternative technique for reconstructing defects in the medial canthal area following tumour removal. MATERIALS AND METHODS . Eight consecutive patients who underwent Mohs¹ micrographic surgery for removal of a basal cell carcinoma in the medial canthal area were prospectively recruited. An experienced dermatologist trained in Mohs¹ micrographic surgery removed the tumour, and subsequently an oculoplastic surgeon reconstructed the defect. An incision is made from the superior end of the defect superomedially towards the midline of the dorsum of the nose following one of the natural lines of the skin (spec name). The incision runs in arcuate fashion just medial to the eyebrow and then reaches the dorsum of the nose and extends on the contralateral aspect of the nose towards the medial canthal area. The skin is then undermined to free up the newly formed flap. The flap is advanced towards the lesion and fixed intra-dermally with Vicryl Rapide® sutures to ensure anchoring into the concavity of the medial canthal region. The skin is then sutured with prolene sutures. RESULTS . The defects presented were oval or round in shape with diameters ranging from 0.5 to 2 cm. In all cases the transnasal flap covered the entire area and the defect was successfully reconstructed. Mean follow-up is 10.8 months (±4.5 SD) (range 4–17 months); all patients had an excellent cosmetic result and were subjectively satisfied. CONCLUSIONS . The transnasal advancement flap seems to have some advantages over the usual reconstruction techniques in use to repair medium defects in the medial canthal area. These are the avoidance of vertical scars in the glabellar area, eyebrow hair is not transposed into the medial canthal area, the skin match is excellent, both in colour and thickness, and surgical scars are hidden within the natural lines of the nasal bridge. We advocate the use of this technique for all minor to medium skin defects.     

Superiorly hinged blepharoplasty flap for reconstruction of medial upper eyelid defects following excision of xanthelasma palpebrum

This paper documents an interventional case series which describes a novel technique for reconstructing large medial upper eyelid skin defects following excision of xanthelasma palpebrum. All visible upper eyelid xanthelasma is excised and a superiorly hinged blepharoplasty skin flap is created with a classic skin crease and lateral blepharoplasty incision, the latter acting as an effective 'back-cut' to allow medial advancement of the flap into the defect. Excess triangles of skin are excised and the flap is sutured without tension into the defect in a conventional manner. The patients selected were patients with medial upper eyelid skin defects not amenable to direct closure following surgical excision of xanthelasma. The main outcome measures were the upper eyelid aesthetic and functional outcome, postoperative complications and need for revisionary surgery. In our study seven patients with bilateral medial upper eyelid xanthelasma excised and reconstructed with this technique were identified. Good aesthetic outcome and high patient satisfaction without functional compromise was achieved in all patients at the last follow-up visit. Patient age ranged from 30–52 years old. Follow up ranged from 8 to 18 months. In conclusion, the superiorly hinged blepharoplasty skin flap is a novel and simple technique for the reconstruction of skin defects that are not amenable to direct closure following xanthelasma excision. It avoids the complications of skin grafting and non-surgical ablative methods, particularly in dark-skinned patients.     

Reconstruction of the upper eyelid with flaps and free grafts after excision of Basal cell carcinoma

Purpose: To describe a reconstructive technique of the superior eyelid with flaps and free grafts after excision of a basal cell carcinoma. Methods: Single case report of a 79-year-old woman who presented to our hospital with a basal cell carcinoma of the upper eyelid margin with initial erosion. Results: A large and full-thickness excision of the carcinoma was performed. The reconstruction technique should be customized to the individual patient. In this case, the use of a full-thickness tarsal graft from the contralateral upper eyelid, followed by an ipsilateral bipedicled flap and finally by a skin graft, was an effective surgical procedure, performed in one stage, without complications, and with good functional and esthetic results. Conclusions: Malignant neoplasms represent the leading cause of plastic reconstruction in the orbital region. Surgical techniques must be individualized for each patient and for each type of carcinoma. Reconstructive techniques with free grafts and flaps yield excellent results in the orbital region, particularly when some advice and a few fundamental rules are followed, namely accurate hemostasis of the receiving graft bed by moderate use of diathermy, careful suturing of the edges, and application of a compressive dressing for at least 4 days. Postoperative complications are very rare.     

Partial and Total Reconstruction of the Lower Eyelid

Our techniques for reconstruction of the lower lid are based on the maintenance of tarsal support in the reconstructed lid. The surgical approach is dictated by the position and extent of the defect produced by tumor excision. Lysis of the extension of the lateral canthal ligament to the lower lid allows closure of small, full-thickness defects. Mobilization of tarsal remnants by temporal advancement flaps provides for closure of larger defects. An advancement flap of split-thickness upper lid tarsus is combined with a pedicle flap of skin from the upper lid for total lower lid reconstruction.     

Complicated eyelid reconstruction after an unusual glabellar flap repair

Remote flaps may be used for lid reconstruction when tissue loss is extensive and there is insufficient tissue in the adjoining areas. Median forehead flaps are usually used for upper lid, medial canthal or nasal repairs. We describe a complicated reconstruction of the lid and correction of a deformity which resulted from the injudicious use of a glabellar flap for lower lid repair. Improper use of a median forehead flap may interfere with the functioning of the lid, leading to corneal exposure and poor cosmesis. Lower lid defects are better repaired by advancement flaps or techniques like Tenzel's semicircular flap, reverse Cutler Beard, Hughes procedure or Mustarde's repair.     

鼻眶筛骨骨折后内眦畸形的晚期整复及其疗效

目的探讨鼻眶筛骨骨折后内眦畸形的手术方法及其疗效。方法回顾性分析1999年1月至2004年1月上海交通大学医学院附属第九人民医院眼科诊治的83例（83只眼）单侧鼻眶筛骨骨折后内眦畸形患者行内眦韧带固定和畸形矫正术的临床资料和随访结果。依据内眦移位眼睑畸形的不同和皮肤的瘢痕情况,而分别选择“Y—V”成形、“Z”改形、“Mustard”法及旋转皮瓣矫正内眦皮肤和软组织异常;根据鼻眶筛骨骨折后“中心骨段”骨折或移位的情况。选择缝合固定、钛钉固定、钻孔固定及中心骨段复位钛板固定方法行内眦韧带固定术;对伴有泪道阻塞患者。泪道手术与内眦畸形矫正术同期进行;对伴有眼球移位或鼻梁塌陷患者,先行眼眶重建和隆鼻术,二期行内眦整复手术。83例患者术后随访12～30个月。结果72例患者术后内眦点水平和垂直位置与健侧基本对称。水平和垂直向移位均≤1mm。内眦凹陷恢复,外观满意。但是11例患者术后6个月内出现内眦移位的复发,其中6例患者再次施行内眦韧带固定和内眦成形手术,术后畸形改善,再无复发移位。结论根据鼻眶筛骨骨折情况和内眦移位严重程度,选择不同的内眦韧带固定方法和内眦成形术,矫正内眦畸形效果显著,疗效稳定。     

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.