Canthal Dystopia Research Articles

A New Approach on Reconstruction of Frontonasal Encephalomeningocele Assisted With Medpor

The frontoethmoidal encephalomeningocele, which is a congenital brain herniation through skull defect at the frontoethmoidal region, is a common problem in Southeast Asia. Patients usually present with perinasal mass(es), and its pressure affects facial structures resulting to conditions such as telecanthus, medial canthal dystopia, long nose, and elevated medial eyebrows. Currently 1-stage surgical correction is widely accepted. Facial incision is routinely made for accessing the facial structures, removing the mass as well as resecting the covering skin which is usually expanded and redundant. Resultant facial scar is usually extensive and becomes a stigma of the disease even after a surgical correction. This study demonstrates the possibility of doing definitive surgery with minimal facial incision and bone defect reconstruction with the alloplastic material. In this study, we used the porous polyethylene implant for bone defect. This can be an alternative approach to autogenous reconstruction of frontoethmoidal encephalomeningocele.

Three Different Consecutive Manifestations of Morphoeic BCC in the Same Patient: Presenting First as Ectropion, then Entropion, and Finally Medial Canthal Dystopia with Epicanthus Inversus

Morpheaform basal cell carcinoma (BCC) can cause diagnostic difficulty due to an atypical clinical presentation. Successful treatment requires a high index of clinical suspicion together with an early confirmatory biopsy. We present the case of an 81-year-old lady with a delayed diagnosis of morphoeic BCC due to an unusual presentation of evolving lid malposition, and we highlight the limitations of a punch biopsy in diagnosing atypical lesions. An appropriate biopsy technique is vital, with consideration for repeat biopsies when necessary, especially if the clinical picture is changing over time.

Efficacy and Complications of the Transconjunctival Entropion Repair for Lower Eyelid Involutional Entropion

To evaluate the efficacy of the transconjunctival entropion repair (TCER) for lower eyelid involutional entropion. Retrospective, noncomparative, interventional case series. One hundred fifty-one eyelids in 120 patients who underwent TCER for involutional entropion over a 12-year period from February 1991 through January 2003. Surgical technique addressed all 3 anatomic factors underlying the entropion and was performed through a transconjunctival incision. Lateral tarsal strip procedure addressed horizontal eyelid laxity, lower eyelid retractor reinsertion addressed retractor disinsertion, and excision of a strip of the preseptal orbicularis oculi addressed preseptal orbicularis override. Entropion resolution, entropion recurrence, postoperative eyelid retraction, and complication rate. Transconjunctival entropion repair resulted in resolution of entropion, with a success rate of 96.7% (146 of 151 eyelids); entropion recurrence rate was 3.3% (5 of 151 eyelids). No patient had postoperative eyelid retraction or scleral show, and there were no overcorrections or secondary ectropions in any of the 151 eyelids. Postoperative complications occurred in 6 of 151 eyelids (4.0%) of 6 of 120 patients (5.0%) and included stitch abscess (1 eyelid, 0.7%), lateral tarsal strip dehiscence (2 eyelids, 1.3%), lateral canthal dystopia (2 eyelids, 1.3%), and conjunctivochalasis (1 eyelid, 0.7%). The transconjunctival lower eyelid entropion repair is effective and safe with low recurrence and complication rates. The TCER circumvents the risk of lower eyelid retraction and overcorrections that may occur with the transcutaneous approach.

A Technique for Medial Canthal Fixation Using Resorbable Poly-L-lactic Acid–Polyglycolic Acid Fixation Kit

Achieving secure bony fixation of medial canthus is a challenge. We used a resorbable poly-L-lactic acid-polyglycolic acid screw (LactoSorb office fixation kit) in 5 cases: 2 with traumatic medial canthal dystopia, 1 with scleroderma and orbital fat atrophy causing malapposition of the medial canthus to globe, and 2 with invasive medial canthal tumors necessitating subtotal medial orbital exenteration. The resorbable screw with preplaced suture was drilled into the medial orbital wall, using a handheld self-drilling tap. The preplaced suture was used to anchor the medial canthus. We achieved satisfactory canthal position in all 5 cases. There were no complications in 4 cases during a mean +/- SD follow-up of 11.3 +/- 6 months; however, the scleroderma case developed wound dehiscence 6 weeks after surgery. The LactoSorb kit is a safe and effective technique to achieve bony medial canthal fixation in carefully selected cases.

Lax eyelid syndrome or ‘progeria’ of eyelid tissues

PURPOSE The Lax Eyelid Syndrome was described by Van den Bosch and Lemij 1 as an uncommon disorder seen in non-obese elderly people and characterised by chronic ocular surface irritation symptoms and a “floppy upper eyelid”. The authors present some new features of the lax eyelid syndrome. METHODS The authors report five patients, belonging to a younger age group, who presented with premature laxity of all the eyelid tissues. This caused medial and lateral canthal dystopia and eyelid malposition including ptosis, entropion and ectropion. Initial surgical correction was often followed by recurrence after some time. CONCLUSIONS The authors highlight the differences between lax eyelid syndrome, cutis laxa, floppy eyelid syndrome and the blepharochalasis syndrome and suggest that lax eyelid syndrome can be thought of as “progeria” or premature ageing of the eyelid tissues to distinguish it clearly from these other conditions.

Anchored flaps in post-Mohs reconstruction of the lower eyelid, cheek, and lateral canthus: avoiding eyelid distortion.

To describe a system of post-Mohs reconstruction that addresses lower eyelid susceptibility to unopposed tractional, cicatricial, and gravitational forces. Large flaps are anchored to fixed tissue to avoid transmitting flap tension to the eyelids. This is a retrospective, cohort study drawn from approximately 40 patients with post-Mohs defects of the nonmarginal lower eyelid, cheek, and lateral canthus. Surgical intervention involved horizontally oriented, relaxed skin tension line-designed advancement flaps, usually with eyelid margin stabilization. The use of anchoring sutures and any requirement for flap-graft combinations were based on defect size and the elasticity of adjacent tissues. Anchoring eyelid and cheek flaps to underlying periosteum permitted broad flap dissection and advancement without distortion, as the semimobile eyelid and canthi were protected from the resulting flap tension. Anticipated defect size limits for flap reconstruction often were exceeded. Defects too broad for flap reconstruction alone could be downsized, leaving a relatively small area for graft resurfacing. Anchored cheek flaps extend recognition of the continuity of the lower eyelid and midface to the primary reconstruction of tumor-free defects, and they address the relation by restoring deep attachments that minimize eyelid and canthal dystopia.

Small-Incision Periosteal Flap Canthopexy: Aesthetic Applications

Purpose: To describe a small-incision approach to eyelid laxity repair employing a short, periosteal flap canthopexy to be used in association with aesthetic eyelid procedures. Methods: Cadaver specimens were used for surgical dissection to demonstrate the relevant anatomy and technique. Histologic sections through the lateral orbit were examined to identify the lateral canthal anatomy. Patients with ≥2 + lateral canthal ligament laxity, lateral canthal dystopia or rounding, a lower eyelid distraction measurement of ≥6 mm, or frank or incipient ectropion were selected for the procedure. Clinical records, including preoperative and postoperative photographs, were retrospectively reviewed to evaluate the surgical outcome. Results: One hundred fifty-six eyelids met inclusion criteria for small-incision eyelid laxity repair. Thirty-six procedures were performed for ectropion or lower lid laxity alone. The remaining 120 were performed in association with other eyelid or facial procedures. Sixteen included adjunct upper lid blepharoplasty. Six eyelids were tightened in combination with both upper and lower blepharoplasty. Forty-eight lid repairs were combined with upper lid blepharoplasty and ptosis repair. Twenty-eight lid procedures included ptosis repair alone. Twenty-two lower lid laxity repairs were combined with other procedures. Average follow-up was 58 days. Lower lid and canthal angle positions were symmetric with improvement in laxity, contour, and apposition to the globe in all cases. No reoperations were required. Conclusions: A novel canthopexy technique for eyelid laxity repair is described. This new technique offers significant advantages. Aesthetically, the incision is well hidden, and the canthal angle is preserved, allowing for improved cosmesis. Anatomically, the periosteal flap raised inside the orbital rim correctly restores lid-to-globe apposition and allows a secure bite through the periosteum. It allows for greater technical ease in securing the eyelid tissues within the orbital rim and in adjusting the final tension and height.

The madame butterfly procedure: Management of the unhappy postblepharoplasty patient with lower-eyelid retraction, round eye, and scleral show

The unhappy postblepharoplasty patient with lateral canthal dystopia, round eye, and scleral show presents perhaps the single greatest challenge to the aesthetic reconstructive surgeon. The problem may be as simple as a lax eyelid that is inferiorly displaced by gravity, or as complex as an eyelid that has full-thickness vertical inadequacy in each of the three eyelid lamellae. The Madame Butterfly procedure with hard palate graft reliably addresses full-thickness lower-eyelid vertical tissue inadequacy by totally reconstructing the lower eyelid with the use of the classic three-individual-layer reconstructive technique. Vertical and horizontal adequacy or inadequacy for each of the three eyelid layers are determined and then individually addressed in the total eyelid reconstruction. The Madame Butterfly procedure has the potential to fully reconstruct and reposition the lower eyelid and lateral canthus so that the final position, function, and appearance are as good or better than they were before they were changed by time, gravity, and previous surgery.

The Transeyelid Subperiosteal Midface-Lift in the Unhappy Postblepharoplasty Patient

The unhappy postblepharoplasty patient with lateral canthal dystopia, round eye, and scleral show presents perhaps the single greatest challenge to the aesthetic reconstructive surgeon. The problem may be as simple as a lax eyelid, which is inferiorly displaced by gravity or as complex as an eyelid, which has full thickness vertical inadequacy in each of the three eyelid lamellae. The transeyelid subperiosteal midface-lift with lower eyelid reconstruction is a reliable procedure for addressing full thickness lower eyelid vertical tissue inadequacy by totally reconstructing the lower eyelid by the classic three individual layer reconstructive technique. Vertical and horizontal adequacy or inadequacy for each of the three eyelid layers is determined and then individually addressed in the total eyelid reconstruction. This procedure has the potential to fully reconstruct and reposition the lower eyelid and lateral canthus such that the final position, function, and appearance is as good or better than it was before the changes caused by time, gravity, and previous surgery.

Evolution of the lateral canthoplasty: techniques and indications.

Lateral canthoplasty is a useful method to restore eyelid function and to protect the ocular surfaces. The success of the procedure depends on the proper analysis of periorbital anatomy as it relates to the specific indication for lateral canthoplasty. We report the experience with 1565 lateral canthoplasties with emphasis on the evaluation of newer techniques that better address anatomic and functional requirements. Between 1981 and 1994, 1565 lateral canthoplasties were performed in 684 patients. Of these, 1369 "reconstructive" lateral canthoplasties were performed in 586 patients and 196 "cosmetic" lateral canthoplasties were performed in 98 patients. All operations were performed by a single surgeon (Jelks), and follow-up ranged from 1 to 14 years. The evolution of the operative technique for lateral canthoplasty has been toward an operation that corresponds with the anatomy of the individual. Indications for the procedure include lateral canthal dystopia, horizontal lid laxity, ectropion, entropion, lid margin eversion, lid retraction with or without soft-tissue deficiency, and aesthetic improvement. The types of procedures performed will be reviewed in detail. The evaluation of the newer forms of lateral canthoplasty as unique reconstructive tools and as adjuncts to aesthetic surgery will be discussed.

Reducing eyelid retraction following subperiosteal face lift

The most common complication of lower blepharoplasty is malposition of the lower eyelid. This deformity may present as scleral show, ectropion, entropion, or canthal dystopia, with dry eye or epiphora. These problems occurred frequently in our initial series of patients undergoing blepharoplasty with subperiosteal face lift. The key to prevention lay in avoiding the potential causes of these problems: overresection of eyelid skin, retraction of the orbital septum, orbicularis oculi dysfunction, postoperative swelling, and downward pull from the facial suspension. This article reviews the cases of 14 consecutive patients who underwent a modified subperiosteal face lift with blepharoplasty. Eleven of the patients had a concomitant endoscopically assisted brow lift. This group is compared with a prior series of 16 patients who underwent 12 endoscope-assisted brow lifts without special modifications. The modifications in the second series consisted of the following: (1) Improved patient selection; (2) minimal tissue trauma; (3) intact orbital septum; (4) lengthening of the septum; (5) secure midfacial suspension; (6) three-step lateral canthoplasty; (7) limited resection of skin; and (8) specific postoperative care. Results regarding the incidence of eyelid malposition and reoperations were subjected to Fisher's exact test. In the 14 consecutive patients who underwent the modified procedure, two temporary episodes of lower eyelid malposition occurred (follow-up of 12 to 20 months). In the 16 patients who underwent a nonmodified procedure, five temporary and three permanent episodes of eyelid malposition occurred (follow-up of 20 to 30 months). Fisher's exact test demonstrated a significant difference with a p value of 0.038. Modifications of the subperiosteal face lift and lower blepharoplasty reduced significantly but did not eliminate the incidence of lower eyelid malposition.

Long Term Results Following Immediate Reconstruction of Orbital Fractures: A Critical Morphometric Analysis

M Dawar, OM Antonyshyn. Long term results following immediate reconstruction of orbital fractures: A critical morphometric analysis. Can J Plast Surg 1993; 1(1):24-29. The purpose of this study is to review the long term morphological results following primary reconstruction and bone grafting of orbital fractures. All patients presenting to the Victoria General Hospital in Halifax, Nova Scotia between July 1988 and December 1990 with orbital fractures of sufficient severity to require immediate reconstruction were included in the study. The series consists of 39 fractured orbits in 29 patients. In all patients, a standardized data sheet was used in recording patient demographics, and clinical and intraoperative findings. The surgical management of orbital fractures and in particular the redraping of periorbital soft tissues was performed according to a standard protocol. Long term morphometric assessment was performed between 11 and 38 months postoperatively, with a mean follow-up of 27 months. A McCoy facial trisquare and Hertel exophthalmometer were used in the anthropometric evaluation of ocular globe position and position of the periorbital soft tissue landmarks. Postoperative assessment of globe position revealed a 5% incidence of enophthalmos and an 11 % incidence of hyperophthalmia. Minor asymmetries in globe position measuring less than 2 mm were noted in a further 61 % of patients. Ectropion was documented in 8% of patients, but an asymmetry in the height of the palpebral fissure was noted in a further 34% of patients. In terms of canthal relations, lateral canthal dystopia was the most commonly observed deformity, with vertical dystopia occurring in 18% of patients and transverse dystopia in 33% of patients. The observed sequelae and complications of orbital fractures are discussed and possible causative factors identified.

Miniplate Reconstruction of the Lateral Orbital Rim after Orbital Decompression for Graves Disease

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. 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. 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. 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.

Ocular and adnexal complications of unilateral orbital advancement for plagiocephaly.

Strabismus, ptosis, lateral canthal dystopia, nasolacrimal obstruction, and cranial nerve palsy were noted preoperatively in 32%, 21%, 14%, 12%, and 9% of 34 patients, respectively, undergoing ophthalmologic evaluation prior to unilateral orbital advancement for plagiocephaly. Thirty-two percent of the patients had normal preoperative ocular and adnexal examination results. Ptosis, strabismus, and amblyopia were frequently acquired postoperative abnormalities in 29%, 18%, and 18% of the patients, respectively. Forty-four percent of the patients had no new abnormalities following craniofacial surgery.