Lateral Orbital Rim Research Articles

One-piece bone flap osteotomy using thread wire saw for fronto-orbital advancement with distraction osteogenesis in craniosynostosis.

The objectives of this study are to describe our new technique of one-piece bone flap osteotomy for fronto-orbital advancement with distraction osteogenesis in craniosynostosis using a thin, flexible, and safe thread wire saw (the T-saw) and to compare the results with those of classic osteotomy using an osteotome. Initial osteotomy is performed between two pterion burr holes using a craniotome with a guarded footplate. The outer sphenoid wing and lateral orbital rim are separated using a reciprocating saw. Limited dura dissection from inner cortex between burr holes in the pterion and nasion is performed. The T-saw is inserted through the epidural space behind the superior orbital wall between the lateral orbital rim and nasion burr hole; the osteotomy is performed with gentle reciprocating strokes. Dura protection with a malleable retractor is not absolutely necessary. Five patients underwent one-piece fronto-orbital bone flap osteotomies using a T-saw in 2009-2014. The median age was 26 months (7-132 months), median operation time was 275 min (183-303 min), and median estimated blood loss was 65 mL (20-250 mL). These values did not differ from those of control cases. No complications, including incomplete osteotomy, occurred. The T-saw creates an osteotomy as a "one-stroke sketch," so incomplete osteotomy never occurs. The osteotomy can be performed safely without protecting the dura. Osteotomy with T-saw does not negate the advantages of fronto-orbital advancement with distraction osteogenesis, including shorter operative time, less intraoperative bleeding, and fewer complications.

Case of the Weeping Wound

An 87-year-old woman presented with a subcutaneous fluid collection overlying the right lateral orbital rim 2 days after undergoing a lateral tarsal strip. Drainage and excision of fibrinous granulation tissue occurred twice within the first postoperative month, with the formation of a lacrimal pseudocyst. The pseudocyst repeatedly enlarged following drainage, necessitating 4 needle aspirations. A third attempt at excision, coupled with cautery to the wound base, and loose wound closure succeeded in breaking the cycle of pseudocyst recurrence. However, the wound continued to drain, so aggressive cautery and botulinum toxin were used to obliterate the area of presumed lacrimal gland laceration and slow tear production. The possibility of damage to the lacrimal system should be entertained in the scenario of a postoperative weeping wound. Formation of a lacrimal pseudocyst should be considered when a cystic lesion appears following surgical intervention in the lateral canthal region.

The tarsal belt procedure for the correction of ectropion: description and outcome in 42 cases

Background/aimsEctropion correction is a challenge in plastic surgery. Correction of the lower lid area, including restoration of the shape and position of lid margin, is the surgical goal. In this...

Total lower lid reconstruction: clinical outcomes of utilizing three-layer flap and graft in one session.

To report the clinical outcomes of utilizing a three-layer flap and graft in reconstruction of the lower lid in one session. Seventeen patients with total or near total lower eyelid defect were included. The defects were reconstructed in three layers. Posterior lamella was reconstructed by using tarsoconjunctival free graft from the ipsilateral upper lid and periosteal flap from lateral orbital rim. Mobilization of residual orbicularis muscle provided a rich blood supply; and the anterior lamella was reconstructed by skin flap prepared from upper lid blepharoplasty as a one-pedicular or bipedicular bucket handle flap. The cause of lower eyelid defect was basal cell carcinoma in 15 patients and trauma in two of them. No intraoperative and postoperative complication occurred. Patients were followed from 10 to 15mo postoperatively. Cosmetic results were favorable in all patients and we had acceptable functional results. Thickness of the reconstructed tissue was a concern in early postoperative period. Three-layer lower lid reconstruction in one session is an effective technique for total lower lid reconstruction with minimal complications and acceptable functional and aesthetic outcomes and can be considered as a safe alternative for the preexisting techniques.

The Looi Suture Technique for Anchoring the Lateral Tarsal Strip to the Lateral Orbital Wall

The lateral tarsal strip procedure (LTS) was first reported by Anderson and Gordy in 1979 for the management of paralytic or senile eyelid laxity. Since its description, the LTS procedure has been subject to several modifications by various authors. In this study, we described the Looi suture technique, a small modification in the technique of suturing the LTS to the lateral orbital wall periosteum. Using this technique, the surgeon achieves a larger area of contact between the anterior surface of the tarsal strip and the lateral orbital wall periosteum, promoting a stronger adhesion. With a double-armed suture, the technique also allows for adjustment of the lower lid tension to avoid over- or under-correction of horizontal lid laxity. This study aimed to evaluate the technique. This was a retrospective non-comparative case series of 39 eyelids of 31 patients who underwent LTS with Looi suturing technique for the correction of involutional lower lid laxity which had resulted in either entropion or ectropion. In this procedure, a novel technique utilising a double armed 5/0 Ethibond suture is used to secure the LTS to the lateral orbital rim, with the aim of increasing appositional contact between the LTS and periosteum. In 36 eyelids with entropion, the procedure was combined with lower lid retractor repair, and in 3 eyelids with ectropion, with medial tarsoconjunctivoplasty. Surgery was successful in 37 of 39 eyelids (94.87%) after one procedure. The remaining 2 eyelids required repeat procedures to achieve anatomical success. Both cases had been performed by trainee surgeons under supervision. Postoperative follow-up period ranged from 1 day (in a visiting overseas patient) to 2 years. This study described the Looi suturing technique in performing the LTS procedure and we found it a simple and effective modification when dealing with lower lid laxity.

Free transplantation of autogenous palmaris longus tendon in the repair of cicatricial ectropion of lower eyelid

Treatment of cicatricial lower eyelid ectropion is often difficult and requires surgical intervention. Numerous techniques have been developed over the years to treat the cicatricial lower eyelid ectropion. This article describes an effective surgical technique using the free transplantation of autogenous palmaris longus tendon in the repair of cicatricial lower eyelid ectropion. The operation was performed with the patient under local anaesthesia. After the contracture of the lower eyelid skin or conjunctiva had been thoroughly released, a palmaris longus tendon graft was obtained through small transverse incisions along the non-dominant forearm. The graft is suspended between the medial canthal ligament and lateral orbital rim with proper tension. Then a local skin flap was transferred to cover the wound at the lower eyelid. In this study, 15 patients were treated using autogenous palmaris longus tendon between December 2008 and October 2012. At the 9–18 months of follow-up assessment, there were no major complications reported with any of the cases, and all have achieved good function and satisfactory appearance of the lower eyelid. However, five patients (33%) still had lagophthalmos, but it was in remission. In conclusion, free transplantation of autogenous palmaris longus tendon in the repair of cicatricial ectropion of the lower eyelid is an effective procedure for cicatricial ectropion, the functional and cosmetic results were satisfactory, the recurrence rate is low. Especially for the moderate and severe ectropion this method is a good choice.

Analysis of Lower Eyelid Aging in an Asian Population for Customized Lower Eyelid Blepharoplasty

The objectives of this study were to evaluate the factors that contribute to aging in the lower eyelids and periorbital changes in Asians and to analyze the contribution of different anatomic factors before surgery. We analyzed photographs and examination findings of 108 patients older than 80 years who had consultations for lower eyelid blepharoplasty. Structural changes were categorized to 7 anatomical categories, and each category was scored from 0 to 3 based on severity. The total point for each category for all patients was divided by the 456 total possible points and was considered a cumulative contribution score for that category. "A uniqueness score" for each patient was calculated as the maximum score in 1 category divided by the patient's total score to reflect the percentage contribution of the patient's most severe anatomic problem. A total of 108 cases (51 male and 57 female patients) were evaluated. The mean age was 57 ± 11 years (age range, 30-75 years). The cumulative contribution score for each category was as follows: orbital fat prolapse 33.8 (medial 15.3, central 11.7, lateral 6.8), skin laxity 22.3%, periorbital hollow 20.8 (tear trough 15.5, lateral orbital rim 5.3), septal confluence 9.5, orbicularis oculi muscle hypertrophy 3.6, triangular malar mound 3.4, and eyelid fluid 0.5. The average uniqueness score was 40.1%, and skin laxity and orbital fat prolapse had the highest average uniqueness score, but no single category played a dominant role in most patients. Medial orbital fat prolapse and skin laxity had the highest proportion of grade 3 scores of 9.5% and 6.7%, respectively. When the patients were grouped according to age, either younger than 50 years or older than 50 years, there was a prominent difference in orbital fat prolapse and skin laxity between the 2 groups. Various anatomic factors were related to periorbital changes in Asian patients. Understanding of the complex factors that contribute to periorbital changes during the aging process may allow for adequate and customized surgery for each patient and help in prevention of postoperative complications.

Iatrogenic Cerebrospinal Fluid Oculorrhea

Cerebrospinal fluid leakage into the orbit (CSF orbitorrhea) or through the orbit to the exterior (CSF oculorrhea) occurs when there is a communication between orbit and subarachnoid space. It has rarely been described. We report a case of CSF oculorrhea following surgery for recurrent sphenoid wing meningioma. A 67-year-old patient who underwent craniotomy for a recurrent sphenoid wing meningioma complained of tearing from the ipsilateral eye. Fluid collection was observed in the right periorbital area contiguous with craniotomy wound. With wide retraction of eyelids, a 1-cm longitudinal full-thickness laceration through the conjunctiva toward the lateral orbital rim was visualized in the area of the lateral canthal tendon. Steady leakage of pink-tinged serous fluid through the forniceal laceration was observed. With a presumed diagnosis of iatrogenic CSF oculorrhea, the patient was treated conservatively with resolution by postoperative day 6.

The “Leicester Lasso” Lateral Canthoplasty

To describe an innovative technique of lateral canthal tendon (LCT) anchoring to the lateral orbital rim on its inner aspect using a "lasso" technique, in order to provide the ideal vector. A retrospective case review of seven patients (n = 7), performed from 2009 to 2013 at our institution by the senior author (RGS). Excellent results in all cases with optimal restoration of form and function. The 'Leicester Lasso' technique is a safer technique of securing the LCT to the orbital rim.

Subciliary Augmentation of the Lower Eyelid in Asians Using a Deep Temporal Fascia Graft: A Preliminary Report

Pretarsal fullness of the lower eyelid has recently gained popularity in the Asian population. Hyaluronic acid injection is a simple, nonsurgical method for creating pretarsal fullness of the lower eyelid, but the effects last only 6-12months. A need exists for a surgical procedure with long-term effects. We describe the use of a deep temporal fascia graft for subciliary augmentation of the lower eyelid. Between September 2009 and October 2011, seven Japanese patients underwent subciliary augmentation of the lower eyelid. This retrospective study was conducted on four of the seven patients who were followed for more than 1year. A skin incision of approximately 1cm was made at the lateral canthus along the subciliary crease of the lower eyelid and the skin was undermined to create a subcutaneous tunnel. A stab incision was then made 2mm below the ciliary margin near the level of the lower lacrimal punctum. The orbicularis oculi muscle was incised under the skin incision at the lateral canthus, and the stump of the incised muscle was suspended to the periosteum of the lateral orbital rim. A deep temporal fascia graft was placed in the undermined subcutaneous plane of the lower eyelid. Lower-eyelid pretarsal fullness was maintained at more than 1year after surgery. The eyelids regained a natural appearance, and the patients were highly satisfied. Morphometric measurements demonstrated increased projection and width of the lower-eyelid pretarsal fullness. Deep temporal fascia grafting is safe and reliable for subciliary augmentation of the lower eyelid. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Suborbicularis Oculi Fat (SOOF) and the Fascial Planes

During anatomic and surgical dissections, a connection was seen between the superficial layer of the deep temporal fascia and the prezygomatic area. These findings were in contrast to previous evaluations. This study defines this connection, which is important to understand from both surgical and anatomic standpoints. To define the connection between the superficial layer of the deep temporal fascia and the prezygomatic area and demonstrate the presence of a deep fascial layer in the midface. Anatomical study performed at the Laboratoire d'Anatomie de la Faculté de Médecine de Nice, Sophia Antipolis, France; at the Centre du Don des Corps de l'Université Paris Descartes, Paris, France; and at the Department of Experimental Medicine, Histology, and Embryology Unit of the University of Pavia, Pavia, Italy. Twenty-four hemifaces of 14 white cadavers were dissected to define the relationship between deep temporal fascia and the midface. Four biopsy samples were harvested for histologic analysis. Dissection of 24 hemifaces from the fresh cadavers revealed the following findings. There is a connection of the deep fascia of the temple (superficial layer of deep temporal fascia) to the midface that divides the fat deep to the orbicularis muscle into 2 layers. One layer of fat is the so-called suborbicularis oculi fat (SOOF), which is superficial to the deep fascia, and the other layer of fat (preperiosteal) is deep to the deep fascia and adherent to malar bone. These findings are in contrast to previous anatomical findings. RESULTS In 12 hemifaces, the superficial layer of the deep temporal fascia directly reached the prezygomatic area as a continuous fascial layer. In 16 hemifaces, the superficial sheet of the deep temporal fascia inserted at the level of the zygomatic and lateral orbital rim and continued as a deep fascial layer over the prezygomatic area. In all specimens, a deep fascial layer was present in the prezygomatic-infraorbital area. This deep fascial layer is adherent to the muscles of the infraorbital area, and it divided the fat located deep to the orbicularis oculi muscle into 2 layers: the SOOF and a deeper layer. Histologic examination of the biopsy samples confirmed these findings. This study demonstrates the existence of a deep fascial layer in the midface. This fascia is connected to the superficial layer of the deep temporal fascia, and it divides the fat deep to the orbicularis oculi muscle into 2 layers. This new finding carries interesting implications related to the classic concept of the superficial musculoaponeurotic system. NA.

Posttraumatic Cavernous Hemangioma of the Skull

A 59-year-old man presented with a slowly enlarging mass in the lateral orbital rim of the left eye for 1 year. He also reported a history of crania defect in the left front bone (6 years earlier) which was confirmed on the former computed tomographic (CT) scan. On examination, the solid mass lesion located in the left frontal extends to the lateral orbital rim of the left eye. CT scan showed a mass with poorly defined margins, which invaded the neighboring tissue and nearly damaged the bone, and located on the exact site of the preceding crania defect. Complete resection was performed, and the clinical diagnosis of cavernous hemangioma was confirmed on histopathologic examination. Skull cavernous hemangiomas are rare tumors for which the origin is not yet clear. We report a case in which the intraosseous hemangiomas developed at the same site of the preceding crania defect.

Obturator Nerve Anatomy and Relevance to One Stage Facial Reanimation

INTRODUCTION: Single stage facial reanimation with a partial gracilis muscle coapted to the contralateral facial nerve seems an optimal surgical solution yet hasn’t supplanted the two-stage approach.1–5 Insufficient obturator nerve length may limit reach to sizeable contralateral facial nerve branches possibly necessitating interposition nerve grafting, compromise optimal muscle positioning, or risk nerve coaptation under tension. The study evaluates whether retroperitoneal obturator nerve dissection would effectively lengthen the nerve thus obviating the aforementioned limitations. METHODS: Ten hemifaces and obturator nerves of five cadavers were dissected. Facial measurements included modiolus to contralateral facial nerve branches of sufficient size at the vertical line of the lateral orbital rim. Obturator nerve measurements included gracilis neurovascular hilum to: 1) obturator canal entry point (ab) 2) intra-obturator canal point where additional adductor branches are inseparable by internal neurolysis (ac) 3) retroperitoneal point of separation between anterior and posterior obturator branches (ad). Obturator nerve reach for cross facial nerve coaptation was assessed. RESULTS: Succesful coaptation was achieved with obturator nerve dissection to point b in approximately 20%, to point c in 60-70%, and to retroperitoneal point d in 90-100% of the time CONCLUSION: Successful coaptation to large contralateral facial nerve branches is feasible in 90-100% of cases if the entire anterior obturator branch is harvested. Yet, the increased risk of retroperitoneal dissection and sacrifice of additional adductor branches decreases the viability of this approach. Obturator canal dissection (point c) provides reach in 60-70% of cases but short interposition nerve grafting may prove necessary.

Orbitomalar Suspension With Combined Single Drill Hole Canthoplasty

Whether resulting from a surgical complication or involutional change, lower eyelid retraction and canthal dystopia can lead to lagophthalmos and frank ectropion. The authors present their experience with a single drill hole fixation for both the lateral canthus and suborbicularis oculi fat for severe canthal dystopia and lower eyelid retraction. In this retrospective, consecutive study, the medical records of 13 patients who underwent single drill hole canthoplasty and suborbicularis oculi fat suspension were reviewed. A 4-0 nonabsorbable polypropylene suture was used to secure the canthal tendon, passed through a single lateral orbital rim drill hole from inside out. The suborbicularis oculi fat was then suspended in the same manner. Outcome measurements included linear marginal reflex distance 2, lagophthalmos, and subjective assessment of the results by the patient. Preoperatively, the average linear marginal reflex distance 2 was 7.3 ± 1.0 mm, the average lagophthalmos was 3.5 ± 0.8 mm, and the average horizontal palpebral fissure width was 25.7 ± 1.3 mm. Postoperatively, average linear marginal reflex distance 2 was 5.3 ± 0.7 mm (p < 0.05), average lagophthalmos was 0.3 ± 0.4 mm (p < 0.05), and average horizontal palpebral fissure width was 30.2 ± 0.7 mm (p < 0.05). All patients noted symptomatic relief and were satisfied with the appearance of their eyelids at 6 months of follow up. Single drill hole canthoplasty with suborbicularis oculi fat suspension is a viable alternative to previously described procedures. By using a single bony drill hole, rigid fixation is achieved with avoidance of multiple fixation points.

Trigonocephaly: Lille's surgical technique

From the early beginning, in 1977, of our experience in the treatment of trigonocephaly and with the follow-up of 263 patients, we have been convinced that it was a condition related to the skull base. It is now proved thank to the comparison between patient's CT scan and normal template (normal skull of the same age) in vestibular orientation. We used to correct this condition by a frontal reshaping and a rotation of the superior and lateral orbital rim along an oblique axis. We call that movement: "valgisation."

Eyelid-associated complications after autogenous fat injection for cosmetic forehead augmentation

BackgroundWe report two cases of unilateral upper eyelid swelling with multiple small lumps as an unusual complication of autogenous fat injection for cosmetic forehead augmentation.Case presentationTwo female patients were referred to our clinic for unusual unilateral eyelid swelling, with multiple small lumps. The duration of symptoms differed in each case, but both patients had a history of autogenous fat injection for cosmetic forehead augmentation at a local plastic surgery clinic. The lumps were small (diameter 5 mm~10 mm), palpable, hard, and nonmobile, and were evaluated by magnetic resonance imaging (MRI). Lumps from the eyelids of two patients were excised under general anesthesia. All of the masses were located deeply and found near the superior orbital rim or lateral orbital rim. The lumps exhibited chronic inflammation with fibrosis. Some of the lumps showed foamy histiocytic aggregation and foreign body lipogranuloma, resulting from iatrogenic fat injection. After excision, all masses and swelling disappeared, and moderate ptotic eyelid or lagophthalmos of affected eyes also improved.ConclusionsTo our knowledge, eyelid swelling with multiple lumps in the eyelid is a very rare complication of autogenous fat injection for cosmetic forehead augmentation. This report should be helpful for ophthalmic clinicians who encounter these unusual symptoms.

Identifying a Safe Zone for Midface Augmentation Using Anatomic Landmarks for the Infraorbital Foramen

Midface augmentation is commonly used to improve the appearance of concave faces and to achieve balance in the facial contour. It can also be an adjunct to orthognathic or reconstructive surgery. However, an inherent risk of midface augmentation is injury to the infraorbital nerve where it exits the infraorbital foramen (IOF). This can result in significant morbidity, including loss of sensation to the midface, nasal sidewall, upper lip, and lower eyelid. The authors identify a safe zone of dissection in the midface for subperiosteal placement of infraorbital, paranasal, malar, and submalar implants, which avoids injury to the infraorbital nerve. Given the popularity of transconjuctival and intraoral access to the midface skeleton, the authors identified relevant bony and dental landmarks from radiographic images and measured distances between the IOF and these landmarks. Forty-four computed tomography scans of adult hemifaces were used to accurately locate the IOF in relation to the anatomic landmarks. Most often, the IOF's location correlated with the second premolar on a vertical axis. The average distance between the IOF and the infraorbital rim, piriform aperture, tip of the second premolar cusps, and lateral orbital rim was approximately 8.61, 17.43, 41.81, and 25.93 mm (respectively) in men and 8.25, 15.69, 37.33, and 24.21 mm (respectively) in women. A safe zone of dissection for midface augmentation has been identified, which differs from previous findings. Awareness of this zone may help clinicians locate the IOF and avoid injury to the nerve.

Swinging door lateral orbitotomy for management of anteriorly placed orbital tumours

A 70 years old female; who came to us; with drooping of right upper eyelid, gradual progressive diminution of vision with a slowly progressive swelling over right upper outer orbit of 1 year duration. Examination revealed non-axial proptosis with downward and inward deviation of the right eye. An irregular, lobulated nontender swelling was present in the superolateral orbit. CT scan revealed a well circumscribed oval encapsulated lesion with no bony destruction. The mass was removed by a modified lateral orbitotomy without removing lateral orbital rim. Histopathological evaluation showed it to be a pleomorphic adenoma of the lacrimal gland. Patient made an uneventful postoperative recovery. This presentation describes a method of lateral orbitotomy for anterior orbital lesions in which the lateral orbital rim is swung outwards without detaching it from its attachment to the temporalis muscle. This surgical approach may reduce the chance of avascular necrosis of the lateral orbital wall bone and infections of the orbit.

Delayed Repair of Lateral Orbital Wall and Orbital Floor Fracture

Timing of surgical management of facial fractures may differ from the current standard when an associated severe ophthalmologic injury exists; this may necessitate a delay in repair to protect the patient's vision. We set out to demonstrate that good functional and aesthetic outcomes can be achieved in cases where zygoma bone fracture repair had to be delayed for more than 21 days after injury with a specific surgical plan.Using the electronic database from Montreal General Hospital, a level I trauma center, a retrospective review of all facial fractures occurring from 1994 to 2009 was performed. Our review returned a total of 22,727 trauma patients admitted to Montreal General Hospital. Of these, 2672 sustained 1 or more facial fractures. Among the facial trauma patients, 945 patients' injuries included a zygoma fracture, 324 (35.3%) of which were managed operatively. Seven cases had their surgery delayed for more than 21 days after injury, 2 of which were managed using simple osteotomies and plate fixations, without the need for bone grafts. Both patients demonstrated a satisfactory outcome with improvement relative to their preoperative status. We provide a detailed description of our most recent case of a 73-year-old woman in whom the surgical repair of the lateral orbital rim and orbital floor was delayed for 10 weeks to allow healing of her associated traumatic retinal detachment.For patients with associated ocular injuries who cannot undergo orbital fracture repair within 21 days of the trauma, delayed surgery may still result in an acceptable aesthetic result.

Lateral Orbital Rim; Open or Closed in Mammals

We tried to determine the relationship between the presence of the lateral orbital rim and shape of the skull in certain mammals. From the literature, 15 mammals with the orbit closed at the back by a bony bar (closed group) and 18 mammals with the orbit closed at the back without a bony bar (open group) were selected. Calculation of interorbital-zygomatic breadth ratio (IZR, interorbital breadth/zygomatic breadth) and nasal-skull ratio (NSR, length of nasals/greatest length of skull) was performed.IZR of the closed group (0.73 ± 0.27) was significantly greater than that of the open group (0.35 ± 0.63, P = 0.000). NSR of the closed group (0.32 ± 0.97) was significantly lower than that of the open group (0.41 ± 0.67, P = 0.023).The open group (primarily carnivores) showed a lower interorbital-zygomatic breadth ratio, and here both orbits were located in close proximity. Although this bony structural arrangement is favorable for stereoscopic vision, the total field of view particularly lateral vision becomes limited. It is our view that the opened lateral orbital rim compensates for the limited lateral vision.