Medial Canthal Reconstruction Research Articles

Glabellar superciliary bilobed flap for reconstruction of large medial canthus region defect

The aim of this study was to describe a series of patients who have undergone a medial canthal reconstruction with a glabellar superciliary bilobed flap. A series of 30 patients were included with medial canthal defects after excision of medial canthal tumour who underwent reconstruction using a glabellar-superciliary bilobed flap of adjoining skin and subcutaneous tissue. Eighteen procedures were performed under local anaesthesia. The remaining 12 cases were combined with major lid reconstruction and performed under general anaesthesia. Complete closure of the defect, aesthetic outcome, complications, and re-operations were all used as outcome measures. Primary closure of the donor site was achieved in all cases without wound dehiscence. In all cases, the cosmetic appearance was highly satisfactory to the surgeons and patients and there were no intraoperative complications. The glabellar superciliary bilobed flap is an effective, quick, simple, and single-stage technique for medial canthal region reconstruction. It provides excellent cosmesis and is associated with minimal complications. It can be modified according to the nature of the periorbital skin, location, size, and depth of the defect.

The Bridged Digital Artery Perforator Flap as an Alternative Reconstructive Option for Dorsal Digital or Toe Soft Tissue Defects.

Dorsal digital soft tissue defects are considered among the most challenging to reconstruct. Numerous treatment options are proposed, including advancement flaps, antegrade, retrograde flow flaps, adipofascial flaps, and digital artery perforator flaps. However, the optimal treatment remains controversial. The concept of the "bridge principle," consisting of the indirect transfer of the flap to the defect area through a muscular bridge, has recently introduced by authors for medial canthal reconstruction. The aim of the study was to examine the feasibility of its application in digital reconstruction for dorsal defects and the development of a new flap. The utilization of the dorsal subcutaneous adipofascial digital or toe tissue as a "bridge" led to description and development of bridged digital artery perforator flaps as an alternative treatment of such defects. From November 2017 to September 2019, a series of 14 patients (mean age of 57.1 years) suffered from dorsal digital or toe soft tissue defects of different dimensions and sustained reconstruction with this new technique. Twelve digits and 2 toes have been concerned. The mean size of the defects was 1.3 × 1.1 cm. All flaps survived without a sign of venous congestion. No functional digital or toe problems were observed during the follow-up period (mean of 11.6 months). Minor wound dehiscence presented in 2 cases (2 of 14 [14.3%]) and a transient skin swelling around the flap in 1. A new concept was introduced to resolve a challenging problem. Initial outcomes are very encouraging. These flaps could be a valuable and reliable reconstructive option.

The Use of a Hemi Glabellar Flap for Reconstruction of Medial Canthus Defects.

Background: Medial canthal reconstruction is a challenging task due to its complex anatomy. The glabellar flap is a common viable technique; however, this results in narrowing of the eyebrows, bulky nasal dorsum horizontal scarring, which is aesthetically displeasing, and possible injury of the supratrochlear artery. Multiple variations have been proposed in the literature, which is often complex. In this paper, the senior author (AK) has developed an intuitive, simple technique by utilising half of the glabellar skin in 12 patients with good clinical outcomes.Materials and methods: A rotational advancement flap involving the upper lateral nasal wall with the hemi glabellar was formed and transferred to the medial canthal defect. The donor site was closed in a V-Y manner. Complete closure of defect was achieved in all patients.Results: Reconstruction using the hemi glabellar technique was performed on 12 patients following resection of basal cell carcinoma (BCC) in or near the medial canthus area. Superficial cellulitis was noted in two patients; they were managed on oral antibiotics. Bruising was reported in seven patients which resolved spontaneously in 4-7 days. All patients had a good outcome at two months and six months follow up; there was no flap loss, and all patients were satisfied with the aesthetic outcome.Conclusion: The technique highlighted in this article can be performed quickly and applies to the reconstruction of medial canthus defects with excellent aesthetic outcomes, an inconspicuous scar and supple skin with matching colour.

A Modified Rhomboid Flap for Medial Canthal Reconstruction.

Background:The reconstruction of medial canthal defects is often challenging in achieving continuity of color and texture, obtaining adequate tissue for large defects, and the reproduction of natural external appearance with inconspicuous scars. We describe a technique for reconstruction of the medial canthal area, using a modified rhomboid flap.Methods:The technique is based on the use of a modified rhomboid flap for medial canthal defects—superiorly based on the root of the nose for defects mostly above the medial canthal tendon, inferiorly based on the cheek for defects mostly below the medial canthal tendon, and in cases of large defects, using a combination of the two flaps. We present a case series of five patients successfully reconstructed with the mentioned technique after resection of medial canthal basal cell carcinoma.Results:Of the five patients with a mean age of 76.2 years (range 62–84 years), reconstruction was performed in three patients with a superiorly based rhomboid flap, in one patient with an inferiorly based rhomboid flap, and in another patient with a large defect using a combination of the two flaps. Mean follow-up was 374.4 days (range 30–1247 days). All patients achieved a complete primary closure with no further surgery and satisfactory cosmetic and functional results.Conclusion:The modified rhomboid flap is a simple and reliable technique for all defects of the medial canthal area.

Medial Canthal Reconstruction of Skin Defects With Full-Thickness Skin Grafts.

Medial Canthal Reconstruction of Skin Defects With Full-Thickness Skin Grafts.

Transnasal or transglabellar semicircular flap for medial canthal reconstruction

To review the results of medial canthal reconstruction with the medial (transnasal or transglabellar) semicircular flap. Medical charts of 38 patients who underwent the described procedure were reviewed. After tumor excision, a semicircular flap created along the nasal bridge or glabella was advanced to the canthal defect; if necessary, this flap was combined with other reconstructive methods. The patients (19 male, 19 female; mean age, 66years) had basal cell (n = 36) or squamous cell (n = 2) carcinomas. The mean tumor diameter was 9.2mm (range, 3-21mm). Tumor epicenters were in the midcanthal area in 21 patients (55%) and in the infra- or supracanthal areas in 17 patients (45%). After excision, 22 patients had only canthal defects, and 16 had an associated upper and/or lower eyelid defect. To cover the defect, the medial semicircular flap alone was used in 19 patients (50%) and in association with other flaps in 19 patients (50%). The excisional defect was primarily closed in 37 patients (97%). Flap necrosis or infection did not occur. During follow-up (range, 1-91months; median, 19months), 10 patients (26%) developed a total of 17 complications. Three patients (8%) required secondary surgery for eyelid reconstruction-related complications. Transnasal or transglabellar semicircular flap may be a good alternative for medial canthal reconstruction. For large or complex defects, the medial semicircular flap can be combined with other periocular flaps. In the latter case, postoperative complications requiring secondary surgery may develop.

A Novel Medial Canthal Reconstruction Technique in Children With Blepharophimosis Syndrome.

There are different techniques for medial canthoplasty in blepharophimosis syndrome where individuals have epicanthus inversus and telecanthus leading to typical facial appearances. These methods have potential problems with scarring, epistaxis, and extrusion of metal plates. The authors describe a novel technique of medial canthal reconstruction using titanium microplates with microscrew fixation to the anterior lacrimal crest, with effective, safe, and reproducible results. Seven children with blepharophimosis syndrome underwent medial canthus reconstruction surgery at a single center with the collaboration of a pediatric oculoplastic surgeon and craniofacial plastic surgeon to improve eye opening through correction of the lid contours and telecanthus. This is a safe, effective, and reproducible technique, with minimal morbidity and rapid postoperative recovery in children. It produces cosmetically acceptable scars and a strong stable reconstruction of the medial canthal insertion.

Effect of Eyelid Involvement in the Reconstruction of Medial Canthal Defects

The purpose of this study was to present surgical techniques for the reconstruction of medial canthal defects with and without the involvement of the eyelid. This study included 31 patients who underwent medial canthal reconstruction after tumor excision during a 6-year period. Data regarding patient demographics, defect size, tumor pathology, surgery techniques, functional and cosmetic outcomes, and complications were recorded. The reconstructive methods used in the study were divided into groups as per the site of the defect (medial canthal, medial canthal with upper eyelid, medial canthal with lower eyelid, and medial canthal with both eyelids). The most common histopathological diagnosis of the lesions was basal cell carcinoma (74.2%). Postoperative complications (6.4%) included flap necrosis in one patient and lid margin notching in another. Among patients who underwent reconstruction, 8 (25.8%) had only medial canthal defect, 6 (19.3%) had medial canthal defect extending to the upper eyelid, 7 (22.6%) had medial canthal defect extending to the lower eyelid, and 10 (32.3%) had medial canthal defect extending to both the eyelids. The functional outcome was regarded as normal in 30 (96.8%) patients and limited in 1 (3.2%) patient. Cosmetic outcomes were satisfactory in all the patients. The use of alternative reconstructive approaches for different subunits of the medial canthus is an efficient method to achieve superior functional and cosmetic outcomes.

Effect of Eyelid Involvement in the Reconstruction of Medial Canthal Defects Following Tumor Excision

The aim of this study is to present surgical techniques for medial canthal defects with and without involvement of eyelid. This study included 31 patients who had undergone medial canthal reconstruction after tumor excision during a 6-year interval. Data about patient demographics, defect size, tumor pathology, surgery techniques, functional and cosmetic outcomes, and complications were recorded. The reconstructive methods used in the study were divided into groups according to the site of the defect (medial canthal, medial canthal with upper eyelid, medial canthal with lower eyelid, and medial canthal with both eyelids). Most common histopathologic diagnosis of the lesions was basal cell carcinoma (74.2%). Postoperative complications (6.4%) included flap necrosis in 1 patient and lid margin notching in 1 patient. Among patients who underwent reconstruction, 8 (25.8%) had only medial canthal defect, 6 (19.3%) had medial canthal defect extending to upper eyelid, 7 (22.6%) had medial canthal defect extending to lower eyelid, and 10 (32.3%) had medial canthal defect extending to both eyelids. The functional outcome was regarded as normal in 30 (96.8%) patients and limited in 1 (3.2%) patient. All of the patients considered cosmetic result as satisfactory. Alternative reconstructive approaches for different subunits of the medial canthus are an efficient way to provide superior functional and cosmetic outcomes.

Management of traumatic telecanthus by medial canthopexy

The medial part of the orbital region is a complex structure of several facial bones. It has attachments for support of the eye and lacrimal collecting system. In that, medial canthus is an important structure for esthetic and functional reasons. Medial canthal deformities can result from nasoethmoidal trauma, cancer resection, craniofacial exposure, congenital malposition, or age-related change. Various techniques have been used for medial canthal reconstruction, specifically to achieve bony fixation of the medial canthal tendon. The surgical treatment of traumatic telecanthus remains one of the most challenging areas in facial reconstruction. Transnasal wiring has been one of the most commonly used methods to perform medial canthopexy. However, it is technically difficult and may cause damage to the contralateral orbital structures. Here, we present a case report of management of traumatic telecanthus by medial canthopexy in an 11-year-old female patient using titanium miniplate.

Changing the Paradigm in Medial Canthal Reconstruction: The Bridge Principle and the Croissant-Like Keystone Island Perforator Flap as An Alternative for Medium Size Soft Tissue Defects in Internal Canthus Reconstruction.

Medial canthus is a common area of skin cancer prevalence. Defects in this region represent a challenging reconstructive task. The nasal version of keystone perforator island flap (KPIF) has proven its versatility. The aim of the present study was to expand its utilization in the neighbor medial canthus area. A modified croissant-like KPIF (CKPIF) was used resolving inner convexity-related problems. The presence of procerus in the glabella area, bridging a surface from nasalis up to the frontalis, changed the traditional dissecting flap technique. Thus, the authors introduce the bridge principle, which consists of the indirect transfer of the flap to the defect site through a muscular "bridge" (the procerus). The authors report their experience in medial canthal reconstruction combining a modified KPIF with a new dissecting "principle." From November 2016 to July 2017, a series of patients presenting soft tissue defects of various dimensions in the medial canthus, secondary to tumor extirpation, sustained reconstruction with a CKPIF dissected with the bridge principle. A total of 15 patients were treated with this new technique. Their mean age was 75.3 years. The mean size of the defect was 2.08 cm (length) × 1.5 cm (width). All flaps survived without any sign of venous congestion. A transient epiphora presented in 4 patients (4/15 or 26.6%), which was subsided 2 months later. A new approach following a novel paradigm was introduced to resolve an old problem. Initial outcomes are encouraging. However, longer series are needed to extract definitive and safer conclusion.

Medial canthal reconstruction with multiple local flaps

BackgroundIt is often difficult to reconstruct comparatively large defects in the medial canthal region. The authors have performed reconstruction with multiple local flaps in 4 medial canthal defects after resection of malignant skin tumors. MethodThe defects exceeded the medial canthal region, extending to the upper eyelid and the lower eyelid. The medial canthal defect was covered by transposition of a glabellar flap, the upper eyelid defect was covered by an upper eyelid myocutaneous advancement flap, and the lower eyelid defect was covered by a cheek rotation flap. Then the donor site of the glabellar flap was covered by a Rintala flap. ResultsThere was no recurrence in any of the cases, and good results were obtained. One case showed mild linear contracture, but the patient did not want corrective surgery. ConclusionThis method is somewhat complicated compared to reconstruction with a single flap, but it is a combination of standard local flaps and is a simple reconstructive procedure. By adding additional resection, the suture line is consistent with the border of the facial unit, so postoperative scarring is inconspicuous. This technique is aesthetically useful because of the continuity of colour and texture resulting from the use of adjacent flaps.

Rhomboid flap: An option to medial canthal reconstruction

Rhomboid flap: An option to medial canthal reconstruction

The transnasal bilobed flap for medial canthal reconstruction

The transnasal bilobed flap for medial canthal reconstruction

Median forehead flap - beyond classic indication

Introduction. The paramedian forehead flap is one of the best options for reconstruction of the median upper two-thirds of the face due to its vascularity, color, texture match and ability to resurface all or part of the reconstructed area. The forehead flap is the gold standard for nasal soft tissue reconstruction and the flap of choice for larger cutaneous nasal defects having a robust pedicle and large amount of tissue. Materials and Methods. We are reporting a clinical series of cutaneous tumors involving the nose, medial canthus, upper and lower eyelid through a retrospective review of 6 patients who underwent surgical excision of the lesion and primary reconstruction using a paramedian forehead flap. Results. The forehead flap was used for total nose reconstruction, eyelids and medial canthal reconstruction. All flaps survived completely and no tumor recurrence was seen in any of the patients. Cosmetic and functional results were favorable. Conclusions. The forehead flap continues to be one of the best options for nose reconstruction and for closure of surgical defects of the nose larger than 2 cm. Even though is not a gold standard, median forehead flap can be an advantageous technique in periorbital defects reconstruction.

A novel technique for full thickness medial canthal reconstruction; playing with broken lines

PurposeTo introduce a new modification of transposition flap technique for reconstruction of the medial canthal region. MethodsThis prospective study included 58 patients with the full thickness involvement of both upper and lower lid in the medial canthal area. Reconstruction of posterior lamella was performed by utilizing periosteal flaps and tarsoconjunctival grafts, and anterior lamellar reconstruction was performed using transposition of multiple full-thickness skin flaps, a modified form of rhomboid flap technique. Post-surgical outcomes, advantages, and drawbacks of this technique are discussed. ResultsBetween 2010 and 2014, 58 patients with basal cell carcinoma (BCC), proven by histopathologic study, underwent medial canthal reconstruction. The mean age was 72.8 ± 8.3 years. In 30 patients, the lacrimal apparatus was excised, and periosteal flaps or tarsoconjunctival grafts were prepared to reconstruct the posterior lamella. Anterior lamellar reconstruction was performed in all patients, and the mean number of transposition flaps was 3.63 in addition to the blepharoplasty flap. Patients were followed for 24 months. None of the patients developed flap necrosis or other intraoperative and postoperative complications, with acceptable aesthetic and functional outcomes. ConclusionFull-thickness reconstruction of the medial canthal area by utilizing periosteal flaps and modified transposition flap technique all in one session can be considered an alternative method in medial canthal reconstruction, with acceptable functional and aesthetic outcomes.

Medial and lateral canthal reconstruction with an orbicularis oculi myocutaneous island flap.

BackgroundThe eyelid and canthal areas are common locations for cutaneous tumors. The medial canthus includes, among many other apparatuses, the canthal tendon and lacrimal canaliculi, and its characteristic thin and supple skin is hard to mimic and restore using tissue from other regions. Accordingly, reconstruction of the canthal area can prove challenging for surgeons. Although various methods, such as skin grafts and local flaps from adjacent regions, have been utilized for reconstructive purposes, they present known disadvantages. However, we were able to successfully reconstruct both lateral and medial canthal area defects by using orbicularis oculi myocutaneous island flaps.MethodsOur study included seven patients who underwent medial or lateral canthal region reconstruction, using orbicularis oculi myocutaneous island flaps, between 2011 and 2014, following either cutaneous tumor excision or traumatic avulsion injury.ResultsFive patients had basal cell carcinoma, one had squamous cell carcinoma of the eyelid, and one had sustained a traumatic avulsion injury of the eyelid and canthal area. Entire flap loss was not observed in any patient, but one-a heavy smoker-showed partial flap loss, which healed with secondary intention and yielded acceptable results. Donor site morbidity was not observed, and all patients were satisfied with their surgical outcomes.ConclusionsThe canthal regions can be successfully reconstructed with orbicularis oculi myocutaneous island flaps. These flaps offer several key advantages, including similarity in texture, color, and thickness to the recipient site and a negligible incidence of donor site morbidity.

Reconstruction of the Medial Canthus Using an Ipsilateral Paramedian Forehead Flap

BackgroundThe medial canthus is an important area in determining the impression of a person's facial appearance. It is composed of various structures, including canthal tendons, lacrimal canaliculi, conjunctiva, the tarsal plate, and skin tissues. Due to its complexity, medial canthal defect reconstruction has been a challenging procedure to perform. The contralateral paramedian forehead flap is usually used for large defects; however, the bulkiness of the glabella and splitting at the distal end of the flap are factors that can reduce the rate of flap survival. We reconstructed medial canthal defects using ipsilateral paramedian forehead flaps, minimizing glabellar bulkiness.MethodsThis study included 10 patients who underwent medial canthal reconstruction using ipsilateral paramedian forehead flaps between 2010 and 2012. To avoid an acute curve of the pedicle, which can cause venous congestion, we attempted to make the arc of the pedicle rounder. Additionally, the pedicle was skeletonized from the nasal root to the glabella to reduce the bulkiness.ResultsAll patients had basal cell carcinoma, and 3 of them had recurrent basal cell carcinoma. All of the flaps were successful without total or partial flap loss. Two patients developed venous congestion of the flap, which was healed using medicinal leeches. Four patients developed epiphora, and 2 patients developed telecanthus.ConclusionsLarge defects of the medial canthus can be successfully reconstructed using ipsilateral paramedian forehead flaps. In addition, any accompanying venous congestion can be healed using medicinal leeches.

Split paramedian forehead flap for medial canthal reconstruction

Split paramedian forehead flap for medial canthal reconstruction

Island Pedicle and Horizontal Advancement Cheek Flaps for Medial Canthal Reconstruction

To describe the surgical technique for and results of island pedicle cheek flap repair of medial canthal defects. We retrospectively reviewed the charts of all patients with medial canthal defects repaired with island pedicle and horizontal advancement cheek flaps from November 2007 and July 2009. Patient demographics, risk factors for poor wound healing, diagnosis, operative findings, technique, and postoperative results were reviewed. Twenty-five patients with a mean age of 61 years underwent reconstruction with island pedicle and horizontal cheek flaps. Basal cell carcinoma (88%), squamous cell carcinoma (8%), and melanoma in situ (4%) were the indications for surgery. Mohs micrographic surgery (76%) and radical excision with controlled margins (24%) were the methods of excision. Twenty percent of patients were smokers, 8% had diabetes, and 8% were systemically immunosuppressed. Mean defect diameter was 24 mm, and canalicular involvement was present in 3 cases. LactoSorb anchors were necessary for flap fixation in 16% of cases, and additional closure with glabellar rotation flaps was used in 20% of cases. Mean follow-up time was 13 months. Wound dehiscence, mild webbing, and mild ectropion were rare and required no secondary revisions. The advantages of this technique include a well-vascularized pedicle, appropriate volume for filling the defect, and inferior support of the island pedicle flap with the horizontal advancement flap. The island pedicle cheek flap is a powerful and reliable technique for medial canthal defect reconstruction and allows good reconstruction of the natural canthal contour with low rates of minor complications.