Medial Canthal Region Research Articles

Scarless Epicanthoplasty and Concomitant Double Eyelidplasty in Chinese Eyelids.

The presence of mild or moderate medial epicanthus is typical in Asian patients. Numerous epicanthoplasty techniques have been described previously. However, these methods usually leave obvious scars in the medial canthal area. The aim of this report is to introduce a novel epicanthoplasty technique and a concomitant double eyelidplasty which avoid leaving scars in the medial canthal region. From July 2013 to July 2015, 252 patients received epicanthoplasty and concomitant double eyelidplasty with this new technique. The medial epicanthus was corrected through the medial end of the eyelid crease incision. One hundred eighteen of these patients were followed up for 3-24months (8months in average). The preoperative and postoperative interepicanthal distances were measured at pre, 3 and 6months post-operation. The aesthetic results were evaluated with patient visual analog scale (VAS) scores. The average intercanthal distance significantly decreased 3months after the operation (32.7±2.3mm vs 36.5±2.6mm, p<0.05, paired t test). Little retraction was noticed at 6months after the operation (33.0±2.4 vs 32.7±2.3mm, p<0.05, paired t test). The mean patient VAS score associated with satisfaction of overall outcome was 4.2 at 6months after operation (range 2.5-5.0). This new method provides an effective way to correct the medial epicanthus without leaving any scar in the medial canthal region. Patients with mild to moderate medial epicanthus are good candidates for this procedure. 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 .

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.

Central artery perforator propeller flap for nasal and medial canthal defects

Non-melanoma skin cancer is the most common type of skin cancer of the nasal dorsum and the medial canthal region, which is caused by chronic sun exposure. Limited adjacent tissue and the need for aesthetically pleasing result make the reconstruction of these regions very challenging. To overcome this challenge, we designed a perforator propeller flap based on the central artery. Between January 2014 and November 2015, we covered the nasal or medial canthal defects of 22 patients with central artery perforator propeller flaps. The mean age of the patients was 60.4 years (range: 47-81 years). The median follow-up period was 7.5 months (range: 2-23 months). The pathological diagnoses were basal cell carcinoma for 14 patients and squamous cell carcinoma for the remaining eight patients. The size of the defects ranged from 2×2 to 3.5×4cm, and that of the flaps ranged from 2×3.5 to 3.2×6cm. We did not observe any major complications requiring surgery, such as total flap loss, hematoma, or dog-ear deformity. However, venous congestion was seen in five patients and partial flap necrosis (that healed without intervention) in two patients. The central artery perforator propeller flap is a reliable and versatile flap for the reconstruction of the nasal dorsum and medial canthal region. Reconstruction with this flap is a single-stage procedure that can cover large defects without causing dog-ear deformity or eyebrow asymmetry compared with other local flap options.

Proboscis Lateralis : Report Of One Congolese Case

Introduction: Proboscis lateralis is known as a rare anomaly related to facial fusion defect. The optimal care of the patient with a multidisplinary approach that may involve an ophthalmologist, plastic surgeon, oro-maxillofacial surgeon or otolaryngologist has necessary.Case-report: It's a case note ofa 1 day-old female infant was consulted into our department because of the complaint of nasal anomaly. The physical examination revealed a tubular structure originated from the medial canthal region, an absent left nasal structure or right heminasal hypoplasia with a normal right nasal structure. According to those signs, the diagnostic of proboscis lateralis was given.Discussion: PL is known as a rare anomaly related to facial fusion defect.The precise embryologic mechanism responsible for the development of PL has not been defined.Nowadays, it does not seem to be any racial predilection in proboscis lateralis.In this case, it is very difficult to prove the association between: the embryologic mechanism of PL, the bad follow up of pregnancy, and the prenatal history of exposure to alcohol, drugs auto medicationConclusion: Ignorance and poor management, and lack of equipment yield impossible the care of proboscis lateralis's patient in our context.

A useful flap combination in wide and complex defect reconstruction of the medial canthal region: Glabellar rotation and nasolabial V-Y advancement flaps

Background Reconstruction of medial canthal defects after tumour excision is difficult owing to the thin skin of the region and the concavity of the anatomical landmarks, which enclose complex structures such as the medial canthal ligament and the lacrimal system. Local reconstruction methods for this region include secondary healing, full-thickness skin grafts, and skin flaps from the frontal, transnasal, glabellar and upper eyelid regions. Objective To demonstrate a useful combination of two local flaps in wide defects of the medial canthal region. Methods Between 1998 and 2012, a combination of glabellar rotation and nasolabial V-Y advancement flaps were used in 11 patients with wide complex defects after excision, including periosteum, of invasive basal cell carcinoma. Results All patients were tumour free and underwent functional and aesthetic reconstruction of the medial canthal region. There were no major complications, and no relapses were observed. Conclusion This technique achieves good match in colour and texture, and has satisfactory results both aesthetically and functionally. In addition, donor area morbidity is minimal and surgical technique is simple.

Medial canthal support structures: the medial retinaculum: a review.

The medial canthus is supported by several structures with a complicated 3-dimensional arrangement in a narrow space. Although the medial canthal tendon occupies a major portion of the area, the medial canthal support structures include the following entities: Horner's muscle, the medial rectus capsulopalpebral fascia including the medial check ligament, the medial horn of the levator aponeurosis, the medial horn supporting ligament, the medial horn of the lower eyelid retractors, the preseptal part of the orbicularis oculi muscle, and 3 variations of the Lockwood's ligament. We named the composite of these structures the "medial retinaculum," which is similar to the "lateral retinaculum" of the lateral canthus. Profound comprehension and consideration of the medial retinaculum warrants safe and effective surgery in the medial canthal region.

Modified auricular cartilage sling for paralytic ectropion

To evaluate the outcomes of a modified auricular cartilage sling for paralytic ectropion. We treated 17 eyelids of 17 patients (average 67 years old) with an auricular cartilage sling between 2004 and 2012. All patients had paralytic ectropion with lower eyelid ptosis. Cartilage was harvested via an incision just inside the anterior rim of the helix. Skin incisions were made at the subciliary, medial and lateral canthal regions. The auricular cartilage graft was sutured to the medial canthal tendon medially, lateral orbital rim laterally, inferior tarsus superiorly, and lower eyelid retractors inferiorly. Average follow-up period was 40 months (range 16-60months). The median L-MRD (mm) was improved from 8.4 preoperatively (interquartile range 7.5-8.9) to 5.2 postoperatively (4.8-5.3). The median lagophthalmos (mm) was improved from 5.8 preoperatively (4.7-7.0) to 2.2 postoperatively (1.6-2.6). 16 patients had corneal exposure preoperatively and this resolved completely in 12 patients. All patients experienced good anatomical and functional results with relief of their preoperative pain/discomfort symptoms without complications. No patients required reoperation and none experienced infection, exposure of the cartilage graft, or recurrence of lower eyelid malpositions. Postoperatively, all lower eyelids moved downward with down-gaze. The auricular scar left no significant cosmetic deformity. The modified auricular cartilage sling with 4 point fixation for paralytic ectropion appears to maintain normal eyelid mobility with down-gaze and avoids the problem of lower eyelid fixation.

Periorbital Reconstruction With the Expanded Pedicled Forehead Flap

The complexity of structures within the periorbital region makes reconstruction of this area particularly a challenging endeavor. Within the literature, different techniques have been described for reconstruction of the external lamellae of the upper and lower eyelids as well as the medial and lateral canthal regions.Herein, we present the expanded pedicled forehead flap as a versatile and useful surgical option for reconstruction of various defects around the eye globe. A tissue expander is inserted underneath the forehead skin and serially expanded. The pedicle of the expanded pedicled flap is designed either from the superior portion of the expanded skin and interpolated to reconstruct the upper and lower eyelids, and the medial or lateral canthal areas; or from the inferior portion of the expanded skin and interpolated over the eyebrow to reconstruct the area between the upper eyelid crease and eyebrow.Fifteen patients with periorbital nevi or severe scarring were treated using the expanded forehead flap between the years 2003 and 2012. Thirteen patients had complex periorbital defects involving multiple anatomic areas, and 2 patients had defects confined to the upper eyelid area only. Operative and postoperative course for 13 patients was uneventful. One patient had a late infection of the tissue expander but nonetheless continued with the reconstructive process. In 1 patient, the tissue expander was removed due to infection, and subsequent reconstruction was not carried out. The aesthetic and functional results of reconstruction were very good, and with excellent skin color and thickness match. In 1 patient, the flap was defattened in an ancillary procedure. No partial or complete flap loss was observed in this study. We conclude that the expanded pedicled forehead flap is a safe and reliable method for reconstruction of different segments of the periorbital region, while providing good aesthetic and functional reconstructive results with minimal donor-site morbidity.

Inverted Papilloma Originating Primarily from the Nasolacrimal Duct: A Case Report and Review of the Pertinent Literature.

Introduction. Inverted papilloma (IP) is an uncommon, benign yet aggressive neoplasm characterised by high recurrence rates and tendency towards malignant transformation. The majority of IP cases originate in the ethmoid region, lateral wall of the nasal fossa, and maxillary sinus. The authors report a case of an IP originating primarily from the nasolacrimal duct (NLD). Case. A 69-year-old Caucasian gentleman presented with a lump in his right medial canthal region, epiphora, and discharge bilaterally. Radiological investigation revealed a well-defined, heterogeneous mass within the proximal NLD eroding the bony canal, protruding into the middle meatus and into the right orbit. The tumour was excised en bloc utilizing a combined external and endoscopic approach based on its location. Histology revealed hyperplastic ribbons of basement membrane-enclosed epithelium growing endophytically into the underlying stroma with no evidence of invasive malignancy. The patient made an uneventful recovery with unchanged visual acuity and normal extraocular movements. Conclusion. The case demonstrates variability within the sinonasal tract that IP can develop and the individuality of each case necessitating tailored operative techniques for complete excision whilst minimising recurrence rates. We also present a combined endoscopic approach for the en bloc resection of a NLD IP with no clinical recurrence at 15-month follow-up.

Two Cases of Skin Necrosis after Canaliculodacryocystorhinostomy in Young Women

Purpose: To report 2 cases of skin necrosis over the medial canthus following canaliculodacryocystorhinostomy in young women diagnosed with canalicular obstruction. Case summary: (Case 1) A 31-year-old female presented to our clinic with epiphora in the right eye that had developed 2 years prior. On examination, a right upper and lower canalicular obstruction was noted and the patient underwent canaliculodacryocystorhinostomy with silicone tube intubation. Topical 0.04% mitomycin-C eyedrops were applied twice a day from postoperative day 1 for 7 days. The patient revisited our emergency center with swelling, redness, and tenderness in the medial canthal region that developed 3 days after the initial surgery. Furthermore, a skin ulceration had developed followed by an exudative oozing with crust. (Case 2) A 23-years-old female visited our clinic with epiphora in the right eye that had developed 3 months prior. Ophthalmic examinations revealed a common canalicular obstruction in the right eye and canaliculodacryocystorhinostomy with silicone tube intubation was performed. Seven days postoperatively, the patient developed mild pain and tenderness over the right lacrimal sac and medial canthal erythema with purulent discharge was noted. Furthermore, a localized skin necrosis had developed. Conclusions: Localized skin necrosis may rarely develop after canaliculodacryocystorhinostomy in young women. If localized skin symptoms develop postoperatively, the patient should be closely monitored. J Korean Ophthalmol Soc 2015;56(11):1798-1803

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.

A useful flap combination in wide and complex defect reconstruction of the medial canthal region: Glabellar rotation and nasolabial V-Y advancement flaps.

Reconstruction of medial canthal defects after tumour excision is difficult owing to the thin skin of the region and the concavity of the anatomical landmarks, which enclose complex structures such as the medial canthal ligament and the lacrimal system. Local reconstruction methods for this region include secondary healing, full-thickness skin grafts, and skin flaps from the frontal, transnasal, glabellar and upper eyelid regions. To demonstrate a useful combination of two local flaps in wide defects of the medial canthal region. Between 1998 and 2012, a combination of glabellar rotation and nasolabial V-Y advancement flaps were used in 11 patients with wide complex defects after excision, including periosteum, of invasive basal cell carcinoma. All patients were tumour free and underwent functional and aesthetic reconstruction of the medial canthal region. There were no major complications, and no relapses were observed. This technique achieves good match in colour and texture, and has satisfactory results both aesthetically and functionally. In addition, donor area morbidity is minimal and surgical technique is simple.

A functional periorbital subunit allograft: Vascular, anatomic, and technical considerations for future subunit facial transplantation

Injury to the face can result in the loss of critical specialized structures (the eyelids, lips, ears and nose). Vascularized composite allotransplantation (VCA) allows the surgeon to replace exactly what has been lost. The success of the clinical face transplants suggests the possibility of transplanting specialized units of the face. In this study we explore the neurovascular anatomy and technical specifics for harvest of a functional composite eyelid subunit flap. 12 fresh cadaver heads were studied, each yielding two flaps (N=24). The facial (FA) and superficial temporal arteries (STA) were cannulated and injected with a gelatin/acrylic dye mixture. 6 cadaver heads were evaluated via high-resolution three-dimensional CT scans with contrast. The dye injected into the STA uniformly stained the tissue of the eyelid/periorbital subunit. Injection into the FA resulted in staining of the skin and soft tissues in the medial canthal region and superior eyelid skin in 66% of specimens. CT scan studies confirm our findings with injection into the STA resulting in contrast infiltration of the palpebral arterial arcades in all cases. Injection of the FA resulted in contrast infiltration of the palpebral arterial arcades in 2 of 3 cases. Based this study, a periorbital flap can be based on the STA. Motor innervation of the flap is via the zygomatic and buccal branches of the facial nerve with sensory innervation via the infraorbital, supraorbital and supratrochlear nerves. FA could be used, but its ability to perfuse the entire flap was inconsistent.

Surgical Ciliated Cyst of the Medial Canthal Region After the Management of a Midfacial Fracture

Surgical ciliated cysts are an uncommon complication of maxillary surgery. We report a case of such a cyst that developed at the right medial canthal region 10 years after the surgical treatment of a severe midfacial fracture. The cyst presented as a round cystic lesion protruding through a small bony defect. The lesion was completely excised, and histologic result showed a pseudostratified ciliated epithelial lining.

Medial epicanthoplasty using the “inside-out” technique

The epicanthal fold, a skin remnant covering the medial canthal region, is especially common in Asians. Although numerous surgical techniques for the treatment of the epicanthal fold have been developed, the results.in terms of scars and a natural look remain controversial. In this regard, the authors have developed a new method for medial epicanthoplasty. From January 2005 to December 2011, medial epicanthoplasty was performed on 1132 patients using a technique in which the skin flap inside of the medial epicanthal fold is moved outward (the “Inside-Out” technique). Preoperative and postoperative (2 months) interepicanthal distance was measured. Satisfactory results were achieved in the majority of cases. While nine patients complained of visible scarring after the operation, the scar formation spontaneously resolved within 6 months. This new “Inside-Out” technique for the treatment of the epicanthal fold is easy, simple, and delivers good aesthetic results.

Heminasal Proboscis, A Rare Craniofacial Cleft

Craniofacial clefts are extremely rare congenital anomalies, the importance of which lies in their great range of variety of anatomic forms and their complex management. Proboscis is one of the rare cases of this kind in which half of the nose is separated from the face and it is only pedicled on the right or left medial canthal regions by a nose-like, rudimentary tubular structure. This article reports the case of a 3-month-old infant with left-sided proboscis. Left lower eyelid coloboma was also present. The proboscis was treated with local flaps at the age of 3 months, and at the age of 10 months the coloboma was managed.

Proboscis lateralis

Proboscis lateralis is a rare congenitally acquired facial abnormality characterized by a soft-tissue tube- or trunk-like appendage projecting from the surface of the face, most frequently rooted in the medial canthal region. Proboscis lateralis is generally associated with a wide range of concomitant craniofacial anomalies, giving rise to multiple theories describing the embryological pathogenesis and various classification systems to account for the pathological associations. This paper provides a literature review of the rare manifestations of proboscis lateralis and represents a summary of current literature related to embryological pathogenesis, definitive diagnosis, and surgical management approaches.

Medial Kantal Bölge Defektleri İçin Uygun Bir Seçenek: Purse-String Kapama

Objective: Reconstruction of the defects in the medial canthal region are often challenging for the plastic surgeons because of the particular properties of the surrounding skin. Although there are several reconstructive options reported for this region, there is no single procedure that achieves the best result. In this paper we reported the use of the purse string closure method in medial canthal region defects. Material and Methods: Eight patients with lesions in the medial canthal region were operated in our clinic. All of the defects were closed with the purse string method. Sutures were removed after 3 weeks and patients were followed for 6 to 36 months (median:16.5 months). Results: All of the lesions were diagnosed as basal cell carcinomas. In the early postoperative period, 4 patients complained about skin tension and restriction of eyelid movements, one patient additionally had a minimal wound dehiscence. Eyelid movements and skin tension improved at the end of 1st week. The wound dehiscence healed after the 2nd week without any intervention. Rugae formation and skin distortion disappeared within 6 to 8 weeks. No tumor recurrences were observed. Conclusion: The convenience and the facility of the method to deal with complications offers a good choice for reconstruction of the defects in medial canthal region.

Management of bi-canalicular block: A novel technique

Medial canthal dystopia with canalicular obstruction is a common presentation following injury to the medial canthal region. Conjunctivodacryocystorhinostomy with Lester's Jones tube is considered as the standard treatment in such cases. Alternatively, these patients can be managed by retrograde intubation dacryocystorhinostomy with medial canthoplasty. We herein describe the modification of retrograde bicanalicular intubation, combined with medial canthoplasty (monopedicle flap) which gives good cosmetic results.

Topographic Evaluation of the Medial Canthus—Alar Groove Line in Terms of Determining the Boundaries of Lateral Osteotomies

Nasolacrimal duct injury is a rare complication of rhinoplasty. Detailed regional anatomy knowledge is mandatory to avoid this complication. To display a reference line to protect the nasolacrimal duct from injury during lateral osteotomy, dacryocystography images of 10 patients who underwent rhinoplasty surgery at the authors' clinic were obtained. Lateral osteotomy lines and a line from the medial canthus to the alar groove were marked with radio-opaque wires before procedures. Horizontal and sagittal distances from these lines to the nasolacrimal duct were measured at the beginning, midpoint, and end of the nasolacrimal duct. No sign of nasolacrimal duct injury was observed postoperatively. The mean horizontal distances from the osteotomy lines to the nasolacrimal duct entrance, midpoint, and exit were respectively 0.23±0.12cm, 0.25±0.11cm, and 0.24±0.11cm, and the mean sagittal distances were respectively 0.61±0.21cm, 1.96±0.28cm, and 2.38±0.32cm. The mean horizontal distances from the medial canthus-alar groove line to the nasolacrimal duct entrance, midpoint, and exit were respectively 0.57±0.1cm, 0.51±0.1cm, and 0.46±0.13cm, and the mean sagittal distances were 0.91±0.27cm, 1.34±0.27cm, and 1.79±0.3cm. The osteotomy lines and the nasolacrimal duct were closest in the medial canthal region. The imaginary line from the medial canthus to the junction of the alar wings and cheek was always lateral and anterior to the nasolacrimal duct. Considering the three-dimensional shape of the nose, especially its projection, placement of lateral osteotomies medial to the medial canthus-alar groove line would decrease the risk of nasolacrimal duct injury. 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 .