Medial Canthal Region Research Articles

The Use of the Superthinned Inferior Pedicled Glabellar Flap in Reconstruction of Small to Large Medial Canthal Defect

Medial canthal defects resulting from tumor resection are often too large to be closed directly because local tissue is in short supply. They can be repaired by using skin-muscle flaps or full-thickness skin graft to highlight a different technique, which may improve the cosmetic results achieved with this flap by reducing the tendency for the eyebrows to be drawn together. The superthinned inferior pedicled glabellar flap technique was used prospectively in 8 patients requiring medial canthal reconstruction. All patients were satisfied with the cosmetic and functional results. Photographs of all patients illustrate the preoperative and postoperative appearances of the eyebrows.This superthinned inferior pedicled glabellar flap technique is recommended to avoid drawing the eyebrows and bulky appearance in medial canthal region together when using the glabellar flap.

Apocrine Sudoriferous Cyst in Medial Canthal Region Occurred after Trauma

Purpose: To report a case of apocrine sudoriferous cyst in the left medial canthal region occurred after trauma. Case summary: A 75-year-old woman was referred for mass in the medial canthal region after trauma. The patient had got injured and been sutured on left medial canthal region when she was 11 years of age. The painless mass in the left canthal region has occurred after that. The orbital computed tomography showed a 20ⅹ12ⅹ19 mm-sized cystic mass. On physical examination, left telecanthus, left exotropia and left hypertropia were also observed. The cyst contained turbid grayish fluid and was removed completely through transcutaneous incision. On histopathologic examination, the cyst was confirmed to apocrine sudoriferous cyst lined by two-layered cuboidal epithelia.

Supraorbital Artery Island Flap for Periorbital Defects

The forehead skin has the same color and texture as the periorbital region as well as the other parts of the face. The forehead is a local flap donor area for the reconstruction of full-thickness periorbital defects. This report presents eight cases in which full-thickness defects resulting from tumor resection have been repaired with supraorbital artery island flaps. Of eight patients, one was female and the rest were male with a mean age of 72.8 years (range, 64-88 years). Defects were located in the medial canthal region, lateral canthal region, glabella, and lateral part of the orbita. The flaps ranged from 2 x 3 cm to 6 x 7 cm in size. The patients were followed for 7 to 18 months. No complications occurred, except for decreased sensation on the forehead, and trapdoor deformity was seen in one case. The outcome was functionally and aesthetically satisfactory in all cases and all patients were happy with the outcome. The supraorbital artery island flap is a good alternative for the repair of defects around the orbita in that the color and texture of this flap match up with the orbital region and that it is pliable, simple, safe, and sensorial and requires only a single-session procedure.

Blepharophimosis–ptosis–epicanthus inversus syndrome: objective analysis of surgical outcome in patients from a single unit

The aim was to objectively assess surgical outcome in blepharophimosis-ptosis-epicanthus inversus syndrome (BPES). Retrospective review of 14 consecutive patients with BPES. Mustardé double z plasty (at about age 4) and autogenous fascia lata Crawford brow suspension (9-12 months later) were used in all. One consultant performed all operations. Patient photographs were scanned and magnified for analysis. Preoperative and postoperative intercanthal distance, vertical palpebral aperture and cosmetic outcome were measured. Values were converted into ratios. Bilateral (mildly asymmetrical) ptosis and symmetrical epicanthic folds were found in all preoperatively. Seventy-one per cent had severe folds. Preoperative intercanthal distance ratio range was 1.26-1.60 (non-BPES=1.0). Median reduction post surgery was 26% (P=0.001, Wilcoxon's signed ranks test). Patients with largest preoperative ratio displayed greatest correction (P=0.029). Mustardé technique completely abolished all epicanthic folds and unmasked prominent caruncles in all. Fifty per cent had mild scarring postoperatively in the medial canthal region. Median change in marginal reflex distance ratio (right)=22.2% (P=0.012), left=18.2% (P=0.008), Wilcoxon's signed ranks tests. Postoperatively all had formed eyelid creases with improved upper lid position symmetry. This is the first known study objectively assessing surgical outcome in BPES. Mustardé double z plasty and Crawford autogenous fascia lata brow suspension are an effective surgical combination in the treatment of this syndrome, with overall cosmetic benefit.

Medial Epicanthoplasty Using the Skin Redraping Method

The presence of epicanthal folds and the absence of supratarsal folds are unique features in the eyelids of Asians. The resulting appearance leads many to seek cosmetic improvement in the medial canthal area. Although many techniques have been described for the elimination of epicanthal folds, scarring and design complexity are barriers that must still be overcome by surgeons. From December of 2002 to December of 2004, the authors performed medial epicanthoplasties using the skin redraping method (tension-free epicanthoplasty) to correct epicanthal folds in the eyelids of 215 Asian patients. The authors' method is very simple to design and easy to perform. The procedure requires only the elevation of skin, eliminating volume of muscle, and trimming of skin. Other ancillary procedures, such as flap design, anchoring, plication, or subdermal fixation, are not required. Most of the patients obtained satisfactory results. No patients complained about visible scarring and none required revision surgery. Scarring can be avoided on the noticeable medial canthal region because the only incisions needed are supratarsal and subciliary incisions. The ability to avoid tension resulting from skin redraping is another important factor contributing to the minimization of scarring. The skin redraping method is simple to design and easy to perform. It does not create tension or visible scars on the medial canthal region.

Mucocele del seno frontal de presentación atípica: Informe de un caso

We report a case of a 46-year-old woman who developed a tender, painful mass in the left superior eyelid over a period of about 6 months. This was a frontal mucocele with atypical clinical and histopathologic features. Most mucoceles arise from the frontal or ethmoidal sinuses. Frontal mucoceles usually cause outward and downward displacement of the globe, and are often associated with fullness in the supero-nasal and medial canthal region and a palpable mass.

Basal Cell Carcinoma of the Caruncle

An 82-year-old white man presented with a 2- to 3-month history of a lesion in his left medial canthal region. Surgical excision of the lesion was performed, and histopathology showed a nodular basal cell carcinoma of the caruncle. Because of incomplete surgical margins after the initial excision, a second excision was performed, followed by a course of adjuvant radiotherapy. No tumor recurrence was detected in the caruncle after 6 months of follow-up.

A combined flap reconstruction for full-thickness defects of the medial canthal region

The medial canthus is an aesthetically and functionally important area. Adequate consideration of the local anatomy is essential when reconstructing this area. We developed a combined flap technique with a simple combination of standard flaps for the treatment of extensive defects of the nose and upper and lower eyelids, including full-thickness medial canthus defect. In our technique, a median forehead island flap is used for the nasal region, the anterior surface of the eyelid is reconstructed along aesthetic unit, and the posterior surface is reconstructed with a palatal mucoperiosteal graft. A cheek flap is then used for the reconstruction of the lower eyelid. When reconstructing a small defect of the upper eyelid, the upper eyelid is advanced, while a V-Y advancement flap within the upper eyelid is used for a large defect. To reconstruct the acute angle of the medial canthus, a 0.3 mm titanium wire was passed through the tip of the tarsal plate of the upper and lower eyelids to be reconstructed and was fixed in the perforated nasal bone on the affected side. Using this technique, the acute angle of the medial canthus is well preserved after surgery, and is located symmetrically with its counterpart on the intact side. Our technique provides good reconstructive results and should serve as a valid alternative for the reconstruction of this area.

Upper eyelid rotation flap for reconstruction of medial canthal defects

M edial canthal defects resulting from cancer resection after Mohs micrographic surgery present challenging reconstruction dilemmas. In fact, medial canthal reconstruction has been controversial because of the time-honored method of second-intention healing in wound management of this area. Yet, small flaps and grafts for repair of cutaneous medial canthal defects may result in a quicker healing process with excellent cosmetic results. The main difficulties of reconstruction of the medial canthal region are the lack of local availability of similar thin eyelid skin, and the concavity of the defect to be repaired. The area of the medial canthus includes the free tissue margins of the upper and lower eyelids, the bony attachments of the medial canthal tendon, the lacrimal puncta, and arteriovenous and neural bundles that supply and innervate the region. The literature describes a multitude of surgically complex and intricate reconstruction methods including eyelid myocutaneous transposition flaps, glabellar flaps, cheek flaps, V-Y advancement flaps, and skin grafts for repair of defects of the medial canthus. Although these reconstructive options represent tested and widely used choices for medial canthal restoration, they are limited in that these techniques often provide a less than ideal color or texture match, provide tissue that is either too thick or too thin, or place incisions that cross aesthetic units and boundaries. We describe a novel flap that is conceptually simple to design and execute for the repair of medial

Heminasal Proboscis With Associated Microphthalmos and Encephalocele

Heminasal proboscis is a rare congenital malformation that presents complex management issues when associated with other craniofacial abnormalities. A newborn male, known to have a facial mass on prenatal ultrasonography, was delivered by planned induction at 37 weeks' gestation. He was intubated immediately because of anticipated respiratory difficulty. He had a right-sided proboscis, pedicled on the right medial canthal region. Additional airway evaluation identified a piriform aperture and choanal stenosis. Magnetic resonance imaging confirmed a hypoplastic orbit with aplastic optic nerve and a naso-orbito-ethmoidal encephalocele. Right upper and lower eyelid colobomas were present. The airway was initially stabilized with a tracheostomy. Beginning at the age of 10 weeks, he underwent several staged procedures to excise the encephalocele and to reconstruct the nose, orbit, eyelid, and lacrimal drainage system. The encephalocele was exposed via a bicoronal approach and frontal craniotomy. The dural defect was repaired with a pericranial flap. Nasal reconstruction provided an adequate nasal passage and tip after three staged procedures. Creation of a conjunctival flap prepared the right eye for later insertion of a prosthetic shell. The patient remained successfully decannulated 3 years after his last reconstructive procedure. Identification of all associated anomalies is important before initiating surgical repair. The presence of coexisting craniofacial abnormalities requires a multispecialty approach and coordination of surgical procedures.

An assessment of incomplete facial Basal cell carcinoma excision.

To determine the rate and cause(s) of incomplete excision of basal cell carcinoma, occurring on face. A non-interventional, descriptive study. Plastic Surgery Unit, Hayatabad Medical Complex, Peshawar, from January 2002 to March 2004. Patients with basal cell carcinoma of the face reporting to the OPD were included in the study and were booked for surgery. After excision, all tumors specimens were marked at 12 o'clock and sent to laboratory for histopathology to confirm the diagnosis and to know the completeness/incompleteness of tumor excision. If biopsy reported residual tumor in any of the margins it was noted and projected as percentage for the purpose of our results. Out of 56 patients, 49 (87.5%) had complete excision of tumor. Six (10.7%) had residual tumor while in one (1.7%) patient, biopsy report failed to mention the involvement/clearance of margins. Six patients with residual tumor were given postoperative radiotherapy. All patients were followed for a minimum of 2-1/2 years (critical period for recurrence) with careful watch on those with residual tumor. So far, only 2 of these 6 had recurrence of lesion. Both of them were greater than 2 cm in diameter and were located on medial canthal and nasolabial region. Chances of incomplete tumor excision are more on the mid face region. Patients with residual tumor are more prone to recurrence.

Immunohistochemical Diagnosis of a Rare Case of Epithelioid Malignant Peripheral Nerve Sheath Tumor with Multiple Metastases

The epithelioid variant of malignant peripheral nerve sheath tumor (MPNST) is a rare tumor with poor prognosis that sometimes involves the head and neck. The diagnosis is based principally on the histological examination, and it is generally very difficult to reach the correct diagnosis. An 84-year-old Japanese woman presented with a tumor mass of 2 week's duration in the right medial canthal region. Although the tumor was excised surgically, metastases occurred three times on her face and head, and the patient died of distant systemic multiple metastases. In the histopathological analysis, the tumor showed a composite pattern comprising spindle or polygonal cells arranged in irregular bands, and a population of larger epithelioid cells in solid sheets and nests. In the immunohistochemical analysis, the tumor cells were positive for S-100 protein, vimentin, and nerve growth factor receptor (NGFR), and negative for cytokeratin and HMB 45 (melanoma-associated antigen). These findings confirmed the diagnosis of MPNST. Epithelioid MPNST has complex histopathological findings and histopathological features similar to other epithelioid tumors, especially malignant melanoma. Immunohistochemical examination using NGFR and HMB-45 is important in the differential diagnosis.

The orbicularis oculi myocutaneus flap in the repair of the medial canthal region. A new strategy for canthal resurfacing

The aim of this study was to review the surgical anatomy and the variants of the orbicularis oculi myocutaneus flap (OOMF) for reconstruction of inner canthus defects. Anatomic studies in fresh heads were carried out to demonstrate its blood and nerve supply. Four cases of epitheliomas of the inner canthus were treated with surgical excision and reconstructed with medially based island and nonisland OOMF. A 36-months follow-up showed no deformities of the flap, good colour matching and satisfaction scars. The flap is recommended for small to medium size defects of the inner canthus in patient with skin excess in the eyelid.

Successful non-surgical “salvage therapy” of morpheaform basal cell carcinoma in patients refusing surgery

We report two cases of morpheaform basal cell carcinoma of the face which were successfully treated with imiquimod 5% cream when conventional Mohs micrographic surgical excision was declined. Imiquimod 5% cream was used as monotherapy in the first case (morpheaform BCC on the forehead). A combination regimen of imiquimod 5% cream plus diclofenac solution was utilized in order to optimize therapy in the second case (morpheaform BCC on the lateral nose and medial canthal region) which demonstrated perineural invasion. Clincal and histologic clearance were seen after 16 weeks of topical drug application. Tolerable side effects included site specific tissue reaction.

Medial Canthal Reconstruction Using a Medially Based Upper Eyelid Myocutaneous Flap

Periorbital reconstruction following skin cancer ablation represents a challenging problem. A thorough understanding of the complex periorbital anatomy is necessary to preserve lid function and protect the ocular surface. The medial canthal region represents the most difficult periorbital zone to reconstruct. This area has a complex anatomy involving both the medial canthus itself and the lacrimal apparatus. The authors present their experience with a versatile technique for reconstruction of the medial canthal periorbital region, namely, a medially based upper eyelid myocutaneous flap. In the 10 patients in whom this procedure was used, there was one partial and no complete flap losses. The authors believe that the medially based upper lid myocutaneous flap offers an excellent solution to the difficult problem of medial canthal periorbital reconstruction. (Plast. Reconstr. Surg. 110: 1636, 2002.)

Selective antibiotic use to prevent postoperative wound infection after external dacryocystorhinostomy.

The use of systemic antibiotic prophylaxis in lacrimal drainage surgery is controversial. Some studies have reported high rates of postoperative infection and surgical failure after lacrimal drainage surgery when systemic antibiotic prophylaxis was not routinely administered. Many ophthalmologists have traditionally used antibiotics only in selected patients undergoing dacryocystorhinostomy (DCR), and this study evaluates the success of this strategy. This was a retrospective interventional case series of 138 consecutive patients who underwent 163 external DCR procedures. Antibiotics were given only when inflammatory signs were present in the medial canthal region or when purulent material was noted during surgery. Patients with persistent external medial canthal inflammatory signs received amoxicillin/clavulanate or cephalexin orally 3 to 7 days before and 1 week after surgery. Patients in whom purulent lacrimal sac material was noted during surgery received cefazolin intravenously. Postoperative results were evaluated in terms of wound infection and related complications and surgical success. Systemic antibiotics were given in 15 of 163 (9%) cases. Nine (6%) cases received intraoperative (intravenous) antibiotics; 5 (3%) cases received perioperative (oral) antibiotics; and 1 (1%) case received both. None of the patients had postoperative deep soft tissue infection (cellulitis). Skin changes compatible with superficial wound infection occurred in 2 (1%) cases and responded well to topical treatment. Surgery was successful in 157 of 163 (96%) cases. Of 6 failures, none were associated with postoperative wound infection. Selective use of antibiotics limited to patients with signs of lacrimal sac inflammation appears sufficient to prevent soft tissue infection after DCR.

No-scar Asian epicanthoplasty: a subcutaneous approach.

The epicanthal fold is a normal finding in the medial portion of the upper eyelid in many Asians. We describe a simple technique of removing the excess muscle and softening or eliminating the epicanthal fold without making incisions in the medial canthal region, thus avoiding complications such as scarring or web formation Interventional case series. The subcutaneous epicanthoplasty was performed on all Asian patients undergoing concurrent upper eyelid blepharoplasty or aponeurotic ptosis repair. Thirty-eight Asian patients underwent epicanthal fold correction between January 1996 and December 2000. All patients had softening of the epicanthal fold; however, some cases of mild undercorrection were noted. Softening or elimination of the Asian epicanthal fold can be accomplished without making skin incisions in the medial canthal region. Our technique is a simple, graded procedure that can be performed in conjunction with upper blepharoplasty or ptosis repair.

Superomedially based upper eyelid musculocutaneous flap for closure of medial canthal defects

The medial canthal region has a complex anatomy and is associated with significant neighboring structures. These features limit reconstructive options and make those procedures difficult. A superomedially based upper eyelid musculocutaneous flap has been designed. Using this flap, which is basically a Tripier flap with a single superomedial pedicle, six medial canthal defects were reconstructed following the resection of benign and malignant lesions. The pedicle was based supramedially and this allowed defects to be reconstructed that included the medial parts of the upper and lower eyelids and resulted in minimal morbidity.

Reconstruction of the inner canthus region with a forehead muscle flap: a report on three cases

We report our experience of using a forehead flap to repair the defect left by the excision of skin tumours in the medial canthal region involving both eyelids in three patients. Both eyelids and the inner canthus were reconstructed using a myofascial flap taken from the forehead, combined with septal chondro-mucosal grafts, oral mucosa and skin grafts. After a careful anatomical study of the vascularisation of the frontal region, we used only the frontal myofascial portion, a part of the forehead muscle vascularised by the deep branch of the supraorbital artery and by the supratroclear artery; the skin left behind is adequately nourished by the fine mesh of anastomoses in the area between the two supratroclear arteries, the supraorbital artery and the terminal vessels of the superficial temporal artery. The particularly thin, elastic and resistant features of this flap enabled us to repair a loss of substance in a difficult area with a successful outcome in terms of morphology, function and cosmetic appearance.

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

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