Correction of Retracted Ala Using Spacer Graft in Secondary Cleft Lip and Nose Deformity

PURPOSE: In patients with unilateral cleft lip and nose deformity, alar retraction is commonly seen on the non-cleft side after cleft side is corrected. Spacer graft was used to drag down the inferior border of the alar cartilage of the non-cleft side so as to match the cleft side. By performing spacer graft and septal extension graft together, symmetry and cosmetic improvements were achieved. METHODS: Seven unilateral cleft lip and nose deformity patients underwent surgery for alar retraction correction. The median age was 24 years (ranged from 15 to 34 years), and the median follow-up period was 7.4 months (ranged from 6 to 12 months). The perpendicular length from the longitudinal axis of the nostril to the alar rim, the nasolabial angle and the ala-labial angle were measured in the lateral view photo. The longest perpendicular length from the cephalic border of the alar rim to the parallel line of the alar base was measured in the frontal view photo. RESULTS: Improvement in alar retraction was seen after the surgery. There were no specific complications during the follow-up and the symmetry of both nostrils was satisfactory. No increase in the nasolabial angle or exposure of the nostrils was seen after the tip projection via tip plasty. CONCLUSION: The fundamental factor in correcting alar retraction with secondary cleft lip and nose deformity is repositioning the alar rim with spacer graft, which seems to be more physiologic than other methods. The method combining spacer graft with septal extension graft will bring symmetry as well as more cosmetic improvement in correction of alar retraction with secondary cleft lip and nose deformity.

Spacer Graft Combined with Canthal Sling in Paralytic Ectropion

Lower eyelid retraction and ectropion is a result of two factors; (1) weakened intrinsic forces associated with senile change or (2) from extrinsic forces by the augmented distraction activity as a result from scar contracture after surgery, laser therapy, or trauma. Facial nerve palsy, in patients with leprosy, causes paralysis of the orbicularis muscle. Its antagonizing muscles, namely, the levator of the upper lid and the capsulopalpebral fascia of the lower lid, function as normal. This counterbalance results in lagophthalmos and retraction of the eyelids. Conventional surgical methods used to correct the ectropion and retraction of the lower lid include lateral canthoplasty, lateral canthopexy, lateral tarsal strip procedure and medial tarsorrhaphy. Recently the use of spacer graft has been incorporated in treating lower eyelid retraction. The use of spacer grafts creates separation between the tarsal plate and the capsulopalpebral fascia, to introduce materials like palatal mucoperiosteum, conchal cartilage or AlloDerm into the space between the two structures. In this study, we designed as AlloDerm or deep temporal fascia graft to function not only as a spacer graft but also as canthal sling. The use of a long spacer graft-sling to supplement the canthal sling showed superior results in elevating the lower eyelid and reducing ectropion. The use of the spacer graft in this method is more effective than other conventional methods.

Spacer graft using deep temporal fascia in the treatment of paralytic ectropion / 나학회지

BACKGROUND: Spacer graft is known to be a very effective surgical method in the treatment of paralytic ectropion. OBJECTIVE: This study was performed to evaluate deep temporal fascia as a spacer instead of Alloderm in spacer graft to correct paralytic ectropion. METHODS: In seven patients with the lower lid ectropion as a sequela of Hansen's disease, a strip of deep temporal fascia, 4.0cm long and 0.5cm wide, was obtained from the scalp. A separation between the tarsal plate and the capsulopalpebral fascia was made and the strip was inserted into the space. Two ends of the strip were fixed to the medial and lateral canthal ligaments respectively like a sling. RESULT: In all patients, immediate postoperative improvement was achieved, which was to the same degree in the patients treated with Alloderm previously reported. And no serious complications were observed in both donor and graft sites. CONCLUSION: As a spacer in spacer graft, patient's own deep temporal fascia shows good cost-effectiveness ratio and can be an alternative to Alloderm. However, further studies are neccessory to find out the long term efficacy, especially recurrence.

Spacer graft combined with canthal sling in paralytic ectropion(Part 2) / 나학회지

The lower eyelid descent and ectropion is resulted from either a decrease in intrinsic forces by senile change or an increase in extrinsic forces by the augmented distraction activity as a result of surgery, laser therapy, or trauma. Although facial nerve palsy in patients with leprosy causes paralysis of the orbicularis muscle, its antagonizing muscles, namely, the levator of the upper lid and the capsulopalpebral fascia of the lower lid, are functioning properly, resulting in lagophthalmos and retraction of the eyelids. There are various conventional surgical methods to correct the ectropion and retraction of the lower lid such as lateral canthoplasty, lateral canthopexy, lateral tarsal strip procedure as well as medial tarsorraphy. Spacer graft, recently introduced, is used to create separation between the tarsal plate and the capsulopalpebral fascia, and to insert maerials like palatal mucoperiosteum, conchal cartilage or Alloderm into the space between the two structures. In this study, we added to one more process to the routine procedure, canthal sling, in which two ends of lengthened Alloderm by 15mm were fixed to both canthal ligaments like a fascial sling. Spacer graft combined with concomitant cnathal sling was proven to be effective in elevating and reducing retraction of the lower lid, and to be superior to any other conventional methods.

No title available / 나학회지

The lower eyelid is anatomically composed of three layers consisting of the anterior lamellar, the middle lamellar and the posterior lamellar. The anterior lamellar is composed of skin and the orbicularis muscle. The middle lamellar is composed of the orbital septum and orbital fat. The posterior lamellar is composed of the tarsus and the capsulopalpebral fascia and conjunctiva. The function of the lower eyelid is dependent upon a net result of balanced forces from the tarsal plate, canthal tendon and the orbicularis muscle sling acting on the lower eyelid. These forces provide the intrinsic support required to maintain contact between the lower eyelid and the globe. Forces acting against the intrinsic support of the lower eyelid (extrinsic forces) provide inferior and anterior net vector from the globe. The normal anatomic function and aesthetic appearance of the eyelid is achieved when the intrinsic forces are greater than or equal to extrinsic forces. The lower lid descent and ectropion characterized by unfavorable imbalance are a result of either a decrease in intrinsic forces by weaking the support as in senescence or an increase in extrinsic forces by strengthening the distraction forces as a result of surgery, laser treatment, or trauma. Either way, the extrinsic forces become greater than intrinsic forces. Facial nerve palsy of a leprosy patient causes paralysis of the orbicularis muscle but its antagonistic action muscles (the levator muscle of the upper lid and the capulapalpebral fascia of the lower lid) are functioning resulting in retraction and lapophthalmus of the upper and lower eyelid. Ectropion and retraction in the lower eyelid require various traditional surgical methods such as cantopexy, canthoplasty, lateral tarsal strip procedure as well as medial tarsorrhaphy. In addition to traditional methods, we used a spacer graft consisting of hard palate mucosa or Alloderm. Spacer grafts can be used in either a posterior or anterior method. In the posterior method, the spacer graft is used to create separation between the tarsal plate and the capsulopalpebral fascia / conjunctiva structure. A 5 to 25mm elliptical strip of hard palate mucosa is harvested from the patient and insterted between the two structures. The conjunctiva is dissected in this procedure. In the anterior method, we disinserted the lower edge of the tarsus and the capsulopalpebral fascia. A 5 to 25mm elliptical shaped strip of Alloderm was then inserted between the two structures. The conjunctiva remains intact in this procedure. In addition, a 5 to 35mm Alloderm strip was inserted to immitate the function of the fascia sling and increase the elevation of the lower lid as a spacer graft. The spacer graft with traditional surgical methods was more effective in elevating the lower lid and significantly reducing retraction than using traditional methods alone.