Prevention of ectropion in reconstruction of facial defects.

Lower eyelid malpositions and ocular damage occur with inadequate reconstructions of facial defects that encroach on the periocular region. Reconstructive principles and techniques are presented that are essential in the prevention of ectropion in these situations. Eyelid and periocular anatomy is reviewed. The use of canthalplasties, canalicular reconstruction, and ancillary techniques for facial flaps are presented.

Periorbital melanocytic lesions: excision and reconstruction in 40 patients.

The treatment of melanoma arising in the periorbital region is a difficult reconstructive problem. The abundance of vital structures in close proximity to one another makes the resection and subsequent reconstructive procedures extremely challenging. Reported here is experience with periorbital melanocytic lesions in 40 patients with the emphasis on the types of reconstruction performed. Forty patients with periorbital melanocytic lesions were treated between 1984 and 1995. The periorbital region was subdivided into five zones. These zones are the following: zone I, upper eyelid; zone II, lower eyelid; zone III, medial canthus; zone IV, lateral canthus; and zone V, contiguous structures. Ocular melanomas were not included in this study. The distribution of the lesions in our 40 patients was zone I (n = 1), zone II (n = 14), zone III (n = 1), zone IV (n = 9), and zone V (n = 31). The ages of the patients ranged from 3 to 84 years at the time of reconstruction, with an average age of 57 years. Resection and reconstruction were performed simultaneously in all patients. Thirty-six of the patients were reconstructed with one procedure, three patients required two procedures, and one patient required five procedures. The tumor type was superficial spreading melanoma in 15 patients, melanoma in situ in 17 patients, malignant spindle cell neoplasm in 2 patients, desmoplastic melanoma in 2 patients, amelanocytic melanoma in 1 patient, epithelioid melanoma in 1 patient, and atypical melanocytic nevus in 2 patients in which an early, evolving melanoma could not be excluded. Elective lymph node dissection was performed in four patients for intermediate thickness lesions (1.5 to 4.0 mm). The types of reconstructions performed included full-thickness skin grafts, upper lid myocutaneous flaps, cheek advancement flaps, cervicofacial flaps, inferiorly based nasolabial flaps, tarsoconjunctival flaps, frontalis muscle flaps, medial transposition Z-plasty, and primary closure. The resection of periorbital melanomas can be difficult because of the number of important anatomic structures in the region. The challenge to the surgeon in handling head and neck melanomas in general lies in the need to provide the best functional and aesthetic result while still resecting the primary lesion with the intent of effecting a cure. We present our series to demonstrate that the adequacy of margins of resection need not be compromised to facilitate reconstruction and that excellent results are obtainable with reconstructive procedures performed after adequate resections. Several different types of flaps and grafts can be used, with the indications varying depending on the location of the lesion and the extent of resection. The major reconstructive options will be reviewed in detail.

Evolution of the lateral canthoplasty: techniques and indications.

Lateral canthoplasty is a useful method to restore eyelid function and to protect the ocular surfaces. The success of the procedure depends on the proper analysis of periorbital anatomy as it relates to the specific indication for lateral canthoplasty. We report the experience with 1565 lateral canthoplasties with emphasis on the evaluation of newer techniques that better address anatomic and functional requirements. Between 1981 and 1994, 1565 lateral canthoplasties were performed in 684 patients. Of these, 1369 "reconstructive" lateral canthoplasties were performed in 586 patients and 196 "cosmetic" lateral canthoplasties were performed in 98 patients. All operations were performed by a single surgeon (Jelks), and follow-up ranged from 1 to 14 years. The evolution of the operative technique for lateral canthoplasty has been toward an operation that corresponds with the anatomy of the individual. Indications for the procedure include lateral canthal dystopia, horizontal lid laxity, ectropion, entropion, lid margin eversion, lid retraction with or without soft-tissue deficiency, and aesthetic improvement. The types of procedures performed will be reviewed in detail. The evaluation of the newer forms of lateral canthoplasty as unique reconstructive tools and as adjuncts to aesthetic surgery will be discussed.

The inferior retinacular lateral canthoplasty: a new technique.

Lateral canthoplasty is a useful method of restoring lower eyelid position and thereby protecting the ocular surfaces. The success of the lateral canthoplasty procedure depends on the proper analysis of periorbital anatomy. Newer lateral canthoplasty techniques have become progressively refined in an attempt to avoid the drawbacks and pitfalls of older procedures. We present the inferior retinacular lateral canthoplasty, developed to effectively address the problems associated with lower lid laxity and/or malposition. The inferior retinacular lateral canthoplasty is a versatile reconstructive procedure that also can be used as an adjunct to aesthetic surgery. The evolution of the inferior retinacular lateral canthoplasty from over 15 years of clinical experience is discussed.

Periocular reconstruction: a systematic approach.

The records and photographs of 90 patients who underwent reconstructive procedures on the eyelids, canthi, and periocular tissues between 1982 and 1988 were reviewed retrospectively. The defects created by either fresh tissue histologically controlled resection or primary excision were analyzed according to location, size, and degree of resection and visual status. Histologic types included nodular, morphea, and fibrosing basal cell carcinomas; well to poorly differentiated squamous cell carcinoma; and melanoma in situ. The adequacy of both ocular protection and tissue preservation was assessed between 1 and 6 years postoperatively. Anatomic as well as functional reconstructions were performed with a complication rate of 12 percent. There were two tumor recurrences requiring extensive craniofacial extirpation and reconstruction. A systematic method of classifying periocular defects was developed in order to analyze various reconstructive options as well as the type and frequency of complications encountered. This classification system is applicable to primary benign and malignant lesions as well as defects. Analysis of patients who underwent periocular reconstruction in the context of this classification system reveals that larger defects and those involving the medial canthus are more prone to complications. Recurrent complications in the medial and lateral canthal region underscore the necessity of routinely utilizing ancillary procedures such as lacrimal intubation and canthopexy. Recommendations for periocular reconstruction are suggested based on this classification system.

Preoperative evaluation of the blepharoplasty patient. Bypassing the pitfalls.

Patients predisposed to postoperative eyelid malposition can be identified by the careful preoperative analysis of the periorbital anatomy in conjunction with a good medical history. When necessary, ancillary procedures are performed at the time of the initial blepharoplasty to avoid undesirable deformities.

Repair of lower lid deformities.

The most common complication of blepharoplasty is an unnatural distortion of the lower eyelid. Identification of the underlying anatomic deformities dictates the reconstructive procedures. Emphasis is placed on utilization of the dermal-orbicular pennant lateral canthoplasty.

The influence of orbital and eyelid anatomy on the palpebral aperture.

A multitude of factors influence the palpebral aperture: the surrounding bony orbital anatomy, the internal orbital volume, the integrity of the eyelids, and their muscular and tarsoligamentous support system. Furthermore, it is influenced by the relative amount of associated periorbital skin, fat, and soft tissues. Unique individual combinations of the above eyelid and orbital anatomic influences cause the variations in the palpebral apertures.

Clinical and radiographic evaluation of the orbit.

A complete clinical examination of the orbit must include a detailed physical evaluation of the eye and its associated structures. Whether the examination is for a traumatic, infectious, inflammatory, or neoplastic condition of the orbit, the main concern is determination of the visual status and preservation of vision.

Early correction of orbicularis oculi paralysis with an encircling silicone prosthesis.

Fifteen patients with paralysis of the 7th and 5th nerves or the 7th nerve alone were treated with an encircling silicone prosthesis. There has been no serious ocular complication observed over the last 3 years. The prosthesis has been removed in 9 of the 15 patients in whom good 7th nerve recovery has occurred. In the remaining 6 patients, the prosthesis is being well tolerated.

Dry eye syndrome and other tear film abnormalities.

The goal of cosmetic blepharoplasty is to obtain an improvement in the appearance of the eyelids without causing functional or symptomatic alterations in the patients. Patients with undiagnosed problems in tear production who have cosmetic blepharoplasties are a common source of extremely dissatisfied patients with alarming ocular symptoms. Although keratoconjunctivitis sicca is the most common manifestation of an abnormal tear film state, there are other conditions of which the eyelid surgeon should be aware. Knowledge of methods used in the diagnosis of states of tear deficiency will allow the surgeon to better select candidates for cosmetic eyelid procedures.

Uniocular nystagmus in monocular visual loss.

Uniocular nystagmus was studied by electro-oculography in ten patients with monocular visual loss caused by ocular and optic nerve lesions. In these patients, visual loss was congenital or acquired in childhood or adult life. In all patients the oscillations were present in the primary position of gaze and were vertical, pendular, and of variable and low frequency (less than, or equal to, 1.0 HZ) and amplitude (usually less than 5 degrees). Refixation saccades, smooth pursuit, optokinetic nystagmus, and vestibuloocular responses to rotation in the horizontal and vertical planes were within normal limits. The irregularity, low frequency, and low amplitude of this form of nystagmus cause it to often be missed during casual clinical examination, but easily differentiate it from other causes of uniocular nystagmus.