Lateral canthal reconstruction for the treatment of macroblepharon/diamond eye conformation in dogs.

PURPOSE: To introduce a novel surgical technique for treatment of macroblepharon and diamond eye conformation in dogs. METHODS: Lateral canthal reconstruction was used in dogs with prominent eyelid malformations resulting in ocular surface disease. Lateral canthus was resected and new lateral canthus was created using a two-layer closure. This technique was performed either alone or in combination with additional procedure(s). Additionally, this technique was used to resect lateral canthal dermoid. RESULTS: One hundred and fifty-three eyes of 85 dogs were included in the study. Procedure was done for macroblepharon and/or lateral canthal entropion (149 eyes of 81 dogs) or for lateral canthal dermoid (four eyes of four dogs). Procedure was done either alone (n = 68 eyes) or in combination with additional procedure (n = 85 eyes). Favorable cosmetic outcome and client satisfaction was achieved in all dogs. Good to excellent functional outcome was recorded in all but 6 eyes of 4 dogs, which required additional surgery. Most common complications included slight undercorrection or overcorrection. CONCLUSIONS: Lateral canthal reconstruction is a simple yet effective surgical procedure for macroblepharon and/or lateral canthal entropion. If done early, it prevents development of secondary eyelid malformation ("pagoda defect") in giant breed dogs. If done after severe eyelid malformation has developed, combining this technique with concurrent pagoda resection is recommended to achieve ideal eyelid conformation. None.

Comparison of Intense Pulsed Light Treatments including Upper Lid or Lateral Canthus in Patients of Meibomian Gland Dysfunction.

Background: To determine the differences in the effects of intense pulsed light (IPL) treatment when including the upper and lower lid or lateral canthus area in patients with meibomian gland dysfunction (MGD). Methods: Patients who underwent three IPL treatment sessions at 3-week intervals were divided into three groups according to the treatment sites: group A, lower lid; group B, upper and lower lids; and group C, lower lid and lateral canthal area. Before and after the IPL treatment sessions, we obtained the lid abnormality score (LAS), meibum expressibility (ME), meibum quality (MQ), lipid layer thickness (LLT), type I Schirmer test (ST), tear break-up time (TBUT) test, corneal fluorescein staining scores (CFSs), and Ocular Surface Disease Index (OSDI). Results: IPL treatment significantly improved LASs, ME, MQ, TBUT, CFS, and OSDI values in all groups. Differences in LAS values before and after IPL treatment were significantly greater in groups B and C than those in group A. Conclusions: IPL treatment encompassing the upper lid and lateral canthus together with the lower lid elicited additional improvement in patients with MGD. The additional effect on treating the lateral canthus was similar to the effect observed on the additional treatment of the upper lid.

Congenital solitary osseous choristoma of the left lateral canthus: a case report.

BACKGROUND: An ocular osseous choristoma is a growth of mature, compact bone in the ocular or periocular soft tissue, and it is the rarest form of ocular choristoma, accounting for only 1.7% of all epibulbar choristomas. CASE PRESENTATION: Herein we present the case of a 20-month-old girl who was referred to the oculoplasty clinic with a progressively growing mass in the left lateral canthus. It had been present since birth without ocular involvement. Upon examination the mass was firm with a smooth surface, measured 9 × 6 × 3 mm, and exhibited no episcleral attachment or ocular involvement. An excisional biopsy was performed, and the histopathological findings were consistent with osseous choristoma of the left lateral canthus. CONCLUSIONS: This report highlights the importance of considering osseous choristoma in the differential diagnosis of eyelid lesions, particularly those that have been present since birth. It also emphasizes the need for further studies investigating associations between osseous choristomas and ocular canthi.

Lacrimal Sac, Classified within the Orbital Tissue.

PURPOSE: To disclose that the lacrimal sac is classified within the orbital tissue. MATERIALS AND METHODS: Ten orbits of 9 Japanese cadavers aged 64 to 85 years at death were included. The attachment site of the orbital septum in the medial canthal area was grossly dissected. The relationship between the orbital septum attachment site and the location of the lacrimal sac was examined. RESULTS: In the upper region, the orbital septum was attached to the most superior area of the lacrimal fossa and the medial canthal tendon. In the lower region, the septum was attached to the anterior lacrimal crest and the medial canthal tendon. In both the upper and lower regions, none of the septa attached to the posterior lacrimal crest. The lacrimal sac was situated behind the orbital septum. CONCLUSION: The lacrimal sac, which is situated behind the orbital septum, is classified within the orbital tissue.

The lacrimal sac, which is situated behind the orbital septum attaching to the anterior lacrimal crest and the medial canthal tendon, is classified within the orbital tissue.

Difficulties of nasocutaneous fistula repair, following lacrimal outflow system malignancy resection.

PURPOSE: To evaluate the incidence of nasocutaneous fistula (NCF) development, following en bloc resection of lacrimal outflow system malignancies (LOSM), and describe the methods of surgical repair. METHODS: Retrospective review of all patients who underwent resection of LOSM with reconstruction and post-treatment protocol at the University of Miami between 1997 and 2021. RESULTS: Of the 23 included patients, 10 (43%) developed postoperative NCF. All NCFs developed within one year of surgical resection or completion of radiation therapy. NCF was seen more frequently in patients who underwent adjuvant radiation therapy and those who had reconstruction of the orbital wall with titanium implants. All patients underwent at least one revisional surgery to close the NCF, including local flap transposition (9/10), paramedian forehead flap (5/10), pericranial flap (1/10), nasoseptal flap (2/10), and microvascular free flap (1/10). Local tissue transfer, pericranial, paramedian, and nasoseptal forehead flaps failed in most cases. Two patients had long-term closure; one patient who underwent a paramedian flap and a second who underwent a radial forearm free flap, suggesting that well-vascularized flaps may be the most viable option for repair. CONCLUSIONS: NCF is a known complication, following en bloc resection of lacrimal outflow system malignancies. Risk factors for formation may include adjuvant radiation therapy and use of titanium implants for reconstruction. Surgeons should consider utilizing robust vascular-pedicled flaps or microvascular free flaps for repair of NCF in this clinical scenario.

Positional relationships of the origin and course of zygomaticus major with the nasal ala, tragus, philtrum, and lateral canthus for aesthetic treatments and surgeries.

PURPOSE: The aim of this study was to characterize the origin and course of the zygomaticus major muscle (Zmj) with its topographic relationships with the nasal ala, tragus, philtrum, and lateral canthus. METHODS: The Zmj was examined in 50 specimens of 25 embalmed adult Korean cadavers. Facial muscles were dissected to expose the origin and course of the Zmj in 48 specimens of 24 cadavers. The 25th cadaver was sectioned to obtain images of the Zmj. RESULTS: The positional relationships of the Zmj origin with the nasal ala and the tragus were classified into three categories. A horizontal line through the center of the Zmj origin and the nasal ala passed through the tragus in 20 of 48 specimens (41.7%), the intertragic notch in 18 specimens (37.5%), and above the tragus in 10 specimens (20.8%). In a horizontal section of the head, the Zmj origin was located near the level of the nasal ala and tragus. In a coronal section of the head, the fibers of the Zmj arising at its origin were located close to the zygomatic bone, lateral to the zygomaticus minor muscle. CONCLUSION: By combining dissection with the analysis of sectioned images and ultrasound images of the Zmj, this study has yielded positional information for easily predicting the location of the origin and the course of the Zmj and its related structures underlying the skin.

Bilobed flap reconstruction after en-bloc removal of solitary fibrous tumor of the lacrimal sac.

Purpose: To report a rare case of a solitary fibrous tumor (SFT) of the lacrimal sac and discuss considerations for management of similar cases. Observations: We present the case of a 41-year-old woman who presented with a primary lacrimal sac SFT for which she underwent en-bloc surgical resection. We discuss management options for SFTs and our surgical approach for this case: bilobed flap reconstruction of the medial canthus and inferior orbit. Conclusions: We present an uncommon presentation of a rare tumor and a successful one-stage reconstruction with a bilobed flap.

Medial Canthal Reconstruction - Scar Restricting Vision in Only Seeing Eye of a 75-year-old Female.

Scarring is a common post-injury outcome that can precipitate functional impairment. We present the case of a 75-year-old female who presented with diminished upper eyelid excursion in her right (only seeing) eye due to scarring associated with a facial laceration. She had a history of right eye corneal transplantation and necessitated urgent excision of the scar to release upper eyelid motion. The scar was excised, and a full-thickness skin graft (FTSG) was used, harvested from the skin of the right supraclavicular neck. Post-operative recovery was excellent, and the patient was relieved of restriction of her right upper eyelid opening.

[Lacrimal canalicular transposition for lower canaliculus repair: About four cases]. / Reconstruction du canalicule inférieur par transposition canaliculaire : à propos de quatre cas.

The main function of the eyelids is to support and protect the globe. The lower eyelid and medial canthus are often the location of malignant tumors that can be locally aggressive and require disfiguring surgeries. Chronic epiphora often appears in cases of inadequate reconstruction in this location and can require secondary procedures. We report four cases of medial canthus repair after tumor removal with loss of the inferior canaliculus. The ipsilateral superior canaliculus was removed before being transposed into the lower eyelid. This simple method allows for complete canalicular reconstruction. It obviates the need for artificial material and its potential associated complications. It has the advantage of a one-step eyelid and canalicular reconstruction and prevents epiphora after tumor resection.

Novel findings on the anatomy of medial canthus in dogs.

PURPOSE: Severe entropion of the medial canthus results in ocular surface diseases and tear staining syndrome. However, detailed anatomical structures of the medial canthus and lacrimal ducts in dogs are poorly understood. We aimed to understand the anatomical structures of the medial canthus by analyzing the distances from the medial palpebral commissure to the superior lacrimal punctum (DSP) and to the inferior lacrimal punctum (DIP) and by histological examinations of the medial canthal anatomy. METHODS: Dogs that underwent modified medial canthoplasty (MMC) between April 2017 and March 2021 were studied. As a reference, non-brachycephalic dogs that underwent other surgeries were also examined. DSP and DIP were measured preoperatively in all dogs in both the non-everted and everted positions. Histological examinations of the medial canthal anatomy were performed in four eyes isolated from beagles. RESULTS: The ratios of DIP to DSP (mean ± SD) at the non-everted and everted positions in 242 MMC eyes of 126 dogs were 2.05 ± 0.46 and 1.05 ± 0.13, respectively (p < .01). The ratios of everted to non-everted positions for DIP and DSP were 0.98 ± 0.21 and 1.93 ± 0.49, respectively (p < .01). Histological findings indicated that the orbicularis oculi muscle (OOM) circumjacent lacrimal canaliculus transformed into collagen fibers and were attached to the lacrimal bone. CONCLUSIONS: Histological studies revealed that the OOM circumjacent lacrimal canaliculus transformed into collagen fibers and these collagen fibers may be related to the difference between DSP and DIP.

Width of the orbicularis oculi fibers extending to the upper lip with the lateral and inferior lengths of the orbicularis oculi at the lateral canthus level: application to botulinum neurotoxin type A injection for crow's feet.

PURPOSE: The aim of this study was to determine the width of the fibers that extend from the orbicularis oculi muscle (OOc) to the upper lip, and the lateral and inferior lengths of the OOc at the lateral canthus level. METHODS: The OOc was investigated in the 40 hemifaces of 20 Korean cadavers. The lateral fibers of the OOc (OOc lat) were traced to determine whether or not these fibers extended to the upper lip. RESULTS: The OOc lat extended to the upper lip at the lateral canthus level in 31 of the 40 specimens (77.5%), whereas some inferolateral fibers of the OOc that extended to the upper lip were observed near the level of the lower margin of the OOc in the other 9 specimens (22.5%). The mean ± SD and maximum widths of the OOc lat that extended to the upper lip at the lateral canthus level were 6.9 ± 3.3 mm and 14.3 mm, respectively. CONCLUSION: The obtained data will be helpful to distinguish the muscles that underly the wrinkles around the lateral canthus for safer and more-efficient BoNT-A treatments for crow's feet.

Functional and Symmetry Outcomes After Forehead Flap Reconstruction of Medial Peri-Ocular Defects.

BACKGROUND: Orbital defects have a profound impact on orbital function and symmetry of the face and are difficult to reconstruct given the complexity of this area. The paramedian forehead flap (PMFF) has not been well studied in reconstruction of orbital defects. METHODS: Retrospective review of patients who underwent reconstruction of periorbital defects with PMFF between 2016 and 2021. Variables were ocular adnexal asymmetry, functional outcomes, and orbital complications. RESULTS: Eighteen patients met inclusion criteria. Mean defect size was 11.1 ± 7.5 cm. The most common subsite involved was medial canthus in 88.9% of patients. There was no statistically significant difference between mean medial canthus to midline ratio and mean medial brow to midline ratio when compared to the assumed normal of 1. The medial canthus to pupil ratio and medial canthus to lateral canthus ratio had a statistically significant mean difference from 1.0 (p = 0.003 for both). In 22.2% of patients, the orbit was functional with impairment; the remaining had no impairment. Surgical sequelae occurred in 12/18 (66.7%) of patients, most commonly epiphora in 9/18 (50%) of patients, and ectropion in 5/18 (27.7%). CONCLUSION: The PMFF is feasible for medial periorbital reconstruction with acceptable functional and symmetrical outcomes and low morbidity. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2584-2589, 2023.

Long-term outcomes of a new anatomy-based method for finding the medial cut end during late canalicular repair.

BACKGROUND: Locating the medial cut end during late repair of canalicular lacerations can be challenging. OBJECTIVE: The aim of this study was to evaluate the effectiveness and long-term outcomes of a new anatomy-based method for solving the problem of locating the medial cut end. METHODS: This retrospective interventional study included 85 eyes of 85 consecutive adult patients with unilateral inferior canalicular lacerations who underwent late primary (≥2 days after injury) or secondary (≥6 months after initial treatment) surgery. Before surgery, the lacerations were classified as lateral, central, or medial according to the 'distance from the punctum to the distal end' of the lacerated inferior canaliculus. The time spent to locate the proximal lacerated end (TSL) was recorded. All patients were followed up for ≥1 year to evaluate the lacrimal passage patency and the distance between the superior and inferior punctum (DBSIP, to assess cosmesis). RESULTS: There were 16 (18.82%) lateral-type, 55 (64.71%) central-type, and 14 (16.47%) medial-type canalicular lacerations. The TSL was 3.48 ± 1.05 (range 0.9-6.8) min for all patients and differed significantly among the three types of canalicular lacerations (P < 0.001). Lacrimal irrigation showed patent lacrimal passages in 69 patients (81.18%) at 3 months and a further 4 patients (4.71%) at 6 months, residual stenosis without obstruction in 5 patients (5.88%), and obstruction in 7 patients (8.24%). The postoperative DBSIP on the affected side was shorter than the preoperative DBSIP (2.66 ± 0.66 vs. 3.09 ± 1.72 mm, P = 0.006) and comparable to that on the unaffected side (2.78 ± 0.40 mm). CONCLUSION: Our new anatomy-based method is efficient and achieves good long-term outcomes for all types of late canalicular repair.

Long-term Surgical Outcomes in Patients of Centurion Syndrome: A Mystic Etiology of Epiphora in Young.

AIM: To describe the clinical features and long-term outcomes of the medial canthal tendon (MCT) release procedure in patients with Centurion Syndrome (CS). METHODS: We performed a retrospective analysis of the diagnosed patients with CS from July 2013 to December 2019. CS was diagnosed clinically based on the anterior displacement of MCT, anterior dislocation of lacrimal punctum out of tear lake, prominent nasal bridge, beak sign, and synophyrs. All symptomatic patients were advised the anterior limb of MCT release with modified closure of the skin incision. The outcome measures were based on Munk's score (subjective) and the fluorescein dye disappearance test (objective). A minimum postoperative follow-up of 12 months was an inclusion criterion. RESULTS: We studied 22 patients (44 eyes) having a median age of 14.5 years. Anteriorly displaced MCT and lacrimal punctum were noted in 44 eyes (100%), prominent nasal bridge in 20 patients (90.9%), beak sign in 36 eyes (81.8%), and synophyrs in 17 (77.3%) patients. All 44 eyes underwent MCT release with adjunctive punctoplasty (n = 6 eyes) or lower eyelid retractor plication (n = 4 eyes). At a mean follow-up of 12.6 months, 26 eyes (59.1%) showed complete response, i.e., negative FDDT and grade 0 Munk score. Partial response was noted in 14 (31.8%) eyes, i.e., delayed FDDT and reduction of ≥2 grades on Munk score. CONCLUSION: Along with the classic features of CS, beak sign and synophyrs are important diagnostic ophthalmic-facial features of CS. The transverse closure of surgical wounds may provide effective long-term benefits in the medial canthal tendon release procedure.

A Rare Orbital Pathology: A Large Orbital Dermatofibrosarcoma Protuberans.

Dermatofibrosarcoma protuberans (DFSP) is a rare sarcoma of the dermis. It is a malignant, locally aggressive, and infiltrative tumor with frequent recurrence. In this case, a 44-year-old woman presented with a 15-year history of a swelling in the medial canthus of the right eye that caused tearing. Imaging revealed a septated mass isodense to soft tissue that had eroded the medial wall of the orbit. Macroscopic examination showed an elastic, gray-brown, encapsulated, irregular mass measuring 45x35x22 mm. The surgical margins were positive, so adjuvant radiotherapy was started. The patient was followed for 2 years without recurrence. According to the literature, this mass is the largest orbital DFSP treated by globe-sparing primary resection.

Retiform Hemangioendothelioma: A Rare Tumor in the Medial Canthus: Case Report and Review of Literature.

Retiform hemangioendothelioma (RH) is a rare vascular neoplasm with intermediate malignant potential mostly occurring in extremities. It is important to differentiate this neoplasm from malignant conditions as RH has a good prognosis. As it has a tendency to recur locally, it may be misdiagnosed as a malignant tumor. Herein, we report a rare case of RH occurring in the medial canthus.

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.

Clinical Application of a Bird-Beak-Type Z-Shaped Asymmetrical Flap in the Reconstruction of the Inner Canthus.

Objective: To introduce a new surgical method for the repair of a large inner canthus combined with tissue loss at the inner canthal angle of the eye by using a bird-beak-type z-shaped asymmetrical flap and to summarize its clinical effect. Method: A total of 56 patients with a large inner canthus were randomly selected, and a bird-beak-type z-shaped asymmetrical flap was used on the nasal side of the lower eyelid to repair and reconstruct the inner canthal folds. The inner canthal point was located according to physiological aesthetics. The short and long arms of the z-shaped asymmetrical flap were separated, replaced, fixed, and shaped to reconstruct the skin folds of the inner canthus and restore its aesthetic morphology. Results: All incisions after surgery achieved primary healing, and all 56 cases were followed up for 6-20 months (average 8.6 months). The caruncula lacrimalis was moderately exposed, the inner canthal angles possessed a natural appearance, and the results of the surgery were satisfactory. Five patients developed scar hyperplasia within one month after surgery, and arnica gel was applied topically for 3-6 months until the scar faded or disappeared, but no obvious scars were seen in the surgical area of the remaining patients. In two patients, the internal canthi were asymmetrical, but this improved after adjustment. Conclusion: Repair of a large inner canthus and tissue loss at the inner canthal angle of the eye using a bird-beak-type z-shaped asymmetrical flap is a simple operation, resulting in minimal trauma. Postoperatively, the inner canthal angle possessed a natural appearance with no obvious scarring.

Periocular Trichoblastoma: A Diagnostic Dilemma.

A 41-year-old woman presented with a large medial canthal lesion that extended over the midline. Excisional biopsy revealed a multinodular basaloid tumor, located within the dermis and subcutaneous fat that extended into skeletal muscle at the deep and peripheral margin. Histology was consistent with trichoblastoma. A review of the literature reveals a lack of specific and sensitive immunohistochemistry markers to establish the diagnosis of trichoblastoma. Following reconstruction, the patient has shown no signs of recurrence of the lesion at 24 months.

Epicanthus correction with a modified asymmetric Z-plasty.

The study aimed to explore the clinical efficacy of the modified asymmetric Z-plasty with a central axis from the point near the edge of the skin fold of the medial canthus to the point of the innermost palpebral edge of medial canthus for epicanthus correction. A total of 130 followed-up patients who received modified asymmetric Z-plasty for epicanthus correction in Hunan Provincial People's Hospital from January 2019 to December 2019 were included. All patients were followed up with at 1, 3, and 6 months after surgery, and the scarring and surgical outcomes were assessed. The results showed the surgical wounds were healing well, and the sutures were removed at 7 days postoperatively in all patients. At 6 months postoperatively, epicanthus correction was successful in all patients, the lacrimal caruncle was moderately exposed, the incision was not red, and there were no obvious prominent scars. Slightly prominent and uneven scars below the edge of the lower eyelid were observed in 3 patients. Among these 3 patients, 1 patient received no further treatment, and the outcomes were considered acceptable; the outcomes were improved in the remaining 2 patients after a single session of fractional laser treatment, and none of these patients received further surgery. In conclusion, the modified asymmetric Z-plasty with a central axis from the point near the edge of the skin fold of the medial canthus to the point of the innermost palpebral edge of medial canthus is relatively simple and provides good surgical results for epicanthus correction.