Reconstructive options for the medial canthus and eyelids following tumor excision

Medial Canthal Tendon Reflecting in Lower Eyelid Reconstruction After Palpebral Cancer Surgery: Description of a New Technique

PURPOSE

The aim of this article is to describe a new reconstructive technique of the lower eyelid in the surgery of tumors involving the medial canthal tendon.

METHODS

Our new technique consists of detaching and reflecting the most medial portion of the anterior medial canthal tendon and reinserting it into the posterior lamella. We describe the cases in which our technique can be useful, as well as the results we have obtained.

RESULTS

The result after a year of follow-up showed no disruption of the angulation of the lower eyelid line and no changes in eyelid position.

CONCLUSIONS

The medial canthal tendon reflection could provide both aesthetic and functional results that may be superior to the usual techniques.

Comparison of local flaps versus skin grafts as reconstruction methods for defects in the medial canthal region

BACKGROUND

The medial canthal region features a complex three-dimensional and internal anatomical structure. When reconstructing a defect in this area, it is crucial to consider both functional and aesthetic aspects, which presents significant challenges. Generally, local flaps are preferred for reconstruction; however, skin grafts can be used when local flaps are not feasible. Therefore, we conducted a comparative analysis of surgical outcomes skin grafts when local flaps were not feasible, to determine which surgical method is more effective for medial canthal region reconstruction.

METHODS

Twenty-five patients who underwent medial canthal region reconstruction using skin grafts or local flaps from 2002 to 2021 were enrolled. Patient information was obtained from medical records. Five plastic surgeons evaluated the surgical outcomes based on general appearance, color, contour, and symmetry.

RESULTS

Skin grafts were used in eight patients and local flaps were used in 13. Combined reconstructions were employed in four cases. Minor complications arose in four cases but improved with conservative treatment. No major complications were reported. Recurrence of the skin cancer was noted in two cases. All categories showed higher scores for the local flap compared to both skin graft and combined reconstruction; however, the differences were not statistically significant respectively.

CONCLUSION

The choice of appropriate surgical methods for reconstructing defects in the medial canthal region depends on various factors, including the patient's overall health, the size and depth of the defect, and the degree of involvement of surrounding structures. When a local flap is not feasible, a skin graft may provide favorable surgical outcomes. Therefore, a skin graft can serve as a viable alternative for reconstructing the medial canthal region.

Review of recent advances in managing periocular skin malignancies

Management of cutaneous malignancies can be particularly challenging when they are located in the periocular region. The standard of care for localized disease is complete surgical excision, but this may not be possible without significant disruption to visual structures and facial appearance. Definitive radiation may be an option for some patients who cannot or do not wish to undergo surgery. Advances in systemic treatment options for locally advanced and metastatic skin cancers in the past 10 years have prompted investigation into neoadjuvant treatment of periocular cancers. The use of chemotherapy, immune checkpoint inhibitors, and targeted therapies have all been reported with varying degrees of success. For many patients, targeted therapies or immune checkpoint inhibitors should be considered depending on the cancer type, symptoms, and goals with the input of a multidisciplinary cancer care team. In this article, we systematically review the latest updates in surgical, radiotherapeutic, and medical management of periocular malignancies.

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.

Lateral eyelid island flap for reconstruction of large central and medial full-thickness defects of the lower eyelid

Introduction

To report our experience with lateral eyelid island flaps for reconstruction of large central and medial full-thickness defects of lower eyelid.

Methods

Retrospective case series of patients with large central and medial full-thickness lower lid defects repaired with medial transposition of the lateral lower lid combined with a temporal myocutaneous flap. Preoperatively the authors collected demographic data, etiology and percentage of the defects. Postoperatively the lids were assessed for flap viability and lower eyelid margin position and contour.

Results

The sample was comprised of 10 patients (5 females) with a mean of age 60.10 (SD 13.75) years. The defects ranging from 50% to 75% of the lid width resulted from excision of eight basal cell carcinomas, one (10%) malignant schwannoma and one (10%) squamous cell carcinoma. The median follow-up was 1.58 years (IQR 2.58). Flap ischemia was not observed in any eyelid. One mild ectropion was observed in just one lid. All patients were satisfied with the esthetic results.

Conclusions

Medial transposition of the lateral lower lid island flap combined with horizontal myocutaneous advancement flap is an excellent one-stage procedure that avoids the drawbacks of the two-stages procedures

Biplanar-pivoted V-Y Flap for Reconstruction of Medial Canthal Defects

PURPOSE

To determine the safety and effectiveness of a biplanar-pivoted V-Y flap design in reconstructing medial canthal defects of all sizes.

METHODS

Retrospective review of patients who underwent repair of medial canthal region defects with the biplanar-pivoted V-Y flap from January 2016 to May 2021. Variables collected included age, gender, surgical indication, defect sizes and location, flap(s) and/or graft(s) used, and follow-up time. Outcome measures included complications, patient satisfaction with cosmesis, ability to close the defect with minimal wound tension, and additional surgeries.

RESULTS

Eighteen cases of medial canthal, nasal sidewall, and nasojugal fold area reconstruction were performed using a biplanar-pivoted V-Y flap in 18 patients. The cohort included 7 males and 11 females with a mean age of 72.4 years (range, 52-92 years) and mean follow-up time of 4.4 months (range, 1-14 months). Mean defect size was 2.0 × 1.4 cm (range, 0.5-5.5 cm). Eight patients received concomitant full-thickness skin grafts, five patients underwent simultaneous rotational flap repair, one patient underwent simultaneous nasoglabellar myocutaneous flap repair, and one patient received a simultaneous traditional, nonbiplanar V-Y plasty of the upper eyelid. All defects were closed with no wound tension. No cases of infection, hemorrhage, or wound dehiscence occurred during follow-up. Complications included mild ectropion (2 patients) and mild tip necrosis (1 patient). No patients elected for reoperation. No trapdoor deformity was observed. No patients underwent reoperation for local tumor recurrence.

CONCLUSIONS

The extended mobility of the biplanar-pivoted V-Y flap provides excellent closure of defects involving the medial canthal region with minimal surgical complications.

Medial Canthus Reconstruction with the Paramedian Forehead Flap

Background:

The medial canthus represents the medial confluence of the upper and lower eyelid margins and plays an integral role in the lacrimal duct system. Various flaps have been utilized for the reconstruction of the lower eyelid in the medial canthal region. Our institution primarily utilizes the paramedian forehead flap for the reconstruction of medial canthus defects. Our study looked to evaluate the work of a single plastic surgeon and identify their postoperative outcomes.

Methods:

A retrospective chart review was conducted at Beaumont Health System, Royal Oak, for patients who underwent medial canthal repair by the lead surgeon between the years 2014 and 2018. Demographic data, operative details, complications, medical comorbidities, and patient outcomes were retrospectively gathered and analyzed.

Results:

A total of five patients were isolated. Patients underwent paramedian forehead flap medial canthal repair by the lead surgeon and were found to tolerate the procedure well. All patients had clinically viable flaps with aesthetically pleasing results.

Conclusions:

Utilization of the paramedian forehead flap leads to successful medial canthal repair with adequate coverage. Although the paramedian forehead flap requires three stages to complete, the procedure leaves patients with aesthetically pleasing results. In addition, the paramedian forehead flap has limited cases of ectropion. With the right expertise and patient population, the paramedian forehead flap can be highly successful in the repair of medial canthal defects.

Utility of the Glabellar Flap in the Reconstruction of Medial Canthal Tumors after Mohs Surgery

The goals of periorbital region reconstruction are to obtain both functional and esthetic results. Medial canthus is the second most common periorbital location for basal cell carcinoma. If left untreated, it is locally destructive but rarely metastasizes. Incompletely resected medial canthal tumors recur or penetrate along the lacrimal path and expand to wider lesions. A safety margin is necessary to ensure a complete lesion resection. Since it was introduced in 1941, Mohs surgery has been promoted as an efficient method of dealing with infiltrative periorbital skin tumors. It has been shown to have high rates of complete cancer removal during surgery, minimizing the amount of normal tissue loss and securing better functional and cosmetic outcomes. Due to its concave contour and convergence of skin units with variable thickness, texture and mobility, reconstruction of the medial canthal region (MCR) remains challenging. Reconstructive methods such as free full-thickness skin grafts and glabellar flaps have been used alone or in combination with other techniques. The concavity of the canthus must be achieved, but the maintenance of the normal contour and symmetry of the surrounding tissue is critical. The glabellar flap (GF) is a triangular advancement flap that adequately restores the volume in deeper defects, guaranteeing sufficient vascular support without complex or undesirable scars. We present two cases of basal cell carcinoma affecting the MCR that was successfully reconstructed using a GF alone in one case and together with a cheek advancement flap in the second one. In both cases, tumor excision was performed using Mohs surgery.

Application Possibilities of a New Preloaded Nasolacrimal Duct Intubation System

INTRODUCTION

The LacriJet (FCI S. A. S. - France Chirurgie Instrumentation, Paris, France) represents a novel, simplified and preloaded system for monocanalicular or monocanaliculonasal nasolacrimal duct intubation. It is a further development of the Masterka and shall reduce the intubation time during the surgical procedure. The aim of the present study was to present first experiences with this system for different indications.

MATERIAL AND METHODS

All patients who underwent nasolacrimal duct intubation with the LacriJet at the University of Muenster Medical Center in the period from March to November 2019 were included. The postoperative outcome was evaluated 3 to 6 months later.

RESULTS

In total, 12 nasolacrimal duct intubations with the LacriJet were performed at our center in the above-mentioned period. The main indication for intubation was congenital nasolacrimal duct obstruction (CNLDO). In addition, intubation was performed in cases with eye lid tumors involving the nasolacrimal duct, in a case of canalicular laceration and in a case of canaliculitis. In 3 cases, there was an early dislocation or a complete loss of intubation. Of these, 2 were cases with CNLDO and the third dislocation was due to manipulation by the patient. All in all, the functional results were satisfying.

SUMMARY

The use of the LacriJet is highly suitable for the treatment of CNLDO, stenting in canalicular laceration or lid tumours involving the lacrimal drainage system. However, the known disadvantages of monocanalicular intubation (dislocation, early loss of intubation) also occur with this type of system and a system briefing seems useful. The LacriJet therefore represents a modern and simple method for nasolacrimal duct intubation and can be used for various indications.

Management of Traumatic Lower-Eyelid Avulsion and Complete Loss of the Lacrimal Canaliculus: A Case Report

Eyelid injuries commonly occur as a result of blunt or sharp periocular trauma. When the medial canthal region is affected, injury can be associated with canalicular laceration or avulsion. Complete loss of the lacrimal canaliculus associated with epiphora is a challenging condition, and reconstruction often leads to poor and disappointing results. Surgical treatment of a patient following blunt facial trauma that resulted in medial avulsion of the lower eyelid with tissue loss is presented. A 72-year-old male patient presented with avulsion of the medial 2/3 of the left lower eyelid together with complete loss of the inferior canaliculus. Eyelid tissue was not preserved. The inferior canaliculus was reconstructed using a Mini Monoka (FCI Ophthalmics), which was sutured under the caruncle and was enveloped with surrounding tissue. Loss of the lower eyelid tissue was substituted with a medially shifted Hughes flap and free skin transplant from the ipsilateral upper eyelid. The Hughes flap was divided after 2 weeks, while the Mini Monoka extruded spontaneously approximately 3 months after the injury. Ten months after the injury, the opening of the reconstructed lower canaliculus was positioned under the caruncle and was patent on probing and syringing. The patient is without epiphora and is satisfied with the functional and aesthetic result. In eyelid injuries we follow certain rules of reconstruction, but each case is unique and requires some inventiveness. The idea of inferior canalicular reconstruction following lower-eyelid avulsion with tissue loss is presented.

Polarization and Distribution of Tumor-Associated Macrophages and COX-2 Expression in Basal Cell Carcinoma of the Ocular Adnexae

PURPOSE

Basal cell carcinoma (BCC) is a locally invasive skin tumor which can be subdivided into a circumscribed nodular and an invasive fibrosing subtype. There is increasing evidence that macrophages play an important role in interacting between tumor cells and their microenvironment, thereby affecting not only the invasive potential but also the patients' prognosis. Thus, we wanted to compare these two BCC variants with regard to tumor-related inflammation, COX-2 expression, distribution, and polarization of tumor-associated macrophages.

MATERIAL AND METHODS

30 BCCs (nodular: n = 15; fibrosing: n = 15) of the ocular adnexae were investigated by histopathology and immunohistochemistry. The grade of inflammation was evaluated on hematoxylin and eosin stains (score: 0-3). Immunohistochemical stains for CD68 (macrophages), Ki67 (proliferative activity), and COX-2 as well as immunofluorescence stains for CD68 and CD163 (to distinguish M1 and M2 macrophage subtypes) were performed. SPSS was used for statistical analysis.

RESULTS

Fibrosing BCCs were predominantly located on the lower lid, while nodular BCCs showed a broader distribution (p = 0.013). The fibrosing BCC subtype was associated with a higher degree of inflammation (p < 0.001) and revealed a higher COX-2 immunoreactivity than nodular BCC (p = 0.012). COX-2-positive cells were predominantly located on the infiltrating edge of the tumor. Macrophage polarization was balanced regarding M1 and M2 macrophage subtypes. There was no difference in macrophage number (p = 0.389) or polarization (p = 0.161) between nodular and fibrosing BCC.

CONCLUSIONS

The findings indicate that COX-2 represents a factor for invasion of BCC. Macrophage polarization did not play a major role for aggressive behavior. However, other inflammatory components than tumor-associated macrophages seem to be involved in tissue destruction and thereby an invading growth pattern since fibrosing BCC revealed a significantly more intense inflammatory reaction in the surrounding tissue.

Periorbital Soft Tissue Anthropometric Analysis of Young Adults

The authors aim to determine the periorbital soft tissue anthropometric norms for Turkish young adults for right and left eyes using a noninvasive two-dimensional photogrammetric analysis. Anthropometric measurements of the periorbital soft tissue were taken from 172 female and 56 male Turkish adults aged between 18 and 24 years. The periorbital soft tissue profiles (ocular and palpebral) for males and females were digitally analyzed using linear measurements made with standardized photographic records, taken in a natural head position. Statistically significant differences were found for ocular soft tissue measurements according to gender except inner intercanthal distance (P = 0.125) and right horizontal palpebral aperture (P = 0.240). Statistically significant differences were found for palpebral soft tissue measurements according to gender except right pretarsal skin height (P = 0.112) and left pretarsal skin height (P = 0.056). Results were compared with other ethnic groups. Normal periorbital soft tissue measurements are fundamental anatomical parameters utilized in ophthalmology, optometry, ophthalmic industry, oculoplastic surgery, clinical genetics, dermatocosmetology. Further, normal anthropometric measurements generate reference data for studies in craniofacial dysmorphology, oculoplastic surgery, dermatocosmetology, and comparative physical anthropology.

Overview of Local Flaps of the Face for Reconstruction of Cutaneous Malignancies: Single Institutional Experience of Seventy Cases

Context:

The most common malignant tumours of the face are basal cell carcinoma, squamous cell carcinoma and melanoma. While the results of skin graft are less than satisfactory for large areas to cover, distant flaps are bulky with a poor colour match. Local fasciocutaneous flaps provide reasonable option for reconstruction of facial defects with good colour and texture match and good success rate.

Aims:

This study aimed to analyse the various modalities of reconstruction after resection of facial malignancies and their advantages and disadvantages.

Settings and Design:

This was a retrospective study.

Materials and Methods:

Of 70 patients, 34 were managed with V-Y advancement flap, 24 with nasolabial flap, 8 with median forehead flap and 4 with standard forehead flap cover. The duration of follow-up ranged from 6 months to 2 years.

Statistical Analysis Used:

Nil.

Results:

Of 34 V-Y advancement flaps, 2 showed suture dehiscence at the apex of triangle which was allowed to heal secondarily with regular dressings. All the 24 nasolabial flaps were healthy without any complication. All patients had satisfactory functional and cosmetic outcomes.

Conclusions:

In our experience, local flaps give the best results and are the first choice for reconstruction of the face. Most defects can be best closed by nasolabial, V-Y advancement and forehead flap. Outstanding functional and cosmetic results can be achieved. Proper execution requires considerable technical skill and experience.

Surgical excision with forehead flap as single modality treatment for Basal cell cancer of central face: single institutional experience of 50 cases

Basal cell carcinoma (BCC) is the most common skin cancer worldwide. The WHO has defined it as "a locally invasive, slowly spreading tumor which rarely metastasizes, arising in the epidermis or hair follicles and in which the peripheral cells usually simulate the basal cells of the epidermis." Here we discuss the management of BCCs of central face with surgical excision and reconstruction with forehead flap as single modality treatment. Material and Methods. This is a retrospective review of 50 patients who underwent surgical excision of BCC involving the facial region followed by primary reconstruction using forehead flaps at a single institution. There were 20 males and 30 females, mean age of 59 years. Results. No recurrence at primary site was observed during the follow-up of 1-4 yrs. There was no ectropion or exposure sequela. However, epiphora was evident. Size of lesions ranged from 2 to 6 cm. Keloid formation was seen in 2 (4%) patients. Functional and cosmetic outcomes were satisfactory. Conclusion. For the face, the best reconstructive effort eventually fails in the face of tumor recurrence. The forehead flap represents one of the best methods for repair of extensive facial defects. Complete tumor extirpation, the primary event, is the key.

The use of forehead flaps in the management of large basal cell carcinomas of the medial canthus/medial lower eyelid in Saudi patients

PURPOSE

Basal cell carcinoma (BCC) is the most common skin cancer worldwide. BCC represents 90-95% of all malignant eyelid tumors with lower eyelid/medial canthus lesions being more common than lower eyelid/lateral canthus lesions. Although various local flaps have been used for the reconstruction of medial canthus/adjacent eyelid defects, we find the forehead flap to be the most suited for these cases.

MATERIALS AND METHODS

We are reporting a clinical series of BCC involving the medial canthus and adjacent medial lower eyelid through a retrospective review of 18 patients who underwent surgical excision of the lesion followed by primary reconstruction using forehead flaps. Patients who underwent reconstruction without forehead flaps were excluded. All cases were Saudis and underwent this type of reconstruction. Indications, results, and complications were reviewed with special emphasis on the acceptance of the obvious forehead donor site scar in Saudi patients.

RESULTS

All flaps survived completely Follow-up ranged from 2 to 10 years (mean of 5 years). Tumor recurrence was not seen in any of the patients. Functionally, there was no ectropion and the eyelid margin was well aligned and stable. However, epiphora was evident since lacrimal system reconstruction was not performed.

CONCLUSION

We are presenting the first Saudi series of large medical canthus/lower eyelid defects that underwent reconstruction using forehead flaps. The outcome was satisfactory and there were no cases of tumor recurrence. The only disadvantage is the donor scar which seems to be acceptable in the Saudi population because of their traditional head cover.