Functional Reconstruction of Large Medial Canthal Defects

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.

The Utility of the Paramedian Forehead Flap in Lower Eyelid Reconstruction

BACKGROUND

Malignant cutaneous eyelid tumors account for approximately 10% of all cutaneous cancers. Like other cancerous skin lesions, treatment commonly involves excision with wide margins, requiring tissue reconstruction. The use of the paramedian forehead flap (PMFF) has been described for reconstruction of the medial and upper eyelid, but literature is lacking for its use in lower eyelid anterior lamella reconstruction. We present a case series of patients who underwent reconstruction of lower eyelid defects using the PMFF.

CASE PRESENTATIONS

We present 2 patients who underwent reconstruction of lower eyelid defects using the PMFF surgical technique. The patients had previous history of lower lid repair with other reconstructive methods because of cancerous eyelid lesions. In addition, both received adjuvant radiation therapy, which led to development of ectropion. Postoperative signs, symptoms, and photographs were collected to monitor outcomes.

MANAGEMENT AND OUTCOMES

Reconstructions were performed by the collaborative efforts of a facial plastic reconstructive surgeon and oculoplastic surgeon using a staged PMFF approach. Postoperatively, both patients had significant improvement in ophthalmologic symptoms, particularly ectropion and lagophthalmos. At their most recent follow-up visit, they were satisfied with their functional and aesthetic outcomes.

CONCLUSION

The PMFF may be safely used to reconstruct defects of the lower eyelid anterior lamella. In this study, the PMFF has proven to be an excellent option for patients with complications after previous lower eyelid reconstructions or history of radiation therapy. Overall, the PMFF should be considered as part of the surgeon's reconstructive ladder when addressing lower eyelid defects.

The use of the paramedian forehead flap alone or in combination with other techniques in the reconstruction of periocular defects and orbital exenterations

PURPOSE

The paramedian forehead flap (PMFF) is a reconstructive option for large eyelid defects and orbital exenterations. We report a series of cases where PMFF reconstruction was carried out at various institutions in Australia.

METHODS

This study was a multi-centre, retrospective, non-comparative case series investigating the clinical outcomes of the PMFF for reconstructing periocular defects and orbital exenterations.

RESULTS

This case series describes twenty-seven patients (Female = 15, Male = 12), operated between 1991 to 2019, with a median age of 81 years (range: 45-93 years). Defect locations involved combinations of the medial canthus (16/27, 59.3%), upper eyelids (7/27, 25.9%), lower eyelid (4/27, 14.8%), both upper and lower eyelids (5/27, 18.5%), and orbital (7/27, 25.9%). There were no cases of flap necrosis. Minor post-operative complications were observed in ten patients with the most common being lagophthalmos. Median duration of follow-up was 17months (Range: 2months- 23years).

CONCLUSIONS

The PMFF is a versatile reconstructive tool for a range of periocular defects and orbital exenterations with minor post-operative complications.

Holding back the tears: is there a role for marsupialisation?

Objective

Medial eyelid tumours may result in the loss of the proximal lacrimal system during staged excision and delayed reconstruction, to achieve tumour margin clearance. The remnant canaliculus was marsupialised during reconstruction. The aim was to understand how many patients experienced symptomatic epiphora as a consequence of this.

Methods and analysis

A retrospective study including patients over a 15-year period with medial eyelid tumours, where the proximal lacrimal system was sacrificed to achieve tumour margin clearance. Included were all who had marsupialisation of the remnant distal stump as part of their delayed reconstruction. All who had pre-existing epiphora were excluded. The primary objective was the rate of epiphora following the procedure. A systematic literature review of postoperative epiphora occurring in patients with lid tumours requiring lacrimal system injury/sacrifice during tumour excision.

Results

There were 22 eyes (22 patients). All were basal cell carcinomas except for 1 (4.5%) tarsal conjunctival squamous cell carcinoma. All cases involved the lower lid. There were two (9.1%) patients who developed epiphora. One patient underwent a superior three-snip punctoplasty, botulinum toxin to the lacrimal gland and conjunctivodacryocystorhinostomy with Lester Jones tube insertion. The other patient was not overly troubled and did not require further treatment. The literature review showed the median postoperative rate of epiphora in these patients was 12.5% (range 0%–100%).

Conclusion

Marsupialisation of the remnant canaliculus during delayed reconstruction is a straightforward and effective surgical option, which may help prevent postreconstruction epiphora when the proximal lacrimal system is sacrificed for tumour margin clearance.

Trial registration number

10391.

Canthal Rotation Flap: Analysis of Flap Mechanics

BACKGROUND

Surgical defects of the medial canthus lack reconstructive options that are reproducible, precise, and uncomplicated. The canthal rotation flap is a simple rotation flap that respects the geometry of this anatomic location.

OBJECTIVE

To describe the authors' experience with reconstructive planning, flap mechanics, and geometric analysis of the medial canthus to achieve the best cosmetic outcome when using the canthal rotation flap.

METHODS

A retrospective review of 16 cases performed at Dayton Skin Care Specialists and Skin Care Specialty Physicians between 2016 and 2018 was completed with a blinded visual analog score (VAS).

RESULTS

Sixteen patients with Mohs defects in the medial canthus were reconstructed using the canthal rotation flap. Defect diameters ranged from 0.8 to 2.7 cm. Patient ages ranged from 17 to 88 years. The mean flap dimensions were 4.8 cm by 2.15 cm. No major complications were noted. The VAS scar rating at 2 to 5 months follow-up was available for 10 of 16 patients; the mean VAS was 2.1.

CONCLUSION

The canthal rotation flap is a reliable, single stage repair for small defects of the medial canthus that is optimized for the unique geometry of the medial canthus. This repair technique adds to the paucity of reconstructive options for the medial canthus.