Elizabeth B. Jelks

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.

Evolution of the lateral canthoplasty: techniques and indications.

&NA; 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. (Plast. Reconstr. Surg. 100: 1396, 1997.)

Medial canthal reconstruction using a medially based upper eyelid myocutaneous flap.

&NA; Periorbital reconstruction following skin cancer ablation represents a challenging problem. A thorough understanding of the complex periorbital anatomy is necessary to preserve lid function and protect the ocular surface. The medial canthal region represents the most difficult periorbital zone to reconstruct. This area has a complex anatomy involving both the medial canthus itself and the lacrimal apparatus. The authors present their experience with a versatile technique for reconstruction of the medial canthal periorbital region, namely, a medially based upper eyelid myocutaneous flap. In the 10 patients in whom this procedure was used, there was one partial and no complete flap losses. The authors believe that the medially based upper lid myocutaneous flap offers an excellent solution to the difficult problem of medial canthal periorbital reconstruction. (Plast. Reconstr. Surg. 110: 1636, 2002.)

Periorbital melanocytic lesions : Excision and reconstruction in 40 patients

&NA; 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 fullthickness 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. (Plast. Reconstr. Surg. 102: 19, 1998.)

Successful management of orbital cellulitis and temporary visual loss after blepharoplasty.

Although the number of aesthetic blepharoplasties performed in the United States continues to increase, infection following this procedure remains a rare, unmentioned complication in most series.1–3 Orbital cellulitis is an acute bacterial inflammation accompanied by variable degrees of fever, pain, erythema, chemosis, and proptosis. Orbital cellulitis is a medical emergency that can progress rapidly and requires urgent attention. Without proper management, orbital cellulitis can lead to blindness resulting from increased intraorbital pressure compressing the globe and optic nerve, leading to optic nerve ischemia. Visual loss can also be the result of septic emboli to the optic nerve vasculature.4 Of the six previously reported cases of orbital cellulitis with visual loss,5–10 positive blood cultures for group A -hemolytic Streptococcus or Streptococcus pyogenes were reported. The surgeon should be able to manage these problems quickly and effectively to avoid disastrous consequences such as blindness, septic cerebral infarction, and death. We report successful management of orbital cellulitis and temporary visual loss after blepharoplasty.

A Retrospective Review of Patients Undergoing Lateral Canthoplasty Techniques to Manage Existing or Potential Lower Eyelid Malposition: Identification of Seven Key Preoperative Findings.

Background: Lateral canthal procedures are often indicated to correct or prevent lower eyelid malposition. When determining an appropriate lateral canthal procedure, planning is essential and includes proper analysis and identification of any contributory anatomical factors. Methods: A 12-month retrospective review was performed on patients undergoing lateral canthal procedures. Important components of the preoperative examination were studied to relate patient anatomy and results. Outcomes were followed for a minimum of 5 years. Results: Of 288 consecutive lower eyelid canthal procedures, a total of 146 met the inclusion criteria. Common designated abnormal preoperative findings included a negative vector (62 percent), lid margin eversion (12 percent), scleral show (21 percent), neutral or negative canthal tilt (49 percent and 18 percent, respectively), and lateral canthus -to -orbital rim distance of more than 1 cm (11 percent). The distribution of lateral canthal procedures performed in our study population included inferior retinacular lateral canthopexy (n = 36), inferior retinacular lateral canthoplasty (n = 88), tarsal strip lateral canthoplasty (n = 15), and dermal-orbicular pennant lateral canthoplasty (n = 7). Successful outcomes were noted to be 86 percent and 91 percent according to surgeons and patients, respectively. Conclusions: Specific findings on the preoperative physical examination identify when simple or more complex lateral canthal procedures should be performed. The authors report seven key physical findings that should be documented to effectively determine a lateral canthal procedure that is appropriate for prevention and management of lower eyelid malposition. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

3D Topographical Surface Changes in Response to Compartmental Volumization of the Medial Cheek; Defining a Malar "Augmentation Zone".

Background: Given the widespread use of facial fillers and recent identification of distinct facial fat compartments, a better understanding of three-dimensional surface changes in response to volume augmentation is needed. Advances in three-dimensional imaging technology now afford an opportunity to elucidate these morphologic changes for the first time. Methods: A cadaver study was undertaken in which volumization of the deep medial cheek compartment was performed at intervals up to 4 cc (n = 4). Three-dimensional photographs were taken after each injection to analyze the topographic surface changes, which the authors define as the “augmentation zone.” Perimeter, diameter, and projection were studied. The arcus marginalis of the inferior orbit consistently represented a fixed boundary of the augmentation zone, and additional cadavers underwent similar volumization following surgical release of this portion of the arcus marginalis (n = 4). Repeated three-dimensional computer analysis was performed comparing the augmentation zone with and without arcus marginalis release. Results: Volumization of the deep medial cheek led to unique topographic changes of the malar region defined by distinct boundaries. Interestingly, the cephalic border of the augmentation zone was consistently noted to be at the level of the arcus marginalis in all specimens. When surgical release of the arcus marginalis was performed, the cephalic border of the augmentation zone was no longer restricted. Conclusions: Using advances in three-dimensional photography and computer analysis, the authors demonstrate characteristic surface anatomy changes in response to volume augmentation of facial compartments. This novel concept of the augmentation zone can be applied to volumization of other distinct facial regions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

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.

Lateral Canthal Surgery in Blepharoplasty

The development of lateral canthal surgical procedures parallels the understanding and treatment of lower eyelid malpositions caused by congenital or acquired conditions. Protection of the eyes with preservation of vision is the rationale for lateral canthal procedures. Lateral canthal procedures are designed to manage existing lower eyelid malpositions. They are surgical techniques employed at the time of blepharoplasty to prevent lower eyelid malpositions.

A Novel 3D Analysis of Arcus Marginalis Release for Midface Rejuvenation.

PURPOSE: Many experts believe the arcus marginalis plays a critical role in tear-trough deformity.1-5 Arcus marginalis release (AMR) is performed with fat repositioning to soften the lidcheek junction and achieve a more youthful midface contour. The following study used 3D photography and computer analysis to document changes in the tear-trough and midface contour in response to AMR with malar lipostructure.