Henry I. Baylis

Transcaruncular approach to the medial orbit and orbital apex.

OBJECTIVE To present a versatile approach to the medial orbit and orbital apex through the caruncle. DESIGN Retrospective, noncomparative, case series with description of surgical technique. PARTICIPANTS Twenty-five consecutive patients underwent orbital surgery by use of a transcaruncular approach. INTERVENTION Inferior and medial wall fracture repair or orbital decompression by means of a transcaruncular or combined transfornix-transcaruncular approach. MAIN OUTCOME MEASURES The surgical indications and complications were recorded for each patient. RESULTS Ten patients (10 orbits) underwent combined inferior and medial orbital wall fracture repair through a combined transfornix-transcaruncular approach. In 8 of 10 (80%) orbits, the inferior oblique muscle was disinserted during surgery. Fifteen patients (24 orbits) underwent orbital decompression surgery for dysthyroid orbitopathy. An isolated transcaruncular approach was used in 5 of 24 orbits, and a combined transfornix-transcaruncular approach was used in 19 of 24 orbits. There were no complications related to either approach. CONCLUSIONS Orbital bone removal and fracture reduction may be safely completed through a combined transfornix-transcaruncular approach. The transcaruncular approach provides excellent and safe exposure of the medial orbital wall, and it avoids scarring associated with the Lynch approach.

Autogenous auricular cartilage grafting for lower eyelid retraction.

The authors discuss the surgical correction of lower eyelid retraction in dysthyroid, socket, and blepharoplasty patients. Sixty-three patients underwent a lateral canthal tightening combined with a vertical lengthening of the posterior lamella using autogenous posterior auricular cartilage. The average follow-up was for 2 years. We propose this combined procedure as the surgery of choice in the treatment of lower eyelid retraction seen in these three groups of patients.

Lower eyelid retraction after blepharoplasty.

We used a simple procedure to correct retraction of the lower eyelid after blepharoplasty. Through a lateral canthotomy skin incision, the retracting layer of tissue within the lower eyelid at the level of the orbital septum is lysed and the lower eyelid is elevated and fixed in the desired position by attaching a tongue of lateral canthal tendon and lateral tarsus to the lateral orbital rim under a posteriorly based periosteal flap.

Obtaining Auricular Cartilage for Reconstructive Surgery

The cartilage in the scaphoid fossa between the helix laterally and the antihelix medially provides excellent underlying support for soft-tissue eyelid and nasal reconstruction. After subcutaneous infiltration anesthesia is administered through both the anterior and posterior auricular skin, an incision is made along the posterior rim of the helix. A dissection plane between the perichondrium and skin exposes the cartilage. The cartilage is removed without incising the anterior skin surface. This technique is particularly useful in cicatricial entropion, upper or lower eyelid retraction, eyelid reconstruction, and socket reconstruction.

Complications at Mucous Membrane Donor Sites

Full-thickness mucous membrane is an acceptable autogenous graft to replace the deficient conjunctiva resulting from intrinsic disease, surgical resection for carcinoma, or reconstruction of contracted sockets. The mouth provides an excellent source of mucous membrane graft material with few donor site complications. However, we encountered four cases of donor site complications after full-thickness mucous membrane grafting. All cases involved submucosal scarring with contracture. Because the inner aspect of the mouth is a multicontoured surface, the submucosal scarring resulted in web formation and limitation of movement of the mandible or lip. In two cases, we resected submucosal fibrotic scar tissue and designed a standard or multiple Z-plasty to release mucosal tension. This allowed a return to normal oral function.

The transconjunctival approach to the orbital floor and orbital fat : a prospective study

The transconjunctival approach to the inferior orbit and orbital fat offers the potential advantage of avoidance of scar creation in the lower eyelid skin and anterior lamellae. Complications of this approach, including conjunctival fornix shortening and eyelid margin malposition, have been occasionally reported. We prospectively observed 25 patients undergoing transconjunctival blepharoplasty and orbital floor surgery. Fornix depth, eyelid margin position, and the presence or absence of eyelid retraction were measured preoperatively and at each postoperative visit. No significant permanent change in these parameters was observed. Temporary entropion was observed in two patients; this resolved with conservative treatment. One self-limited suture granuloma was observed. In a subgroup of six patients, the conjunctival incision was closed on one side and left unclosed on the other. No adverse healing was noted on the unclosed side. We conclude that the transconjunctival approach is associated with a low incidence of complications, and that it does not significantly after the fornix depth or eyelid margin position. A skin incision is avoided. The inferior orbital septum is not violated, greatly reducing the risk of development of lower eyelid retraction.

Correction of upper eyelid retraction.

We used two surgical procedures to treat upper eyelid retraction in ten patients: either a posterior myectomy or the anterior levator muscle recession technique. Our choice was usually based on the amount of retraction. We used the posterior myectomy technique to treat up to 2 mm of retraction or localized retractions (five cases), particularly after blepharoptosis surgery. We used the anterior recession method to treat more than 2mm of retraction (five cases), particularly when associated with dysthyroid ocular disease. Complex eyelid contour abnormalities were treated with a combined recession-resection approach to the aponeurosis of the levator palpebrae superioris muscle (one case).

The Use of Botulinum Toxin in the Medical Management of Benign Essential Blepharospasm

Twenty-eight patients with mild or moderate cases of benign essential blepharospasm were treated with botulinum toxin Type A. Average follow-up was six months. The injection technique used on these patients is illustrated. The treatment was effective in virtually all patients treated, although transient; the mean interval of relief of spasm was approximately two and one-half months. Potential side effects include ptosis and epiphora. Botulinum toxin as an initial treatment or as an adjunct in postsurgical residual blepharospasm shows promise in this preliminary study.

Cerebellar Heterotopia in the Orbit

An infant with slowly progressive proptosis was found to have heterotopic cerebellum in her left orbit. Although cerebellar cell rests are common, to our knowledge none has been found previously in the orbit. It probably arose either from abnormal germ cell migration or from aberrant germ cell differentiation. Orbital heterotopia probably can be classified in the larger category of orbital encephaloceles because of similarities in presentation, clinical course, and treatment, although there can be differences in the embryologic mechanisms of their development.

Frontalis muscle flap advancement for correction of blepharoptosis.

PURPOSE To describe a technique of frontalis muscle flap advancement to repair myogenic ptosis in lieu of a graft or suture material. METHODS Ten ptotic eyelids in eight patients were repaired using the frontalis flap technique. Patients were selected at random by two separate surgeons; all patients had eyelid excursion measured as poor (or less than 6 mm). RESULTS Nine of 10 ptotic eyelids were adequately corrected by the frontalis flap technique, with follow-up intervals ranging from 18 to 42 months. Adequate correction was defined as ptosis corrected within 1 mm of the fellow eyelid. Complications of frontalis advancement were few and primarily transient. CONCLUSIONS Frontalis flap advancement is a technically simple, safe, and effective technique for the repair of myogenic ptosis. The primary advantage of frontalis muscle flap advancement over a graft or suture material that it elevates the eyelid directly by moving the insertion of the frontalis muscle into the eyelid, rather than by graft or suture material.