William B. Stewart

Eyelid Reconstruction by the Semicircle Flap Technique

The semicircle flap technique of eyelid reconstruction is a modified lateral advancement-rotation flap. The procedure combines the use of selective lysis of the limbs of the lateral canthal tendon with a semicircular skin-muscle flap confined to the region of the lateral canthus within the boundary established by the lateral eyebrow and the arc it defines. Reconstruction of one half to more than three fourths of the lower or upper eyelid can be accomplished without borrowing tissue from the eyelids, nose, ear, or mouth. Large forehead, brow, or cheek flaps are elininated, as is the need for closure of the palpebral fissure during the early healing course. The procedure has been used in the reconstruction of 36 lower eyelids and five upper eyelids in 40 patients, with a follow-up period of six months to six years. The usual indication for the use of this procedure is reconstruction of a central, marginal lid defect following the excision of a neoplasm. However, it may also be useful in cases of tissue loss caused by trauma, or for severe lid malpositions for which major kid reconstruction is necessary. The early and long-term cosmetic and functional results have been gratifying.

Reconstruction of the Periocular Mucous Membrane by Autologous Conjunctival Transplantation

We have extended the concept of autologous conjunctival transplantation for corneal resurfacing as recommended by Thoft to reconstruction in 14 patients with unilateral abnormalities of the bulbar and palpebral conjunctiva caused by alkali burns (2), irradiation (2), neoplasms (3), degenerative diseases (5), trauma (1), and developmental anomalies (1). Large, free conjunctival grafts from bulbar and forniceal donor sites were used. No complications have been noted at the recipient or donor sites. Grafts of normal conjunctiva provided intact basement membrane, goblet cells, and epithelium that help restore normal ocular and lid surfaces. The use of free conjunctival grafts provides significant advantage over the use of buccal mucous membrane grafts. The techniques and results of our experience with free conjunctival grafts in 14 patients are discussed.

Computer-Designed Prostheses for Orbitocranial Reconstruction

Three-dimensional imaging is an adjunct to preoperative evaluation and surgical management in some patients with complex anatomic defects of various etiologies. Deformities defined by conventional computerized tomography can be viewed as accurate three-dimensional images calculated from the original scan. The images are viewed on a high-resolution video monitor and can be photographed for a permanent record. A computer-controlled milling device can use these data to fabricate prostheses. The prostheses aid reconstructive surgery through use as an alloplastic implant, as a template to fashion autogenous bone grafts, or as a model for tissue removal. We have utilized three-dimensional imaging in combination with computer-assisted prosthesis manufacture in six patients with complex orbitocranial deformities. Four patients have undergone reconstructive surgery with satisfactory results and no complications thus far. The use of computer-designed prostheses adds a new aspect to orbitocranial reconstructive surgery that facilitates increased accuracy in the correction of anatomic defects.

Lacrimal gland and fossa lesions: an approach to diagnosis and management.

Lesions of the fossa of the lacrimal gland present special problems in diagnosis and management. Clinical recognition and differentiation of benign mixed cell lacrimal gland tumors from other inflammatory and neoplastic lesions of the lacrimal gland fossa are feasible and should provide the basis for the approach to proper management. Lesions conforming to the clinical picture of benign mixed cell lacrimal gland tumors need not undergo incisional biopsy, but require en bloc excision with adjacent tissues through a lateral orbitotomy to ensure complete excision and to prevent late recurrence. Incisional biopsy is indicated and should not be delayed in suspected infectious and noninfectious inflammatory lesions that have not responded rapidly to medical therapy, and in other lesions suspected of being neoplastic and not amenable to total local excision. An expedient approach to these lesions is essential if the prognosis of epithelial lacrimal gland neoplasms is to be improved.

Orbital exenteration. The reconstructive ladder.

Following orbital exenteration, there is a spectrum of immediate and delayed options for orbital reconstruction. Goals of reconstruction after exenteration include detection of recurrent disease, restoration of boundaries between the orbit and surrounding structures, and optimal aesthetics. Local solutions to problems of the exenterated orbit, such as healing by granulation or application of split-thickness skin grafts, are advantageous for detecting recurrent disease. Regional solutions, involving transfer of periorbital tissue into the orbit, may mask recurrent disease and create adjacent deformity; however, these solutions can be used to restore orbital boundaries and shallow the orbital cavity. Distant solutions, such as skin-muscle flaps and free tissue grafts, allow for facial reconstruction in patients with extensive orbital and periorbital defects.

Temporoparietal fascial flap for orbital and eyelid reconstruction

The temporoparietal fascial flap is a recognized technique for the transfer of vascularized tissue in the craniofacial region. The flap has a predictable axial vessel, provides thin vascularized tissue, and can be harvested with minimal donor-site morbidity. The temporoparietal fascial flap is well suited for orbital or eyelid reconstruction because of its proximity to the orbit. The flap is useful for reconstruction of anatomic barriers between the orbit, intracranial cavity, and paranasal sinus spaces. We present four patients in whom the temporoparietal fascial flap was used for orbital reconstruction following extirpative surgery for orbital neoplasm and two patients in whom the flap was used for lower eyelid and malar reconstruction.

Correction of lower eyelid retraction by transconjunctival retractor excision and lateral eyelid suspension.

PURPOSE To investigate the effectiveness of a procedure that addresses both the lower eyelid retractors and the lateral canthus in the treatment of patients with lower eyelid retraction. METHODS Through a combined lateral canthotomy and full-length transconjunctival incision, the lower eyelid retractors were disinserted across the horizontal length of the eyelid, recessed to the inferior fornix, and excised. A lateral canthopexy elevated the mobilized eyelid, and horizontal length disparity was corrected. RESULTS Forty lower eyelid operations in 23 patients yielded good results; all patients attained significant improvement in both eyelid position and function. No reoperations were required during a mean follow-up period of 28 months. CONCLUSION Although not ideal for severe cases requiring posterior lamellar spacers or anterior lamellar (skin) grafts, this union of techniques successfully treats many types of lower eyelid retraction.

Surgery of the Eyelid, Orbit and Lacrimal System

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Diffuse nodular eyelid lipogranuloma following sutureless transconjunctival blepharoplasty dressed with topical ointment.

PURPOSE Transconjunctival blepharoplasty is becoming the approach of choice for many cosmetic surgeons. The authors describe a case of a diffuse, multinodular eyelid lipogranuloma following transconjunctival blepharoplasty, after which the unsutured wound was dressed with a topical ointment. METHODS Report of clinical course and histopathologic findings. RESULTS A patient developed multiple firm, nontender masses of the left lower eyelid that enlarged despite topical and systemic medical therapy. Prior to referral, the progressive lesions had recurred despite three successive attempts at surgical eradication. Histopathologic examination of excised tissue demonstrated a multifocal lipogranulomatous inflammation consistent with reaction to retained ointment. CONCLUSIONS Sclerosing lipogranulomas are a known complication of intradermal lipid injection, as well as a late complication of sinus surgery after postoperative nasal packing with ointment-saturated gauze. The application of a topical ointment should be avoided until after transconjunctival lower blepharoplasty unless wound closure is secure or until conjunctival epithelialization is complete.

Calcifications in lesions of the fossa of the lacrimal gland.

It is frequently reported that calcification in the fossa of the lacrimal gland is a reliable sign of malignancy. We present a small, previously unreported series of lacrimal gland fossa calcifications, in which in three out of five cases the lesion was benign. Calcification can be a misleading radiographic sign and should not, in and of itself, be considered diagnostic of malignancy. This is important because proper preoperative diagnosis of lacrimal fossa tumors is essential as management differs.