This article is the continuation of a multi-part series examining recent trends in oculoplastic surgery. Part III of this series will focus on new techniques in eyelid reconstruction.
Eyelid Reconstruction
For large lower eyelid defects, Brent Skippen et al. described three one-stage alternatives to the Hughes procedure.
Technique #1 involves making a full thickness lateral-based advancement flap. The superior part of the incision is extended from the lateral canthus for a length equal to the defect’s horizontal length. The lower incision is made 1 to 2mm more than the vertical dimension of the wound. The full thickness eyelid flap is then advanced medially and sutured into place.
Technique #2 involves a vertical tarsal plate advancement flap covered by a full thickness skin graft. This method is useful in lower eyelid defects with partial tarsus remaining for the entire length of the defect, and where the anterior lamellar defect is larger than the posterior lamellar defect. A vascularized flap is fashioned by dissecting the retractors and septum, then cutting down vertically at the medial and lateral borders of the remaining tarsal plate, toward the inferior fornix. This tarsoconjunctival flap is then advanced superiorly until it rests approximately 3mm above the desired final position. The flap is sewn into place and the anterior lamella is replaced with a full thickness skin graft.
Technique #3 is useful in defects involving both the anterior and posterior lamella. The posterior lamella is replaced by hard palate and/or buccal mucosa. The anterior lamella is fashioned by mobilizing a myocutaneous advancement flap in a V-Y manner from directly inferior to the defect. The flap is advance superiorly in an overcorrected position of about 3mm to avoid post-operative eyelid retraction and is sewn into place.
Stewart et al. describes an innervated frontalis flap that will support both anterior and posterior lamellar grafts in extensive upper eyelid defects. The frontalis muscle is accessed through the superior margin of the defect. Dissection is carried superiorly anterior to the surface of the frontalis muscle. A stab incision is made through skin at the insertion of the galea into frontalis. The galea is incised and the dissection is carried inferiorly. A frontalis flap including galea, was fashioned to match the measurements of the defect and was stopped 4.5 cm above the orbital rim to preserve innervation of the flap. The flap was then reflected inferiorly and sandwiched between posterior and anterior lamellar grafts.
Epicanthoplasty
Epicanthoplasty is a popular, yet challenging procedure, especially in Asia. One of the main challenges is avoidance of a visible scar.
Tao et al. describes a novel U-Flap epicanthoplasty for Asian patients, which creates a tension-free flap with minimal scar.
The incision points follow the following pattern. Line AB is an extending curve of the natural lid crease to a point between the bridge of the nose and the medial canthus. Point C is at the end of the medial canthal fold where it meets the lower eyelid. Line BC completes the triangle described above and is perpendicular to line AB. Lines AB and BC should be equal in length.
Point C’ is the intended new medial canthus. Point D is the medial most point between A and C. AB, BC, BC’, and CD are incised.
The ABCD U-flap and underlying orbicularis muscle are dissected off of the medial canthal tendon. The orbicularis muscle is removed. After dissection, the flap spontaneously rotates upward without tension. C is fixed subcutaneously to the medial portion of the medial canthal tendon or periosteum, toward point C’. Flap ACD is transposed to AC’D and the redundant skin is trimmed. The donor site is closed by suturing points DB.
Hwang and Kim reviewed 46 articles in which 43 were for eliminating epicanthal folds and three were for reconstructing removed epicanthal folds. The most frequently cited article was Z-epicanthoplasty by Park, followed by “Jumping Man” by Mustarde and “Asymmetrical Z-plasty” by Del Campo. What the authors found was that the Z-plasty was the most frequent and is still increasing in frequency. Excision has decreased and advancement increased but stabilized in 2010. Interestingly, redraping continues to increase.
Saonanon reviewed the clinical significance of the epicanthal fold when evaluating Asian eyelids and highlighted key steps in performing successful epicanthoplasty. The epicanthal fold, common in the Asian population, is composed of the preseptal part of the orbicularis oculi muscle.
Epicanthoplasty can be categorized into two general approaches: transposition and advancement. Either way, the key to success is releasing all vertical tension by subcutaneous tissue dissection and orbicularis oculi myectomy. Newer techniques with orbicularis oculi myectomy offer less skin incision, smaller flap creation and minimal or no medial canthal ligament plication to minimize wound tension.
Potential complications include hypertrophic scarring, which is the most significant complication. Incidence ranges from zero to 3 percent and is most prominent at six to eight weeks. Most surgeons will wait six months before attempting correction. In the time being, warm compresses, massage, topical silicone or intralesional steroid injections can be given. Canalicular injury is also a risk, as the lacrimal drainage system is adjacent to the surgical incision site.
Next month’s article will switch gears as we discuss new techniques in non-surgical oculoplastic procedures.