Septo-capsulopalpebral fascial recession flap technique in lower blepharoplasty: An experience of 453 consecutive cases and a review of the literature.

BACKGROUND: Lower blepharoplasty is one of the most common cosmetic rejuvenation procedures. Occasionally, adverse effects of the operation, ranging from operated and somewhat flattened unnatural look of the lower eyelid region to more severe cases of ectropion, retraction leading to functional disabilities, further compound the problem. The author has developed a technique focusing on two aspects in terms of the outcome of the operation in developing a technique that ensures a uniformly consistent and esthetically perceptible result. METHODS: The anatomic basis for the technique is reviewed and described. We performed lower blepharoplasty using the septo-capsulopalpebral fascial recession flap. The procedure requires skin incision, maintenance of pretarsal muscular roll, skin-muscle flap elevation, orbital septum release, orbital fat removal, septo-capsulopalpebral recession flap, skin excision, and closure. RESULTS: No complications have occurred in 453 patients, including hematoma and dry eye. Lid malposition such as entropion or lagophthalmos was not seen in any patient. Regardless of the preoperative variations in the lower lid, the method corrected the prolapsed lower eyelid and provided satisfactory esthetic result after the operation. Recurrences have not been observed during the follow-up period. CONCLUSION: Lower blepharoplasty using the septo-capsulopalpebral fascial recession flap is effective to correct baggy eyelid, with minimal risk of cicatricial ectropion or tarsal capsize and retraction. Further, the esthetic result is enhanced by the author's method of making the pretarsal muscular roll with prevention of its loss.

A New Composite Eyeball-Periorbital Transplantation Model in Humans: An Anatomical Study in Preparation for Eyeball Transplantation.

BACKGROUND: Vascularized composite allotransplantation offers a new hope for restoration of orbital content and perhaps vision. The aim of this study was to introduce a new composite eyeball-periorbital transplantation model in fresh cadavers in preparation for composite eyeball allotransplantation in humans. METHODS: The composite eyeball-periorbital transplantation flap borders included the inferior border, outlined by the infraorbital rim; the medial border, created by the nasal dorsum; the lateral border, created by the lateral orbital rim; and the superior border, created by the superior part of the eyebrow. The pedicle of the flap included the facial artery, superficial temporal artery, and external jugular vein. The skin and subcutaneous tissues of the periorbital region were dissected and the bony tissue was reached. A coronal incision was performed and the frontal lobe of the brain was reached by means of frontal osteotomy. Ophthalmic and oculomotor nerves were also included in the flap. After a "box osteotomy" around the orbit, the dissection was completed. Methylene blue and indocyanine green injection (SPY Elite System) was performed to show the integrity of the vascular territories after facial flap harvest. RESULTS: Adequate venous return was observed within the flap after methylene blue dye injection. Laser-assisted indocyanine green angiography identified a well-defined vascular network within the entire composite eyeball-periorbital transplantation flap. CONCLUSIONS: For the first time, a novel composite eyeball-periorbital transplantation model in human cadavers was introduced. Good perfusion of the flap confirmed the feasibility of composite eyeball-periorbital transplantation in the clinical setting. Although harvesting of the flap is challenging, it introduces a new option for reconstruction of the periorbital region including the eyeball.

Orbital floor reconstruction with ethyl-2-cyanoacrylate.

The orbital floor is one of the most frequently broken bones in maxillofacial fracture, and orbital reconstruction is needed in many cases. Various materials are used for orbital floor reconstruction. We report here orbital reconstruction using autologous orbital bone with cyanoacrylate. Entrapped soft tissues were freed and repositioned intraorbitally and bone fragments were gathered with a microscope simultaneously. The bone fragments were fixed to a board of bone with ethyl-2-cyanoacrylate and returned to the orbital fracture site. Of 96 fresh orbital floor fractures, this method was used for 31 (32.3%) patients. Simple reduction was performed in 48 patients. Bone graft with iliac crest was performed in the other 12 patients. Reconstruction with alloplastic materials was performed in 5 patients. Diplopia was corrected in 26 patients on whom this method was performed. The reconstructed bone collapsed into the maxillary sinus in 1 patient who underwent iliac bone graft on reoperation. Another 4 patients did not show diplopia preoperatively. None of the patients showed enophthalmos, foreign body reaction, or infection postoperatively. We were able to perform orbital bone reconstruction with autologous orbital bone without another donor site in 30 (62.5%) of 48 cases that required grafting. The indications for this method are that a sufficient quantity of bone fragments can be obtained and returned on a board of bone which can be stabilized in the orbit without collapsing into the maxillary sinus. Good results were obtained, and we consider this to be a safe and useful method.

Lipoenxertia autóloga periorbitária no rejuvenescimento facial: análise retrospectiva da eficácia e da segurança em 31 casos / Autologous periorbital fat grafting in facial rejuvenation: a retrospective analysis of efficacy and safety in 31 cases

INTRODUÇÃO: Os sulcos periorbitários e zigomático e o malar flácido estão entre as características mais marcantes de envelhecimento ou de desarmonia facial. A reposição do volume é um método simples e eficiente, e o lipoenxerto pode ser o melhor material. O presente trabalho traz uma análise de 31 pacientes submetidos a autolipoenxertia, com ênfase na eficácia e na segurança da técnica. MÉTODO: Análise retrospectiva de 31 pacientes consecutivos, submetidos a lipoenxertias periorbitária e malar, concomitantemente ou não a outros procedimentos estéticos. A avaliação foi feita por meio de comparação entre fotografias pré e pós-operatória, bem como pelo grau de satisfação dos pacientes. RESULTADOS: Dos 31 pacientes, 26 (83,9%) classificaram o resultado pós-operatório como ótimo, 3 (9,7%), bom, e 2 (6,4%), regular. Na avaliação dos autores, 24 (77,5%) pacientes apresentaram resultado ótimo, 5 (16,1%), bom, e 2 (6,4%), regular. Houve necessidade de retoque de lipoenxertia em apenas 4 pacientes, por sugestão do cirurgião. As complicações foram mínimas e passageiras. CONCLUSÕES: A lipoenxertia facial é fácil e eficaz, e as complicações são mínimas quando realizada por cirurgiões qualificados.

BACKGROUND: Periorbital and zygomatic hollows as well as flaccid cheeks are among the most evident characteristics of aging or facial disharmony. Volume replacement is a simple and efficient procedure, and fat grafting is considered as the best treatment for these characteristics. This study evaluates 31 patients who underwent autologous fat grafting and emphasizes the safety and efficacy of this procedure. METHODS: A retrospective analysis of 31 consecutive patients who underwent periorbital and zygomatic fat grafting, alone or in combination with other cosmetic procedures, was carried out. Final evaluation was performed by assessing pre- and postoperative photographs as well as the degree of patient satisfaction. RESULTS: Of 31 patients, 26 (83.9%) reported excellent postoperative outcomes; 3 (9.7%), satisfactory outcomes; and 2 (6.4%), poor outcomes. According to the authors' evaluation, 24 (77.5%) patients had excellent outcomes, 5 (16.1%) had satisfactory outcomes, and 2 (6.4%) had poor outcomes. Retouching of the fat graft was recommended for only 4 patients. The complications observed were minimal and transient. CONCLUSIONS: Facial fat grafting is a simple and effective procedure that presents minimal complications when performed by skilled surgeons.

The use of the orbital septum in inferior palpebral reconstruction: the pocket technique.

BACKGROUND: Surgery involving massive inferior palpebral demolition often imposes the use of free flaps for the reconstruction of the anterior and posterior lamellae. PURPOSE: We describe a surgical technique which provides for the use of a homologous pedunculated elastic flap on which we wrap the free flap as in a pocket, in order to guarantee that the free flap itself takes root better. METHODS: A study of 10 patients admitted to our hospitals for massive inferior palpebral demolition surgery between March 2002 and November 2004 was undertaken, and clinical records (age, sex, involved site of lesions, surgery technique) were accurately noted: in all patients we performed the 'pocket technique'. RESULTS: The pocket technique has encouraged optimal attachment of the implanted free tissue, in absence of necrotic phenomena or tissue extrusion. CONCLUSIONS: Reconstructive surgery of the inferior eyelid avails itself of consolidated techniques. In case of extreme tissue reduction, the variation we wish to suggest is simple to understand and easy to perform, significantly reducing inflammatory reaction and/or post-surgical rejection, allowing excellent aesthetic results.

The use of autologous autoclaved bone in orbital reconstruction after exenteration for invasive cutaneous carcinoma.

PURPOSE: To describe a technique for reconstructing the orbital bony architecture after invasion by tumour. METHODS: Orbital bone invaded by tumour was osteotomized (post-exenteration), autoclaved to remove tumour cells, and then refixated in order to re-establish the normal orbital anatomy. RESULTS: Despite some shrinkage of the bone fragment in the autoclaving process, after refixation the contour and topography of the bony orbit was essentially normal. CONCLUSION: Autoclaved bone can be used to reconstruct the exenterated orbit; it is a fast and technically simple strategy for maintaining orbital anatomy when faced with bony invasion by tumour.

[Use of median fronto-naso-orbital flap to decrease the incidence of complications in patients undergoing craniofacial resection]. / Uso del colgajo frontonasoorbitario para disminuir la frecuencia de complicaciones en pacientes sometidos a resección craneofacial.

BACKGROUND: Resection of malignant neoplasms invading the anterior cranial base is performed with craniofacial resection (CFR) with acceptable results in complication rates and oncologic outcomes. However, still there are series with major morbidity in up to 40% of patients, and mortality of 5%. A retrospective study was performed to evaluate the results in terms of morbidity, mortality, function and aesthetics using a median fronto orbital flap (MFOF). METHODS: The MFOF was used in 28 consecutive patients who presented to the Head and Neck Service from 1992 to 1999, in the Instituto Nacional de Cancerología, Mexico City, and was combined with a superior rhinotomy for en bloc resection of the ethmoid complex in the last 12 cases. 89% of patients had malignant neoplasms. RESULTS: 1 death occurred in this series (3%) and the global morbidity was 35%. Aesthetics and function were good to excellent. Percentages of tumor-free survival for malignant lesions was 76% and 41% at 2 and 5 years follow up, respectively. CONCLUSION: CFR is a safe approach for treatment of neoplasms of the anterior skull base. MFOF mobilization decreases complication rates and gives superb exposure for en bloc resection of tumors invading the ethmoidomaxillary complex specially when combined with a superior rhinotomy. A positive impact on quality of life was obtained.

[Plastic repair of a defect in the base of the skull with soft tissues from the orbit after the removal of an extensive esthesioneuroepithelioma]. / Plastika defekta osnovaniia cherepa miagkimi tkaniami glaznitsy posle udaleniia rasprostranennoi éstezioneiroépiteliomy.

The paper describes a clinical observation of closure of sphenoidal sinus defect and plastic repair of dura mater by using orbital tissues after removal of a tumor from the medial portions of the middle cranial fossa, which spread into the orbit and sphenoidal sinus, in complete irreversible loss of visual function, ophthalmoplegia and ptosis in a patient with skull soft tissue hypotrophy due to multiple operations and radiation therapy and hence unsuitable for displacement and closure. This observation shows it possible to use orbital soft tissue for repair of the base of the skull, in cases when integumentary cranial tissues are impossible to use as a plastic material due to their hypotrophicity. At the same time severe dysfunctions, such as blindness and ophthalmoplegia enable orbital tissues to be employed without significantly deteriorating any functional and cosmetic effect.

Injerto dermograso como implante para la formación de volumen orbitario / Dermoadipose graft as implant for the formation of orbitary volumen

En 1978 Smith y Petrelli utilizaron por primera vez los injertos dermograsos como implantes en pacientes con extrusión y migración de los mismos. Desde entonces se reportan buenos resultados con esta técnica. Se realizó un estudio propectivo en el Hospital Oftalmológico de nuestra Señora de la Luz en el periodo de 1 año, en el cual se incluyeron 11 pacientes: 5 casos (45.4 por ciento) con diagnóstico de extrusión de implante, 6 (54.5 por ciento) por corrección cosmética (ptisis bulbi secundaria a traumatismo y por contractura del contenido orbitario). Se realizó la técnica modificada por Smith Bosniak y Lisman. El 100 por ciento ce los pacientes ovtubieron buen volumen orbitario, 10 pacientes tuvieron buenos fondos de saco y de obtuvo movilidad regular del injerto en el 63 por ciento. La pérdida del volumen orbitario fue mínima o nula en 8 casos y estos presentaron una profundidad del surco palpebral superior aceptable. Se encontró esta técnica útil en el manejo de casos difíciles, proporcionando el suficiente volumen para ofrecer una buena rehabilitación cosmética.

Controlled bending of cranial bone grafts: a simple surgical technique.

The cranium serves as a primary bone graft donor site in reconstructive craniofacial surgery. However, the mechanical properties of cranial bone predispose to fragmentation when excessive bending forces are applied, or to a return to the original shape when bending forces are insufficient. The precise and sustained contouring of cranial bone therefore remains a practical clinical problem. This paper describes a simple surgical technique which relies upon the application of a miniplate to the cortical surface of the cranial bone segment prior to bending. The miniplate serves to reinforce the segment, allowing accurate shaping of cranial bone and maintenance of the newly acquired contour.