The Need for Overcorrection When Using a Suborbital Cervicofacial Hike Flap.

BACKGROUND: The senior author has previously described a deep-plane cervicofacial hike flap as a workhorse for reconstruction mid-cheek defects. One important modification commonly used involves overcorrection of the defect in order to reduce the incidence of ectropion. This report outlines the senior author's experience in surgical treating complex cheek defects with an overcorrected deep-plane cervicofacial hike flap. METHODS: The authors performed a retrospective review of the senior author's patients with cheek and eyelid reconstruction. The authors initially identified all patients who had undergone a deep-plane cervicofacial hike flap, then filtered those charts for patients who had overcorrection of their deformity in order to prevent ectropion. RESULTS: A total of 3 patients had an overcorrected flap. Overcorrection was accomplished either by cheek advancement with suture fixation to the deep temporal fascia, or by placement of drill holes and bone anchors. Lower eyelid malposition was avoided in all 3 patients. Patient satisfaction at long term follow-up was very high, and no revision surgery was needed. CONCLUSION: If gravitational or cicatricial forces can potentially distort the eyelid in patients with cheek or eyelid reconstruction, it is necessary to overcorrect the cheek flap. This modification of the deep-plane cervicofacial flap is an important tool in reconstructing defects in this area.

[Lateral canthopexy - a simple addition to lower lid blepharoplasty]. / Die laterale Kanthopexie - eine wenig aufwendige, wertvolle Ergänzung der Unterlidblepharoplastik.

Rejuvination of the lower lid is a challenging procedure. Lower lid malposition and ectropion are serious postoperative complications. Therefore presurgical assessment of the lower lid function and laxity are a must before performing a blepharoplasty. Lateral canthopexy is an effective procedure to minimise the risk of postsurgical ectropion. Its necessity increases with rising age of the patients. The canthopexy supports the lower lid postion in the case of increasing vertical tension.

Barbed suture suspension technique for prevention of lower eyelid ectropion after Mohs micrographic surgery.

Mohs micrographic surgery of the lower eyelid poses a risk of ectropion. Even though the lower eyelid is a very frequent location for basal cell carcinoma, prevention techniques for ectropion after Mohs micrographic surgery have rarely been introduced. After Mohs micrographic surgery of the lower eyelid, the authors applied a barbed suture suspension technique for the prevention of lower eyelid ectropion. Following primary wound closure, barbed sutures were prepared by cutting one side of a 4-0 Prolene suture and applied around the lower eyelid. Sutures were maintained for 7 days and then removed. Evaluation 10 weeks after surgery found that ectropion had been minimized or prevented entirely.

Orbitomalar suspension during high SMAS facelift.

BACKGROUND: Traditional facelift techniques have some limitations: superficial musculo-aponeurotic system (SMAS) dissection may be incomplete in the superior medial orbitomalar region, and the centrofacial approach does not incorporate SMAS elevation. OBJECTIVES: Orbitomalar suspension (OMS) during high SMAS facelift combines the best of other techniques and may enhance aesthetic results and improve blending of the eyelid-cheek junction while minimizing the risk of lower eyelid ectropion. The authors examine the efficacy and complication rates of the OMS procedure. METHODS: Sixty patients underwent OMS as a primary component of high SMAS facelift and lower blepharoplasty. The technique is designed to accomplish superior-medial repositioning of the cheek while stabilizing lower eyelid position, reducing the risk of postoperative ectropion. RESULTS: Minor complications related to the OMS procedure occurred in three patients, all of whom had palpable and slightly visible Vicryl knots on one or both lateral upper eyelids. In one patient, the right side was reopened with a limited incision and the knot was removed. One case of lower eyelid malposition occurred and required revision. This patient presented on day three with unilateral left ectropion (2 mm), but the broken suture was easily replaced under local anesthesia, and the patient had no further ectropion. Two patients had transient lower eyelid malposition, which resolved within four weeks of surgery after gentle massage and lateral eyelid support with steri-strips. Two patients with prominent eyes and inferior orbital rim recession (negative vector) were not fully corrected; however, their lid position was no worse than the preoperative position and curvature. CONCLUSIONS: OMS during high SMAS facelift complements the deeper plane by adding a medial and superior vector of elevation to the cheek. Blending of the lower eyelid-cheek junction is accomplished with little risk of lower eyelid malposition.

Preventing Lateral Canthal Malposition in Modern Blepharoplasty.

Current goals in lower eyelid blepharoplasty include blending the lower eyelid-cheek junction, which is highlighted in the authors' six-step lower lid blepharoplasty technique. One major question in lower lid blepharoplasty is how to prevent lower lid malposition and ectropion, because these are untoward outcomes after an aesthetic procedure. In the authors' technique, they perform a superficial lateral retinacular canthopexy that is effective and safe and also prevents lower lid malposition or ectropion. A retrospective review of 104 patients who underwent six-step lower lid blepharoplasty was performed. In the authors' series, there was no significant difference between preoperative and postoperative intercanthal angles (p < 0.05), and the lateral canthal position did not change significantly from its preoperative position. The authors' six-step blepharoplasty technique addresses signs of midfacial aging, and the lateral canthopexy technique has been shown to have a minimal complication rate and maintains canthal position. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

[Prevention and management of locoregional complications of botulinum A toxin injections in cosmetic treatment]. / Prévention et gestion des complications locorégionales des injections de toxine botulique A en esthétique.

Botulinum toxin serotype A injections used in treating dynamic wrinkles is one of the least invasive cosmetic procedures. High patient satisfaction and low onset of always moderate side effects contribute to the growing popularity of botulinum toxin injections in cosmetic treatment over the past few years. Years of experience and use, in therapeutics [1,2] and esthetics (20 years) have proven the efficacy and the safety of this wrinkle treatment. Today, no severe or long-term side effects have been reported in esthetics. This article discusses only the most frequent locoregional effects. They are rare, moderate, transitory, and totally reversible. Properly informing and selecting patients will contribute to successfully preventing and managing these effects.

Full-thickness lower eyelid reconstruction with a conchal chondro-perichondral graft and local coverage with Mio-cutaneous flaps--our divisional experience.

BACKGROUND: Eyelid reconstruction represents a challenge because of the complexity of this structure. Full-thickness eyelid defects demand the reconstruction of 2 fundamental elements: anterior and posterior lamellae. The available reconstructive techniques are all associated with the attention to restore the support and responsibility of eyelid stability, represented physiologically by the tarsus. In 1987, Matsuo proposed a reconstructive technique that involved the use of a chondro-perichondral graft harvested from the auricular concha to reconstruct the posterior lamella, and an adjacent skin flap to restore the anterior lamella. MATERIALS AND METHODS: We report our divisional experience of a series of 28 patients operated on from 2000 to 2004, whose eyelid restoration was achieved with the use of Matsuo's technique modified with the purpose to avoid complications such as ectropion or lagophtalmus. RESULTS: All the grafts survived, and no major complication such as ectropion or lagophthalmos has been detected. Our specialistic judgment has ranged from good to excellent regarding symmetry, eyelid closure, and donor site morbidity. Patients were entirely satisfied with the functional result obtained, and generally with the esthetic outcome also, judged as ranging from good to extremely satisfactory. CONCLUSIONS: The success of eyelid reconstruction using modified Matsuo's technique depends, in our minds, on an adequate knowledge of traditional eyelid reconstruction methods, and on a few technical fine points that help to reduce postoperative complications and to optimize the quality of the end result; hence, this technique has become the gold standard in lower eyelid reconstruction in our division.

Further experience with the pinch technique for repair of eyelid deformities.

The pinch technique has been found to be useful in repairing cosmetic eyelid deformities. However, the local anesthetic containing hyaluronidase must be injected only in small amounts and only into the subcutaneous space. Scar tissue and skin that is firmly adherent to underlying muscle do not yield a satisfactory ridge, and therefore, the pinch technique should not be used. Ectropion can be predicted by the observation of eversion of the lid margin when even only minimal skin is pinched, and impending ectropion can be discovered by our "lean forward and look up" maneuver. An ectropion repair can then be combined with the blepharoplasty surgical operation. The pinch technique has also been found useful when upper and lower blepharoplasties are joined laterally to elevate the lateral canthus and eliminate "crow's feet." One component of a repair of trichiasis also involves the use of the pinch technique.

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.

Temporary tarsorrhaphy suture to prevent or treat scleral show and ectropion secondary to laser resurfacing or laser blepharoplasty.

The temporary tarsorrhaphy suture is introduced as a simple effective technique to prevent scleral show or ectropion secondary to laser skin resurfacing or laser blepharoplasty. In all but severe cases of prior existing scleral show or ectropion, the temporary tarsorrhaphy suture has been completely effective. It is also successfully used to prevent scleral show and ectropion for patients with poor lid snap and loss of elasticity of the lower eyelid at the time of laser skin resurfacing and blepharoplasty. A 5-0 Prolene suture is placed through the gray line to approximate the upper and lower eyelids and is left in place for 5 days. This supports the lower eyelid during the critical period of dermal and epidermal regeneration and during the formation of new collagen and elastin.

Lower-eyelid distractor.

An instrument is designed to measure the distractibility or horizontal laxity of the lower eyelid. It gives precise measurement of laxity independent of the examiner. It enables the surgeon to determine when and how much tightening of the lower eyelid is necessary to achieve the desired result in repair of entropion or ectropion and in cosmetic blepharoplasty.

The prevention and treatment of lower lid ectropion following blepharoplasty.

Ectropion and scleral show are the most common complications following lower lid blepharoplasty. Certain conditions predispose patients to ectropion, and these should be evaluated. In some cases, the addition of a wedge tarsectomy or tarsal strip procedure to a blepharoplasty in association with careful technique and postoperative measures is important in prevention of postblepharoplasty ectropion. Postoperative ectropion should initially be treated conservatively with massage. This may be effective up to 6 months postoperatively. If conservative measures fail, the etiology of the ectropion should be addressed. Laxity of the tarsus and canthal ligaments benefit from a horizontal lid-shortening procedure. Where there is vertical shortening from excessive skin resection or scarring of the orbital septum, there should be release and grafting of the deficiency.

Early release of third-degree eyelid burns prevents eye injury.

Burns to the eyelids occur in more than 20 percent of flame injuries and can lead to ocular damage and even blindness. Burn wound contracture can cause ectropion of the eyelid, resulting in exposure keratitis, corneal ulcers, and conjunctivitis. At our hospital, early eyelid release and grafting has made a significant difference in the long-term outcomes of third-degree eyelid burns; however, the question of just how early eyelid release and grafting should take place is an unresolved issue. Fifty-seven children with third-degree eyelid burns were reviewed; 17 had eyelid release within 7 days of receiving eyelid burns and 40 had a delay in eyelid release of more than 7 days after injury. Analysis was by chi-square with the Yates continuity correction or Fisher's exact test when appropriate. Corneal ulcers developed in 2 of 17 of the early eyelid release of third-degree burns, compared with 25 of 40 delayed releases (p = 0.001), exposure keratitis in 3 of 17 early releases, and 30 of 40 in delayed release (p = 0.000); conjunctivitis was identified in 1 of 17 early releases and 14 of 40 delayed eyelid releases (p = 0.025). Release of eyelid burns within 7 days of injury can prevent the development of exposure keratitis, progressive conjunctivitis, corneal ulceration, and the need for corneal surgery. We suggest that early release and grafting should be the treatment of choice for children and young adults with third-degree burns to the eyelids.

Prophylactic lateral canthopexy in lower blepharoplasties.

Lower eyelid malposition is a known complication of lower (lid) blepharoplasty surgery. The prevention of this complication is easier than its treatment. Over the past 5 years in my practice, 247 patients have had lower blepharoplasties with a canthopexy procedure and in some cases a tarsal strip canthoplasty. The criterion for a lateral tarsal strip canthoplasty was a lid distraction distance greater than or equal to 10 mm. Lid distraction distance is the distance the eyelid can be pulled away from the globe after the initial skin incision has been made and measured with calipers. If the eyelid can be pulled away from the globe less than 10 mm, then a canthopexy is performed, which occurred in 98% of cases. Patients had lateral canthopexies regardless of age or preoperative assessment. Herein, I describe a simple method of canthopexy that can be performed on most patients having a lower blepharoplasty, to not only achieve a cosmetically superior result but also to prevent eyelid malposition or ectropion.

The lateral transorbital canthopexy for correction and prevention of ectropion: report of a procedure, grading system, and outcome study.

BACKGROUND: There are numerous approaches to correcting laxity of the lateral canthal tendon, each with advantages and drawbacks. Critical evaluation of these techniques is not possible, however, as there is no grading system currently in use to describe this condition or to report outcomes, and prospective trials are lacking. OBJECTIVES: To report and assess a new procedure for repair of the lateral canthus (lateral transorbital canthopexy) and to describe the Ectropion Grading Scale (EGS), with a prospective outcome analysis of their use. DESIGN: Prospective outcome study of 15 consecutive patients (16 procedures). SETTING: Tertiary referral center in Zurich, Switzerland. PATIENTS: Consecutive sample of patients referred for treatment of ectropion of various causes. INTERVENTIONS: Preoperative and postoperative EGS grades were recorded, a preoperative and postoperative patient-based questionnaire was administered, and lateral transorbital canthopexy was performed. MAIN OUTCOME MEASURES: Outcome was determined by improvement in EGS grade and results of the patient-based symptom questionnaire. RESULTS: There were no surgical failures or complications in the study. An average of 83% reduction in patient-reported discomfort was achieved. Two patients with facial paralysis needed medial canthal repositioning. The EGS allowed clear recording of lower eyelid position before and after lateral transorbital canthopexy, and the procedure was uncomplicated to perform. CONCLUSIONS: Lateral transorbital canthopexy is an effective technique for the correction of lower eyelid laxity and appears to allow refined, durable adjustment of the lateral canthus. Self-reported patient satisfaction confirmed the high rate of success of the procedure in this study. The EGS permits critical evaluation and reporting of results and may assist in predicting which patients will need concomitant correction of the medial canthus. Arch Facial Plast Surg. 2000;2:9-15

[Early management of scrape and denuding injuries of the face after bicycle accidents. Prevention of scar ectropion]. / Frühbehandlung von Abschürfungs und Ablederungsverletzungen des Gesichts nach Fahrradunfällen. Vorbeugung von Narbenektropien.

Bicycle accidents may cause typical skin defects in the maxillary area if the unprotected face of the bicyclist hits the ground. Cicatricial ectropion is a frequent result. We report on 22 patients with facial skin defects after bicycle accidents and demonstrate a new concept for early treatment of facial skin abrasions and skin defects. Transtarsal traction sutures, temporary closure of skin defects by synthetic skin, and delayed free-skin grafting can prevent cicatricial ectropion even in large skin defects extending beyond the orbital margin. The overall time for treatment is significantly reduced.

Aesthetic blepharoplasty, ectropion and incipient ectropion.

Postoperative ectropion of the lower lid is the most common serious complication of aesthetic blepharoplasty. Important points in the surgical technique are described. The emphasis is on judicious skin excision. The management of postoperative ectropion is outlined. A lax, pre-ectropic lower lid constitutes an additional risk. The technical modifications which will prevent changing an incipient ectropion into a postoperative ectropion are reviewed.