Faculty Bibliography

Background/Purpose: The reconstruction of the wide Tessier #4 cleft is classically limited by persistent lower lid ectropion/medical canthal disruption or the incorporation of unaesthetically located scars which violate the subunit border principle of facial reconstruction. We present a novel repair technique which: can be applied at infancy; does not require tissue expansion; restores stable lower eyelid and medial canthal position; and respects the subunit border principle of facial repair. Methods/Description: A neonate with a complete, wide, Tessier #4 facial cleft presents with an over 2/3rd lower eyelid loss. Presurgical tape therapy was applied to lengthen the lateral tissues transversely and vertically. A Tenzel flap extended to a Schrudde cervicofacial flap was planned to radically mobilize the lower eyelid to the medial canthus in a tension-free manner. A robust vascular supply was maintained to this large flap using a deep plane dissection. Results: Surgical repair was performed at 3 months of age. No tissue expansion was used. A Tenzel pattern flap was mobilized in the subcutaneous plane. This flap was raised in continuity with a Schrudde cervicofacial flap raised in the deep plane. Facial nerves were directly visualized and preserved during the operation. A conjunctival flap was raised from the floor of the orbit was used to reconstruct the posterior lamella of the lower eyelid. The Tenzel/Schrudde flap was rotated, without tension over the defect and to the nose/cheek junction. At the time of inset, there was redundant flap skin superiorly at the level of the lower eyelid and medially at the area of the medial canthus. This redundancy was incorporated into the reconstruction to prevent ectropion and medial canthus disruption. Suspensory sutures were applied to the infraorbital rim and pyriform aperture to prevent sagging of the flap. A Millard repair was used to reconstruct the lip at the level of the philtrum. The flap demonstrated 100% take despite radical mobilization. The final scar followed the philtral line, the nasal/cheek junction, the subcilliary line and the anterior auricular/retro auricular border. Lower eyelid and medial canthal position was stable after 6 months. Facial nerve function was preserved with this approach. Conclusions: A Tenzel/Schrudde deep-plane cervicofacial flap can be safely applied to infants with a wide Tessier #4 facial cleft. No tissue expansion is needed. This is the first repair technique which places final scars perfectly along the subunit borders of the face while preserving lower eyelid and medial canthal position, even in the patient with significant lower eyelid loss

Total eyelid loss, full thickness loss of the upper and lower eyelids, is uncommon and surgically challenging. Eyelid reconstruction after such injuries can be further complicated by loss of adjacent tissue. When tissue for local flaps is unavailable, free flaps must be considered. Few cases of total eyelid reconstruction via microvascular free flap have been reported, especially with an intact globe and good visual acuity. In this report, we describe the use of a microvascular free flap based on the radial artery for total eyelid reconstruction in a patient with an intact globe and useful visual acuity.

PURPOSE: To determine the effect of ptosis on compensatory frontalis contraction in patients without visual input and to identify if a sensory stimulus contributes to brow elevation. METHODS: A prospective study. Clinical photographs were measured by 2 masked oculoplastic surgeons to determine brow height in 8 patients with unilateral ocular prosthesis in 3 conditions: at baseline, after a gold weight was applied to the upper eyelid inducing acute ptosis, and with the gold weight plus topical anesthetic. The measured brow height was then compared between the 3 scenarios. RESULTS: Mean brow height increased after application of the gold weight when compared with baseline, and this difference reached significance (p = 0.012). After topical anesthetic was applied, the mean brow height decreased but not back to baseline. When mean brow height during the gold weight with topical anesthesia was compared with baseline and with the gold weight only scenarios, the difference was not significant (p > 0.05). CONCLUSIONS: Frontalis contraction is observed when acute ptosis is simulated in anophthalmic patients, confirming that a contracted visual field cannot be the only stimulus for compensatory brow elevation. A sensory or proprioceptive mechanism is suggested but not confirmed by the trend of reduction in brow elevation with topical anesthesia.

BACKGROUND: The objective of this study was to determine the effects of lower eyelid transconjunctival blepharoplasty (TCB) on lower eyelid position. METHODS: Transconjunctival blepharoplasty was performed alone in 15 lower eyelids without simultaneous canthoplasty or upper eyelid procedure. In this study, blepharoplasty was performed by the transconjunctival approach without removal of skin. Four eyes received TCB plus Erbium laser, two patients received TCB plus trichloroacetic acid peel (TCA), and three patients received TCB plus fat transposition. Pre-operative and post-operative margin reflex distance 1 (MRD 1) and margin reflex distance 2 (MRD 2) were compared, with MRD 1 acting as the control. RESULTS: Average time to post-operative photo was 4.6 months (1-10 months). The changes in MRD 2 and MRD 1 were compared pre- and post-operatively, and the difference reached significance by one-tailed comparison (P < 0.05). In 11/15 eyes (73 %), MRD 2 decreased post-operatively. In 6/7 eyes (86 %), lower lid scleral show was eliminated post-operatively. There were no cases of lid retraction noted. CONCLUSIONS: Transconjunctival blepharoplasty (+/- skin resurfacing) did not induce lid retraction but elevated the lower lid in majority of patients. Elevation of the lower lid can reduce or eliminate scleral show inferiorly, providing further cosmetic advantage. The presumed mechanism of lower lid height elevation is partial recession of the lower lid retractors during the surgical approach to the fat pockets. LEVEL OF EVIDENCE IV: This journal requires that the authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

PURPOSE:: To describe a case series of ointment granuloma as a complication of sutureless transconjunctival blepharoplasty. METHODS:: A retrospective review of the medical records of 8 patients with this complication was conducted, including the histopathology of excised tissues. Institutional review board oversight was waived as this was not an institutional study but a Health Insurance Portability and Accountability Act-compliant retrospective chart review from the private medical practice of one of authors' coauthors. It adhered to the principles set forth in the Declaration of Helsinki. RESULTS:: Eight patients developed painless lower eyelid and anterior orbital masses following presumed successful blepharoplasty. Each had received intra- or immediate postoperative lubricating ointment. The mean time from surgery to appearance of the lesions was 50 days (range: 9 days-10 months). Three patients responded to intralesional injection of steroid with complete resolution. Five patients required surgical excision of the lesions without recurrence to date. Histopathological examination of the excised tissues revealed large, pleomorphic lipid-dropout pools bordered by attenuated histiocytes and giant cells. CONCLUSIONS:: The appearance of eyelid lumps or fullness in the early and mid-postoperative recovery should suggest ointment granuloma. If recognized early, management should commence with intralesional injection of steroids, although the definitive treatment is surgical excision. The authors recommend minimizing the access of topical ointments to the open inferior fornix, placing the medication sparingly onto the cornea at the close of surgery and instructing patients in avoiding overuse.