- Email: [email protected]
Repair of a severe medial canthal defect
REPAIR OF A SEVERE MEDIAL
C A N T H A L DEFECT
By D. RALPH MILLARD, Jr., M.D., F.A.C.S.
From the Department of Surgery, University of Miami School of Medicine, Miami, Florida EXCISION of the medial canthal area may vary from mere skin excision to varying degrees of full-thickness excision including portions of both upper and lower eyelids. T h e skin excisions can be skin-grafted whereas full-thickness losses call for composite methods of repair depending on the extent and position of the excision. In losses of the medial canthus involving the lower lid where the skin sacrifice is large and the available conjunctiva can be advanced either from the same or the opposite lid (Hughes, I943), a classical transposed skin flap from the upper lid is simple and effective. For defects of half of the lid or more a chondromucosal graft method has been developed (Millard, i962 ) which is available even in medial canthal problems. None of the aforementioned procedures offers adequate repair for truly extensive losses in this area. For such reconstructions careful planning is essential and several factors should be considered. When the loss is such that immediate local eyelid tissue is insufficient the forehead becomes a logical donor area. In general its colour and texture render it ideal for the lower lid and its relative stiffness alleviates the necessity of a cartilage graft for duplication of the tarsus. Full-thickness forehead, however, is too bulky for ideal upper lid repair. With the globe intact mucous membrane is necessary for lining. This is available in adequate amounts as free full-thickness grafts of labial, buccal, and septal mucosa. Reconstitution of the puncta has not been found essential in wide excisions for after a temporary epiphora the adjustment is quite satisfactory. If desirable, cilia can be supplied by a free graft strip of scalp or brow or when practical by special design of the main flap (Millard, I962). AN EXTENSIVE REPAIR A 7I-year-old partially blind white male with a twenty-five-year history of a lesion of the medial canthus of the left eye was seen at Jackson Memorial Hospital Tumour Clinic. This basal-cell carcinoma involved half of the upper lid, the medial canthus with adherence to the bone, three-quarters of the lower lid and the adjacent cheek (Fig. I, A). The poor vision was found to be due to a mature cataract in the right eye with lens changes also in the left. As the patient's only vision was being achieved by his left eye where the lids were severely involved in carcinoma, first a right lens extraction by the ophthalmology department gained improvement in vision. Then a plan of repair was outlined to follow a radical excision of the left medial canthus. The area of excision was marked and measured and in the absence of sufficient immediate local tissue the forehead was chosen for the repair. As the mid-vertical position of the forehead is renowned (Kazanjian, 1946) for its excellence as a donor area, the main portion of the flap, designed for the lower lid, was marked along this axis. To take the entire component along the same axis promised undue tension in the closure. Therefore, the portion destined for the upper lid was marked at a right angle on the horizontal axis with the " V " to be the medial canthus (Fig. I, A). This is but an extension of the principle of borrowing from Peter for Paul which by placing a lien on a third party eases the pinch on Peter. The future base of the flap was planned to 90
REPAIR
OF A SEVERE
MEDIAL
CANTHAL
DEFECT
FIG. I A, A basal-cell carcinoma w h i c h was so extensive that local tissue was n o t sufficient for repair. A p a t t e r n to m a t c h t h e p l a n n e d defect was m a r k e d on the mid-vertical a x i s of t h e forehead with a horizontal extension for t h e u p p e r lid a n d a base i n c l u d i n g t h e supra-orbital, frontal, a n d nasal vessels of t h e opposite side. M u c o s a l graft inlays line t h e pockets of t h e potential u p p e r a n d lower lids. B, T h e excision involves half the u p p e r lid a n d over t h r e e - q u a r t e r s of t h e lower i n c l u d i n g a portion of t h e cheek along with t h e skin of t h e side of t h e nose, t h e medial c a n t h u s , its ligament, a n d t h e o u t e r layer of t h e left nasal bone. A m a t c h i n g forehead flap previously lined with m u c o u s m e m b r a n e has been elevated. C, T h e bi-lobed flap w h e n t u r n e d over reveals well-established m u c o s a lining for u p p e r a n d lower lids. D, T h e composite flap was slid into position a n d fixed with sutures.
91
92
BRITISH JOURNAL OF PLASTIC SURGERY
incorporate the supraorbital, frontal and nasal vessels of the opposite side to allow an unimpeded slide of the flap into the defect. Surgical delay of this flap prior to transport is not necessary, but establishment o f mucous membrane lining is mandatory. Incisions along the prospective lid margins were followed by undermining. The lower lid was dissected at near forehead full
FIG. 2
nlm
~. YES NO
Fig. 2.--Result of reconstruction one and a half years later reveals good function with almost invisible forehead donor scars. The patient at 2 years post-reconstruction is still well without recurrence.
Fig. 3.--Yes--mucosal graft overlying the edge of the skin flap. No--edge-to-edge approximation of graft and flap,
FIG. 3
thickness to maintain the support required but the upper lid was dissected at halfthickness to reduce its bulk. Buccal mucous membrane grafts were applied to line the under surface of these pockets by inlay with sutures and packing (Fig. I, a). Three weeks later, when the mucosal grafts were well established, the turnout was excised widely (senior resident H. Cohen). The total excision included a full-thickness half
REPAIR OF A SEVERE MEDIAL CANTHAL DEFECT
93
o f the upper lid, the medial canthus with its ligament, and the outer surface of the nasal bone as well as skin of the side of the nose, a full-thickness three-quarter of the lower lid and a portion of the cheek. The composite flap shaped like an 8 oz. right-hand boxing glove with mucosa lining the thumb, index, and middle finger positions was elevated (Fig. i, B and c). It was then sutured into the defect with the " thumb " to the upper lid and the " thenar web " the medial canthus. The forehead donor area, after undermining, closed with ease along each axis (Fig. I, D). Five weeks later, after the initial oedema had subsided, the glabella pedicle was divided, revised and returned to its original site and the excess skin of the right upper eyelid was trimmed to match the reconstructed lid. The final result is seen in Figure 2. When the patient was seen three months after repair a corneal erosion was noted and a small area of lower-lid epithelium was found to be touching the cornea in a certain position of the globe. Replacement of the area of epithelium with mucosa allowed healing of the cornea with thinning which brings up several important points. No matter how extensive the ablation or how carefully planned the repair even a miUimetre of epithelium in contact with the cornea at any position of the globe can cause damage. In retrospect it is suggested that although the reconstructed lids may appear to be functioning well during the early post-operative phase the chance of slight contracture of the mucous membrane graft with inrolling of the skin must be considered. As emphasised by Mustardd (I964) labial and buccal mucosal grafts tend to ,contract more than those from the septum. As an extra precaution it is suggested when necessary to use these grafts that they be brought well over the edge of the flap so as to line not only the new lid but its potential palpebral margin (Fig. 3). This leaves a margin of safety for contracture so that slight inversion of the skin edge will be harmless. Any patient undergoing eyelid reconstruction, who fails to keep a clinic appointment, should be summoned so that regular exfiminations can detect early corneal irritation and achieve immediate correction of the cause to prevent infection increasing the erosion. Over two years from the time of excision there is no evidence of carcinoma recurrence and the repair is functioning well (Fig. 2). An Obrigg scleral contact lens fitted by Dr Olga Ferret has brought vision to 20-80. A left lens extraction could further improve vision to match the 20-40 of the right eye but under the circumstances o f this case the ophthalmology department does not feel that further surgery is indicated. SUMMARY
Literature on repair of medial canthal defects appears to be limited. For this reason the subject is discussed briefly and exemplified by an extensive defect repaired with a bi-lobed forehead flap lined with buccal mucosa. REFERENCES HUGHES, W. S. (I943). " Reconstructive Surgery of the Eyelids." Kimpton. KAZANJIAN,V. H. (I946). Surg. Gynec. Obstet., 83, 37. MILLARg, D. R., Jr. (I96a). Plast. reconstr. Surg., 30, 267. MUSTARD~, J. C. (I964). Personal communication.
Submitted for publication, November I964.
London : Henry
C A N T H A L DEFECT
By D. RALPH MILLARD, Jr., M.D., F.A.C.S.
From the Department of Surgery, University of Miami School of Medicine, Miami, Florida EXCISION of the medial canthal area may vary from mere skin excision to varying degrees of full-thickness excision including portions of both upper and lower eyelids. T h e skin excisions can be skin-grafted whereas full-thickness losses call for composite methods of repair depending on the extent and position of the excision. In losses of the medial canthus involving the lower lid where the skin sacrifice is large and the available conjunctiva can be advanced either from the same or the opposite lid (Hughes, I943), a classical transposed skin flap from the upper lid is simple and effective. For defects of half of the lid or more a chondromucosal graft method has been developed (Millard, i962 ) which is available even in medial canthal problems. None of the aforementioned procedures offers adequate repair for truly extensive losses in this area. For such reconstructions careful planning is essential and several factors should be considered. When the loss is such that immediate local eyelid tissue is insufficient the forehead becomes a logical donor area. In general its colour and texture render it ideal for the lower lid and its relative stiffness alleviates the necessity of a cartilage graft for duplication of the tarsus. Full-thickness forehead, however, is too bulky for ideal upper lid repair. With the globe intact mucous membrane is necessary for lining. This is available in adequate amounts as free full-thickness grafts of labial, buccal, and septal mucosa. Reconstitution of the puncta has not been found essential in wide excisions for after a temporary epiphora the adjustment is quite satisfactory. If desirable, cilia can be supplied by a free graft strip of scalp or brow or when practical by special design of the main flap (Millard, I962). AN EXTENSIVE REPAIR A 7I-year-old partially blind white male with a twenty-five-year history of a lesion of the medial canthus of the left eye was seen at Jackson Memorial Hospital Tumour Clinic. This basal-cell carcinoma involved half of the upper lid, the medial canthus with adherence to the bone, three-quarters of the lower lid and the adjacent cheek (Fig. I, A). The poor vision was found to be due to a mature cataract in the right eye with lens changes also in the left. As the patient's only vision was being achieved by his left eye where the lids were severely involved in carcinoma, first a right lens extraction by the ophthalmology department gained improvement in vision. Then a plan of repair was outlined to follow a radical excision of the left medial canthus. The area of excision was marked and measured and in the absence of sufficient immediate local tissue the forehead was chosen for the repair. As the mid-vertical position of the forehead is renowned (Kazanjian, 1946) for its excellence as a donor area, the main portion of the flap, designed for the lower lid, was marked along this axis. To take the entire component along the same axis promised undue tension in the closure. Therefore, the portion destined for the upper lid was marked at a right angle on the horizontal axis with the " V " to be the medial canthus (Fig. I, A). This is but an extension of the principle of borrowing from Peter for Paul which by placing a lien on a third party eases the pinch on Peter. The future base of the flap was planned to 90
REPAIR
OF A SEVERE
MEDIAL
CANTHAL
DEFECT
FIG. I A, A basal-cell carcinoma w h i c h was so extensive that local tissue was n o t sufficient for repair. A p a t t e r n to m a t c h t h e p l a n n e d defect was m a r k e d on the mid-vertical a x i s of t h e forehead with a horizontal extension for t h e u p p e r lid a n d a base i n c l u d i n g t h e supra-orbital, frontal, a n d nasal vessels of t h e opposite side. M u c o s a l graft inlays line t h e pockets of t h e potential u p p e r a n d lower lids. B, T h e excision involves half the u p p e r lid a n d over t h r e e - q u a r t e r s of t h e lower i n c l u d i n g a portion of t h e cheek along with t h e skin of t h e side of t h e nose, t h e medial c a n t h u s , its ligament, a n d t h e o u t e r layer of t h e left nasal bone. A m a t c h i n g forehead flap previously lined with m u c o u s m e m b r a n e has been elevated. C, T h e bi-lobed flap w h e n t u r n e d over reveals well-established m u c o s a lining for u p p e r a n d lower lids. D, T h e composite flap was slid into position a n d fixed with sutures.
91
92
BRITISH JOURNAL OF PLASTIC SURGERY
incorporate the supraorbital, frontal and nasal vessels of the opposite side to allow an unimpeded slide of the flap into the defect. Surgical delay of this flap prior to transport is not necessary, but establishment o f mucous membrane lining is mandatory. Incisions along the prospective lid margins were followed by undermining. The lower lid was dissected at near forehead full
FIG. 2
nlm
~. YES NO
Fig. 2.--Result of reconstruction one and a half years later reveals good function with almost invisible forehead donor scars. The patient at 2 years post-reconstruction is still well without recurrence.
Fig. 3.--Yes--mucosal graft overlying the edge of the skin flap. No--edge-to-edge approximation of graft and flap,
FIG. 3
thickness to maintain the support required but the upper lid was dissected at halfthickness to reduce its bulk. Buccal mucous membrane grafts were applied to line the under surface of these pockets by inlay with sutures and packing (Fig. I, a). Three weeks later, when the mucosal grafts were well established, the turnout was excised widely (senior resident H. Cohen). The total excision included a full-thickness half
REPAIR OF A SEVERE MEDIAL CANTHAL DEFECT
93
o f the upper lid, the medial canthus with its ligament, and the outer surface of the nasal bone as well as skin of the side of the nose, a full-thickness three-quarter of the lower lid and a portion of the cheek. The composite flap shaped like an 8 oz. right-hand boxing glove with mucosa lining the thumb, index, and middle finger positions was elevated (Fig. i, B and c). It was then sutured into the defect with the " thumb " to the upper lid and the " thenar web " the medial canthus. The forehead donor area, after undermining, closed with ease along each axis (Fig. I, D). Five weeks later, after the initial oedema had subsided, the glabella pedicle was divided, revised and returned to its original site and the excess skin of the right upper eyelid was trimmed to match the reconstructed lid. The final result is seen in Figure 2. When the patient was seen three months after repair a corneal erosion was noted and a small area of lower-lid epithelium was found to be touching the cornea in a certain position of the globe. Replacement of the area of epithelium with mucosa allowed healing of the cornea with thinning which brings up several important points. No matter how extensive the ablation or how carefully planned the repair even a miUimetre of epithelium in contact with the cornea at any position of the globe can cause damage. In retrospect it is suggested that although the reconstructed lids may appear to be functioning well during the early post-operative phase the chance of slight contracture of the mucous membrane graft with inrolling of the skin must be considered. As emphasised by Mustardd (I964) labial and buccal mucosal grafts tend to ,contract more than those from the septum. As an extra precaution it is suggested when necessary to use these grafts that they be brought well over the edge of the flap so as to line not only the new lid but its potential palpebral margin (Fig. 3). This leaves a margin of safety for contracture so that slight inversion of the skin edge will be harmless. Any patient undergoing eyelid reconstruction, who fails to keep a clinic appointment, should be summoned so that regular exfiminations can detect early corneal irritation and achieve immediate correction of the cause to prevent infection increasing the erosion. Over two years from the time of excision there is no evidence of carcinoma recurrence and the repair is functioning well (Fig. 2). An Obrigg scleral contact lens fitted by Dr Olga Ferret has brought vision to 20-80. A left lens extraction could further improve vision to match the 20-40 of the right eye but under the circumstances o f this case the ophthalmology department does not feel that further surgery is indicated. SUMMARY
Literature on repair of medial canthal defects appears to be limited. For this reason the subject is discussed briefly and exemplified by an extensive defect repaired with a bi-lobed forehead flap lined with buccal mucosa. REFERENCES HUGHES, W. S. (I943). " Reconstructive Surgery of the Eyelids." Kimpton. KAZANJIAN,V. H. (I946). Surg. Gynec. Obstet., 83, 37. MILLARg, D. R., Jr. (I96a). Plast. reconstr. Surg., 30, 267. MUSTARD~, J. C. (I964). Personal communication.
Submitted for publication, November I964.
London : Henry