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PREVENTION OF ECTROPION IN RECONSTRUCTION OF

FACIAL DEFECTS

Glenn W. Jelks, MD, and Elizabeth B. Jelks, MD

Ectropion, or eversion of the lid margin away from the globe, can occur after surgical reconstruction of facial defects that encroach on the lower eyelid (Fig. 1). The most common cause of this deformity is mechan- ical distraction of the eyelid; however, scar contracture, orbicularis oculi paralysis, and tarsal-ligamentous laxity of the eyelid also can contribute to the deformity. The eyelid and periocular anatomy have been divided into surgical zones to facilitate the most appropriate method of reconstruction (Fig. 2). Correcting facial defects (zone V) that are contiguous with the lower eyelids (zone 11) and especially the canthal areas (zones I11 and IV) requires special knowledge of the regional anatomy to select a method of reconstruction that prevents lid malpositions, epiphora, corneal decom- pensation, and visual loss. Lower eyelid malpositions are graded mild when there is slight eversion of the cilia inferiorly with or without scle- ral show, moderate when the lid margin is everted with lower eyelid descent and scleral show, and severe when frank ectropion is present. Chronic ectropion results in exposure keratinization of the conjunctiva, which contributes to ocular irritation and can lead to loss of vision. There are specialized structures of the eyelids that protect the eyes from expo- sure to the elements. Numerous oil, mucus, and aqueous-producing tear glands are present within the tarsal-conjunctival mucous lining of the up- per and lower eyelids. Blinking of the eyelids distributes this complex three-layer tear film over the surfaces of the eyes to protect them. Eye- lid reconstruction and contiguous periocular facial reconstruction should

This article appeared in Clinics in Plastic Surgery, Vol. 28, No. 2, April 2001, as part of an issue on head and neck reconstruction.

From the New York University School of Medicine, New York, New York

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VOLUME 34 * NUMBER 4 AUGUST 2001 783

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Figure 1. Ectropion of the lower eyelid is present 10 days following an advancement flap re- construction of a lower eyelid and cheek defect. Note the mechanical distraction of the lid and lateral canthus.

try to preserve these important structures. Furthermore, reconstruction, which requires replacement of lost tissue, should replace the deficiency with similar tissue. Lower eyelid (zone 11) reconstruction should provide a good skin cover, stable lid margin, and mucous lining with adequate in- ternal support (Fig. 3).

The medial canthus (zone 111) is a complex region containing the ori- gins of the orbicularis oculi muscle, the lacrimal collecting system, and

Figure 2. Surgical zones of the eyelids and periocular structures. Zone 1, upper eyelid; zone 11, lower eyelid; zone 111, medial canthal structures including the lacrimal drainage sys- tem; zone IV, lateral canthal area; zone V, periocular contiguous area-glabella, eyebrow, forehead, temple, malar, nasojugal and nasal areas.

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Figure 3. A, 78-year-old woman with frank ectropion of the right lower eyelid as a result of biopsy of cheek carcinoma. Proposed surgical excision of cheek lesion and right upper eye- lid laterally based myocutaneous flap are outlined for reconstruction. 6, Immediate post- operative result following transposition of upper eyelid flap to defect created in lower eyelid to correct ectropion and vertical advancement closure of cheek defect. A lateral canthal plasty of the tarsal strip type was performed. C, Result 3 months later. Note the functional and aesthetic position of the lower eyelid and cheek area.

associated neurovascular structures. The lateral canthus (zone IV) is an integral anatomic unit of the temporal aspects of the eyelids. The lateral canthal area is more correctly called a lateral retinaculum, consisting of (1) the lateral extensions of the aponeurosis of the levator superioris mus- cle (lateral horn of the levator); (2) continuations of the preseptal and pre- tarsal orbicularis oculi muscles (the lateral canthal tendon); (3) the infe- rior suspensory ligament of the globe (Lockwood’s ligament); and (4) the check ligament of the lateral rectus muscle. The lateral retinaculum struc- tures attach to a confluent region of the lateral bony orbital wall on a small promontory just within the lateral orbital rim known as Whitnull’s t u b e r ~ l e . ~ , ~ ~ When contiguous facial reconstruction involves the canthal ar- eas, particular attention should be paid to the lacrimal drainage system medially, and lower eyelid bony fixation laterally. When complex full- thickness eyelid and contiguous forehead, brow, cheek, and medial and

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lateral canthal defects are present, reconstruction can require transposi- tion, rotation, and advancement flaps. The most versatile facial flap is the inferior-based cervical facial flap. If distractive mechanical, gravitational, and contraction forces displace the reconstructed lid from its intended po- sition, a poor cosmetic and functional result occurs. A poorly planned and executed composite flap reconstruction of a cheek and eyelid defect often leads to poor appearance, irregular tear film, epiphora, corneal exposure, and potential visual deterioration (see Fig. 1). When grafts and flaps in the periocular area are used, careful attention to corneal protection, lid func- tion, skin color and texture is mandatory. The basic principles of eyelid reconstruction are to (1) replace deficient tissue with similar tissue if avail- able; (2) maintain function of upper eyelid at all costs because it is essen- tial for ocular protection; (3) reconstruct full-thickness eyelid defects with an outer layer of skin and muscle, an inner layer of mucosa, and a semi- rigid supporting structure interposed between them.

Reconstruction in the periorbital region usually is performed with the patient under sedation and the use of local infiltrative and regional block anesthesia. If general anesthesia is used, local infiltration with a di- lute anesthetic with epinephrine still should be used to decrease bleed- ing. Protection of the cornea with protective corneal lenses coated with ophthalmic ointment should be routine. A topical ophthalmic anesthetic should be applied to the cornea before inserting the protective lenses.

Facial defects that partially involve the lower eyelid and the medial and lateral canthal areas present challenges to the surgeon. Lower eye- lid malposition and ectropion can result if sound principles of reconstruc- tion are not followed. Visual loss can occur if the surgeon fails to restore the protective integrity of the eyelids. The essential surgical guidelines for prevention of ectropion in cheek and lower eyelid reconstruction are as follows:

(1) wide undermining of the inferior cervical facial flap; (2) relaxing Burrow’s triangle at inferior aspect of flap; (3) de-epithelialized flap fashioned from the tip of the advancing flap

(4) hitching sutures from maxillary periosteum to inferior cervical fa-

(5) canalicular repair and microsilicone intubation if canaliculus in-

(6) horizontal eyelid shortening in all patients with horizontal eyelid

(7) lateral canthalplasty on all cheek advancement reconstruction. The lateral canthalplasty can be an inferior retinacular, dermal-

orbicular, or tarsal strip variation. The inferiorly based cervical facial flap (Fig. 4) is the most versatile local flap for reconstruction of lower eyelid and contiguous nasal, canthal, cheek, and temple defects. The flap is in- cised along the nasolabial fold, elevated in the subcutaneous plane above the facial muscles, and advanced to cover the defect without tension. The use of a relaxing Burrow’s triangle at the oral commisure allows

for fixation to the medial canthal tendon;

cial flap dermis to align flap without tension;

volved with resection;

laxity; and

PREVENTION OF ECTROPION IN RECONSTRUCTION OF FACIAL DEFECTS 787

Flgure 4. A, Skin, subcutaneous tissue, and portions of the orbicularis oculi muscle follow- ing controlled excision of a basal cell carcinoma. B, A widely undermined inferior cervical fa- cial flap has been elevated medially and superiorly to cover the defect without tension. Note the Burrow’s triangle at the oral commissure and the redundant flap tissue at the lower eyelid interface. Forceps hold the tip of the flap, which has been de-epithelized. C, Close-up view of suture passed through the tip of flap before attachment to the medial canthal tendon at the bony insertion. Note the forceps holding the medial lower eyelid tissue to facilitate pas- sage of the flap. D, The tip of the flap has been inserted into the medial canthal tendon and is secured with suture tied over the skin of the medial canthus. Note the tensionless closure.

Illustration continued on following page

vertical advancement of the flap. The tip of the flap is de-epithelized to provide tissue to anchor the flap to the medial canthal tendon. Eleva- tion of the lower eyelid medially provides access to the tendon. A lat- eral canthalplasty always is performed by way of the lower or upper eyelid. Hitching sutures of 3-0 absorbable material attach the maxillary

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Figure 4 (Continued) €, Immediate postoperative closure. A lateral canthalplasty was per- formed through a small incision in the lateral upper eyelid crease. Hitching sutures from the maxillary periosteum to the dermis of the flap were placed to take tension off of the flap. F, Result 9 months later. Note the lower eyelid and cheek position.

periosteum to the dermis of the advanced cervical facial flap. This proce- dure ensures a tensionless closure along the lower eyelid and nasolabial region. Redundant cervical facial flap tissue usually is resected at the lower eyelid interface.

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