Upper eyelid reconstruction

There are several options available for upper eyelid reconstruction that depend on the extent of involvement of the anterior and posterior lamella. Knowledge of the anatomy will ensure that in addition to the creation of an aesthetically acceptable eyelid reconstruction, a functional upper lid will be restored. The purpose of this article is to outline the anatomy of the eyelid, to analyze the components of eyelid defects, and to provide options for lid reconstruction.     

Current concepts in aesthetic upper blepharoplasty

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Discuss nomenclature and anatomy associated with upper blepharoplasty. 2. Perform preoperative assessment, decision-making, and counseling of patients. 3. Describe current surgical planning, eyelid marking, and various techniques used in upper blepharoplasty, including lasers. 4. Recognize and treat postoperative complications from blepharoplasty.Traditional blepharoplasty has often involved the excision of both lax skin and muscle and excessive removal of fat, leaving patients long term with a hollow orbit and a harsh, operated appearance that accelerates the aging process. Current methods of periorbital rejuvenation are more conservative, are based on concise preoperative evaluation, and involve the limited resection of the coveted soft tissue from the eye to restore a youthful appearance. The authors describe anatomy, preoperative assessment, decision-making and counseling of patients, surgical planning, eyelid marking, and various techniques, including lasers, along with postoperative complications associated with current concepts in aesthetic upper blepharoplasty.     

Lower eyelid reconstruction with the upper eyelid rotation flap

A new technique of lower eyelid reconstruction was developed by using an ipsilateral upper eyelid rotation flap. After resection of a tumor in the lower eyelid, it is possible to replace the defect by a full-thickness upper eyelid rotation flap. Knowledge of exact eyelid anatomy is necessary to perform this kind of operation. In addition to the well-known techniques, the rotation flap constitutes a complete anatomic reconstruction of the lower eyelid with no functional loss of the upper eyelid.     

Medial canthal reconstruction using a medially based upper eyelid myocutaneous flap

Periorbital reconstruction following skin cancer ablation represents a challenging problem. A thorough understanding of the complex periorbital anatomy is necessary to preserve lid function and protect the ocular surface. The medial canthal region represents the most difficult periorbital zone to reconstruct. This area has a complex anatomy involving both the medial canthus itself and the lacrimal apparatus. The authors present their experience with a versatile technique for reconstruction of the medial canthal periorbital region, namely, a medially based upper eyelid myocutaneous flap. In the 10 patients in whom this procedure was used, there was one partial and no complete flap losses. The authors believe that the medially based upper lid myocutaneous flap offers an excellent solution to the difficult problem of medial canthal periorbital reconstruction.     

A computational/experimental platform for investigating three-dimensional puzzle solving of comminuted articular fractures

Reconstructing highly comminuted articular fractures poses a difficult surgical challenge, akin to solving a complicated three-dimensional (3D) puzzle. Preoperative planning using computed tomography (CT) is critically important, given the desirability of less invasive surgical approaches. The goal of this work is to advance 3D puzzle-solving methods towards use as a preoperative tool for reconstructing these complex fractures. A methodology for generating typical fragmentation/dispersal patterns was developed. Five identical replicas of human distal tibia anatomy were machined from blocks of high-density polyetherurethane foam (bone fragmentation surrogate), and were fractured using an instrumented drop tower. Pre- and post-fracture geometries were obtained using laser scans and CT. A semi-automatic virtual reconstruction computer program aligned fragment native (non-fracture) surfaces to a pre-fracture template. The tibiae were precisely reconstructed with alignment accuracies ranging from 0.03 to 0.4 mm. This novel technology has the potential to significantly enhance surgical techniques for reconstructing comminuted intra-articular fractures, as illustrated for a representative clinical case.     

The bare area of the upper conjunctiva: a closer look at the anatomy of transconjunctival upper blepharoplasty

Transconjunctival upper blepharoplasty is a novel technique for which the overall experience has been limited. The authors have used this technique in 42 patients for eyelid rejuvenation, with predictable results and low morbidity. The authors previously described the "bare" area in the medial upper conjunctiva, which was initially noted during their clinical series. This area serves as an anatomic window to access the medial upper eyelid fat pad with a high degree of safety. To clarify the anatomy of this approach, an anatomic study of the upper medial eyelid was performed on the orbits of 10 cadavers (20 orbits). The bare area was further elucidated during these dissections and its microscopic components described in detail. Its spatial relationship to the medial orbital wall and trochlea was also examined during this study. The authors hope that these findings will aid surgeons planning to use this technique.     

Early experience with computed tomographic angiography in microsurgical reconstruction

Preoperative angiography is frequently used in the planning of microsurgical reconstruction. However, several potentially devastating complications can result from angiography, including arterial occlusion and pseudoaneurysm. Computed tomographic angiography is a relatively new technique that can provide detailed information about vascular anatomy as well as soft and bony tissue without the risks of traditional angiography. In addition, three-dimensional image reconstruction uniquely demonstrates anatomical relationships among blood vessels, bones, and soft tissue. Fourteen computed tomographic angiograms were obtained in 10 patients undergoing microsurgical reconstruction of the head and neck, lower extremity, or upper extremity. The average patient age was 46.9 years (range, 22 to 67 years). Charges related to the computed tomographic procedure were compared with those of conventional preoperative imaging for microsurgical repair. At our institution, the average computed tomographic angiogram charge was 1140 US dollars, whereas the average charge for traditional arteriography was 3900 US dollars. When compared with intraoperative evaluation, computed tomographic angiograms demonstrated clinically relevant surgical anatomy. No complications were noted for the radiographic procedure or after free flap reconstruction. Computed tomographic angiography provides high-resolution, three-dimensional arterial, venous, and soft-tissue imaging without the risks of traditional angiogram and at a lower cost.     

The evaluation and management of lower eyelid retraction following cosmetic surgery

Lower eyelid retraction is a common complication after cosmetic surgery of the lower eyelids, midface, and the adjacent face. Lower eyelid retraction is defined as the inferior malposition of the lower eyelid margin without eyelid eversion. Lower eyelid retraction presents clinically with scleral show; round, sad-looking eyes; lateral canthal tendon laxity; and symptoms of ocular irritation, including photophobia, excessive tearing, and nocturnal lagophthalmos. These patients frequently require ocular lubricants, including artificial tears and ointments, which often provide only minimal alleviation of their symptoms. The author has observed that lower eyelid retraction is usually accompanied by midface descent. On the basis of surgical observations, the causes of lower eyelid retraction seem to be multifactorial and include scarring between the orbital septum and capsulopalpebral fascia (or lower eyelid retractors), lateral canthal tendon laxity, and midface descent. After describing the causes of lower eyelid retraction, the author presents a system for evaluating patients that can assist the surgeon in choosing the surgical procedure(s) required to correct the lower eyelid malposition. The surgeon must know how to tighten a lax lateral canthal tendon, be familiar with the anatomy of the lower eyelid from conjunctiva to skin side, and know how to surgically elevate the midface. The techniques for correcting lower eyelid retraction are also presented. Appropriate surgery, which is determined on the basis of the preoperative evaluation, has allowed for the correction of these previously difficult-to-treat lower eyelid malpositions with minimal complications.     

Simple approach to harvest of the anterolateral thigh flap

The free anterolateral thigh flap has proven to be invaluable for many types of reconstruction, ranging from upper and lower extremity trauma to head and neck reconstruction. There exist some controversies relating to certain difficulties in flap harvest because of the intramuscular route of its major perforator, which can exceed 80 percent and create a longer, more tedious dissection. Strategies to expedite flap harvest and minimize technical challenges have been proposed. The authors propose a simplified approach to harvest the anterolateral thigh flap founded on topographic surface anatomy and the intrinsic vascular anatomy of the flap. No Doppler imaging or angiography is used for preoperative perforator mapping.     

Computer-assisted secondary reconstruction of unilateral posttraumatic orbital deformity

Until now, computer-assisted surgery has not been practiced as part of the surgical routine of posttraumatic orbital reconstruction. The purpose of this study was to investigate the use of a navigation system for computer-assisted preoperative planning with virtual reconstruction to obtain symmetry of the orbits and intraoperative control of virtual contours in comparison with the clinically achieved surgical results. A further objective of the computer-assisted orbital analysis was to use an ideal measurement for the two-dimensional and three-dimensional changes following orbital reconstruction and to check the equality of the postoperative values for the affected orbits in comparison with those of the unaffected sides. Patients with unilateral posttraumatic orbital defects (n = 18) underwent computer-assisted surgery and preoperative planning using a spiral computed tomography database. Surgical procedures were preplanned with virtual correction by mirroring an individually defined three-dimensional segment from the unaffected side onto the deformed side, creating an ideal unilateral reconstruction. These computer-models were intraoperatively used as virtual templates to navigate the preplanned contours and the globe projection using the Stryker-Leibinger navigation system. Individual noninvasive registration with an overall inaccuracy of approximately 1 mm was achieved by using a maxillary occlusal splint with four markers. The mirroring of the unaffected side allowed an ideal virtual reconstruction. A mean decrease in enlarged orbital volume of 4.0 (SD +/- 1.9) cm was achieved, as was a mean increase in the sagittal globe projection of 5.88 (SD +/- 2.98) mm. With a paired Student test, the decrease between the preoperative and postoperative differences of the affected and unaffected sides was proved significant for orbital volume, globe projection, and computed tomography-based Hertel scale changes (p < 0.01). In 15 of 18 cases, simultaneous malar bone advancement resulted primarily in an additional increase in orbital volume before intraorbital augmentation with calvarial split-bone grafts could be performed. Intraorbital bony augmentation included one (n = 1), two (n = 7), three (n = 8), and all four (n = 2) orbital walls. Computer-assisted preoperative planning enables the surgeon to predict reconstructive surgical steps before the operation. Highly vulnerable structures such as the optic nerve can be detected and avoided intraoperatively, and virtually preplanned bone graft positions and/or orbital frame contours can be checked. Computer-assisted preoperative planning and surgery thus advance the difficult surgical field of orbital reconstruction, particularly through a greater exploitation of radiologic information without additional radiation to the patient.     

A stereotactic system for guiding complex craniofacial reconstruction.

A stereotactic system has been designed to address the problem of achieving symmetry in complex and extensive craniofacial defects. Preliminary testing suggests that such a system, which allows for the intraoperative application of preoperative CT planning, will be useful in guiding the reconstruction of congenital or acquired bony time, is being used to investigate the correlation of intraoperative globe position following enophthalmos correction with long-term outcome, particularly as it relates to the size and location of the orbital defect, and the timing of the procedure.     

Use of virtual surgery and stereolithography-guided osteotomy for mandibular reconstruction with the free fibula

Fibular osteotomy remains a challenging aspect of mandibular microsurgical reconstruction, dependent largely on surgeon experience, intraoperative judgment, and technical speed. Virtual surgical planning and stereolithographic modeling is a relatively new technique that can allow for reduction in the learning curve associated with neomandible contouring, enhanced levels of accuracy, and acceleration of a time-consuming intraoperative step. The authors present a video (narrated and edited from planning sessions and intraoperative use of technique to illustrate the technology) and describe their favorable results. Five patients underwent composite resection of the mandible and free fibula osteocutaneous reconstruction over a 6-month period (December of 2009 to June of 2010) at a single institution using a virtual planning session and stereolithographic modeling. Outcomes assessed included technical accuracy, aesthetic contour, and functional outcomes. All patients achieved negative margins with cutting guide-directed resection. Use of this technique eliminated the need for intraoperative measurement and yielded fibular segments with excellent apposition and faithful duplication of the preoperative plan. Minimal adjustments were needed for inset. Flap survival was 100 percent. All patients have maintained preoperative occlusion and a symmetric mandibular contour on Panorex study, three-dimensional computed tomography, and clinical examination. Accuracy of the reconstructed contour was confirmed using computed tomographic image overlay. This virtual surgical planning technique combined with stereolithographic model-guided osteotomy is the mainstay of the authors' approach to fibular osteotomy when dealing with patients requiring mandibular reconstruction. The authors feel this technology facilitates realization of technical accuracy, aesthetic contour, and functional outcomes and may be particularly useful if free fibular mandibular reconstruction is performed less frequently. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.     

Muscle reconstruction in cleft lip repair

This article presents a method of muscle reconstruction in the cleft lip patient that grossly reproduces the interlacing muscle anatomy in the central portion of the upper lip and thereby addresses both the static and the functional requirements of cleft lip repair. This lip repair procedure is combined with paranasal muscle reconstruction, preoperative nasoalveolar molding, and postoperative nasal stenting to constitute a comprehensive approach to cleft lip/nose repair.     

Lower eyelid reconstruction with a cheek flap supported by fascia lata.

The use of a cheek rotation flap is a well-known method for reconstruction of a large defect of the lower eyelid. In this technique, a separate lining tissue supporting the cheek flap is required for full-thickness reconstruction. Previously, a chondromucosal graft or conchal cartilage has been used to support this flap. Recently, we have used a homologous or autologous fascia lata as support for the cheek flap instead of rigid tissues like cartilages. A fascia lata strip is fixed with tolerable tension to the medial canthal tendon and lateral orbital rim. The inner surface of the fascia and the cheek flap is lined with a buccal mucosa graft to decrease irritation of the conjunctiva and cornea. We present here seven patients in whom this procedure was used for lower eyelid reconstruction following resection of a malignant skin tumor. Based on follow-ups of 7 to 22 months, the functional and aesthetic results have been good in all cases. This procedure may be applicable for total or subtotal reconstruction of the lower eyelid.     

An algorithm for abdominal wall reconstruction

Acquired abdominal wall defects result from trauma, previous surgery, infection, and tumor resection. The correction of complex defects is a challenge to both plastic and reconstructive and general surgeons. The anatomy of the abdominal wall, as well as considerations in patient assessment and surgical planning, are discussed. A simple classification of abdominal wall defects based on size, depth, and location is provided. Publications regarding the various abdominal reconstruction techniques are reviewed and summarized to familiarize the reader with the treatment options for each particular defect. Finally, an algorithm is presented to guide the surgeon in selecting the optimal reconstructive technique.     

Modified skin incisions for mastectomy: the need for plastic surgical input in preoperative planning.

Skin-sparing mastectomy by definition describes the procedure of mastectomy, either simple or modified radical, with a minimum amount of skin excision. The surgical skin excision must: (1) include the nipple-areola complex, (2) include the biopsy site, and (3) allow for access to the axilla for possible dissection. In 27 mastectomies, the senior author has had direct input in the preoperative skin planning. All patients underwent immediate breast reconstruction. In large-breasted women, the mastectomy was performed to a Wise-type pattern. In small-breasted women, the mastectomy involved minimal skin excision followed by reconstruction. Non-continuous incisions were frequently used in small-breasted women, thereby minimizing breast scarring. When appropriately applied, skin-sparing mastectomy can greatly improve the final aesthetic result of the breast.     

The superior thyroid artery perforator flap: anatomical study and clinical series

The redundant tissues of the anterior neck are well suited as a donor site for fasciocutaneous flaps in head and neck reconstruction, with similar skin quality and numerous underlying perforators. However, historic cadaveric research has limited the use of this as a donor site for the design of long and/or large flaps for fear of vascular compromise. The authors undertook an anatomical study to identify the vascular basis for such flaps and have modified previous designs to offer the versatile and reliable superior thyroid artery perforator (STAP) flap. Forty-five consecutive computed tomographic angiograms of the neck were reviewed, assessing the vascular supply of the anterior skin of the neck. Based on these findings, eight consecutive patients underwent head and neck reconstruction using a flap based on the dominant perforator of the region. In all cases, a perforator larger than 0.5 mm was identified within a 2-cm radius of the midpoint of the sternocleidomastoid muscle at its anterior border. This perforator was seen to emerge through the investing layer of deep cervical fascia as a fasciocutaneous perforator and to perforate the platysma on its ipsilateral side of the neck, proximal to the midline. This was seen to be a superior thyroid artery perforator in 89 of 90 sides and an inferior thyroid artery perforator in one case. Eight consecutive patients underwent preoperative imaging and successful flap planning and execution based on this dominant perforator. The superior thyroid artery perforator (STAP) flap demonstrates reliable vascular anatomy and is well suited to reconstruction of a broad range of head and neck defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.     

One-stage reconstruction of a large upper lid defect in a newborn

Full-thickness defects of the upper eyelids require immediate reconstruction to ensure protection of the cornea. A technique is described for a one-stage reconstruction of a large congenital defect of upper eyelid in a newborn. The reconstruction was composed of a mucosa-lined transpositional musculocutaneous flap. The advantages of this method over previous methods are discussed.     

Lower eyelid reconstruction with a conchal cartilage graft

A conchal cartilage graft without skin or mucosa was used as a posterior lining for lower eyelid reconstruction in seven patients. The raw surface of the graft was smooth enough to cause no corneal irritation and was epithelialized from the surrounding mucosa about 3 to 4 weeks after the operation. The lower eyelid reconstructed in this method produced a stable lid margin.