122 Reconstruction of the Medial and Lateral Canthi
LATERAL CANTHAL DEFECTS
GENERAL CONSIDERATIONS
The lateral canthus is the least common site for an eyelid tumor. Most of the reconstruction in the lateral canthal area combines reconstruction with an upper lid, lower lid, or both. There may also be use for various flaps or grafts if the defect extends lateral to the lateral orbital rim.
PERIOSTEAL FLAPS
If a defect extends to the lateral orbital rim but does not include periosteum, the periosteum that covers the frontal and zygomatic bones in the area of the frontal zygomatic suture can be reflected medially (378–394). It is left attached at the lateral orbital rim. The medial portion of the periosteal flap may be divided and crossed. The lateral aspect of each lid is then attached to the flap with polyglactin 910 sutures. Conjunctiva from the appropriate cul-de-sac can be advanced to line the posterior aspect of the flap. The anterior surface can then be covered with advancement or rotational skin flaps from nearby areas. The periosteal flap essentially replaces the lateral canthal tendon. Therefore, it can be used in conjunction with other eyelid repair.
378 |
378 Periosteal flap for lateral canthal reconstruction. a: Large lateral |
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canthal defect involving the upper and lower lid. Dotted line indicates |
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the incision for a periosteal flap. b:The periosteal flap is reflected |
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medially. An incision is made in the medial part of the periosteal flap to |
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create two separate flaps which are crossed in order to give proper |
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angulation to the lateral aspects of the upper and lower lids. Dotted |
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lines indicate skin flaps to be fashioned. c: Skin flaps are created. d:The |
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periosteal flaps are sewn to the tarsal ends of the eyelids with 5-0 |
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polyglactin 910 sutures. Conjunctiva that is available is used to line the |
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posterior aspect of the periosteal flaps.The skin layer is created by |
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advancing upper lid skin inferiorly and lower lid skin superiorly.The |
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lateral canthal angle is formed with interrupted 6-0 or 7-0 chromic |
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sutures. e: Skin is closed with interrupted 6-0 silk and/or running 7-0 |
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polypropylene sutures. |
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Lateral Canthal Defects |
123 |
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379 |
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380 |
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381 |
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382 |
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379–383 Lateral canthal repair with periosteal flap. 379: Basal cell |
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383 |
carcinoma involving lateral upper lid and lateral canthus. 380: Repair |
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performed as described in 378. 381:Three weeks after surgery. |
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382, 383: Six weeks postoperative. |
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124 Reconstruction of the Medial and Lateral Canthi
384 |
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385 |
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386
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384–394 Combined lateral canthal, lower lid and upper lid repair. 384: Basal cell carcinoma involving the lateral lower and upper lids as well as the lateral canthus. 385:The entire tumor shown on a drawing for frozen section evaluation by the pathologist. 386: Defect in the lower and upper lids and lateral canthus. 387: Periosteal flap has
been fashioned as described in 378 and is held in the forceps. 388:Tarsoconjunctival flap, as described in 235, is fashioned and brought down to fill the lower lid defect. 389:Tarsoconjunctival flap is sewn in place, and the periosteal flap in the forceps is to be sewn to this flap to create the attachment to the lateral canthus. 390: Periosteal flap has been sewn to the tarsoconjunctival flap and lines are drawn to outline the skin flaps. A skin muscle flap from below will be brought up to cover the tarsoconjunctival flap. A skin muscle flap in the lateral upper lid will be brought down to cover part of the periosteal flap for the upper part of the lateral canthal repair. 391: One day postoperative. Skin flaps are in place. 392, 393:Three weeks postoperative. Lateral canthus is ‘pinched’ but the patient was satisfied. 394:Ten weeks after surgery the lateral canthus is well formed.
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Lateral Canthal Defects |
125 |
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389 |
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390 |
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391
393
REFERENCES
1.Older, JJ (2001). Monocanalicular stent used to dilate stenotic punctum. Ocular Surgery News 19(2).
2.Fox SA, Beard C (1964). Spontaneous lid repair. Am. J. Ophthalmol., 58: 947–952.
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