A forcep was used to simulate the new canthal angle to make sure the approropriate amount of lid was being excised. Details on this procedure can be found in the article Eyelid Reconstruction, Lower Eyelid. Lower Eyelid Retraction Repair . (B) 6-0 Vicryl sutures through tarsus. Other complications of upper lid reconstruction include the following: Postoperative upper lid ectropion can result from anterior lamella shortening. doi:10.1001/archopht.1995.01100110118035. Eyelid marginal positional abnormalities usually are not serious complications but can be frustrating for both patient and surgeon, sometimes requiring further surgery for correction. McVeigh KA, Caesar R. Upper Eyelid Reconstruction Using a Blepharoplasty Flap. Both function and cosmesis measure outcome. This usually involves primary excision with either frozen section control or Moh’s technique. No real controversies exist in this field. (D) Lid margin suture placed. 2019:6838415. The flap, used on six patients with partial eyebrow and upper eyelid defects, included an orbicularis oculi muscle pedicle. The wedge resection is positioned to remove thickened keratinized conjunctiva. This procedure involves marking the eyelid crease and drawing a line “perpendicular to the crease line along the aspect of the lesion closest to the” eyelid’s center, so that the eyelid is divided into four quarters. 2013 May. Balloon Dacryplasty with Stent . Greater initial defects have poorer outcomes. The wedge excision can be performed in the medial third of the lid. Terms of Use| 33 (2):147-9. J Ophthalmol. 2014 Nov. 28(11):1292-6. It is important that sufficient eyelid is left medial to the resection to enable vertical mattress sutures to be placed across the eyelid margin without risking damage to the punctum or to the inferior canaliculus. 29(3):227-30. The Cutler-Beard procedure is indicated for large central defects of the upper eyelid (see image below). All material on this website is protected by copyright, Copyright © 1994-2021 by WebMD LLC. As in any eyelid reconstruction, canthal attachments must be secure and in proper position. Figure 1 Intraoperative photographs showing the steps of levator weakening combined with tarsotomy, tarsus wedge resection, and the anterior lamella recession procedure in a 64-year-old female with a history of bilateral upper eyelid entropion and retraction secondary to trachoma. Fig. Wedge resection, which was once ... Use of calipers or some other simple method of measurement may assist in symmetrical resection of the contralateral eyelid if that is required. Dear Editor: Eyelid margin defects are produced by injuries, burns, bites, scars, and benign and malignant lesions. Jorge I de la Torre, MD, FACS Professor of Surgery and Physical Medicine and Rehabilitation, Chief, Division of Plastic Surgery, Residency Program Director, University of Alabama at Birmingham School of Medicine; Director, Center for Advanced Surgical Aesthetics Purpose: Pentagonal wedge resection is a technique used to address a wide variety of eyelid pathology. J Ophthalmol. Please confirm that you would like to log out of Medscape. One such technique is the sliding tarsoconjunctival flap (see image below). Upper eyelid ectropion is not usual and it may occur without a known associated systemic disease. Wang YC, Dai HY, Xing X, et al. EYELID RECONSTRUCTION CODES Be aware that procedure codes 67961 (Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid margin) and 67966 In nonbridging techniques, a tarsoconjunctival or substitute graft was typically utilized for the posterior lamella, while the anterior lamella was repaired with a skin flap. When a fullthickness resection of the eyelid is not possible because of horizontal tightness of the lid, it is possible to excise a wedge of the eyelid margin itself. Stent Placement for Tearing . 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Eye (Lond). Share cases and questions with Physicians on Medscape consult. Anterior lamellar repositioning is one surgical approach to correct eyelash ptosis. J Plast Reconstr Aesthet Surg. A superior lateral cantholysis adds horizontal mobility and allows closure of larger defects using direct tarsal suturing and closure (see image below). This “wedge resection” begins with a 4-sided en-bloc resection of the mass. This is corrected by performing a wedge resection at the lateral canthus, either before or after the entropion surgery. Ophthal Plast Reconstr Surg. Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Association for Academic Surgery, Medical Association of the State of AlabamaDisclosure: Nothing to disclose. Bengoa-Gonzalez A, Laslau BM, Martin-Clavijo A, Mencia-Gutierrez E, Lago-Llinas MD. 2013 May-Jun. [4]. A semilunar resection may result easier and more cosmetic when joining the two ends. American Association for Pediatric Ophthalmology and Strabismus, American Society of Cataract and Refractive Surgery, American Society of Ophthalmic Plastic and Reconstructive Surgery, Contact Lens Association of Ophthalmologists, International College of Surgeons US Section, Royal College of Physicians and Surgeons of Canada, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society for Reconstructive Microsurgery, Medical Association of the State of Alabama, American Council of Academic Plastic Surgeons, American Society for Aesthetic Plastic Surgery. Jennings E, Krakauer M, Nunery WR, Aakalu VK. A wedge shaped section is removed when the cancer is near the edge of the lip, nostril, eyelid or ear with the edges of the excision gently sutured together to reform the edge, producing a straight line incision. In most instances, postoperative ptosis should not be reoperated on for 6 months, especially if progressive improvement is noted. 2014 Feb. 2(2):e111. This technique involves the rotation of a semicircular musculocutaneous flap beginning at the lateral canthus, extending downward in a semicircular fashion. This results in a defect that is full thickness and involves approximately one third of the eyelid. Corresponding Author: Giancarlo A. Garcia, MD, Gavin Herbert Eye Institute, University of California, Irvine, 850 Health Sciences Rd, Irvine, CA 92697 [Medline]. McVeigh and Caesar described an upper eyelid repair technique that uses a blepharoplasty flap to fix defects caused when a broad-based upper eyelid lesion situated between the eyelid crease and eyelashes is excised. Wang YC, Dai HY, Xing X, et al. This results in good approximation of the eyelid margin. The adnexal lesion was resected by a wedge resection and histopathology was performed. (A) Large upper lid defect. Mathijssen IM, van der Meulen JC. Upper eyelid tightening procedures (block resection or tarsal strip with lateral canthal tightening) for member who has refractory corneal or conjunctival inflammation related to exposure from floppy eyelid … Upper eyelid defects involving one third or less of the horizontal length of the upper eyelid usually can be repaired by direct closure. The initial skin incision along the haired-nonhaired border includes upper and lower eyelids and lateral canthus. Most commonly, wedge resection with reconstruction of eyelid is used for reconstruction after removal of cutaneous malignancies. Eyelid lesions can range from benign cysts and inflammatory lesions (hordeolums/chalazions) to malignancies. By continuing to use our site, or clicking "Continue," you are agreeing to our. [5, 6], Another modified version of the Cutler-Beard technique, as described by Bengoa-González et al, uses a tarsoconjunctival graft taken from the contralateral upper lid. Future refinements or modifications of technique remain possible, although at a slower rate, and artificial materials (ie, to use in place of skin and connective tissue) likely will be incorporated as they become available, especially for massive defects. Keywords Floppy eyelid Papillary conjunctivitis Obstructive sleep apnea Wedge resection Floppy eyelid … In breeds with loose eyelids the primary entropion is often a factor of the long eyelids. Matsuo S, Hashimoto I, Seike T, et al. 2019. Layered suture closure of lid margin defect. A modified Cutler-Beard procedure has been recently described by Yoon and McCully. The lower eyelid is for stability along with the canthii, hence, it must be stabilized well. Putterman AM. The length of eyelid margin that is removed should be slightly shorter than the amount of correction needed because fibrosis and wound contraction provide an additional 0.5 to 1.0 mm of correction (see section on wedge and pentagonal resection below). Orbital Decompression . All Rights Reserved. 60(3):241-5. Remember to use a pentagonal wedge excision in the upper lid when removing a large lesion; other wedge excisions can cause lid kinking, notching, and ectropion (see image below). Dacryocystorhinostomy with Stent . The conjunctiva (the most internal layer of the eyelid) and the orbital septum were repaired using 6-0 gut sutures with the tied knots facing outwards to … [11] showed that it may be possible in the future to use tissue expanders with autogeneic conchal chondro-grafts. Zubin J Panthaki, MD, CM, FACS, FRCSC Professor of Clinical Surgery, Department of Surgery, Division of Plastic Surgery, Associate Professor Clinical Orthopedics, Department of Orthopedics, University of Miami, Leonard M Miller School of Medicine; Chief of Hand Surgery, University of Miami Hospital; Chief of Hand Surgery, Chief of Plastic Surgery, Miami Veterans Affairs Hospital Extended Hair-bearing Lateral Orbital Flap for Simultaneous Reconstruction of Eyebrow and Eyelid. A 5-0 Vicryl suture is then used to reapproximate the tarsus. 6.13 (a) A wedge resection is performed just lateral to the position of the medial spindle. Pedicled lower lid-sharing flap for full-thickness reconstruction of the upper eyelid. [8]. It is an excellent method for reconstructing medial or lateral defects of the upper eyelid, but it is not suited for repair of central defects. [Medline]. Get free access to newly published articles. BCC most commonly involves the lower eyelid due to greatest direct sun exposure, followed by the medial canthus, upper eyelid, and lateral canthus. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Received salary from Medscape for employment. This generates a house-shaped defect in an upper eyelid, or an inverted house-shaped defect in a lower eyelid (Figure 3). Wedge Resection Repair . 1996 Case report 1 43 M Lesion above the center of the right upper eyelid, 8mm, discomfort during blinking Excision 0.5years No recurrence Hsu J Chinese Acad of Ophthal. The eyelid is stabilized with a Chalazion clamp or Jaeger eyelid plate while incisions are made with a #15 Bard-Parker blade. [9], Matsuo et al described the successful simultaneous reconstruction of upper eyelid and lateral eyebrow defects using an extended lateral orbital flap that included sideburn hair. 1995; 34(4):572-574 1995 Case report 1 10 F Lesion above the right upper eyelid margin, 3mm Orbit. [Medline]. [10]. Reconstruction of Upper Eyelid Defects Secondary to Malignant Tumors with a Newly Modified Cutler-Beard Technique with Tarsoconjunctival Graft. Reconstruction of upper eyelids due to surgical resections of neoplasms, such as skin cancers excised by Mohs micrographic surgery, requires additional consideration. (C) Either 6-0 silk or 6-0 gut sutures for the margins. Upper eyelid defects involving one third or less of the horizontal length of the upper eyelid usually can be repaired by direct closure. A free tarsoconjunctival graft from the patient's contralateral upper eyelid is another useful technique. Yoon MK, McCulley TJ. (D) Skin closure with interrupted 6-0 silk or 6-0 gut sutures. Pentagonal wedge resection (Figure 3) at the lateral third of the upper eyelid is a reasonable approach to tightening the upper lid. The graft includes an extra 3 mm of conjunctiva from the tarsus’s superior edge, with this excess conjunctival side being “sutured superiorly to the conjunctiva [of the damage eyelid] or to the superior retractor muscles and laterally and medially to the margins of the defect or to the canthal tendon.” In this way, according to the authors, the posterior lamella is completely reconstructed. Rajak SN, Malhotra R, Selva D. The 'over-the-top' modified Cutler-Beard procedure for complete upper eyelid defect reconstruction. [Medline]. [Full Text]. 2009 Jun 24. 1-4. Most of the reported surgical techniques are mainly based on a lateral tarsal strip anchored to the orbital rim. (E) Skin graft placed. The lesion and the diagonally lying area are excised, with excess upper eyelid skin then used to create an advancement flap and the defect closed by moving the flap inferiorly. From the Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, College of Medicine. 7 If the lesion involves the medial canthus, magnetic resonance imaging ... Vo TA, et al. If nonabsorbable sutures were used, the patient should return for suture removal in 1 week. The upper eyelid should be reconstructed with lightweight, pliable tissue as it is for mobility. Wedge resection of the eyelid can be utilized for removal of diseased segments of the eyelid from neoplasm and trichiasis and even for tightening of eyelid laxity. When a full- thickness resection of the eyelidis not possiblebecause ofhorizontal tightness of the lid, it is possibleto excise a wedgeofthe eyelidmarginitself. 2020 Sep 29. This procedure was successful in decreasing widened, hypertrophic, erythematous eyelid margins in three patients. Orbital Tumor Removal/Biopsy . [Medline]. Accessibility Statement, Our website uses cookies to enhance your experience. J Craniofac Surg. Neal R Reisman, MD, JD Chief of Plastic Surgery, St Luke's Episcopal Hospital; Clinical Professor of Plastic Surgery, Baylor College of Medicine (C) Flap moved horizontally to fill in defect, with edges sutured to orbital rim and levator remnants. Two sutures are placed partial thickness through the anterior surface of the tarsus and then tied. General: The goal should be total removal of the cancer. Arch Ophthalmol. BACKGROUND Lower lid involutional entropion is a common eyelid pathology affecting the elderly population. 77 Suppl 1:A71. 24(3):1038-41. Widened, hypertrophic, erythematous eyelid margins occasionally occur secondary to congenital anomalies or previous surgical procedures. Advancements in the repair of large upper eyelid defects: A 10-year review. [Medline]. Lower eyelid horizontal shortening | Lower eyelid horizontal trimming Horizontal shortening of the lower eyelid by wedge trimming Initial level in treating the aging lower eyelid retraction, scleral show and ectropion of a slight to moderate grade is its shortening by en bloc trimming of the tarsal cartilage and the conjunctiva in a horizontal fashion and subsequent layered closure. Upper eyelid defects involving loss of one third to one half of the horizontal length of the upper eyelid require other techniques. Vertical shortage of upper lid skin is worsened by the effect of altered lid mobility. A free graft of tarsus and conjunctiva is harvested from the contralateral side and is sutured in place with edges parallel to the edges of the defect. Pedicled lower lid-sharing flap for full-thickness reconstruction of the upper eyelid. However, in general, all of the procedures described in this article have adequate, if not excellent, outcomes, even for larger defects, if meticulous attention to detail is taken in the repair. http://www.medscape.com/resource/aesthetic-medicine, encoded search term (Upper Eyelid Reconstruction Procedures) and Upper Eyelid Reconstruction Procedures, Fast Five Quiz: Hidradenitis Suppurativa Management, Platelet-Rich Plasma: Evolving Role in Plastic Surgery, Counterfeits: An Ugly Truth in Aesthetic Medicine, 'Conservative Parameters' Key to Maximizing Cosmetic Laser Results in Skin of Color, 6 Body Modifications: Dermatologic Risks and Adverse Reactions, Doctor Charged With Attempted Murder of Plastic Surgeon, As End to Pandemic Mask-Wearing Nears, South Koreans Scramble to Arrange Cosmetic Surgery, Telemedicine and Plastic and Reconstructive Surgery, Guidance Issued on COVID Vaccine Use in Patients With Dermal Fillers. This technique uses a full-thickness segment of lower eyelid tissue that is passed under an intact bridge, the lower eyelid margin. The upper eyelid may also appear elongated, thickened, and overlap over the lower eyelid laterally. Customize your JAMA Network experience by selecting one or more topics from the list below. (B) Tarsus conjunctival flap fashioned. The study, which included 13 patients who underwent the procedure immediately following tarsal gland carcinoma excision from an upper eyelid, found no recurrence, hypertrophic scar, bulky appearance, or lagophthalmos, at 1- to 18-month follow-up. Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure. Guidelines for reconstruction of the eyelids and canthal regions. Recurrence × 2, requiring wedge resection Taniguchi Eye (Lond). 2007 May. Codner MA, Weinfeld AB. Zubin J Panthaki, MD, CM, FACS, FRCSC is a member of the following medical societies: American College of Surgeons, American Society for Surgery of the Hand, American Society of Plastic Surgeons, Canadian Society of Plastic Surgeons, American Council of Academic Plastic Surgeons, Miami Society of Plastic Surgeons, Medical Council of Canada, Canadian Military Engineers AssociationDisclosure: Nothing to disclose. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTI4MjA1NC10cmVhdG1lbnQ=. Orbit. Medscape Education, Aesthetic Refresh: Mastering the Lower Face, 2001 To avoid this, use full-thickness skin grafts during the initial reconstruction. Plast Reconstr Surg Glob Open. [Full Text]. [Medline]. This allows for potential spontaneous recovery of function. (B) and (C) Incorrect wedge excisions leading to lid notching and kinking. Neal R Reisman, MD, JD is a member of the following medical societies: American Society of Plastic Surgeons, American College of Surgeons, American Society for Aesthetic Plastic Surgery, Lipoplasty Society of North America, Texas Medical Association, Texas Society of Plastic SurgeonsDisclosure: Nothing to disclose. (A) The correct pentagonal wedge excision that should be used in the upper lid. OBJECTIVES To report the surgical outcome using a simple single‐stitch lateral wedge technique to repair involutional lower entropion. A full-thickness lower eyelid flap is sutured into the defect in the upper eyelid. Wedge Resection of Eyelid Margin in the Treatment of Abnormal Eyelid Margins Allen M. Putterman, MD Widened, hypertrophic, erythematouseyelidmargins occasionally occur second- ary to congenital anomalies or previous surgical procedures. [7], A study by Wang et al indicated that repair of full-thickness upper eyelid defects using pedicled lower eyelid–sharing flaps yields good results. to download free article PDFs, J Plast Reconstr Aesthet Surg. In a retrospective study of patients who underwent the procedure, Bengoa-González and colleagues found no occurrences of upper eyelid retraction, eyelid margin entropion, or graft retraction at mean 41.6-month follow-up. Reconstruction of Upper Eyelid Defects Secondary to Malignant Tumors with a Newly Modified Cutler-Beard Technique with Tarsoconjunctival Graft. 2019:6838415. . for: Medscape. To avoid a postoperative orbital hematoma, meticulous cautery should be used, and ice compress dressings rather than tight pressure dressings should be used afterward, ensuring that visual acuity does not deteriorate. A literature review by Jennings et al looking at the repair of large (>50%) upper eyelid defects over a 10-year period found that the overall tendency was for surgeons to replace the posterior lamella with a graft (most commonly utilizing tarsoconjunctiva from the contralateral upper lid) and to replace the anterior lamella with a skin flap derived from the lower eyelid or the adjacent periorbital area. As with the flap created in a modified Hughes tarsoconjunctival procedure, the Cutler-Beard flap occludes vision for 6-8 weeks and must be divided in a second stage of the surgical procedure. Bridging flaps from the lower eyelid were made up of skin; tissue from the skin, orbicularis, and conjunctiva; or tarsoconjunctiva. Upper Eyelid Gold Weight Placement . When performing a wedge resection, the height of the triangle should be approximately twice its base.Make the skin incision with a No. Lateral tarsal strip repair of the upper lid can be performed, but care must be taken to … A thickening of the palpebral conjunctiva affecting the medial upper eyelid with erosion of the normal eyelid margin anatomy was identified. The upper lid crease is marked along the skin crease and excised as in a routine blepharoplasty. If you log out, you will be required to enter your username and password the next time you visit. Eyelid Cancer Reconstruction Mounir Bashour, MD, PhD, CM, FRCSC, FACS is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American College of International Physicians, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, American Society of Mechanical Engineers, American Society of Ophthalmic Plastic and Reconstructive Surgery, Biomedical Engineering Society, Canadian Medical Association, Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, International College of Surgeons US Section, Ontario Medical Association, Quebec Medical Association, Royal College of Physicians and Surgeons of CanadaDisclosure: Nothing to disclose. 1996;10( Pt 6):751-2. A lateral semilunar full thickness wide wedge resection and an elevator muscle aponeurosis reattachment can correct this type of ectropion. Sufficient tissue to evert the entropic lateral regions of the upper and lower eyelids is resected as for the Hotz-Celsus. Posterior wedge resection (02:11) Excision of upper and lower xanthelasma #1 ... Upper eyelid blepharoplasty with monopolar cautery (03:22) Upper blepharoplasty (02:59) Skin only upper blepharoplasty (03:32) Asian upper blepharoplasty (04:21) Raising the upper lid crease (03:57) Complete loss of the upper eyelid is a difficult problem to treat; a 2013 rabbit study A variety of methods have been described to address the cutaneous redundancy, the most classic of which is the Burow's triangle repair. Simple V-plasty requires sharp resection of the mass with a size 15 surgical blade while the eyelid is immobilized with a chalazion clamp, usually the open side to the conjunctival surface, but this can vary depending on the orientation of the tumor. Then, 6-0 double armed vicryl is used to make one pass through the skin and orbicularis just above the eyelashes, and a horizontal pass through the tarsal plate, and then inferiorly again through the orbiculari… Dacryocystorhinostomy with Jones Tube . Mounir Bashour, MD, PhD, CM, FRCSC, FACS Assistant Professor of Ophthalmology, McGill University Faculty of Medicine; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD Upper eyelid reconstruction is a surgical procedure used to correct lid defects of the upper eyelid that occur from surgical resection of tumors, trauma, or congenital anomalies like a coloboma. Privacy Policy| 2007. This website also contains material copyrighted by 3rd parties. 2018 Mar 7. 2021 American Medical Association. Following resection, the remaining tarsus is used as structural support (posterior lamella), and a skin graft or local musculocutaneous flap is used for the anterior lamella. Lazy pentagonal wedge resection of eyelid margin lesions. Wedge resection, which was once ... Use of calipers or some other simple method of measurement may assist in symmetrical resection of the contralateral eyelid if that is required. [Full Text]. © 2021 American Medical Association. You are being redirected to Once I was satisfied with this, curved hemostats were used to compress the lateral lid and angled it towards the canthus. Attention is then turned to the blepharoplasty incision, and dissection is carried down to the inferior tarsal plate along the upper lid. The upper eyelid position was found to be increased in 22 of 24 eyelids (92.6%), was unchanged in 1 eyelid (4.2%), and decreased in 1 eyelid (4.2%) after surgical correction by full-thickness wedge resection alone.
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