2020–2021 BCSC Basic and Clinical Science Course™
7 Oculofacial Plastic and Orbital Surgery
Part II: Periocular Soft Tissues
Chapter 11: Reconstructive Eyelid Surgery
Eyelid and Canthal Reconstruction
Medial Canthal Defects
The medial canthal area is typically repaired with full-thickness skin grafting (Fig 11-16) or via various flap techniques, although spontaneous granulation of anterior lamellar defects has demonstrated variable success. When full-thickness medial eyelid defects are present, the medial canthal attachments of the remaining eyelid margin must be fixed to firm periosteum or bone. This fixation may be accomplished with heavy permanent suture, wire, or titanium miniplates. Defects involving the lacrimal drainage apparatus are more complex, requiring simultaneous microsurgical reconstruction and possible lacrimal intubation or marsupialization. If extensive sacrifice of the canaliculi has occurred in the resection of a tumor, the patient may have to tolerate epiphora until tumor recurrence is deemed unlikely, after which a conjunctivodacryocystorhinostomy can be considered (see Chapter 15).
Full-thickness skin grafts offer an excellent way to reconstruct the medial canthus compared with the cicatrix resulting from spontaneous granulation, and they are thin enough to allow for early detection of tumor recurrence. Frozen sections and wide margins or Mohs micrographic resection techniques should be performed at the time of initial tumor resection to minimize the risk of recurrent medial canthal tumors and the risk of orbital or lacrimal tumor extension. Large medial canthal defects of anterior lamellar structures may be properly reconstructed through the careful transposition of forehead or glabellar flaps. However, such flaps can have the disadvantage of being thick, thereby making early detection of recurrences difficult. In addition, they may require second-stage thinning or laser resurfacing to achieve the optimal cosmetic result. Mohs micrographic resection of tumors offers the highest cure rates for eradication of medial canthal epithelial malignancies.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.