Summary
Reconstructive surgery of the medial canthus is among one of the most challenging due to its complex anatomy and aesthetic features. In this area even the slightest deformity or asymmetry is noticeable. Reconstructive surgery of this anatomical region aims to restore the tissue defect ensuring an appropriate aesthetic and functional feature, restoring colour, thickness and consistency of the replaced tissue. Orbicularis oculi myocutaneous flap is an option to reconstruct the medial canthal region; in this paper the authors present their experience with orbicularis oculi myocutaneous flap in 10 patients with medial canthal malignant lesions. The patients’ postoperative period was uneventful, the flaps usually showed some degree of temporary venous congestion during the first days after surgery, and any donor site morbidity was observed: no lid lag, ectropion, ptosis, or other eyelid deformity.
This flap offers a similarity in texture, colour, and thickness to the recipient site and a negligible incidence of donor site morbidity, and it can be easily tailored to fit the shape of the soft tissue defect.
Keywords: Reconstruction of medial canthal region, Orbicularis oculi myocutaneous flap, Local flaps
Dear Editor,
Reconstructive surgery of the medial canthus is among one of the most challenging due to its complex anatomy and aesthetic features. This region is crucial to the shape and appearance of the eye, and even the slightest deformity or asymmetry is noticeable:1 the skin covering the medial canthal region is thin and follows the concavity of the periorbital area.2 Reconstructive surgery aims to restore the tissue defect, ensuring an appropriate aesthetic and functional feature, restoring colour, thickness and consistency of the skin, minimally manipulating the adjacent normal tissue without sacrificing safe free oncologic margins.3 Orbicularis oculi myocutaneous flap is an option to reconstruct the medial canthal defect, since the texture of the skin is thin and similar to eyelid one.4,5 The authors present their experience using orbicularis oculi myocutaneous flap to perform medial canthal region reconstruction in 10 patients with medial canthal malignant lesions. The study was conducted in accordance with the Helsinki Declaration of 1964 (revised in 2008). Simultaneous excision of the primary lesion and reconstruction was performed under local anaesthesia in all of the patients. The size of the patient's canthal area defect is measured after tumour resection. An appropriately sized flap is marked on the lateral portion of the upper eyelid and a similar mark to upper blepharoplasty is performed. Laxity of the eyelid skin is evaluated with the conventional pinch test to ensure a tension-free wound closure; the lower margin of the flap is marked within the palpebral sulcus. Skin and muscle are incised together, the skin paddle is outlined and the remaining cutaneous portion of the flap is de-epithelialized (Figure 1). The flap is then elevated on a sub-orbicularis plane with a medial pedicle, preserving the muscular perforators at the medial canthus. The flap can be elevated up to the medial third of eyelid. Once elevated, the flap is rotated, tailored and inset (Figure 2). The donor site is approximated and sutured as in upper blepharoplasty. The procedure was performed in 10 patients, 7 females and 3 males. The mean age of the patients was 71 years. The initial disease was basal cell carcinoma (BCC) in six cases, and squamous cell carcinoma (SCC) in four cases. The resulting defects had a diameter of 10 to 22 mm. The operative time, which included both tumour excision and reconstruction, ranged between 15 min to 40 min. All data are shown in Table 1. The patients’ postoperative period was uneventful, and the entire procedure was well tolerated under local anaesthesia. The flaps usually show some degree of temporary venous congestion during the first 3–5 days after surgery, spontaneously settled within 7–10 days after surgery. Donor site morbidity was not observed in any case, and normal eyelid movement and eye closure were maintained in all patients: no lid lag, ectropion, ptosis, or other eyelid deformity or malfunction was observed during the follow-up. The aesthetic result was satisfactory; the flaps matched the texture, colour, pliability of the surrounding tissue, and incision scars were inapparent after 1 year in all patients. All patients were satisfied with their results.
Figure 1.
Surgical procedure after tumour excision of the medial canthus in a patient, the skin paddle is outlined and the remaining portion of the flap is de-epithelialized.
Figure 2.
Surgical procedure: flap is rotated, tailored and inset.
Table 1.
Demographic data, etiologies of defects and surgery data.
| Patients | Age (years old) | Sex (female or male) | Pathology (BCC or SCC) | Flap diameter (mm) | Operative time (min) |
|---|---|---|---|---|---|
| 1 | 70 | F | SCC | 12 | 35 |
| 2 | 67 | F | BCC | 10 | 28 |
| 3 | 75 | M | BCC | 15 | 28 |
| 4 | 80 | M | BCC | 20 | 38 |
| 5 | 66 | F | SCC | 11 | 26 |
| 6 | 71 | M | SCC | 15 | 33 |
| 7 | 75 | F | BCC | 17 | 25 |
| 8 | 77 | F | SCC | 20 | 34 |
| 9 | 63 | F | BCC | 10 | 15 |
| 10 | 82 | F | BCC | 18 | 40 |
The medial and lateral canthal regions contribute both to the normal function of the eye and physical appearance of a person.6 Inappropriate reconstructive methods may lead to many complications as well as aesthetic unfavourable results. Several techniques have been reported in Literature for the reconstruction of medial canthal region: direct closure or second intention healing for small defects, skin grafts, local and regional transposition or rotational flaps.7 However, grafts often result in a patchy appearance, due to mismatch in colour and texture. When tumour excision leaves the underlying bone or tendon exposed, a skin graft is not a viable option.8 Disadvantage of flaps, glabellar and paramedian flaps in particular, is the discrepancy in donor and recipient skin thickness, which may result in a moderate trapdoor deformity and apparent midline forehead scar, even glabellar propeller perforator flap leaves a concealed donor site scar but a moderate trapdoor deformity.9
The advantages of orbicularis oculi myocutaneous flap are large rotation arch, similarity in texture, colour, and thickness to the recipient area. In addition, the flap raising technique is fast and simple, there is a clear submuscular plane of dissection, flaps of many different shape and large size can be elevated. It can be easily tailored to fit the shape of the soft tissue defect, preventing both contracture of the punctum and distortion of the lacrimal apparatus, as well as eyelid cicatricial ectropion.6 The main disadvantage is patient selection, as the size of the flap strictly depends on the amount of excess of lateral upper eyelid skin. Flap dissection requires full anatomy knowledge in particular during caudal incision and dissection, where upper eyelid elevator can be harvested accidentally. Flap venous congestion is common during the first week post-operative, but settles completely in the following days. The procedure may lead to contralateral asymmetry; however, it is possible to perform a contralateral blepharoplasty in the same surgery. This study has some limitations: there are few patients and there is no control group, it is a preliminary study and a prospective case-control study will be needed to confirm these early results, but the authors believe that orbicularis oculi myocutaneous island flap can provide a reliable alternative to resurfacing the medial canthal region, especially in elderly patients with redundant upper eyelid skin, performing an immediate reconstruction. This flap offers several key advantages, including similarity in texture, colour, and thickness to the recipient site and a negligible incidence of donor site morbidity, in fact the eyelid closure was appropriate in all the patients, no ectropion, medial canthal eversion, incomplete blinking, or ptosis occurred in our series.
Ethical approval and consent to participate
This study was performed with respect to the ethical standards of the Declaration of Helsinki. For this type of article (case series, there are few cases) Ethics Committee or Institutional Review Board approval aren't necessary according to the rules of our Institution.
Consent for publication
Consent for publication was obtained from the patient.
Declaration of Competing Interest
The authors declare that there is no conflict of interest.
Disclosures and funding sources
None.
Footnotes
Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jpra.2023.07.006.
Appendix. Supplementary materials
References
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