Functional Reconstruction of the Full Thickness Medial Canthal Defect with Periosteum Flap, Dacryocystorhinostomy and Local Flap

Purpose

Medial canthal area has complex anatomic and functional structures including medial canthal tendon and nasolacrimal duct.^1,2 Reconstruction of medial canthal area must be include medial canthal tendon,  nasolacrimal duct and soft tissue defect.^1,2 In this study, we present functional reconstruction of full thickness medial canthal area with Y shape periosteum flap, dacryocystorhinostomy and local flap.

 

Material and methods

 

Betwen 2014 and 2017 years, 12 patient were included in this study. All of them had extensive medial canthal lession, so the surgical excision included the nasolacrimal duct and the medial canthal tendon. Simultaneous lesion, nasolacrimal duct and the medial canthal tendon was excised and reconstruction was performed for fullthickness defect. The Y shape periosteal flap was horizontally designed from remnant periosteum of nasal bone and frontal process of maxillary bone. Upper and lower part of the Y shape periosteal flap was sutured to the upper and lower eyelid. A silicone tube was used for dacryocystorhinostomy. Soft tissues defects were reconstructed with glabellar flap in 5 patient and angular artery perforator propellar flap³ in 7 patients, respectively. The silicon tube was removed at 3^th week after surgery. All patients were followed up at least 13 months(13-55). Aesthetic result of surgery,  function of nasolacrimal duct and eyelid laxity was evaluated with Satisfaction Evaluation Scale (SES: -1 = not satisfield, 0 = no change, 1 = moderate, 2 = good, 3 = very good), lacrimal duct irrigation test, lower lid distraction test for all patients at twelve month after surgery.

 

Result

 

8 patients were male,4 female. The mean age of them was 69,5 years.  Defects size of the excised soft tissues ranged from 3.8 cm² to 6.9 cm².  There was no intraoperative or postoperative complication such as flap dehiscence or flap necrosis, lid lag deformity, ectropion and ptosis. Epiphora was observed in two patient. One of the was reoperated and problem was resolved, but other one didn’t want to reoperation. Tension of the periosteal was good.There was no differentiation between glabellar and angular artery perforator flap. All patients except one was very satisfield with the result, other one good satisfield.

 

Conclusion

Reconstructive surgery of medial canthal area is a challenging surgical prosedure because of requiring aesthetic and functional outcome.^1,2 Y shape periosteal flap provides acceptable stability and location of the eye lid.  Full-thickness defects of the medial canthal area by using Y shape periosteal flap, dacryocystorhinostomy and local flap is an alternative technique in medial canthal reconstruction, with acceptable functional and aesthetic outcomes.

 

References

1- Panizzo N, Colavitti G, Papa G, Ramella V, Tognetto D, Arnež ZM. Reconstruction after wide excision in medial canthal region: the extended bilobed glabellar-palpebral flap. J Plast Reconstr Aesthet Surg. 2015 Jan;68(1):131-2.

2-  Stewart CM, Norris JH. Reconstruction of extensive medial canthal defects using a single V-Y, island pedicle flap. Orbit. 2018 Jan 15:1-4.

3-Brunetti B, Tenna S, Aveta A, Segreto F, Persichetti P. Angular artery perforator flap for reconstruction of nasal sidewall and medial canthal defects. Plast Reconstr Surg. 2012 Oct;130(4):627e-628e.