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To develop and evaluate a minimally invasive technique of lateral orbitotomy that provides improved orbital access with fewer complications.A cadaver study was undertaken to develop a technique of transconjunctival lateral orbitotomy that preserves the structural integrity of the eyelid support system and provides extended access to the orbit from floor to roof. We then evaluated the procedure in an outcome study of 30 consecutive patients.The cadaver investigations demonstrated that a transconjunctival lateral retrocanthal approach is technically possible and provides improved direct access to the lateral orbit. In the study of 30 consecutive procedures, there were no complications resulting from the surgical access. The wound healing was rapid, without tissue distortion or scars. The exposure was ample for all surgical interventions.Lateral retrocanthal orbitotomy is a new approach that provides extended access to the entire lateral orbit. The technique is rapid and can be extended in a single continuous incision to the medial orbit. The structural integrity of the lateral retinaculum is preserved, which appears to improve the postoperative cosmetic and functional result.

To describe a new 3-dimensional technique for medial canthal repositioning, precaruncular medial canthopexy (PMC), and to present an outcome study demonstrating its efficacy.Data (age, sex, cause, and initial symptoms) were collected prospectively on patients with malposition of the lower eyelid. All patients were photographed before and after surgery in a set protocol. The type and severity of eyelid malposition were documented using the Ectropion Grading Scale (EGS) before and after each procedure. Surgical outcome was evaluated by objective improvement of ectropion grading and subjective resolution of symptoms.Precaruncular medial canthopexy was performed on 30 eyelids of 27 consecutive patients (10 were revisions) for correction of medial eyelid laxity or malposition. Twenty-six patients had ectropion, and 1 had bilateral entropion. The most common cause of eyelid malposition was facial paralysis (n = 21). Ancillary procedures, most commonly lateral transorbital canthopexy (for correction of lateral ectropion), were performed on 60% of the eyelids at the time of PMC. Twenty-eight procedures resulted in complete restoration of the medial canthus to a normal position (EGS grade I). Two patients had minimal residual medial scleral show after surgery (EGS grade II) but experienced symptom relief. There were no wound infections or perioperative complications.Precaruncular medial canthopexy rapidly and safely restores support in all 3 dimensions without blocking the visual field or damaging the lacrimal system, with minimal morbidity and excellent wound healing. In addition to being a primary technique for correcting medial eyelid malposition, PMC should be routinely considered as an adjunct procedure when correcting lateral eyelid malposition.

There are numerous approaches to correcting laxity of the lateral canthal tendon, each with advantages and drawbacks. Critical evaluation of these techniques is not possible, however, as there is no grading system currently in use to describe this condition or to report outcomes, and prospective trials are lacking.To report and assess a new procedure for repair of the lateral canthus (lateral transorbital canthopexy) and to describe the Ectropion Grading Scale (EGS), with a prospective outcome analysis of their use.Prospective outcome study of 15 consecutive patients (16 procedures).Tertiary referral center in Zurich, Switzerland.Consecutive sample of patients referred for treatment of ectropion of various causes.Preoperative and postoperative EGS grades were recorded, a preoperative and postoperative patient-based questionnaire was administered, and lateral transorbital canthopexy was performed.Outcome was determined by improvement in EGS grade and results of the patient-based symptom questionnaire.There were no surgical failures or complications in the study. An average of 83% reduction in patient-reported discomfort was achieved. Two patients with facial paralysis needed medial canthal repositioning. The EGS allowed clear recording of lower eyelid position before and after lateral transorbital canthopexy, and the procedure was uncomplicated to perform.Lateral transorbital canthopexy is an effective technique for the correction of lower eyelid laxity and appears to allow refined, durable adjustment of the lateral canthus. Self-reported patient satisfaction confirmed the high rate of success of the procedure in this study. The EGS permits critical evaluation and reporting of results and may assist in predicting which patients will need concomitant correction of the medial canthus. Arch Facial Plast Surg. 2000;2:9-15

To delineate the anatomic architecture of the melolabial fold with surrounding structures and to elucidate potential implications for face-lift techniques.A total of 100 facial halves (from 50 cadaveric heads) were studied, including gross and microscopic dissection and histologic findings. Laboratory findings were correlated with intraoperative findings in more than 150 deep-plane face-lift dissections (300 facial halves) performed during the study period.In contrast to previous reports, the superficial musculoaponeurotic system (SMAS) was not found to form an investing layer in the midface. The SMAS, zygomatici muscles, and levator labii superioris alaeque nasi were found to be located in corresponding anatomic layers and to form a functional unit. Additional findings of the present study include the description of 3 structurally different portions of the melolabial fold, of an anatomic space below the levator labii superioris alaeque nasi (sublevator space), and of extensions of the buccal fat pad into the sublevator space and the middle third of the melolabial fold.The findings of the present study may contribute to augment our understanding of the complex anatomy of the midface and melolabial fold. Potential implications for modern face-lift techniques are discussed.

Most approaches to the medial orbit and lower provide suboptimal access and leave visible scars. The transcaruncular approach is an improvement over previous procedures, but disadvantages remain: there is no defined surgical plane through the caruncle; the caruncular tissue is highly vascular; and the approach may cause considerable postoperative morbidity. For these reasons, cadavers were studied to develop a surgical approach that would avoid the caruncle. A prospective outcome evaluation was then performed.Two male and 2 female cadavers were studied to ascertain whether the plane medial or lateral to the caruncle provided optimal access to the medial orbit. Fifteen consecutive procedures were then prospectively evaluated using the medial approach.The "precaruncular" approach medial to the caruncle provided the most direct route to the medial orbit, with a clear, avascular path of dissection and improved exposure. In 15 consecutive procedures, there were no complications. The patients healed rapidly, with minimal postoperative morbidity.The precaruncular approach was demonstrated on cadavers to be more efficacious than approaches directly through or lateral to the caruncle. This finding was confirmed in a prospective evaluation of 15 procedures, in which no complications occurred. More rapid healing was noted than with prior experience using the transcaruncular route. The precaruncular approach provides a preseptal plane to the medial orbit that can be extended to the orbital floor or roof as needed, and offers a direct connection between the posterior lacrimal crest and the tarsal plate for medial canthopexy.

We sought to examine the efficacy of vacuum-assisted closure (VAC) therapy for the reconstruction of full-thickness forehead defects and to determine the appropriate therapeutic strategies for its use. Medical records and photographs were reviewed for 3 patients with full-thickness tissue loss of the forehead region treated with a VAC system. All 3 patients had complete formation of healthy granulation tissue with VAC therapy alone. One patient was treated to full reepithelization of her wound; the other 2 patients underwent successful surgical closure after VAC reduction of the defect. The treatment was well tolerated, with no complications. Although this represents an initial study, it seems that the protocol for VAC therapy presented herein is a reliable technique for the repair of forehead defects that provides excellent functional and aesthetic outcomes.