The document discusses eyelid reconstruction, including:
1. It describes the anatomy of the eyelid, including the palpebral fissure size, positions of the canthi and eyelid margins, and layers of the eyelid.
2. Common reasons for eyelid reconstruction include congenital anomalies, tumors, and trauma. Principles of reconstruction include thorough evaluation, debridement of nonviable tissue, and aligning all tissue layers.
3. Various flap techniques are described for reconstructing different areas of the eyelid, including tarsoconjunctival flaps, cheek flaps, forehead flaps, and V-Y flaps. Complications of reconstruction include issues like corneal abrasion
In this talk , we discuss the assessment and evaluation for patients presenting for cosmetic upper and lower lid blepharoplasty along with surgical technique.
In this talk , we discuss the assessment and evaluation for patients presenting for cosmetic upper and lower lid blepharoplasty along with surgical technique.
Orbital fracture, types, blow in fracture ,blow out fracture ,clinical features ,superior orbital fissure syndrome ,management ,complications ,reconstruction techniques ,Oculocardiac reflex
Bony orbits are Quadrangular truncated pyramids with Anterior cranial fossa above and the maxillary sinuses below.
in this presentation we study the detailed anatomy of the arbit, the bones, relations of each wall, the contents, the apertures, orbital fissures and structures passing, fascia, septa and the surgical spaces of the orbit
Anatomy of Orbit and its clinical importanceAshish Gupta
It's a presentation of Anatomy of Bony Orbit and its applied aspects. It's been made by compiling images from many sources and includes almost all the information needed for a postgraduate .
Orbital fracture, types, blow in fracture ,blow out fracture ,clinical features ,superior orbital fissure syndrome ,management ,complications ,reconstruction techniques ,Oculocardiac reflex
Bony orbits are Quadrangular truncated pyramids with Anterior cranial fossa above and the maxillary sinuses below.
in this presentation we study the detailed anatomy of the arbit, the bones, relations of each wall, the contents, the apertures, orbital fissures and structures passing, fascia, septa and the surgical spaces of the orbit
Anatomy of Orbit and its clinical importanceAshish Gupta
It's a presentation of Anatomy of Bony Orbit and its applied aspects. It's been made by compiling images from many sources and includes almost all the information needed for a postgraduate .
This presentation talks about the anatomy of facial nerve and the facial nerve palsy. Few diagrams and tables have been taken from Neligan's textbook of Plastic Surgery.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
2. • The palpebral fissure 29–32 mm horizontally
9–12 mm vertically
• Lateral canthus 1–2 mm higher than the
medial canthus.
• The upper eyelid usually covers the upper 1–2
mm of the iris
• the lower eyelid rests at the level of the
inferior limbus.
3. • An anterior lamella,skin and orbicularis oculi
muscle, and
• A posterior lamella, formed by the tarsus and
the conjunctiva
4. • The orbicularis oculi is
divided into pretarsal,
preseptal (both lying in
the eyelid) and orbital
(around the eyelids)
portions
5.
6.
7. • The upper tarsus measures 10–12 mm,
• The lower tarsus measures 4–5 mm
• The edges of the tarsi are firmly attached to
the eyelids margins,
• The Meibomian glands are embedded within
the tarsus posterior to the eyelashes.
• Between the duct orifices and the lashes is the
“gray line”,
8.
9.
10. • The orbital septum extends from the edges of
the tarsi to the orbital rims, attaching to the
edge of the rim
• Sharing a common origin with the orbicularis
retaining ligament
11. • The Whitnall’s ligament sends medial and
lateral horns to attach to the zygomatic bone
laterally and the medial canthal ligament and
the posterior lacrimal crest medially.
• The levator aponeurosis inserts into the
anterior surface of the tarsus, sending fibrous
attachments through the orbital septum and
the orbicularis muscle to skin to form the
upper eyelid crease.
12. • The deep part of the levator muscle is Müller’s
muscle, which is sympathetically innervated
13. • Medially, the medial canthal ligaments arise
from the medial edge of the upper and lower
tarsus, and
• Formed of anterior and posterior limbs that
attach to the anterior and posterior limbs of
the lacrimal crest
16. Principles
• Through evaluation of the defect and function of the
lid.
• Components that have been compromised should be
properly identified and documented
• Thorough preoperative ophthalmologic examination,
including visual acuity and field testing, as well as a
Schirmer test,
• Transverse incisions will help to camouflage scars, and
symmetry with contralateral structures;Vertical
incisions should be avoided so as to obviate
contracture and distortion of eyelid function.
17. • Debridement of nonviable tissue
• When approximating lid margins, alignment of
all layers must be achieved.
• Suture material and knots to avoid direct
contact with the surface of the cornea and
globe.
• Reconstructive ladder should be appreciated
21. • greater than 75% by lower-lid switch flap / a
cheek rotation–advancement
• Involve other surrounding zones include a
forehead flap, a Fricke flap, or a glabellar flap
43. • If the tendon is intact but minor laxity is
appreciated, simple plication is recommended
• If the insertion of the tendon is not intact,
canthopexy is recommended
• the medial aspect of the upper and lower
tarsal plates can be sutured to the nasal
periosteum taking care to place the point of
fixation below the anterior lacrimal crest.
44.
45. Lateral Canthal Reconstruction: Zone
IV
• lateral canthal tendon
• all reconstructions include a canthal support
procedure or canthopexy.
• Complete disruptions of the canthus require a
canthoplasty
• Reconstructing the superficial component of
these defects include a cheek advancement
flap or full-thickness skin graft.
46. • anchoring the medial end of the remaining
ligament to either the periosteum at the level
of the Whitnall tubercle or to the bone
directly, using small drill holes in the orbital
rim
47. Reconstruction of Periocular Defects:
Zone V
• Zone V defects are defined as those outside of
but contiguous with zones I to IV
• they can affect lid position and function
48. Complications
• Early :-
• corneal abrasion,
• chemosis (which can often be limited by a
Frost stitch or temporary tarsorrhaphy),
• hematoma,
• flap/graft failure.
49. • Late :-
• Corneal exposure,
• canthal laxity.
• lid malposition,
• abnormal lacrimal drainage, and
• an unsatisfactory cosmetic result.
Editor's Notes
The mucosal
lining is the palpebral conjunctiva. The conjunctiva forms an
uninterrupted layer as it arises from the skin at the free edge
of one lid and extends over the globe to the free edge of the
Other
form the anterior covering of the globe, the bulbar
conjunctiva. The apexes of the folds are known as the superior
and inferior fornices.
Separating the anterior and posterior lamella is the
tarsofascial layer. This layer arises from the orbital rim and begins
proximally as the orbital septum, formed by the confluence
of the periosteum of the orbit and the periosteum of the facial
bones.
Distally, the orbital septum fuses with the lid-retracting membrane.
In the upper lid, this is the levator palpebra aponeurosis;
in the lower lid, it is the capsulopalpebral fascia.
The lacrimal system functions to bathe with and drain the
globe of tears (Fig. 39.2). It consists of the lacrimal gland and
microscopic accessory glands, which secrete the tears, and the
lacrimal ducts or canaliculi, the lacrimal sac, and the nasolacrimal
duct, which provides nasal drainage
The lacrimal gland proper is composed of two lobes: the
main orbital lobe and the smaller palpebral lobe. They are situated
in the lacrimal fossa of the superolateral orbit and upper
lateral eyelid, respectively
The ducts of the palpebral lobe empty into
the upper lateral half of the superior fornix. The ducts of the orbital
lobe pass through the palpebral lobe before exiting
The gray line serves as an important
landmark; the plane between the anterior and posterior
lamella of the eyelids. corresponds to a terminal extension of the orbicularis muscle
The proximal edge of the plate serves as
the insertion for the Mueller muscle, which is innervated by the
sympathetic nervous system.
The proximal edge of the inferior
plate serves as the insertion for a membrane formed by the confluence
of the capsulopalpebral fascia and inferior orbital septum
With an origin on both the
inferior oblique and rectus muscles, the capsulopalpebral fascia….. They secrete an oillike substance onto the conjunctiva,
which facilitates gliding of the lid over the globe
The glands,
which number approximately 10 to 20 on the lower lid and
20 to 40 on the upper lid…. acute (hordeolum or stye
Inferiorly, extends for 1–2 mm on the anterior surface of the inferior orbital rim
the Whitnall ligament, which is formed by
the fascial condensation of the levator aponeurosis.
The Lockwood ligament is the lower-lid analog
of the Whitnall ligament.
The lateral canthal tendon
is formed by the confluence of the upper and lower crura,
which arise off their respective tarsal plates and create a complex
structure known as the lateral retinaculum, inserting onto
the Whitnall tubercle. This key anatomic bony prominence lies
2 mm within the lateral orbit, below the lacrimal fossa
In hyperthyroidism, sensitization of Müller’s
muscle leads to upper eyelid retraction and pseudoproptosis.
On the other hand, in Horner’s syndrome loss of this muscle
action leads to ptosis.
For large defects (those greater than 75%), the Mustarde
lower lid switch flap is an option.9 A large full-thickness portion
of the lower eyelid is rotated based on the marginal vessels
to fill the upper eyelid defect…. This flap is typically delayed
up to 6 weeks before pedicle division and inset…The disadvantage is that it sacrifices a significant portion of
the lower eyelid that must then be reconstructed with cheek
advancement and posterior lamella grafts.
two-thirds full-thickness defects of the lower eyelid that can be created in the form of a V,
reduction of tension by dividing the slip of the lateral canthal ligament to the lower eyelid—lateral canthotomy….
With
the V-shaped defect outlined on the eyelid,
When the lateral canthotomy has been carried out, the conjunctiva provides no resistance to medial
advancement and does not need to be formally divided…
The plates can be effectively sutured together with interrupted 6-0 chromic catgut
on an atraumatic needle, placing the knots on the muscle side of the tarsal plate
The tarsoconjunctival flap for lower eyelid
reconstruction supplies the deficient lower lid with conjunctiva for lining and tarsus for structural support. This
posterior lamella flap should be combined with a free skin graft (or skin flap) to create the new anterior lamella of
the lower lid…. Application of this technique is limited, in that the vertical height of the upper lid tarsal plate measures 10 to
12 mm, and if more than 7 mm of this tarsal plate is removed, the upper lid may itself become crippled and
deformed. Therefore, this technique is most useful for repair of lower lid defects that are no more than 5 to 7
mm in vertical height
The best results are obtained when the horizontal extent of the defect is less than the
distance from the inner to outer canthus….. Defects of the lower lid that extend horizontally the full length of the lid and vertically to the inferior orbital
rim are better repaired by the bipedicle or bucket-handle flap (Tripier) technique…When the lower lid defect exceeds 7 mm vertically and half the horizontal lid length has been resected,
the Tenzel semicircular flap gives excellent results…When all the lower lid must be removed, including the base of the lid past the inferior orbital rim, the
Mustardé cheek rotation flap
A horizontal incision is made through the conjunctiva and tarsus of the upper lid 3 to 3.5 mm from the lid margin
down to the submuscular fascia of the orbicularis muscles. The vertical limbs of the incision are extended in this
P.43
same plane into the superior conjunctival cul-de-sac. Dissection in this area is best accomplished with a
moistened cotton-tipped applicator, because Müller's muscle bleeds quite profusely unless the lid has been
infiltrated with epinephrine…. Inclusion of the upper lid retractor muscles, whose blood supply is derived from
branches of the dorsal nasal, frontal, supraorbital, and lacrimal arteries in the flap pedicle, largely obviates any
chance of slough…. no special
attempt is made to separate Müller's muscle and the levator aponeurosis from the base of the flap…a horizontal advancement flap of skin can be brought in either medially or
laterally to cover the tarsoconjunctival flap.
In defects involving from one-quarter to one-half of the eyelid, a comparatively small cheek rotation is required
If the reconstructed area is wider than about 6 mm, reconstructed part of the lid with a small composite nasal septal graft…..
to use a cheek rotation flap to carry the thin skin that lies lateral to the lateral canthus into the
region of the reconstructed eyelid. The incision line of the flap should curve upward and outward from the lateral
canthus. The length of the cheek incision, as well as the amount of undermining to be carried out, is determined
on a trial-and-error basis by constantly checking whether the flap can be rotated across to fill the defect.
The composite septal graft is held in position using running 6-0 Prolene
sutures to coapt the nasal mucosal edges to conjunctiva
The area of the Imre flap can be extended to embrace all tissue from the lower lid downward and from the nasolabial crease laterally….
The McGregor flap (Chapter 12) should be considered as a first option for lower lid reconstruction, because
it is simpler to execute, includes potions of the lateral orbicularis muscle
For total reconstruction of the lower lid, the length of the incision is about five times the distance from the tip of
the flap to the new lid margin. The original Burow's triangle is converted into a crescent-shaped skin defect at the
base of the flap. The flap is widely undermined beyond the line extending from the lateral canthus to the temporal
side of the crescent-shaped defect (Figs. 14.1C and 14.2). If there is enough conjunctiva available, it can be
used to line the upper margin of the flap
The medial and lateral extent of the Y limbs should be the canthal ligaments, to prevent retraction and possible ectropion…The width of the flap is the same as the
width of the defect, and the height of the flap is 11ú2 times greater…. The flap is advanced upward until it reaches the desired position of the eyelid border without tension. It is
anchored medially and laterally to the orbital periosteum with two nonabsorbable sutures.
The laterally based transverse musculocutaneous flap is a safe, reliable, simple flap that can be used to
reconstruct defects of the lateral two-thirds of the lower lid of up to 15 to 20 mm in vertical height.
The melding of the V-Y advancement with the double rotation flaps of the S-plasty enhances the reparative
efficacy of treatment of circular defects, with particular relevance in the medial canthal territory
Depending on the width of skin available between the
eyebrows, a flap designed in the form of an inverted V can be used to cover a defect at the medial canthus of up
to 15 mm in diameter…One of the simplest and most satisfactory techniques for doing such reconstructions is to bring down the thick
glabellar skin as a V-Y flap in a one-stage operation. Depending on the width of skin available between the
eyebrows, a flap designed in the form of an inverted V can be used to cover a defect at the medial canthus of up
to 15 mm in diameter (Fig. 27.1). In conjunction with other flaps, such a flap may be employed to cover even
larger areas. The flap is incised down to the galea aponeurotica, leaving an adequate pedicle on the bridge of
the nose. The vertical dimension of the flap should be about three times the breadth at its lowest part. Once the
flap has been slid down to cover the defect, it will be found that the forehead wound can be closed in the form of
an inverted Y.
The V-Y glabellar flap is an excellent choice for reconstruction of deep lesions of the medial canthal area
can be secured with a wire loop, which is
passed and anchored in a transnasal fashion …. If the medial retinaculum is detached from the bone, it
must be .reattached via the posterior reflection on the lacrimal
crest posterior to the lacrimal sac….. Methods for fixation include sutures to the periosteum,
drill hole fixation, bone anchors, and in cases of bone
deficiency, transnasal wires or to a gap spanning plate.
laxity of the lateral canthus, even
when corrected, has a tendency to recur over time. Thus, a
slight overcorrection should be the goal…In both
situations, the goal is to overcorrect the tissue laxity as recurrent
laxity is expected.
When the upper portion of the
tendon is intact, a lateral canthal sling is used to provide support
and tighten an otherwise lax lower lid (6). Finally, when
completely obliterated, the lateral canthal ligament can be reconstructed
via a lateral tarsal strip procedure. The tarsal plates
are sutured to a strip of orbital periosteum raised for this purpose
combine a nasal septal cartilage–mucosal
graft for the posterior conjunctival-tarsal layer and a transposition
myocutaneous flap from an adjacent area for the anterior…cutler beard width of the flap should match the width of the upper eyelid
defect, and vertical full-thickness incisions are made to the
inferior fornix at this width. The flap is advanced posterior
to the remaining lid margin and s~red into the upper eyelid
defect with a multilayer closure. The conjunctiva can be separated
from the musculocutaneous flap, and a cartilage graft
can be placed for added support as this flap typically has little
or no tarsus within it.2 The flap is divided at approximately
6 weeks with 2 mm excess vertical height.
(1) a two-stage
reconstruction with obstructed vision between stages, (2) disturbance
to the lower eyelid that may require future revision
and/or lid-tightening procedures, and (3) lack of lashes in the
reconstructed segment.
8 A
superiorly based semicircular flap of up to 6 em in diameter
is designed and advanced medially
The conjunctiva is also undermined
and advanced to provide the lining of the flap. This flap
is ideally suited for those defects that encompass 40% to 60%
of the upper eyelid
lamella.
Hughes sliding tarsoconjunctival flap from
the lower lid….. In elderly
patients, whose lids have more laxity, defects up to 30% of
the horizontal lid dimension may be closed primarily but
may require a lateral canthotomy for a tension-free repair…. A sliding tarsoconjunctival flap bor·
rows tissue from the uninjured portion of the ipsilateral upper
eyelid. This flap is an option for posterior lamella defects
involving the medial or lateral aspect of the upper eyelid….. The
.inferior incision for this horizontally based .flap is 4 mm above
the lid margin and extends to create a .flap that is equal to the
defect size. The superior incision is designed to fit the defect,
and a vertical relaxing incision is required in the tarsal plate to
allow for advancement.2 A full-thickness skin graft is required
for coverage of this flap to reconstruct the anterior lamella…. In central wounds, a tarsoconjunctival flap can be developed
from the lower eyelid as is done for lower eyelid reconstruction
in the Hughes procedure.‘….. The Cutler-Beard bridge .flap is a full-thickness composite
.flap from the lower eyelid…. A transverse full-thickness incision
is made approximately 5 mm inferior to the lid margin in the
lower eyelid, which allows flap elevation without compromising
vascularity to the remaining lower eyelid
The lower eyelid is anatomically analogous
to the upper eyelid, that is, where the capsulopalpebral fascia
is homologous to the levator aponeurosis and the inferior tarsal
muscle is homologous to Mueller•s muscle….. The main difference
is that the lower eyelid is shorter and the tarsal plate
is 4 mm in vertical height compared with 10 mm in the upper
eyelid.
Fricke flap (Fig. 39.7) is a unipedicled myocutaneous transposition
flap composed of the skin and preseptal portion of
the orbicularis oculi muscle of the upper lid…. The Tripier flap is a bipedicled flap from the
upper eyelid transposed to reconstruct lower eyelid defects.
This flap includes preseptal orbicularis oculi muscle. The
Fricke flap is similar but is a unipedicled flap and is adequate
for defects that extend to the mid-lower eyelid or just beyond
If a
myocutaneous transposition flap is raised on both the medial
and lateral pedicle, a bipedicled myocutaneous transposition
flap (Tripier) is generated…Small full-thickness lower lid defects are closed primarily.
Care is taken to align and repair the tarsal plate. As in
partial-thickness defects, a lateral inferior cantholysis may be
required to prevent tension
Full-thickness defects that are 50% or less of the lower
eyelid can be approached with the inferiorly based Tenzel
semicircular flap.8 The semicircular incision extends superiorly
and laterally with a diameter of 3 to 6 em depending on
the defect size and tissue laxity. Dissection is in a submuscular
plane, and the inferior ramus of the lateral canthal tendon
is divided to allow medial rotational advancement…. Hughes tarsoconjunctival flap procedure6
from the upper lid which is best for defects greater than 50%,
including total lower eyelid reconstructions. The flap is developed
starting 4 mm above the upper eyelid margin to avoid
compromising upper eyelid integrity and consists of a segment
of tarsus and conjunctiva. The width is designed to match
the missing posterior lamella segment of the lower eyelid and
advanced into the lower eyelid defect.
cheek flap include dermal anchorage to
the inferior orbit to ensure tension-free closure,
The
lacrimal papilla, puncta, canaliculi, plica semilunaris, caruncula
lacrimalis, and tripartite insertion of the medial canthal
tendon are all located within this square centimeter of tissue…. In this procedure,
the inferior arm is “tucked” under the canthus
This flap is useful in replacing the absent central two-thirds of the lower eyelid used to repair horizontally oriented losses of the lower eyelid, both marginal and nonmarginal, of less than 10 to 15 mm in vertical height….. The flap is outlined with the inferior edge corresponding to the supratarsal fold from point A to point B (Fig.
17.1A). These two points are located above the medial and lateral canthi, respectively, where the fold
disappears. The superior incision ( CD) is made parallel to line AB (Fig. 17.1A), creating a bipedicled flap
approximately 10 to 15 mm wide, depending on the amount of redundant tissue present in the preseptal area. A
wider flap may be used, but this will require a skin graft to close the donor area…. When closing a marginal defect, the undersurface of the flap must be grafted with a composite chondromucosal
Graft. The bipedicle upper eyelid flap is a safe and reliable flap that can be used to reconstruct defects of the
central two-thirds of the lower eyelid up to 15 to 20 mm in vertical height…. The Tripier flap was further modified by converting the skin component into an island on a bipedicled orbicularis oculi muscle
Described below is a skin island orbicularis oculi musculocutaneous flap obtained from the suprabrow area and used for reconstruction of the lower eyelid.
The pivot point should be at the same horizontal level as the outer canthus or palpebral fissure. An arc of rotation is established that will allow the flap to sweep over the entire territory of the lower lid.
A tunnel is made beneath the lateral canthal skin for the entry of the flap toward its final destination
It is important to realize that the marginal eyelid vessels lie about 3 mm from the lid margin
and immediately beneath the layer of the orbicularis muscle.
This flap consists of an inferiorly based full-thickness lower lid flap (skin, orbicularis muscle, orbital septum, lower
lid retractors, and conjunctiva) advanced beneath the lower lid margin to replace the upper lid…. The tumor is excised. Moderate traction is placed on the lid remnants to narrow the width of the
defect. A full-thickness incision is made through the lower lid at the tarsal edge. Vertical full-thickness incisions
are made to a depth of the fornix. Relaxing skin triangles are excised. B: The flap is advanced upward behind
the marginal bridge and sutured in two layers into the upper lid defect. The lower edge of the bridge can be
loosely closed. C: After 6 to 8 weeks, the lid fissure is recreated by a full-thickness scissor cut arched downward
about 2 mm. This cut should be beveled forward in order to have the conjunctiva slightly lower than the skin. D:
The base of the flap is returned to its anatomic position and sutured in two layers. The skin and conjunctiva are
approximated with a running suture of 6-0 catgut…. The flap is divided with scissors in a downward arch, anticipating retraction of
approximately 2 mm. The absence of tarsus not only causes the lid to retract, but also favors development of
entropion…. the dividing incision should be beveled forward, leaving excess conjunctiva to be
rotated over the new lid margin…obstructing vision for 6 to 8 weeks; the lack of a
skeleton (tarsus) in the new lid margin, resulting in a tendency to entropion; the potential for damage to the
lower lid margin; and the absence of lashes in the reconstructed lid.
Because the thickness of a flap from the nasojugal area is greater than that of upper eyelid skin and orbicularis,
more stability is provided to the reconstructed lid and this decreases the need for tarsal replacement…Its base is centered over the angular vessels and lies above the level of
the medial canthal ligament, allowing the flap to reach 90° of transposition…To rotate the flap into the upper lid,
more torsion is necessary than in rotation to the lower lid; this is achieved by having the upper arm of the flap
base extend more onto the surface of the nose, allowing for rotation into the upper lid