The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
FIGURE 1. AYC, A 32-year-old woman who had a blunt trauma to her left eyeball. Axial CT images (A and B) show medial (arrow) and lateral (arrowhead) orbital wall fracture and associated retrobulbar hemorrhage and hemosinus in the left ethmoid sinus, and because of extensive pneumatization of the sphenoid sinus, the lateral orbital wall is unusually thin (B, asterisk), which leads to a blow-out fracture. Oblique coronal reconstructed CT image (C) shows an outwardly displaced lateral orbital wall fracture (arrowhead).
Pure blow-out fracture of the lateral orbital wall has not been reported in the medical literature. We believe that the inferior or medial orbital wall is more prone to fractures rather than the lateral orbital wall. As the inferior or medial orbital wall is adjacent to the sinuses, such as the maxillary or ethmoid sinus, it is much thinner than any other part of the orbital wall. The lateral orbital wall is also more solid because it is bounded by relatively thick sphenoid bone and muscle. The reported lateral orbital wall fractures were caused by the ‘‘blow-in’’ mechanism rather than by the ‘‘blow-out’’ mechanism. Orbital blow-in fracture results from a direct blunt force applied to the orbital plate of the greater sphenoid wing and that leads to the inward displacement of the orbital rim or wall, thus resulting in decreased orbital volume.5 In this patient, the fractured segment of the lateral orbital wall was outwardly displaced, and intraorbital fat was herniated into the pneumatized sphenoid bone through the bone defect. There was an accompanying medial orbital wall fracture, without impacted orbital rim fracture. These findings are highly suggestive that orbital wall fractures are caused by a blow-out mechanism. The patient in this case had extensive pneumatization of the sphenoid sinus and the air extended into the lateral orbital wall. The degree of pneumatization of the sphenoid sinus can be considerably variable. Pneumatization in the greater sphenoidal wing has been observed in 10.7% to 20% of the cases presented in previous reports.6Y8 Based on these previous studies, pneumatization of the greater wing of the sphenoid does not seem to be extremely rare. Extensive pneumatization in the greater sphenoidal wing may make the lateral orbital wall much thinner unusually, being more vulnerable to a sudden increase in intraorbital pressure. To the best of our knowledge, this is the first case report of a lateral orbital wall fracture occurring as a blow-out mechanism. We believe that the lateral orbital wall can be fractured as part of a blow-out fracture in patients with extensive pneumatization in the lateral orbital wall. Therefore, in such cases, physicians must be concerned regarding not only inferior or medial wall fractures but also lateral orbital wall fractures in patients with blunt eyeball trauma.
REFERENCES 1. Smith B, Regan WF. Blow-out fracture of the orbit; mechanism and correction of internal orbital fracture. Am J Ophthalmol 1957; 44:733Y739 2. Waterhouse N, Lyne J, Urdang M, et al. An investigation into the mechanism of orbital blowout fractures. Br J Plast Surg 1999;52:607Y612 3. Jones DE, Evans JN. ‘‘Blow-out’’ fractures of the orbit: an investigation into their anatomical basis. J Laryngol Otol 1967; 81:1109Y1120 4. Curtin HD, Wolfe P, Schramm V. Orbital roof blow-out fractures. AJR Am J Roentgenol 1982;139:969Y972
Brief Clinical Studies
5. Chirico PA, Mirvis SE, Kelman SE, et al. Orbital ‘‘blow-in’’ fractures: clinical and CT features. J Comput Assist Tomogr 1989;13:1017Y1022 6. Hewaidi G, Omami G. Anatomic variation of sphenoid sinus and related structures in Libyan population: CT scan study. Libyan J Med 2008;3:128Y133 7. Earwaker J. Anatomic variants in sinonasal CT. Radiographics 1993;13:381Y415 8. Hamid O, El Fiky L, Hassan O, et al. Anatomic variations of the sphenoid sinus and their impact on trans-sphenoid pituitary surgery. Skull Base 2008;18:9Y15
Eyelid Reconstruction Following Excision of Cutaneous Malignancy Ilaria Zollino, MD,* Carlo Riberti, MD,Þ Marco Candiani, MD,Þ Valentina Candotto, MD,* Francesco Carinci, MD* Purpose: With advancing age, cutaneous malignancy around the eye becomes more prevalent. Different kinds of malignant tumors of the eyelid have features particular to their subtype, and a diagnosis should be obtained before definitive treatment if possible. The aim of treatment is total tumor eradication with the smallest recurrence risk, using the most cost-effective method that is acceptable to the patient. Reconstruction of periocular defects following excision of eyelid malignancy can present difficulties, and various reconstructive procedures can be applied. Methods: The retrospective study carried out has analyzed 173 patients submitted to surgery for skin cancers located in the eyelid region with particular reference to the period January 2005 to January 2012. We analyzed certain data (age, sex, histological types, affected portion of eyelid, incidence recurrence by histological type, incidence recurrent tumors previously treated by surgery [secondary], type of removal, type of reconstruction, and mean time elapsed between the demolitive act and disease recurrence) both individually and in correlation with each other. Multivariate analysis (Cox algorithm) was used to identify those variables that had a clear statistical significance. Results: Melanoma and lentigo maligna have the highest tendency to relapse (33%), but squamous cell carcinoma has more rapid replicative capacity. Conclusions: Extensive demolition should always be followed by extensive reconstruction. Even through intervention with an extensive demolition in cases of large tumors in the eyelid and cantus,
From the Departments of *Maxillofacial Surgery and †Plastic and Reconstructive Surgery, University of Ferrara, Ferrara, Italy. Received March 28, 2013. Accepted for publication June 23, 2013. Address correspondence and reprint requests to Francesco Carinci, MD, Department of DMCCC, Section of Maxillofacial and Plastic Surgery, University of Ferrara, Corso Giovecca 203, 44100 Ferrara, Italy; E-mail: [email protected] This study was supported by a grant from FAR (to F.C.), University of Ferrara, Italy. The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3182a2ed04
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e13
Brief Clinical Studies
The Journal of Craniofacial Surgery
it has not been possible to avoid the recurrence of the disease. The average time of recurrence when compared with reconstruction varies between 28 (minimum) and 39 months (maximum). Key Words: Eyelid, reconstruction, excision, cutaneous malignancy
W
ith advancing age, cutaneous malignancy around the eye becomes more prevalent.1,2 Different kinds of malignant tumors of the eyelid have features particular to their subtype, and a diagnosis should be obtained before definitive treatment if possible.3 The most common skin cancers that present in the periocular region are basal cell carcinoma, squamous cell carcinoma, sebaceous cell carcinoma, and malignant melanoma.1,2 Basal cell carcinomas constitute 80% to 90% of all malignant tumors situated on the eyelids.4Y6 Basal cell manifests itself in middle age as a result of the cumulative effect of years of exposure to sunlight. The most commonly affected sites are the lower eyelid and medial canthus.6Y8 Morpheaform basal cell cancers demonstrate substantial infiltration into the subcutaneous tissues and should therefore be treated more aggressively than simple nodular or nodular ulcerative basal cell cancers because of risk of intracranial extension, spread to the lacrimal sac, and evidence of cranial nerve, conjunctiva, or globe invasion. Studies report that positive microscopic margins following excision of basal cell carcinomas are associated with local recurrence rates between 34% and 50%.9 Squamous cell carcinomas are the second most common malignant lesion of the eyelids, accounting for 5% to 10% of all eyelid malignancies10 and occurring on the lid margins, not uncommonly on the inner conjunctival layer. Squamous cell cancers of the eyelids require a minimum of a 5-mm margin and often require complete lid resection for larger or ulcerated lesions.3 Sebaceous carcinoma of the eyelid is a rare malignant tumor that arises from the meibomian glands and accounting for between 1% and 5% of all of malignant epithelial tumors of the eyelids.11 This tumor is more prevalent among older adults and females and has a propensity for the upper eyelid.12 It has usually been present for several months before diagnosis, and it is often misdiagnosed initially as a recurrent chalazion or blepharoconjunctivitis. Sebaceous carcinomas are aggressive tumors associated with distant metastasis and poor prognosis.3 The final major category for cutaneous malignancies involving the eyelids is malignant melanoma. Melanoma of the eyelids may occur as a primary cutaneous tumor or as a direct extension of a conjunctival melanoma. The histological classifications include lentigo maligna melanoma, superficial spreading melanoma, and nodular melanoma. Nodular melanoma is usually associated with the deepest extension on Breslow classification and tends to be the most aggressive with the worst prognosis.13 Conjunctival involvement should be determined because curative resection may necessitate an orbital exenteration. Preoperative evaluation includes a full metastatic workup. Lymphatic spread to the neck requires en bloc resection with superficial parotidectomy and neck dissection.3 Although the mortality from eyelid skin cancer is very low, the morbidity is significant.10 The aim of treatment is total tumor eradication with the smallest recurrence risk, using the most costeffective method that is acceptable to the patient.14 Reconstruction of periocular defects following excision of eyelid malignancy can present difficulties, and various reconstructive procedures can be applied. So, in evaluating reconstructive demands for eyelid reconstruction, an in-depth knowledge of the anatomy is an absolute prerequisite for success. A poorly performed reconstruction or the injudicious selection of a technique may be harmful for the eye and may necessitate further surgical correction.
e14
& Volume 25, Number 1, January 2014
MATERIALS AND METHODS The retrospective study carried out has analyzed the cases treated at the Institute of Reconstructive Plastic Surgery of the University Hospital of Ferrara, Sant’Anna, with particular reference to the period January 2005 to January 2012. The 173 patients considered were submitted to surgery for skin cancers located in the eyelid region. Most of our cases were diagnosed early, and so they benefited from conservation interventions performed under local anesthesia. The remainder has required complex reconstructive solutions under local anesthesia or general anesthetic.
Statistical Analysis Particular interest has been devoted to the analysis of certain data because they were considered a possible subject for statistical analysis. In particular, we have analyzed age; gender; histological types (basal cell carcinoma, squamous cell carcinoma, basosquamous cell carcinoma, Merkel carcinoma, tricoepithelioma, intraepidermal carcinoma such as Bowen disease, infiltrating ductal carcinoma, sebaceous epithelioma, capillary hemangioma, proliferating pilomatricoma, keratoacanthoma, eccrine poroma, porocarcinoma, infundibular keratosis, schwannoma, apocrine hidrocystoma, apocrine hydroadenoma, basaloid follicular hamartoma, lentigo maligna, and melanoma) (Figs. 1Y3); portion affected eyelid (eyelid left, right, top, bottom, inner canthus, outer canthus); incidence recurrence by histological type; incidence recurrent tumors previously treated by surgery (secondary); type of demolition (excision, internal cantholysis, external cantholysis, exenteratio orbitae); type of reconstruction (direct suture; flaps: rotation, scroll, frontal, glabellar, island, Mustarde cheek rotational flap, eyebrow, jugal, bilobed; grafts); and mean time elapsed between the demolitive act and disease recurrence. We analyzed the previously mentioned data, therefore, both individually and in correlation with each other. We considered it interesting to investigate a possible interaction between them that would allow us to understand correlation between histological type and disease recurrence; incidence to relapse in the primary tumor compared with a tumor already surgically treated (secondary); correlation between tumor extent and type of demolition; and correlation between the type of demolition and type of reconstruction.
RESULTS Eighty-two of the 173 patients treated were female (a percentage of 47.4%), and 91 were male (a percentage of 52.6%) (Table 1). The age range was from 34 to 96 years with a mean age of 69.6 years (Table 2). Next, we analyzed the histological types involved (Fig. 4). Basal cell carcinoma was found in 130 cases, squamous cell carcinoma in 10 cases, basal-squamous cell carcinoma in 7 cases, other types of malignancy (Merkel carcinoma, tricoepithelioma, intraepidermal carcinoma such as Bowen disease, infiltrating ductal carcinoma, sebaceous epithelioma, capillary hemangioma, proliferating pilomatricoma, keratoacanthoma, eccrine poroma, porocarcinoma, infundibular keratosis, schwannoma, apocrine hidrocystoma, * 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
FIGURE 1. Lower lid epithelioma: excision and reconstruction by cheek advancement flap.
apocrine hydroadenoma, basaloid follicular hamartoma) in 23 cases, and lentigo maligna and melanoma in 3 cases. Subsequently, eyelid portions of interest due to the topographical site were analyzed (right eyelid and left eyelid) (Table 3) and the anatomical portion (upper eyelid, lower, inner canthus, outer canthus) (Fig. 5). Demolition techniques used excision in 167 cases, excision and medial cantholysis in 2 cases, excision and lateral cantholysis in 3 cases, and exenteration orbitae in 1 case. Accordingly, histology in 27 cases (15.6%) required a subsequent enlargement with secondary modeling. Of these, 15 cases (8.7%) had already presented to our observation as recurrent tumors, showing a greater tendency to relapse (40%) after only 5.8 months compared with primary tumors (13%) for which the disease-free interval was up to 15.6 months. Further analysis conducted on tumor histology showed that the melanoma and lentigo maligna have the highest tendency to relapse (33%) (Fig. 6). The average time at onset of recurrence after demolitive surgery was also noted and showed that squamous cell carcinoma histology has more rapid replicative capacity (Table 4). Reconstructive techniques used direct suture in 131 cases; flap (rotation, scroll, island, Mustarde cheek rotational flap, frontal, glabellar, eyebrow, jugal, bilobed) in 35 cases; and graft in 7 cases. There was no occurrence of necrosis of the flaps used, but at most, there was minor pain in distal monopedunculated flaps, especially those of the upper eyelid. We did not see hematoma or infection or major nerve deficit. There was just 1 case of scleral show, which was corrected secondarily. At the end of the study, the multivariate analysis (the algorithm of Cox) was used to identify those variables that had a clear statistical significance (Table 5). It has been possible, finally, to note that, even through intervening with an extensive demolition in cases of large tumors in the
FIGURE 2. Lower lid epithelioma: pentagonal excision and reconstruction by lateral cantholysis and McGregor flap.
Brief Clinical Studies
FIGURE 3. Medial canthus epithelioma: excision and reconstruction by lateral cantholysis, Mustarde rotational flap, and mucosal graft harvested from the vestibule of the lower lip.
TABLE 1. Sex Sex Male Female
Frequency
Valid Rate
Cumulative Rate
91 82
52.6 47.4
100.0 47.4
TABLE 2. Medium Age Minimum Age, y 34
Maximum Age, y
Media, y
SD
96
69.65
13.85
eyelid and cantus, it has not been possible to avoid the recurrence of the disease (Table 6). Extensive demolition should always be followed by extensive reconstruction. The average time of recurrence when compared with reconstruction varies between 28 (minimum) and 39 months (maximum) (Table 7).
DISCUSSION The primary goals of eyelid reconstruction are to allow for detection of recurrent disease, to provide adequate eyelid function and globe protection with the restoration of boundaries between the orbit and surrounding cavities, and to achieve acceptable aesthetic results and outcome.15 Because the eyelid is a layered structure, appropriate layered reconstruction is essential, with the minimization of any postsurgical complications.16 Reconstruction of the eyelid and periorbital area is difficult because of the quality of the tissues in this area, which are thin, very elastic, and mobile, whereas the tissues of areas closer to the orbita, which are generally used for reconstruction, are thick and stiff.17 Eyelid reconstruction is indicated in all but a few instances when defects are present. Partial-thickness defects involve skin and orbicularis, whereas full-thickness defects extend from skin through conjunctiva. So, following tumor removal in the periocular region, reconstruction of the defect requires understanding of the differences and uses of soft tissue flaps and skin grafts.18,19 The exact technique to be used depends on the defect size, location, and the elasticity of the surrounding tissues, which in turn depend on the
FIGURE 4. Eyelid cancer: percentage of histological type on 173 cases.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e15
The Journal of Craniofacial Surgery
Brief Clinical Studies
TABLE 3. Eyelid Region Considered
& Volume 25, Number 1, January 2014
TABLE 4. Histologic Type of Carcinoma Involved
Eyelid
Frequency
Valid Rate
Cumulative Rate
Right Left
91 82
52.6 47.4
52.6 100.0
patient’s age. The vertical, horizontal, and depth dimensions of the eyelid injury or defect must be determined, and availability of regional and distant tissue for reconstruction must be evaluated. A graded approach consisting of direct approximation, horizontally oriented advancement flaps, rotation flaps and free skin grafts, in that order, depending on the defect, should give good results in all cases.20 Flaps are usually preferred over grafts because homogeneity of skin color and texture more likely leads to better unification with surrounding tissue.21 Various types of flaps can be fashioned in the periocular tissues. Reconstructive options regarding flaps range from local flaps to distant free flaps. In particular, while skin and skin-muscle flaps are commonly used, tarsoconjunctival flaps are useful in reconstruction of the posterior lamella.15 For reconstructing defects that include 25% to 50% of the upper or lower lid, a Tenzel semicircular advancement flap can be used. For defects that involve more than 50% of the lid margin of the lower eyelid, a Hughes tarsoconjunctival flap with a full-thickness skin graft or a Mustarde cheek rotational flap with a posterior lamellar graft can be used. Defects greater than 50% of the upper lid may use a Cutler-Beard pedicle or Leone flap.2,22 However, although there are advantages in using flaps as compared with a free skin graft for anterior lamellar, the reconstruction of the upper eyelid skin is best replaced by thin skin grafts, preferably taken from the contralateral upper eyelid. Even though flaps from the preseptal upper eyelid skin may be advanced into marginal defects, the use of thicker periocular flaps is inadvisable as they are bulky, and the levator may not be able to lift the resultant bulky eyelid.23 When using free grafts, a vascular source must be provided by either the anterior or posterior lamella. The anterior lamella is best reconstructed by transferring neighboring tissue. Full-thickness skin grafts from the upper lid, inner upper arm, retroauricular, or supraclavicular may be used if there is insufficient adjacent tissue.
Histologic Type
Cases of Relapse
Minimum Time Free From Cancer, mo
Maximum Time Free From Cancer, mo
Medium Rate, mo
17 3
1 1
73 7
14.94 3.66
1
57
57
57
5
2
18
6
1
10
10
10
Basal cell carcinoma Squamous cell carcinoma Basosquamous cell carcinoma Others types of carcinomas Lentigo maligna and melanoma
Defects involving the posterior lamella can be restored using grafts from the hard palate, nasal chondromucosa, upper tarsus (pedicle based or free), or ear cartilage.23 It is important that free grafts replacing the anterior lamella must not be placed upon a free graft reconstructing the posterior lamella and vice versa, because of the lack of a vascular supply. So, an orbicularis advancement flap can be interposed between 2 free grafts with success.3,24 Finally, healing by secondary intention is a viable option when the defect is confined to the medial canthus region. Small defects (G1 cm) in this concave area heal well by secondary intention, but involvement of the lacrimal apparatus requires primary reconstruction. Small defects of the upper eyelid (G5 mm) that do not involve the lid margin or the canthus can be similarly allowed to heal without reconstruction. However, globe protection requires appropriate coverage by the eyelids and adequate tear lubrication. So, all other defects of the eyelid that may lead to secondary complications if not repaired should be repaired. These complications may include lid notching, epiphora, corneal exposure, and lagophthalmos.25
CONCLUSIONS The reconstruction of eyelid defects can range from a simple repair to the integration of multiple procedures to restore functional anatomy to the periorbital region. Eyelids must be reconstructed to TABLE 5. Cox Algorithm That Shows Which Variables Have Been Significant P
Variables Histopathologic type Primary carcinoma/relapse Demolition surgery Reconstructive surgery
0.0195 0.0020 0.0008 0.0096
FIGURE 5. Eyelid cancer anatomic place considered.
TABLE 6. Time of Relapse After Demolitive Surgery
Surgery
FIGURE 6. Eyelid cancer: percentage of relapse.
e16
Excision Excision with medial cantholysis Excision with lateral cantholysis Exenteratio orbitae
Cases
Minimum Time Free From Cancer, mo
Maximum Time Free From Cancer, mo
Medium Rate, mo
167 2
0 1
85 76
38.0 38.5
3
2
13
5.6
1
0
0
0
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
TABLE 7. Time of Relapse After Reconstructive Surgery
Reconstruction Cases Simple suture Flap Graft
131 35 7
Minimum Time Free Maximum Time Free From Cancer, mo From Cancer, mo 1 0 7
85 80 77
Medium Rate, mo 39.7 28.7 33.4
ensure globe protection and adequate tear lubrication, to prevent ectropion and lagophthalmos, and to restore a normal appearance to the eyes and face of the patient, without compromising the oncologic radicality. We believe that it is important to follow a systematic approach to eyelid reconstruction as well as recreating a natural aesthetic appearance.
REFERENCES 1. Abdi U, Tyagi N, Maheshwari V, et al. Tumours of eyelid: a clinicopathologic study. J Indian Med Assoc 1996;94:405Y409, 416, 418 2. Hayano SM, Whipple KM, Korn BS, et al. Principles of periocular reconstruction following excision of cutaneous malignancy. J Skin Cancer 2012:438Y502 3. Paridaens D, van den Bosch WA. Orbicularis muscle advancement flap combined with free posterior and anterior lamellar grafts: a 1-stage sandwich technique for eyelid reconstruction. Ophthalmology 2008; 115:189Y194 4. Amoaku WM, Bagegni A, Logan WC, et al. Orbital infiltration by eyelid skin carcinoma. Int Ophthalmol 1990;14:285Y294 5. Glover AT, Grove AS Jr. Orbital invasion by malignant eyelid tumors. Ophthal Plast Reconstr Surg 1989;5:1Y12 6. Lindgren G, Diffey BL, Larko O. Basal cell carcinoma of the eyelids and solar ultraviolet radiation exposure. Br J Ophthalmol 1998;82:1412Y1415 7. Howard GR, Nerad JA, Carter KD, et al. Clinical characteristics associated with orbital invasion of cutaneous basal cell and squamous cell tumors of the eyelid. Am J Ophthalmol 1992;113:123Y133 8. Salomon J, Bieniek A, Baran E, et al. Basal cell carcinoma on the eyelids: own experience. Dermatol Surg 2004;30:257Y263 9. Park AJ, Strick M, Watson JD. Basal cell carcinomas: do they need to be followed up? J Royal Coll Surg 1994:109Y111 10. Donaldson MJ, Sullivan TJ, Whitehead KJ, et al. Squamous cell carcinoma of the eyelids. Br J Ophthalmol 2002;86:1161Y1165 11. Callahan EF, Appert DL, Roenigk RK, et al. Sebaceous carcinoma of the eyelid: a review of 14 cases. Dermatol Surg 2004;30:1164Y1168 12. Shields JA, Demirci H, Marr BP, et al. Sebaceous carcinoma of the eyelids: personal experience with 60 cases. Ophthalmology 2004;111:2151Y2157 13. Breslow A. Thickness, cross-sectional areas and depth of invasion in prognosis of cutaneous melanoma. Ann Surg Oncol 1970:172Y176 14. Hamada S, Kersey T, Thaller VT. Eyelid basal cell carcinoma: non-Mohs excision, repair, and outcome. Br J Ophthalmol 2005;89:992Y994 15. Levin PS, Ellis DS, Stewart WB. Orbital exenteration: the reconstructive ladder. Ophthal Plast Reconstr Surg 1991:84Y92 16. Saito A, Saito N, Furukawa H, et al. Reconstruction of periorbital defects following malignant tumour excision: a report of 50 cases. J Plast Reconstr Aesthet Surg 2012:65:665Y670 17. Guerrissi J. Surgical reconstruction of the palpebral border: upper lid eyebrow-musculocutaneous island flap. Plast Reconst Surg 2005; 115:1118Y1123 18. Hintschich C. Periocular plastic surgery. Dtsch Arztebl Int 107:141Y146 19. Mathijssen IM, van der Meulen JC. Guidelines for reconstruction of the eyelids and canthal regions. J Plast Reconstr Aesthet Surg 2010; 63:1420Y1433 20. Harris GJ, Garcia GH. Advancement flaps for large defects of the eyebrow, glabella, forehead, and temple. Ophthal Plast Reconstr Surg 2002;18:138Y145
Brief Clinical Studies
21. Fogagnolo P, Colletti G, Valassina D, et al. Partial and total lower lid reconstruction: our experience with 41 cases. Ophthalmologica 228:239Y243 22. Subramanian N. Reconstructions of eyelid defects. Indian J Plast Surg 44:5Y13 23. Inchingolo F, Tatullo M, Abenavoli FM, et al. Upper eyelid reconstruction: a short report of an eyelid defect following a thermal burn. Head Face Med 2009;5:26 24. Menon NG, Girotto JA, Goldberg NH, et al. Orbital reconstruction after exenteration: use of a transorbital temporal muscle flap. Ann Plast Surg 2003;50:38Y42 25. Frey M, Giovanoli P, Tzou CH, et al. Dynamic reconstruction of eye closure by muscle transposition or functional muscle transplantation in facial palsy. Plast Reconstr Surg 2004;114:865Y875
A Rare Remote Epidural Hematoma Secondary to Decompressive Craniectomy Gang-Zhu Xu, PhD,*Þ Mao-De Wang, PhD,* Kai-Ge Liu, PhD,Þ Yin-An Bai, MDÞ Abstract: Remote epidural hematoma (REDH) is an uncommon complication of decompressive craniectomy. Remote epidural hematomas of the parietal occiput region have been reported only rarely. We report a unique case of delayed-onset bilateral extensive straddle postsagittal sinus and bilateral lateral sinus parietal occiput REDH after decompressive craniectomy, of which volume was approximately 130 mL, with left deviating midline structures. The patient was immediately taken back to the operating room for evacuation of the REDH via bilateral parietal and occiput craniectomy. Postoperatively, serial computed tomographic scans performed 3 days later showed that the REDH had been completely evacuated. Two months later, the patient regained full consciousness and obtained a near-complete recovery except for right facial paralysis. Key Words: Acute subdural hematoma, craniectomy, epidural hematoma, remote, postoperative hemorrhage
D
ecompressive craniectomy (DC) is an effective measure to treat the brain hernia and refractory intracranial hypertension that are induced by acute subdural hematoma (ASDH).1 More than half of all patients with severe traumatic brain injury who undergo DC will experience 1 or more related complications.2 One uncommon complication of DC is remote epidural hematoma (REDH).3,4 Although most reported cases of remote hematomas after DC have been of contralateral epidural hematomas (EDHs), REDHs of the parietal From the Departments of *Neurosurgery, First Affiliated Hospital, Medican College of Xi’an Jiaotong University; and †Neurosurgery, Neurosurgery, Affiliated Hospital of Xi’an Medical University, Shaanxi, China. Received March 29, 2013. Accepted for publication June 23, 2013. Address correspondence and reprint requests to Gang-Zhu Xu, PhD, Department of Neurosurgery, First Affiliated Hospital, Medical College of Xi’an Jiaotong University, No. 277, Yanta West Rd, Xi’an 710061, Shaanxi, China; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3182a2ed26
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e17
& Volume 25, Number 1, January 2014
FIGURE 1. AYC, A 32-year-old woman who had a blunt trauma to her left eyeball. Axial CT images (A and B) show medial (arrow) and lateral (arrowhead) orbital wall fracture and associated retrobulbar hemorrhage and hemosinus in the left ethmoid sinus, and because of extensive pneumatization of the sphenoid sinus, the lateral orbital wall is unusually thin (B, asterisk), which leads to a blow-out fracture. Oblique coronal reconstructed CT image (C) shows an outwardly displaced lateral orbital wall fracture (arrowhead).
Pure blow-out fracture of the lateral orbital wall has not been reported in the medical literature. We believe that the inferior or medial orbital wall is more prone to fractures rather than the lateral orbital wall. As the inferior or medial orbital wall is adjacent to the sinuses, such as the maxillary or ethmoid sinus, it is much thinner than any other part of the orbital wall. The lateral orbital wall is also more solid because it is bounded by relatively thick sphenoid bone and muscle. The reported lateral orbital wall fractures were caused by the ‘‘blow-in’’ mechanism rather than by the ‘‘blow-out’’ mechanism. Orbital blow-in fracture results from a direct blunt force applied to the orbital plate of the greater sphenoid wing and that leads to the inward displacement of the orbital rim or wall, thus resulting in decreased orbital volume.5 In this patient, the fractured segment of the lateral orbital wall was outwardly displaced, and intraorbital fat was herniated into the pneumatized sphenoid bone through the bone defect. There was an accompanying medial orbital wall fracture, without impacted orbital rim fracture. These findings are highly suggestive that orbital wall fractures are caused by a blow-out mechanism. The patient in this case had extensive pneumatization of the sphenoid sinus and the air extended into the lateral orbital wall. The degree of pneumatization of the sphenoid sinus can be considerably variable. Pneumatization in the greater sphenoidal wing has been observed in 10.7% to 20% of the cases presented in previous reports.6Y8 Based on these previous studies, pneumatization of the greater wing of the sphenoid does not seem to be extremely rare. Extensive pneumatization in the greater sphenoidal wing may make the lateral orbital wall much thinner unusually, being more vulnerable to a sudden increase in intraorbital pressure. To the best of our knowledge, this is the first case report of a lateral orbital wall fracture occurring as a blow-out mechanism. We believe that the lateral orbital wall can be fractured as part of a blow-out fracture in patients with extensive pneumatization in the lateral orbital wall. Therefore, in such cases, physicians must be concerned regarding not only inferior or medial wall fractures but also lateral orbital wall fractures in patients with blunt eyeball trauma.
REFERENCES 1. Smith B, Regan WF. Blow-out fracture of the orbit; mechanism and correction of internal orbital fracture. Am J Ophthalmol 1957; 44:733Y739 2. Waterhouse N, Lyne J, Urdang M, et al. An investigation into the mechanism of orbital blowout fractures. Br J Plast Surg 1999;52:607Y612 3. Jones DE, Evans JN. ‘‘Blow-out’’ fractures of the orbit: an investigation into their anatomical basis. J Laryngol Otol 1967; 81:1109Y1120 4. Curtin HD, Wolfe P, Schramm V. Orbital roof blow-out fractures. AJR Am J Roentgenol 1982;139:969Y972
Brief Clinical Studies
5. Chirico PA, Mirvis SE, Kelman SE, et al. Orbital ‘‘blow-in’’ fractures: clinical and CT features. J Comput Assist Tomogr 1989;13:1017Y1022 6. Hewaidi G, Omami G. Anatomic variation of sphenoid sinus and related structures in Libyan population: CT scan study. Libyan J Med 2008;3:128Y133 7. Earwaker J. Anatomic variants in sinonasal CT. Radiographics 1993;13:381Y415 8. Hamid O, El Fiky L, Hassan O, et al. Anatomic variations of the sphenoid sinus and their impact on trans-sphenoid pituitary surgery. Skull Base 2008;18:9Y15
Eyelid Reconstruction Following Excision of Cutaneous Malignancy Ilaria Zollino, MD,* Carlo Riberti, MD,Þ Marco Candiani, MD,Þ Valentina Candotto, MD,* Francesco Carinci, MD* Purpose: With advancing age, cutaneous malignancy around the eye becomes more prevalent. Different kinds of malignant tumors of the eyelid have features particular to their subtype, and a diagnosis should be obtained before definitive treatment if possible. The aim of treatment is total tumor eradication with the smallest recurrence risk, using the most cost-effective method that is acceptable to the patient. Reconstruction of periocular defects following excision of eyelid malignancy can present difficulties, and various reconstructive procedures can be applied. Methods: The retrospective study carried out has analyzed 173 patients submitted to surgery for skin cancers located in the eyelid region with particular reference to the period January 2005 to January 2012. We analyzed certain data (age, sex, histological types, affected portion of eyelid, incidence recurrence by histological type, incidence recurrent tumors previously treated by surgery [secondary], type of removal, type of reconstruction, and mean time elapsed between the demolitive act and disease recurrence) both individually and in correlation with each other. Multivariate analysis (Cox algorithm) was used to identify those variables that had a clear statistical significance. Results: Melanoma and lentigo maligna have the highest tendency to relapse (33%), but squamous cell carcinoma has more rapid replicative capacity. Conclusions: Extensive demolition should always be followed by extensive reconstruction. Even through intervention with an extensive demolition in cases of large tumors in the eyelid and cantus,
From the Departments of *Maxillofacial Surgery and †Plastic and Reconstructive Surgery, University of Ferrara, Ferrara, Italy. Received March 28, 2013. Accepted for publication June 23, 2013. Address correspondence and reprint requests to Francesco Carinci, MD, Department of DMCCC, Section of Maxillofacial and Plastic Surgery, University of Ferrara, Corso Giovecca 203, 44100 Ferrara, Italy; E-mail: [email protected] This study was supported by a grant from FAR (to F.C.), University of Ferrara, Italy. The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3182a2ed04
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e13
Brief Clinical Studies
The Journal of Craniofacial Surgery
it has not been possible to avoid the recurrence of the disease. The average time of recurrence when compared with reconstruction varies between 28 (minimum) and 39 months (maximum). Key Words: Eyelid, reconstruction, excision, cutaneous malignancy
W
ith advancing age, cutaneous malignancy around the eye becomes more prevalent.1,2 Different kinds of malignant tumors of the eyelid have features particular to their subtype, and a diagnosis should be obtained before definitive treatment if possible.3 The most common skin cancers that present in the periocular region are basal cell carcinoma, squamous cell carcinoma, sebaceous cell carcinoma, and malignant melanoma.1,2 Basal cell carcinomas constitute 80% to 90% of all malignant tumors situated on the eyelids.4Y6 Basal cell manifests itself in middle age as a result of the cumulative effect of years of exposure to sunlight. The most commonly affected sites are the lower eyelid and medial canthus.6Y8 Morpheaform basal cell cancers demonstrate substantial infiltration into the subcutaneous tissues and should therefore be treated more aggressively than simple nodular or nodular ulcerative basal cell cancers because of risk of intracranial extension, spread to the lacrimal sac, and evidence of cranial nerve, conjunctiva, or globe invasion. Studies report that positive microscopic margins following excision of basal cell carcinomas are associated with local recurrence rates between 34% and 50%.9 Squamous cell carcinomas are the second most common malignant lesion of the eyelids, accounting for 5% to 10% of all eyelid malignancies10 and occurring on the lid margins, not uncommonly on the inner conjunctival layer. Squamous cell cancers of the eyelids require a minimum of a 5-mm margin and often require complete lid resection for larger or ulcerated lesions.3 Sebaceous carcinoma of the eyelid is a rare malignant tumor that arises from the meibomian glands and accounting for between 1% and 5% of all of malignant epithelial tumors of the eyelids.11 This tumor is more prevalent among older adults and females and has a propensity for the upper eyelid.12 It has usually been present for several months before diagnosis, and it is often misdiagnosed initially as a recurrent chalazion or blepharoconjunctivitis. Sebaceous carcinomas are aggressive tumors associated with distant metastasis and poor prognosis.3 The final major category for cutaneous malignancies involving the eyelids is malignant melanoma. Melanoma of the eyelids may occur as a primary cutaneous tumor or as a direct extension of a conjunctival melanoma. The histological classifications include lentigo maligna melanoma, superficial spreading melanoma, and nodular melanoma. Nodular melanoma is usually associated with the deepest extension on Breslow classification and tends to be the most aggressive with the worst prognosis.13 Conjunctival involvement should be determined because curative resection may necessitate an orbital exenteration. Preoperative evaluation includes a full metastatic workup. Lymphatic spread to the neck requires en bloc resection with superficial parotidectomy and neck dissection.3 Although the mortality from eyelid skin cancer is very low, the morbidity is significant.10 The aim of treatment is total tumor eradication with the smallest recurrence risk, using the most costeffective method that is acceptable to the patient.14 Reconstruction of periocular defects following excision of eyelid malignancy can present difficulties, and various reconstructive procedures can be applied. So, in evaluating reconstructive demands for eyelid reconstruction, an in-depth knowledge of the anatomy is an absolute prerequisite for success. A poorly performed reconstruction or the injudicious selection of a technique may be harmful for the eye and may necessitate further surgical correction.
e14
& Volume 25, Number 1, January 2014
MATERIALS AND METHODS The retrospective study carried out has analyzed the cases treated at the Institute of Reconstructive Plastic Surgery of the University Hospital of Ferrara, Sant’Anna, with particular reference to the period January 2005 to January 2012. The 173 patients considered were submitted to surgery for skin cancers located in the eyelid region. Most of our cases were diagnosed early, and so they benefited from conservation interventions performed under local anesthesia. The remainder has required complex reconstructive solutions under local anesthesia or general anesthetic.
Statistical Analysis Particular interest has been devoted to the analysis of certain data because they were considered a possible subject for statistical analysis. In particular, we have analyzed age; gender; histological types (basal cell carcinoma, squamous cell carcinoma, basosquamous cell carcinoma, Merkel carcinoma, tricoepithelioma, intraepidermal carcinoma such as Bowen disease, infiltrating ductal carcinoma, sebaceous epithelioma, capillary hemangioma, proliferating pilomatricoma, keratoacanthoma, eccrine poroma, porocarcinoma, infundibular keratosis, schwannoma, apocrine hidrocystoma, apocrine hydroadenoma, basaloid follicular hamartoma, lentigo maligna, and melanoma) (Figs. 1Y3); portion affected eyelid (eyelid left, right, top, bottom, inner canthus, outer canthus); incidence recurrence by histological type; incidence recurrent tumors previously treated by surgery (secondary); type of demolition (excision, internal cantholysis, external cantholysis, exenteratio orbitae); type of reconstruction (direct suture; flaps: rotation, scroll, frontal, glabellar, island, Mustarde cheek rotational flap, eyebrow, jugal, bilobed; grafts); and mean time elapsed between the demolitive act and disease recurrence. We analyzed the previously mentioned data, therefore, both individually and in correlation with each other. We considered it interesting to investigate a possible interaction between them that would allow us to understand correlation between histological type and disease recurrence; incidence to relapse in the primary tumor compared with a tumor already surgically treated (secondary); correlation between tumor extent and type of demolition; and correlation between the type of demolition and type of reconstruction.
RESULTS Eighty-two of the 173 patients treated were female (a percentage of 47.4%), and 91 were male (a percentage of 52.6%) (Table 1). The age range was from 34 to 96 years with a mean age of 69.6 years (Table 2). Next, we analyzed the histological types involved (Fig. 4). Basal cell carcinoma was found in 130 cases, squamous cell carcinoma in 10 cases, basal-squamous cell carcinoma in 7 cases, other types of malignancy (Merkel carcinoma, tricoepithelioma, intraepidermal carcinoma such as Bowen disease, infiltrating ductal carcinoma, sebaceous epithelioma, capillary hemangioma, proliferating pilomatricoma, keratoacanthoma, eccrine poroma, porocarcinoma, infundibular keratosis, schwannoma, apocrine hidrocystoma, * 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
FIGURE 1. Lower lid epithelioma: excision and reconstruction by cheek advancement flap.
apocrine hydroadenoma, basaloid follicular hamartoma) in 23 cases, and lentigo maligna and melanoma in 3 cases. Subsequently, eyelid portions of interest due to the topographical site were analyzed (right eyelid and left eyelid) (Table 3) and the anatomical portion (upper eyelid, lower, inner canthus, outer canthus) (Fig. 5). Demolition techniques used excision in 167 cases, excision and medial cantholysis in 2 cases, excision and lateral cantholysis in 3 cases, and exenteration orbitae in 1 case. Accordingly, histology in 27 cases (15.6%) required a subsequent enlargement with secondary modeling. Of these, 15 cases (8.7%) had already presented to our observation as recurrent tumors, showing a greater tendency to relapse (40%) after only 5.8 months compared with primary tumors (13%) for which the disease-free interval was up to 15.6 months. Further analysis conducted on tumor histology showed that the melanoma and lentigo maligna have the highest tendency to relapse (33%) (Fig. 6). The average time at onset of recurrence after demolitive surgery was also noted and showed that squamous cell carcinoma histology has more rapid replicative capacity (Table 4). Reconstructive techniques used direct suture in 131 cases; flap (rotation, scroll, island, Mustarde cheek rotational flap, frontal, glabellar, eyebrow, jugal, bilobed) in 35 cases; and graft in 7 cases. There was no occurrence of necrosis of the flaps used, but at most, there was minor pain in distal monopedunculated flaps, especially those of the upper eyelid. We did not see hematoma or infection or major nerve deficit. There was just 1 case of scleral show, which was corrected secondarily. At the end of the study, the multivariate analysis (the algorithm of Cox) was used to identify those variables that had a clear statistical significance (Table 5). It has been possible, finally, to note that, even through intervening with an extensive demolition in cases of large tumors in the
FIGURE 2. Lower lid epithelioma: pentagonal excision and reconstruction by lateral cantholysis and McGregor flap.
Brief Clinical Studies
FIGURE 3. Medial canthus epithelioma: excision and reconstruction by lateral cantholysis, Mustarde rotational flap, and mucosal graft harvested from the vestibule of the lower lip.
TABLE 1. Sex Sex Male Female
Frequency
Valid Rate
Cumulative Rate
91 82
52.6 47.4
100.0 47.4
TABLE 2. Medium Age Minimum Age, y 34
Maximum Age, y
Media, y
SD
96
69.65
13.85
eyelid and cantus, it has not been possible to avoid the recurrence of the disease (Table 6). Extensive demolition should always be followed by extensive reconstruction. The average time of recurrence when compared with reconstruction varies between 28 (minimum) and 39 months (maximum) (Table 7).
DISCUSSION The primary goals of eyelid reconstruction are to allow for detection of recurrent disease, to provide adequate eyelid function and globe protection with the restoration of boundaries between the orbit and surrounding cavities, and to achieve acceptable aesthetic results and outcome.15 Because the eyelid is a layered structure, appropriate layered reconstruction is essential, with the minimization of any postsurgical complications.16 Reconstruction of the eyelid and periorbital area is difficult because of the quality of the tissues in this area, which are thin, very elastic, and mobile, whereas the tissues of areas closer to the orbita, which are generally used for reconstruction, are thick and stiff.17 Eyelid reconstruction is indicated in all but a few instances when defects are present. Partial-thickness defects involve skin and orbicularis, whereas full-thickness defects extend from skin through conjunctiva. So, following tumor removal in the periocular region, reconstruction of the defect requires understanding of the differences and uses of soft tissue flaps and skin grafts.18,19 The exact technique to be used depends on the defect size, location, and the elasticity of the surrounding tissues, which in turn depend on the
FIGURE 4. Eyelid cancer: percentage of histological type on 173 cases.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e15
The Journal of Craniofacial Surgery
Brief Clinical Studies
TABLE 3. Eyelid Region Considered
& Volume 25, Number 1, January 2014
TABLE 4. Histologic Type of Carcinoma Involved
Eyelid
Frequency
Valid Rate
Cumulative Rate
Right Left
91 82
52.6 47.4
52.6 100.0
patient’s age. The vertical, horizontal, and depth dimensions of the eyelid injury or defect must be determined, and availability of regional and distant tissue for reconstruction must be evaluated. A graded approach consisting of direct approximation, horizontally oriented advancement flaps, rotation flaps and free skin grafts, in that order, depending on the defect, should give good results in all cases.20 Flaps are usually preferred over grafts because homogeneity of skin color and texture more likely leads to better unification with surrounding tissue.21 Various types of flaps can be fashioned in the periocular tissues. Reconstructive options regarding flaps range from local flaps to distant free flaps. In particular, while skin and skin-muscle flaps are commonly used, tarsoconjunctival flaps are useful in reconstruction of the posterior lamella.15 For reconstructing defects that include 25% to 50% of the upper or lower lid, a Tenzel semicircular advancement flap can be used. For defects that involve more than 50% of the lid margin of the lower eyelid, a Hughes tarsoconjunctival flap with a full-thickness skin graft or a Mustarde cheek rotational flap with a posterior lamellar graft can be used. Defects greater than 50% of the upper lid may use a Cutler-Beard pedicle or Leone flap.2,22 However, although there are advantages in using flaps as compared with a free skin graft for anterior lamellar, the reconstruction of the upper eyelid skin is best replaced by thin skin grafts, preferably taken from the contralateral upper eyelid. Even though flaps from the preseptal upper eyelid skin may be advanced into marginal defects, the use of thicker periocular flaps is inadvisable as they are bulky, and the levator may not be able to lift the resultant bulky eyelid.23 When using free grafts, a vascular source must be provided by either the anterior or posterior lamella. The anterior lamella is best reconstructed by transferring neighboring tissue. Full-thickness skin grafts from the upper lid, inner upper arm, retroauricular, or supraclavicular may be used if there is insufficient adjacent tissue.
Histologic Type
Cases of Relapse
Minimum Time Free From Cancer, mo
Maximum Time Free From Cancer, mo
Medium Rate, mo
17 3
1 1
73 7
14.94 3.66
1
57
57
57
5
2
18
6
1
10
10
10
Basal cell carcinoma Squamous cell carcinoma Basosquamous cell carcinoma Others types of carcinomas Lentigo maligna and melanoma
Defects involving the posterior lamella can be restored using grafts from the hard palate, nasal chondromucosa, upper tarsus (pedicle based or free), or ear cartilage.23 It is important that free grafts replacing the anterior lamella must not be placed upon a free graft reconstructing the posterior lamella and vice versa, because of the lack of a vascular supply. So, an orbicularis advancement flap can be interposed between 2 free grafts with success.3,24 Finally, healing by secondary intention is a viable option when the defect is confined to the medial canthus region. Small defects (G1 cm) in this concave area heal well by secondary intention, but involvement of the lacrimal apparatus requires primary reconstruction. Small defects of the upper eyelid (G5 mm) that do not involve the lid margin or the canthus can be similarly allowed to heal without reconstruction. However, globe protection requires appropriate coverage by the eyelids and adequate tear lubrication. So, all other defects of the eyelid that may lead to secondary complications if not repaired should be repaired. These complications may include lid notching, epiphora, corneal exposure, and lagophthalmos.25
CONCLUSIONS The reconstruction of eyelid defects can range from a simple repair to the integration of multiple procedures to restore functional anatomy to the periorbital region. Eyelids must be reconstructed to TABLE 5. Cox Algorithm That Shows Which Variables Have Been Significant P
Variables Histopathologic type Primary carcinoma/relapse Demolition surgery Reconstructive surgery
0.0195 0.0020 0.0008 0.0096
FIGURE 5. Eyelid cancer anatomic place considered.
TABLE 6. Time of Relapse After Demolitive Surgery
Surgery
FIGURE 6. Eyelid cancer: percentage of relapse.
e16
Excision Excision with medial cantholysis Excision with lateral cantholysis Exenteratio orbitae
Cases
Minimum Time Free From Cancer, mo
Maximum Time Free From Cancer, mo
Medium Rate, mo
167 2
0 1
85 76
38.0 38.5
3
2
13
5.6
1
0
0
0
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
TABLE 7. Time of Relapse After Reconstructive Surgery
Reconstruction Cases Simple suture Flap Graft
131 35 7
Minimum Time Free Maximum Time Free From Cancer, mo From Cancer, mo 1 0 7
85 80 77
Medium Rate, mo 39.7 28.7 33.4
ensure globe protection and adequate tear lubrication, to prevent ectropion and lagophthalmos, and to restore a normal appearance to the eyes and face of the patient, without compromising the oncologic radicality. We believe that it is important to follow a systematic approach to eyelid reconstruction as well as recreating a natural aesthetic appearance.
REFERENCES 1. Abdi U, Tyagi N, Maheshwari V, et al. Tumours of eyelid: a clinicopathologic study. J Indian Med Assoc 1996;94:405Y409, 416, 418 2. Hayano SM, Whipple KM, Korn BS, et al. Principles of periocular reconstruction following excision of cutaneous malignancy. J Skin Cancer 2012:438Y502 3. Paridaens D, van den Bosch WA. Orbicularis muscle advancement flap combined with free posterior and anterior lamellar grafts: a 1-stage sandwich technique for eyelid reconstruction. Ophthalmology 2008; 115:189Y194 4. Amoaku WM, Bagegni A, Logan WC, et al. Orbital infiltration by eyelid skin carcinoma. Int Ophthalmol 1990;14:285Y294 5. Glover AT, Grove AS Jr. Orbital invasion by malignant eyelid tumors. Ophthal Plast Reconstr Surg 1989;5:1Y12 6. Lindgren G, Diffey BL, Larko O. Basal cell carcinoma of the eyelids and solar ultraviolet radiation exposure. Br J Ophthalmol 1998;82:1412Y1415 7. Howard GR, Nerad JA, Carter KD, et al. Clinical characteristics associated with orbital invasion of cutaneous basal cell and squamous cell tumors of the eyelid. Am J Ophthalmol 1992;113:123Y133 8. Salomon J, Bieniek A, Baran E, et al. Basal cell carcinoma on the eyelids: own experience. Dermatol Surg 2004;30:257Y263 9. Park AJ, Strick M, Watson JD. Basal cell carcinomas: do they need to be followed up? J Royal Coll Surg 1994:109Y111 10. Donaldson MJ, Sullivan TJ, Whitehead KJ, et al. Squamous cell carcinoma of the eyelids. Br J Ophthalmol 2002;86:1161Y1165 11. Callahan EF, Appert DL, Roenigk RK, et al. Sebaceous carcinoma of the eyelid: a review of 14 cases. Dermatol Surg 2004;30:1164Y1168 12. Shields JA, Demirci H, Marr BP, et al. Sebaceous carcinoma of the eyelids: personal experience with 60 cases. Ophthalmology 2004;111:2151Y2157 13. Breslow A. Thickness, cross-sectional areas and depth of invasion in prognosis of cutaneous melanoma. Ann Surg Oncol 1970:172Y176 14. Hamada S, Kersey T, Thaller VT. Eyelid basal cell carcinoma: non-Mohs excision, repair, and outcome. Br J Ophthalmol 2005;89:992Y994 15. Levin PS, Ellis DS, Stewart WB. Orbital exenteration: the reconstructive ladder. Ophthal Plast Reconstr Surg 1991:84Y92 16. Saito A, Saito N, Furukawa H, et al. Reconstruction of periorbital defects following malignant tumour excision: a report of 50 cases. J Plast Reconstr Aesthet Surg 2012:65:665Y670 17. Guerrissi J. Surgical reconstruction of the palpebral border: upper lid eyebrow-musculocutaneous island flap. Plast Reconst Surg 2005; 115:1118Y1123 18. Hintschich C. Periocular plastic surgery. Dtsch Arztebl Int 107:141Y146 19. Mathijssen IM, van der Meulen JC. Guidelines for reconstruction of the eyelids and canthal regions. J Plast Reconstr Aesthet Surg 2010; 63:1420Y1433 20. Harris GJ, Garcia GH. Advancement flaps for large defects of the eyebrow, glabella, forehead, and temple. Ophthal Plast Reconstr Surg 2002;18:138Y145
Brief Clinical Studies
21. Fogagnolo P, Colletti G, Valassina D, et al. Partial and total lower lid reconstruction: our experience with 41 cases. Ophthalmologica 228:239Y243 22. Subramanian N. Reconstructions of eyelid defects. Indian J Plast Surg 44:5Y13 23. Inchingolo F, Tatullo M, Abenavoli FM, et al. Upper eyelid reconstruction: a short report of an eyelid defect following a thermal burn. Head Face Med 2009;5:26 24. Menon NG, Girotto JA, Goldberg NH, et al. Orbital reconstruction after exenteration: use of a transorbital temporal muscle flap. Ann Plast Surg 2003;50:38Y42 25. Frey M, Giovanoli P, Tzou CH, et al. Dynamic reconstruction of eye closure by muscle transposition or functional muscle transplantation in facial palsy. Plast Reconstr Surg 2004;114:865Y875
A Rare Remote Epidural Hematoma Secondary to Decompressive Craniectomy Gang-Zhu Xu, PhD,*Þ Mao-De Wang, PhD,* Kai-Ge Liu, PhD,Þ Yin-An Bai, MDÞ Abstract: Remote epidural hematoma (REDH) is an uncommon complication of decompressive craniectomy. Remote epidural hematomas of the parietal occiput region have been reported only rarely. We report a unique case of delayed-onset bilateral extensive straddle postsagittal sinus and bilateral lateral sinus parietal occiput REDH after decompressive craniectomy, of which volume was approximately 130 mL, with left deviating midline structures. The patient was immediately taken back to the operating room for evacuation of the REDH via bilateral parietal and occiput craniectomy. Postoperatively, serial computed tomographic scans performed 3 days later showed that the REDH had been completely evacuated. Two months later, the patient regained full consciousness and obtained a near-complete recovery except for right facial paralysis. Key Words: Acute subdural hematoma, craniectomy, epidural hematoma, remote, postoperative hemorrhage
D
ecompressive craniectomy (DC) is an effective measure to treat the brain hernia and refractory intracranial hypertension that are induced by acute subdural hematoma (ASDH).1 More than half of all patients with severe traumatic brain injury who undergo DC will experience 1 or more related complications.2 One uncommon complication of DC is remote epidural hematoma (REDH).3,4 Although most reported cases of remote hematomas after DC have been of contralateral epidural hematomas (EDHs), REDHs of the parietal From the Departments of *Neurosurgery, First Affiliated Hospital, Medican College of Xi’an Jiaotong University; and †Neurosurgery, Neurosurgery, Affiliated Hospital of Xi’an Medical University, Shaanxi, China. Received March 29, 2013. Accepted for publication June 23, 2013. Address correspondence and reprint requests to Gang-Zhu Xu, PhD, Department of Neurosurgery, First Affiliated Hospital, Medical College of Xi’an Jiaotong University, No. 277, Yanta West Rd, Xi’an 710061, Shaanxi, China; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3182a2ed26
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e17
