Vol. 114, No. 4
Letters to The Journal
513
Arnold, M. J., and Frohman, L. A.: Salivary gland neoplasms as a late consequence of head and neck irradiation. Ann. Intern. Med. 87:160, 1977. 3. Roarty, J. D., McLean, I. W., and Zimmerman, L. E.: Incidence of second neoplasms in patients with bilateral retinoblastoma. Ophthalmology 95:1583, 1988. 4. Tanimura, A., Nakamura, Y., Nagayama, K., Tanaka, S., and Hachisuka, H.: Myoepithelioma of the parotid gland. Report of two cases with immunohistochemical technique for S-100 protein and elec tron microscopic observation. Acta Pathol. Jpn. 35:409, 1985. 5. Delbridge, L., Poole, A. G., Ekstein, R., Lim, K., and Posen, S.: Simultaneous presentation of parathy roid, thyroid and parotid tumors 44 years after neck irradiation. Aust. N.Z. J. Surg. 59:187, 1989.
Fig. 2 (Saxe, Grossnikiaus, and Someren). Top, The cytoplasm in occasional tumor cells (arrowhead) stains positive for S-100 protein (peroxidase antiperoxidase, x 160). Bottom left, Tumor cells strongly stain for muscle-specific actin (peroxidase antiperoxidase, x 160). Bottom right, Focal intracytoplasmic-positive staining for low-molecular-weight cytokeratins is present in tumor cells (peroxidase antiperoxidase, X 160). strong evidence to suggest the genetic muta tion, which results in bilateral retinoblastoma and 15% of unilateral cases, is a major factor that causes an increased incidence of second nonocular tumors. 3 Second, it has been well established that radiotherapy of the head and neck initiates neoplastic lesions. 2 These two factors combined with the findings that the latency period for parotid gland lesions varies from five to 35 years 6 and that the mean latency period for the appearance of a second primary tumor in patients with bilateral retinoblastoma is 13 years 3 support the hypothesis. Possibly radiation to tissue genetically predisposed to develop a neoplasm resulted in the malignant myoepithelioma in our case.
References 1. Singh, R., and Cawson, R. A.: Malignant myoepithelial carcinoma (myoepithelioma) arising in a pleomorphic adenoma of the parotid gland. An immunohistochemical study and review of the litera ture. Oral Surg. Oral Med. Oral Pathol. 66:65, 1988. 2. Schneider, A. B., Favus, M. J., Stachura, M. E.,
Periosteal Flap for Lower Eyelid Reconstruction Charles R. Leone, Jr., M.D. Department of Ophthalmology, University of Texas Health Science Center. Inquiries to Charles R. Leone, Jr., M.D., 7950 Floyd Curl Dr., Suite 505, Medical Center Tower 1, San Antonio, TX 78229. When the lateral aspect of the lower eyelid is removed and reapproximation to the lateral rim is impossible, particularly with recurrent tu mors, a method must be used to reconstruct the eyelid. To avoid borrowing tarsoconjunctiva from the upper eyelid, a temporal-zygomatic skin flap lined on the inside by conjunctiva can be mobilized, but the eyelid may lack sufficient support and may sag. I have used a technique in which the reconstructed eyelid was connected to the lateral canthus by using the lateral orbital rim periosteum as a sling and a temporal skin flap. With the periosteal flap technique, after it is determined that the medial end of the resected eyelid cannot be approximated to the lateral canthus, the lateral rim is exposed. Just above the level of the lateral canthal angle, perioste um is incised on the anterior surface in a rectan gular manner with the base at the inner aspect of the lateral rim. The vertical width is at least 5 mm and the horizontal length conforms to the length necessary to reach the eyelid segment, usually 1 cm in length (Fig. 1). This flap is mobilized carefully with sharp and blunt dis section by using the tip of a sharp periosteal
514
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AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 1 (Leone). The lateral orbital rim is exposed and the periosteal flap is incised, 5 mm in width and with the length corresponding to the defect. With the flap hinged on the inner aspect of the rim, it is sutured to the tarsus of the remaining eyelid with 6-0 polyglactin. elevator to s e p a r a t e the p e r i o s t e u m from the b o n e . It is n e c e s s a r y to begin slightly a b o v e the level of the c a n t h a l angle to give a n u p w a r d direction or curve to the lower eyelid. The free e n d of the sling is s u t u r e d to the free eyelid s e g m e n t w i t h i n t e r r u p t e d s u t u r e s of 6-0 p o l y glactin, w h i l e m a k i n g certain t h e r e is e n o u g h t e n s i o n to a p p r o x i m a t e the eyelid s n u g l y to t h e globe. If it is too loose, the p e r i o s t e a l sling s h o u l d be t r i m m e d . To mobilize the skin flap, an incision is m a d e at the c a n t h a l angle t o w a r d the e n d of the b r o w a n d t h e n into the t e m p o r a l is muscle fossa for a p p r o x i m a t e l y 2 to 3 cm (Fig. 2). This flap is u n d e r m i n e d to the level of the inferior aspect of the eyelid r e s e c t i o n to facili tate m e d i a l m o v e m e n t of the skin-flap s e g m e n t . If m o b i l i z a t i o n is difficult, the skin flap can b e e x t e n d e d . The m e d i a l e d g e of the skin flap is s u t u r e d to the eyelid s e g m e n t w i t h i n t e r r u p t e d s u t u r e s of 6-0 polyglactin, a n d the s u p e r i o r e d g e of the flap is s u t u r e d to the p e r i o s t e a l sling w i t h i n t e r r u p t e d s u t u r e s of 6-0 plain catgut w i t h the k n o t s p u l l e d t o w a r d the skin surface. The use of lateral rim p e r i o s t e u m as slings or e x t e n s i o n s for u p p e r a n d lower eyelid r e c o n struction for c o n g e n i t a l a b s e n c e of eyelids 1 or after extensive lateral c a n t h a l excision 2 h a s b e e n described. I have successfully u s e d this t e c h n i q u e in eight p a t i e n t s a n d t h e r e h a s b e e n n o incidence of f o r e i g n - b o d y s e n s a t i o n a n d all p a t i e n t s have h e a l e d w i t h o u t c o m p l i c a t i o n . In the p o s t o p e r a t i v e p e r i o d , the p e r i o s t e u m is e p i thelialized after several m o n t h s . The firmness of the periosteal flap k e e p s the lower eyelid in the d e s i r e d p o s i t i o n a n d m a i n t a i n s the u p w a r d curve, as well as s u p p o r t i n g the eyelid in g e n e r -
Fig. 2 (Leone). The temporal skin flap is extended over the orbital rim with a slightly superior curve and is undermined (oblique lines) to the inferior aspect of the eyelid excision to allow rotation (arrow) into the defect. al. This t e c h n i q u e also o b v i a t e s u s i n g t a r s o c o n junctiva from the u p p e r eyelid, w h i c h m a k e s the p r o c e d u r e less c o m p l i c a t e d a n d r e d u c e s potential morbidity.
References 1. Meltzer, M. A.: Lateral canthal reconstruction with periosteal flaps. In Wesley, R. E. (ed.): Tech niques in Ophthalmic Plastic Surgery. New York, John Wiley & Sons, 1986, pp. 368-370. 2. Leone, C. R.: Lateral canthal reconstruction. Ophthalmology 94:283, 1987.
Correspondence Correspondence concerning recent articles or other mate rial published in THE JOURNAL should be submitted within six weeks of publication. Correspondence must be typed double-spaced, on 8Vi x 11-inch bond paper with IVi-inch margins on all four sides and should be no more than two typewritten pages in length. Every effort will be made to resolve controversies between the correspondents and the authors of the article before publication.
Frosted Branch Angiitis Associated With Cytomegalovirus Retinitis EDITOR: In the article, "Frosted b r a n c h angiitis a s s o ciated w i t h c y t o m e g a l o v i r u s r e t i n i t i s , " b y R. F.
Letters to The Journal
513
Arnold, M. J., and Frohman, L. A.: Salivary gland neoplasms as a late consequence of head and neck irradiation. Ann. Intern. Med. 87:160, 1977. 3. Roarty, J. D., McLean, I. W., and Zimmerman, L. E.: Incidence of second neoplasms in patients with bilateral retinoblastoma. Ophthalmology 95:1583, 1988. 4. Tanimura, A., Nakamura, Y., Nagayama, K., Tanaka, S., and Hachisuka, H.: Myoepithelioma of the parotid gland. Report of two cases with immunohistochemical technique for S-100 protein and elec tron microscopic observation. Acta Pathol. Jpn. 35:409, 1985. 5. Delbridge, L., Poole, A. G., Ekstein, R., Lim, K., and Posen, S.: Simultaneous presentation of parathy roid, thyroid and parotid tumors 44 years after neck irradiation. Aust. N.Z. J. Surg. 59:187, 1989.
Fig. 2 (Saxe, Grossnikiaus, and Someren). Top, The cytoplasm in occasional tumor cells (arrowhead) stains positive for S-100 protein (peroxidase antiperoxidase, x 160). Bottom left, Tumor cells strongly stain for muscle-specific actin (peroxidase antiperoxidase, x 160). Bottom right, Focal intracytoplasmic-positive staining for low-molecular-weight cytokeratins is present in tumor cells (peroxidase antiperoxidase, X 160). strong evidence to suggest the genetic muta tion, which results in bilateral retinoblastoma and 15% of unilateral cases, is a major factor that causes an increased incidence of second nonocular tumors. 3 Second, it has been well established that radiotherapy of the head and neck initiates neoplastic lesions. 2 These two factors combined with the findings that the latency period for parotid gland lesions varies from five to 35 years 6 and that the mean latency period for the appearance of a second primary tumor in patients with bilateral retinoblastoma is 13 years 3 support the hypothesis. Possibly radiation to tissue genetically predisposed to develop a neoplasm resulted in the malignant myoepithelioma in our case.
References 1. Singh, R., and Cawson, R. A.: Malignant myoepithelial carcinoma (myoepithelioma) arising in a pleomorphic adenoma of the parotid gland. An immunohistochemical study and review of the litera ture. Oral Surg. Oral Med. Oral Pathol. 66:65, 1988. 2. Schneider, A. B., Favus, M. J., Stachura, M. E.,
Periosteal Flap for Lower Eyelid Reconstruction Charles R. Leone, Jr., M.D. Department of Ophthalmology, University of Texas Health Science Center. Inquiries to Charles R. Leone, Jr., M.D., 7950 Floyd Curl Dr., Suite 505, Medical Center Tower 1, San Antonio, TX 78229. When the lateral aspect of the lower eyelid is removed and reapproximation to the lateral rim is impossible, particularly with recurrent tu mors, a method must be used to reconstruct the eyelid. To avoid borrowing tarsoconjunctiva from the upper eyelid, a temporal-zygomatic skin flap lined on the inside by conjunctiva can be mobilized, but the eyelid may lack sufficient support and may sag. I have used a technique in which the reconstructed eyelid was connected to the lateral canthus by using the lateral orbital rim periosteum as a sling and a temporal skin flap. With the periosteal flap technique, after it is determined that the medial end of the resected eyelid cannot be approximated to the lateral canthus, the lateral rim is exposed. Just above the level of the lateral canthal angle, perioste um is incised on the anterior surface in a rectan gular manner with the base at the inner aspect of the lateral rim. The vertical width is at least 5 mm and the horizontal length conforms to the length necessary to reach the eyelid segment, usually 1 cm in length (Fig. 1). This flap is mobilized carefully with sharp and blunt dis section by using the tip of a sharp periosteal
514
October, 1992
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 1 (Leone). The lateral orbital rim is exposed and the periosteal flap is incised, 5 mm in width and with the length corresponding to the defect. With the flap hinged on the inner aspect of the rim, it is sutured to the tarsus of the remaining eyelid with 6-0 polyglactin. elevator to s e p a r a t e the p e r i o s t e u m from the b o n e . It is n e c e s s a r y to begin slightly a b o v e the level of the c a n t h a l angle to give a n u p w a r d direction or curve to the lower eyelid. The free e n d of the sling is s u t u r e d to the free eyelid s e g m e n t w i t h i n t e r r u p t e d s u t u r e s of 6-0 p o l y glactin, w h i l e m a k i n g certain t h e r e is e n o u g h t e n s i o n to a p p r o x i m a t e the eyelid s n u g l y to t h e globe. If it is too loose, the p e r i o s t e a l sling s h o u l d be t r i m m e d . To mobilize the skin flap, an incision is m a d e at the c a n t h a l angle t o w a r d the e n d of the b r o w a n d t h e n into the t e m p o r a l is muscle fossa for a p p r o x i m a t e l y 2 to 3 cm (Fig. 2). This flap is u n d e r m i n e d to the level of the inferior aspect of the eyelid r e s e c t i o n to facili tate m e d i a l m o v e m e n t of the skin-flap s e g m e n t . If m o b i l i z a t i o n is difficult, the skin flap can b e e x t e n d e d . The m e d i a l e d g e of the skin flap is s u t u r e d to the eyelid s e g m e n t w i t h i n t e r r u p t e d s u t u r e s of 6-0 polyglactin, a n d the s u p e r i o r e d g e of the flap is s u t u r e d to the p e r i o s t e a l sling w i t h i n t e r r u p t e d s u t u r e s of 6-0 plain catgut w i t h the k n o t s p u l l e d t o w a r d the skin surface. The use of lateral rim p e r i o s t e u m as slings or e x t e n s i o n s for u p p e r a n d lower eyelid r e c o n struction for c o n g e n i t a l a b s e n c e of eyelids 1 or after extensive lateral c a n t h a l excision 2 h a s b e e n described. I have successfully u s e d this t e c h n i q u e in eight p a t i e n t s a n d t h e r e h a s b e e n n o incidence of f o r e i g n - b o d y s e n s a t i o n a n d all p a t i e n t s have h e a l e d w i t h o u t c o m p l i c a t i o n . In the p o s t o p e r a t i v e p e r i o d , the p e r i o s t e u m is e p i thelialized after several m o n t h s . The firmness of the periosteal flap k e e p s the lower eyelid in the d e s i r e d p o s i t i o n a n d m a i n t a i n s the u p w a r d curve, as well as s u p p o r t i n g the eyelid in g e n e r -
Fig. 2 (Leone). The temporal skin flap is extended over the orbital rim with a slightly superior curve and is undermined (oblique lines) to the inferior aspect of the eyelid excision to allow rotation (arrow) into the defect. al. This t e c h n i q u e also o b v i a t e s u s i n g t a r s o c o n junctiva from the u p p e r eyelid, w h i c h m a k e s the p r o c e d u r e less c o m p l i c a t e d a n d r e d u c e s potential morbidity.
References 1. Meltzer, M. A.: Lateral canthal reconstruction with periosteal flaps. In Wesley, R. E. (ed.): Tech niques in Ophthalmic Plastic Surgery. New York, John Wiley & Sons, 1986, pp. 368-370. 2. Leone, C. R.: Lateral canthal reconstruction. Ophthalmology 94:283, 1987.
Correspondence Correspondence concerning recent articles or other mate rial published in THE JOURNAL should be submitted within six weeks of publication. Correspondence must be typed double-spaced, on 8Vi x 11-inch bond paper with IVi-inch margins on all four sides and should be no more than two typewritten pages in length. Every effort will be made to resolve controversies between the correspondents and the authors of the article before publication.
Frosted Branch Angiitis Associated With Cytomegalovirus Retinitis EDITOR: In the article, "Frosted b r a n c h angiitis a s s o ciated w i t h c y t o m e g a l o v i r u s r e t i n i t i s , " b y R. F.
