CASE REPORT

Periorbital Surface Anatomy for the Dermatologist Carrie Lynde, Lara Gunton, Tessa Weinberg, and Christian Murray

Background: Optimal management of skin pathology demands accurate anatomic description, especially In the orbit and periorbital region. Case Report: This brief article reviews the clinically important surface anatomy of the orbit and periorbital region for the dermatologist. Contexte: La prise en charge optimale des affections cutanées exige une connaissance exacte de l'anatomie, en particulier des régions orbitaire et périorbitaire. Exposé de cas: Sera décrite, dans ce court article, I anatomie de la surface des régions orbitaire et périorbitaire, d'importance clinique pour le dermatologue.

T

HE PERLORBITAL REGION is a common location for skin cancer, accounting for approximately 5 to 10% of cases.' The four most common malignant skin cancers arising in the periorbital region, in order of decreasing frequency, include basal cell carcinoma (BCC), squamous cell carcinoma, sebaceous carcinoma, and malignant melanoma.' In addition, the eyelid is a common area that is treated cosmetically by dermatologists with neurotoxins and fillers. The ideal management of cosmetic and medical dermatologie conditions requires both open lines of communication between physicians and an intimate knowledge of periorbital surface anatomy. This terminology is summarized in table format for easy review (Table 1 ) and noted in Figure 1 and Figure 2.

midpupillary line (Figure 3). Superiorly, it extended over the lower lash line almost to the gray line. The defect was slightly larger than the chnical appearance of the original BCC and was confirmed to abut the gray line (Figure 4). The defect was not complex, and the oculoplastic surgeon agreed that it was more practical for the patient to be treated within the Mohs unit with primary closure of the lower half of the defect and a full-thickness skin graft for the superior component, using the lower dog ear. Case 2

From the Division of Dermatology, Women's College Hospital, University of Toronto, Toronto, ON.

An 83-year-old woman was referred to the Mohs unit as "BCCs on the right lower eyelid and cheek." She reported tearing. The lower lid BCC measured 20 mm X 12 mm (Figure 5). The cheek lesion appeared separate and just inferior. Superiorly, the lid lesion extended past the lash margin and the gray line. It encompassed the lower lacrimal punctum. Superiorly and medially, it extended to involve the lacus Iacrimalis and the lacrimal caruncle. The treatment options of radiation and surgery were discussed with her. Surgery was deferred until the patient could consult with an oculoplastic surgeon and understand the possible surgical complications. Following this consultation, Mohs surgery was performed on both BCCs, and the lid defect involved the anticipated locations as noted above (Figure 6). Oculoplastic repair was facilitated for the same day.

Address reprint requests to: Christian Murray, MD, FRCPC, Division of Dermatology, University of Toronto, 76 Grenville, Room 842, Toronto, ON M5S JB2; e-mail: [email protected].

Discussion

Case 1 A 64-year-old woman was referred to the Mohs unit as "BCC of the lower eyelid." No other information was provided. She was booked for Mohs surgery and oculoplastic surgical repair. The tumor was clinically 6 mm in diameter and was centered between the lower eyelid lash line and the inferior orbital crease, just lateral to the

DOI 10.2310/7750.2013.13135 (' 2014 Cattadian Dermatology Association

Dermatologists are skin experts, and this means having a detailed understanding of surface anatomy. The relevant

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Table 1. Anatomic Structures of the Periorbital Region''^ Description

Structure Globe Pupil Iris (pigmented) Limbus Sciera Cornea Conjunctiva Palpebral fissure Medial region of the eye Medial canthus Lacrimal caruncle Medial palpebral commissure Lacus lacrimalis

Lateral region of the eye Lateral canthus Lateral palpebral commissure Eyelids Eyelid Eyelashes (cilia) Tarsal plate Meibomian glands Glands of Moll Glands of Zeiss Superior palpebral sulcus Pretarsal skin Preseptal skin Eyebrow Gray line Lacrimal puncta Infraorbital crease Nasojugal fold/groove (tear trough)

The black circular opening in the center of the iris The colored, ring-shaped membrane behind the cornea The junction of the cornea and the sciera at the peripheral rim of the iris The white outer layer of the globe, continuous with the cornea anteriorly The transparent convex anterior portion of the outer coat of the globe that covers the iris and the pupil. It is continuous with the sciera The mucous membrane covering the anterior portion of the globe that lines the mucosal surface of the eyelids The space between the open eyelids The area around the media commissure overlying several complex anatomic structures, including the medial canthal tendon The small hillock located in the center of the lacus lacrimalis Medial junction of the upper and lower eyelids The triangular space separating the medial ends of the upper and the lower eyelids at the inner canthus where the tears collect. It is an extension of the medial canthus and contains the lacrimal caruncle The area around and lateral to the commissure where the upper and lower eyelids join The lateral junction of the upper and lower eyelids Protective covering of the globe, divided into upper and lower eyelids Hairs that emerge from the lash line adjacent to the eyelid margin in 2-3 irregular rows, where sebaceous (Zeiss) glands and sweat glands (Moll) enter Plates of dense connective tissue that contribute to the eyelid form and support Specialized sebaceous glands lying between the tarsal plate and palpebral conjunctiva Modified apocrine sweat glands located at the distal eyelid margin, anterior to the tarsal plate Specialized sebaceous glands located at the margin of the eyelid. They secrete sebum into the eyelash hair follicles First fold of the upper eyelid that overlies the junction of the levator palpebrae superioris and the orbital septum Skin overlying the tarsal plate Skin inferior to the brow and superior to the superior palpebral sulcus Hair that lies along the anterior aspect of the superior orbital rim Visible along the middle of each lid margin and formed by the gap between the pretarsal tissue; it marks the junction of the skin and the conjunctiva Openings of the lacrimal glands on the medial aspect of the upper and lower lids The first fold of the lower eyelid The angular crease between the nasal sidewall and lower eyelid

anatomic definitions are listed in Table 1, although controversy exists surrounding several terms. It should be noted that some terms, such as nasojugal fold or groove and tear trough, can be confusing and are used interchangeably. The nasojugal groove extends onto the lower cheek. The terms medial and lateral canthus are often used inappropriately instead of medial and lateral commissure.

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By strict definition, the medial commissure is the junction of the upper and lower eyelids, whereas the medial canthus is a region overlying a complex set of converging anatomic structures.^ The periorbital region often requires complex reconstruction to preserve function and achieve cosmesis. Accurate anatomic descriptions facilitate communication

Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 2 (March/April), 2014: pp 141-144

Periorbital Surface Anatomy for the Dermatologists

^ ^ -' ' Eyebrow

Lateral palpebrai commissure

Gray Line

Figure 1. A and By Frontal view of the open eye.

Preseptal skin

Figure 4. Case 1: the defect after Mohs surgery removal of the basal cell carcinoma.

Superior Palpebrai Sulcus

Latera! canthus

Medial canthus

Figure 2. Frontal view of the closed eye.

Figure 5. Case 2, referred as basal cell carcinoma of the right eye and right cheek.

Figure 3. Case 1, referred as basal cell carcinoma of the lower eyelid.

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with patients and between colleagues. This optimizes surgical planning with appropriate involvement of other specialists, such as plastic surgeons or radiation oncologists. Acknowledgment Financial disclosure of authors and reviewers: None reported.

References

Figure 6. Case 2: the defect after Mohs surgery removal of the basal cell carcinomas.

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1. Slutsky IB, Jones EC. Periocular cutaneous malignancies: a review of the literature. Dermatol Surg 2012;38:552-69, doi:10.1111/¡.15244725.2012.02367.x. 2. Tyers AG, Collin JRO. A colour atlas of ophthalmic plastic surgery. 3rd ed. Oxford (UK): Butterworth Heinemann Elsevier; 2008. p. 2-27.

Canadian Dermatology Association I Journal of Cutaneous Medicine and Surgery, Vol 18, No 2 (March/April), 2014: pp 141-144

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Periorbital surface anatomy for the dermatologist.

Optimal management of skin pathology demands accurate anatomic description, especially in the orbit and periorbital region...
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