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Treatment Lateral Canthal NasalReconstruction Migration A ModifiedofTemplate for Microtia Tested by Surgical Simulation on Ipomoea batatas and Rounding Sir: Sir: ateral canthal nasal migration and rounding occaicrotia reconstruction is a challenge for plastic sionally occurbecause after lateral cossurgeons of its canthoplasties variable clinicaland presenmetic (Fig. 1, above). It has1 Although been my tationblepharoplasties and difficult surgical reconstruction. experience that many methods plastic surgeons treat this by several reconstructive have been proposed, reattaching the with inferior temporal tarsus to the as lateral reconstruction autologous costal cartilage, elaborbital a tarsalbystrip or pexy procedure, with orated wall andwith modified Tanzer, Brent, and Nagata, or without orbital wall drilltoholes. remains thelateral best option with which obtainAlthough favorable lateral canthal tightening strip results with fewertendon complications than and othertarsal reconstruc2 procedures are indicated in some cases, a point is tive options. commonly reached where the lower eyelid is so horThe three-dimensional topography of the external izontally tight that these no longer ear accurately reflects the procedures shape of theare internal cartieffective. Because3 the lower lidanatomical is already and horizonReproducing struclaginous skeleton. tally preoperatively, frequently turaltight details of the externalthis eartechnique is a challenge for any displaces the lower punctum temporally with secondplastic surgeon and requires a high level of surgical skill ary and, with leads to recurrent nasal andepiphora training to fulfill thetime, patient’s expectation. Surgical

migration the lateral canthus. In these cases, a latsimulationof allows development of these skills, reducing eral canthotomy with surgical reconstruction of improving the temporal mistakes, shortening time, and reupper lower is a relatively method 4 Weeyelids performed a surgicalsimple simulation exsults inand vivo. of achievingstudy, a longer horizontal palpebral fissure perimental evaluating traditional and modified and a more acute angle to the lateral canthus. It can auricular templates as guides for carving ear framealso improve temporal peripheral vision that might works on Ipomoea batatas, comparing and analyzing the be compromised obtained results. on abduction of the eye because of theThe lateral canthustemplates covering were the eye in this position traditional based on sheets of of gaze. paper and sketched lines representing the main strucThe usually in thetragus, office tures of procedure the externalis ear (i.e.,performed helix, antihelix, under local anesthesia. Following preparation and antitragus, triangular fossa, scaphoid fossa, and condraping of the eyelids, topical tetracaine is applied over cha) (Fig. 1). The proposed modified templates were the eye and a scleral shield is placed over the eye to probased on paper sheets, with lines representing the main tect it. Then, 2% lidocaine with epinephrine is injected structures and markings detailing the depths of each of subcutaneously and subconjunctivally over the temthese structures as follows: whole painted, striped, and poral upper and lower eyelids and lateral canthus. A unpainted (meaning deep, not deep, and elevated, reWestcott scissors severs the lateral canthus horizontally spectively). The striped lines, at the same time, repreby the distance (in millimeters) that is needed to make sented more depth when drawn (Fig. 1). the horizontal palpebral fissurecloser equaltogether to the opposite

Ipomoea batatas,center). also known sweet normal side (Fig. 1, If bothassides arepotato, in needwas of used because of its similarity in consistency and flexibility to human rib cartilage.5 Each sweet potato model was referred to as an individual case. Five common carving tools with different curves and angles were used to sculpt the models. Eight novel surgeons were tested; half of them used the traditional template and the other half used the modified template. The exercise was repeated twice. The resulting auricular sculptures were evaluated based on aesthetic results, ranked according to resemblance to the real ear model, being classified as poor, fair, or good results. Aesthetically different auricular frameworks were obtained using the two different types of templates. Better definition of three-dimensional structures (i.e., helix, antihelix, tragus, antitragus, scaphoid fossa, triangular fossa, and concha) and better aesthetic results were obtained using the modified template (n  16).

LM

Copyright 2014 by the American American Society Copyright©©2012 by the Society of of Plastic Plastic Surgeons Surgeons

Fig. 1. (Above) Rounding and nasal migration of the lateral canthus. (Center) A Westcott scissors severs the lateral canthus. (Below) Silk sutures (6-0) connect conjunctiva to skin over the temporal upper andand lower eyelids.auricular templates. Fig. 1. Traditional modified

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Plastic and Reconstructive Surgery • February 2015 Allen M. Putterman, M.D.

111 North Wabash, Suite 1722 Chicago, Ill. 60602

DISCLOSURE The author has no financial interest to declare in relation to the content of this article. ACKNOWLEDGMENT This work was supported by an unrestricted grant from Research to Prevent Blindness, New York, N.Y. (EY001792).

Activated Clotting Time Monitoring during Osteocutaneous Free Fibula Flap Surgery Sir:

R

Fig. 2. (Above) Patient with lateral canthal nasal deviation and rounding after having had a ptosis procedure in the upper lid and a tarsal strip procedure of the lower lid to treat horizontal lower lid laxity. (Below) Same patient after horizontal lateral canthal lengthening.

treatment, the distance (in millimeters) is based on the normal horizontal palpebral fissure of 30 to 32  mm. Usually, this amounts to an opening of 2 to 4 mm. Several 6-0 silk sutures are placed in the temporal upper and lower lids, connecting skin to conjunctiva (Fig. 1, below). The internal suture ends are cut on the knot, and the ends pointing away from the eye are cut 2 to 3 mm from the knot. The scleral lens is removed and a topical eye ointment is applied to the lateral canthus. Sutures are usually removed 7 days postoperatively. Although this might not be a new procedure to many surgeons, I find it is one that is commonly overlooked in the treatment of lateral canthal nasal deviation and rounding in patients who have a tight lower lid after previous eyelid surgery. Also, I have observed that patients find this procedure very acceptable, because of its simplicity and the possibility that it can be reversed by reconnecting the temporal eyelids, if necessary. I have performed this procedure on over 75 eyelids with good success (Fig. 2). DOI: 10.1097/PRS.0000000000000902

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outine use of intraoperative systemic heparin during microsurgical reconstruction is not indicated. However, systemic heparinization is used by the microsurgeon in specific cases such as an intraoperative vessel thrombosis or a documented hypercoagulable state.1 Intraoperative monitoring of heparinization with activated clotting time is the criterion standard in vascular and cardiac surgery. Since the 1970s, activated clotting time monitoring has become routine in peripheral vascular surgery, with target levels of 180 to 200 seconds.2 Moreover, in cardiac surgery, routine activated clotting time monitoring during cardiopulmonary bypass is associated with decreased postoperative blood loss.3 Activated clotting time monitoring during microsurgical reconstruction has not been previously reported. In this report, activated clotting time monitoring was used intraoperatively to monitor the effectiveness of systemic heparin in a known hypercoagulable patient undergoing mandibular reconstruction with a free fibula osteocutaneous flap. Activated clotting time monitoring

Fig. 1. Intraoperative photograph demonstrating a 7-cm defect of the left mandibular body and ramus. The soft-tissue defect included the soft palate, retromolar trigone, and floor of mouth.

Treatment of lateral canthal nasal migration and rounding.

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