Mustardé’s epicanthoplasty







Table 8.1

Indications for surgery







Epicanthus with moderate–severe telecanthus
Staged repair for blepharophimosis syndrome


Table 8.2

Preoperative evaluation













Associated craniofacial syndromes (i.e., Treacher Collins and Crouzon syndromes)
Type and severity of epicanthal fold present
Degree of telecanthus
Other associated findings of blepharophimosis syndrome (ptosis, vertical skin deficiency, ectropion)
History of prior surgeries


Introduction


Mustardé’s technique of epicanthoplasty is indicated for the treatment of epicanthal inversus associated with moderate to severe telecanthus. Mustardé’s epicanthoplasty involves transposition of 4 Z-plasty flaps in conjunction with medial canthal tendon anchoring to the periosteum. In contrast, root Z-epicanthoplasty ( Chapter 7 ) addresses the epicanthus but does not alter the position of the medial canthi. Mustardé’s epicanthoplasty involves longer and more complex incisions and places the tissues under more tension, potentially resulting in higher scar-related complications necessitating a discussion with the patient and family.


Mustardé’s epicanthoplasty is often performed in the setting of blepharophimosis syndrome. The treatment of blepharophimosis syndrome is performed in a staged fashion and is best performed after the age of 2 years. The first step is correction of the epicanthus and telecanthus. If the telecanthus is severe, Mustardé’s soft-tissue fixation of the medial canthus alone may not be sufficient to reduce the telecanthus. In this case, placement of a midline transnasal wire is performed concurrently to powerfully reduce the intercanthal distance and allow for tension-free closure of the Z-plasty flaps. Ptosis correction is performed in the next stage and the type of operation depends on the degree of levator function. Typically, levator function is poor, which often necessitates frontalis suspension ( Chapter 15 ). The next stage is correction of any vertical skin shortage and lateral canthal surgery.




Surgical Technique





Figures 8.1A and 8.1B


Marking of the midline

This is a patient with blepharophimosis syndrome with congenital epicanthal inversus associated with moderate telecanthus ( Figure 8.1A ). A vertical mark is made at the patient’s midline ( Figure 8.1B ).





Figures 8.2A–E


Marking of flap

The desired site (P 1 ) of the new medial canthus is marked at one-half the distance between the midline and the pupillary center ( Figure 8.2A ). This distance is best measured with the patient looking in the distance without convergence. The mark is made in line with both pupils. A horizontal line is then drawn from P 1 to the original canthus P 2 . The paramarginal eyelid arms are then marked for a distance of 2 mm less than the length of (P 1 – P 2 ) ( Figure 8.2B ). Next, the vertical arms are marked, starting at the midpoint between (P 1 – P 2 ), and this subtends a 60° angle with the P 2 arm ( Figure 8.2C ). The length of these vertical arms is also (P 1 – P 2 ) – 2 mm. Finally, the backcut arms are marked with the same arm length as the others but the angle subtended is 45° ( Figure 8.2D ). Figure 8.2E shows the final marking prior to incision.

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May 16, 2019 | Posted by in Reconstructive surgery | Comments Off on Mustardé’s epicanthoplasty
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