Cutis Laxa and the Value of Rhytidectomy: 4 Patients and Years of Follow-Up

The modalities of the esthetic treatment of cutis laxa (CL) patients have rarely been discussed. Here, the authors present 4 CL rhytidectomy cases. The surgery method was designed based on the traditional full-incision face-lift technique combined with lamellar superficial musculoaponeurotic system flap elevation and plication. Temporal, buccal, mandibular, and cervical regions were targeted. The shortest follow-up was 30 months, and the longest was 72. The results were assessed by subjective satisfaction and third-party photo evaluation. The subjective satisfaction was graded into worse than preoperation, no improvement, slight improvement, moderate improvement, and obvious improvement. The satisfaction rate was the sum of moderate and obvious improvement. Eighteen uncorrelated professionals participated in the third-party photo evaluation, in which the preoperative and follow-up photos were presented, and frontal, temporal, mid-face (including jowl), and cervical (including mandibular line) regions were evaluated as improved or nonimproved. The outcome of the subjective satisfaction was graded as no improvement (2/12, 16.7%), slight improvement (3/12, 25%), moderate improvement (4/12, 33.3%), and obvious improvement (3/12, 25%). The satisfaction rate was 58.3%, most investigators denied the frontal and temporal region improvement, 60% observed mid-face improvement, and 80% noticed cervical improvement. Most patients and their parents had positive attitudes towards the treatment results; however, the full expectation was not achieved. The cervical region maintained the best improvement after our treatment and the mid-face ranked second. This surgery method conduces to the esthetic requirement of CL patients; however, skin laxity remains a challenge.

The effect of upper eyelid blepharoplasty on eyelid and brow position

This article evaluates the effect of upper eyelid blepharoplasty on eyelid margin position and brow height. This study is a retrospective analysis of patients who underwent upper eyelid blepharoplasty without concurrent blepharoptosis repair or brow surgery. The medical records of the participants were retrospectively reviewed and an established image analysis software was used to quantify the upper margin reflex distance (MRD1) as well as brow height using high quality standardized clinical photographs. A total of 19 patients (38 eyelids and brows) met the inclusion criteria. The mean preoperative MRD1 was 2.8 mm, and the mean post-operative MRD1 was 3.5 mm, revealing an increase of MRD1 from upper blepharoplasty alone of 0.7 mm (p = 0.0001). The mean preoperative brow position was 17.5 mm above the pupil, and the mean post-operative position was 17.4 mm, for an average change of position of -0.2 mm (p = 0.39) following upper eyelid blepharoplasty. Upper eyelid blepharoplasty without ptosis surgery results in a statistically significant increase in MRD1. Brow position does not demonstrate a statistically significant change in patients who undergo upper eyelid blepharoplasty for simple dermatochalasis.

Oculoplastic approach to congenital cutis laxa syndrome

Cutis laxa is a rare congenital or acquired disorder of elastic tissue, characterized by loose skin with folds and multiple internal organ involvement, which may cause life-threatening complications. We present a patient with cutis laxa syndrome who had cross eyelids with esotropia. Bilateral lateral canthal tendon repositioning and bilateral medial rectus recession procedures were performed in a single session. The patient had acceptable eyelid and globe cosmesis after the procedure.

LEVEL OF EVIDENCE IV

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Marked bilateral lower eyelid ectropion in cutis laxa: a paraneoplastic process in multiple myeloma

PURPOSE

To describe a bilateral involutional lower eyelid ectropion in a patient with cutis laxa, a paraneoplastic process in multiple myeloma.

DESIGN

Case report.

RESULTS

A 60-year-old male presented with a marked involutional left lower eyelid ectropion. Systemic history included cutis laxa, a paraneoplastic feature of multiple myeloma. After surgical treatment, the ectropion recurred; furthermore, a right lower eyelid ectropion developed. In addition, a distinct dermatochalasis of both upper eyelids was present.

CONCLUSIONS

This case is the first description of a marked bilateral involutional ectropion in cutis laxa acquisita.

[Fast installation of blepharochalasis]

Blepharochalasis is characterized by recurrent painless oedema of the eyelids leading to alteration of periorbital skin with a nearly complete loss of elastic fibers. It usually affects the upper eyelids bilaterally. An 11-year-old girl suffered from recurrent erythematous swelling episodes during 3 months. The manifestations were confined to the periorbital region. She gradually noticed a bilateral loss of elasticity of the skin of the upper eyelid. The skin showed some folding and laxity. A mild aponeurotic ptosis was present. A skin biopsy showed the absence of elastic fibres. Blepharochalasis is a disease of young people. It has been divided in two hypertrophic and atrophic types. The condition typically follows recurrent painless episodes of oedema infiltrating both upper eyelids. The eyelid oedema usually resolves after several days and recures several times a year.

Association of cutis laxa and genital prolapse: a case report

Cutis laxa (CL) is an extremely inherited or acquired connective tissue disorder characterised by a markedly reduced systemic elastin content. Genital abnormalities in patients with CL have been rarely reported. We report such a case in a 48-year-old CL patient affected by genital prolapse, focusing on immunohistological and molecular biology assessment of elastin and collagen type I, III, VI content in the main uterine ligaments. The woman was referred to our department for the onset of a rapidly progressing genital prolapse and urinary incontinence. The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and sacrocolpopexy. Punch biopsies from both cardinal and uterosacral ligaments revealed a dramatic reduction in elastin and an increase in collagen type VI content. The present report seems to underline the central role exerted primarily by elastin in the supportive connective tissue and might contribute to the knowledge of extracellular matrix abnormalities at the basis of genital abnormalities in CL patients.

Plastisch-chirurgische Korrekturen der Körperform – Rekonstruktion und Ästhetik

Body contouring surgery is traditionally part of plastic surgery training. Reconstructive techniques are needed most in trauma cases, tumor reconstructions, treatment of degenerative diseases and metabolic diseases such as Madelung's deformity, body contouring after massive weight loss, and all aesthetic plastic surgery. With various surgical techniques, liposuction became an important option in the overall treatment plan. Body contouring surgery in the massive weight loss patient is a rapidly expanding field of plastic surgery. Its challenge is the management of excess skin remaining after bariatric surgery. To achieve an aesthetic body contour, patients must accept numerous long scars. They must understand that recurrent laxity and scar migration is not necessarily a failure of the operation but rather an expected outcome. Body contouring surgery is challenging, time-consuming, and not without complications. The patient population has very real aesthetic and appearance concerns that must be addressed in an effective, definite, and safe manner.

Radiosurgery versus carbon dioxide laser for dermatochalasis correction in Asians

BACKGROUND AND OBJECTIVES

Carbon dioxide (CO(2)) laser and radiosurgery are techniques commonly employed in oculoplastic surgery. However, there is no literature comparing their results in blepharoplasty.

STUDY DESIGN/MATERIALS AND METHODS

Twenty Chinese patients with dermatochalasis underwent radiosurgery in one upper eyelid and CO(2) laser in the contralateral eyelid. Intraoperative time, hemorrhage, and pain control were assessed. Subjects were evaluated at postoperative 1 hour, 1 week, 1 month, and 3 months for hemorrhage and wound healing by a masked assessor.

RESULTS

All patients reported minimal pain with either technique. A significantly shorter operative time was achieved with CO(2) laser, with better intraoperative hemostasis. There was no significant difference in postoperative hemorrhage and wound swelling between radiosurgery and CO(2) laser. No significant intraoperative complications were noted.

CONCLUSIONS

Both radiosurgery and CO(2) laser are equally safe and effective for upper lid blepharoplasty. CO(2) laser achieves shorter operative time with superior intraoperative hemostasis.

Cicatricial ectropion: repair with myocutaneous flaps and canthopexy

BACKGROUND

To evaluate the effectiveness of myocutaneous upper eyelid flaps combined with canthopexy to treat cicatricial lower eyelid ectropion.

METHODS

A prospective non-comparative case series undertaken in a private practice setting. Consecutive patients with moderate lower eyelid cicatricial ectropion and upper eyelid dermatochalasis underwent transfer of a bipedicle or monopedicle flap from the upper eyelid combined with canthopexy. The main outcome measures included the occurrence of complications, eyelid position and cosmesis.

RESULTS

Sixty-two consecutive cases of cicatricial ectropion repair using myocutaneous flaps and canthopexy. After a mean follow up of 20 months, 58 (93.5%) of the cases had the lower lid punctum facing posterosuperior into the tear lake, showed lid globe apposition and satisfactory eyelid position. There was mild recurrence of cicatricial ectropion in four patients (6.5%). There were no cases of graft failure or granuloma formation.

CONCLUSION

The use of a myocutaneous flap from the upper eyelid combined with a canthopexy suspension suture for repair of cicatricial ectropion may offer good eyelid position and function. This technique has the advantage of avoiding full thickness blepharotomy and was associated with a low incidence of early recurrence.

[Evaluation of dry eye in the preoperative and postoperative period of blepharoplasty]

PURPOSES

To evaluate the importance of objective examinations in conjunction with ocular history and orbital and periorbital anatomy, to identify patients at risk of developing a post-blepharoplasty dry eye complication.

METHODS

A prospective study was performed on 29 patients with dermatochalasis who were studied before and three months after blepharoplasty. Changes in ocular symptoms, physical examination and in objective tests, like Schirmer's test, tear film break-up time and rose Bengal coloration were evaluated.

RESULTS

No statistically significant alteration in results of objective tests, except Schirmer II test, was found between the pre- and postoperative period. Regarding eyelid anatomy, alterations in palpebral fissure and excursion of the upper eyelid were observed that were statistically significant postoperatively.

CONCLUSIONS

It is possible to state that the palpebral fissure alterations happen frequently in patients submitted to esthetic blepharoplasty. It was also possible to conclude, by this study, that the objective tests for dry eye evaluation, did not show significant alterations postoperatively, except for Schirmer II test.

Bilateral blepharochalasis

Blepharochalasis is a rare disorder characterized by recurrent painless periorbital oedema, which leads to atrophy of the periorbital skin. Pathomechanism of the disease is probably immunological with a nearly complete loss of elastic fibres. The authors describe a 17-year-old woman, who was followed for 7 years. IgA deposits were found in the periorbital tissues, which confirm the immunological background of the condition. Electron microscopy results show that not only elastic but also collagen fibres were affected.

[Eyelid measures before and after upper blepharoplasty--quantitative evaluation]

PURPOSE

To evaluate eyelid measures before and after upper blepharoplasty surgery using a digital image system.

METHODS

Eighteen eyelids of 9 patients with dermatochalasis were evaluated at the Hospital das Clínicas de Botucatu-UNESP regarding eyelid measures before and after upper blepharoplasty. All patients were female, aged between 40 and 75 years. The images were acquired by a photographic camera, transferred to a computer and then analyzed by the Scion Image Frame Grabber program. The evaluated parameters were upper eyelid position in primary gaze position, upper palpebral sulcus and lateral eyelid angle. The measures were obtained before and after 60 days of upper dermatochalasis surgery.

RESULTS

After the surgery, there was an increase of upper eyelid position and upper palpebral sulcus; the lateral palpebral angle did not show any alteration.

CONCLUSION

Eyelid position changes after blepharoplasty and digital image processing provides quantitative measures of the eyelid, allowing a better quantification of the surgical results.

Acquired Lax Eyelid Syndrome

PURPOSE

To describe the demographics, symptoms, and findings of acquired lax eyelid syndrome and to assess the efficacy of the 4-eyelid tarsal strip-periosteal flap technique to treat horizontally lax upper and lower eyelids.

METHODS

A retrospective, case-series review of 80 patients (320 eyelids) evaluated from January 2000 to April 2004 for lax upper and lower eyelids causing chronic irritation was performed. Ten patients with diagnosed floppy eyelid syndrome or obstructive sleep apnea were excluded. Height and weight of all patients were recorded to calculate body mass index. Lateral tarsal strip fixation of all 4 eyelids to periosteal flaps based inside the orbital rim was performed to achieve horizontal tightening. Postoperative follow-up ranged up to 52 months. Preoperative/postoperative symptoms and examination findings of upper and lower eyelid distraction, keratopathy, and conjunctival inflammation were compared.

RESULTS

The most common presenting symptoms were epiphora (85.7%) and irritation (80%). The most common examination findings were upper and lower eyelid horizontal laxity and palpebral conjunctival injection (100% patients). Thirteen of 70 patients (18.6%) were obese, based on body mass index; 26 of 70 patients (37.1%) were mildly overweight; 29 of 70 patients (41.4%) were normal weight; and 2 of 70 patients (2.9%) were underweight. After surgery, 91% of patients had improved or resolved symptoms and signs; 2.5% of dehiscences occurred with the use of the 4-eyelid technique. Gradual continued improvement was observed for up to 1 year.

CONCLUSIONS

Evaluation of patients presenting with chronically irritated eyes should include distraction of both the upper and lower eyelids and examination for conjunctival inflammation. Acquired lax eyelid syndrome is similar to floppy eyelid syndrome; however, 43.3% of patients were normal weight or underweight. The 4-eyelid tarsal strip-periosteal flap fixation is a rapid and effective technique for correction of this syndrome.

Radiosurgery Versus Conventional Surgery for Dermatochalasis

PURPOSE

To compare hemorrhage and wound healing after radiosurgery and conventional surgery for dermatochalasis.

METHODS

We performed a prospective study of 13 patients with dermatochalasis who underwent radiosurgery in one upper eyelid and conventional surgery with scalpel and scissors in the contralateral eyelid. Hemorrhage and wounds were evaluated after surgery the same day, 1 week later, and 3 months after surgery by a masked observer. Hemorrhage was evaluated on a scale from 0 (no hemorrhage) to 4; wounds were evaluated by use of Hollander score, from 0 (poorest outcome) to 6 (best outcome).

RESULTS

We found a tendency toward better wound healing and a higher Hollander score at 1 week after radiosurgery (p=0.014) and no significant differences in wound healing and hemorrhage between radiosurgery and the conventional technique.

CONCLUSIONS

Both radiosurgery and conventional surgery for dermatochalasis showed good results at the 3-month follow-up.

Lax eyelid syndrome or 'progeria' of eyelid tissues

PURPOSE

The lax eyelid syndrome was described by Van den Bosch and Lemij as an uncommon disorder seen in non-obese elderly people and characterised by chronic ocular surface irritation symptoms and a "floppy upper eyelid". The authors present some new features of the lax eyelid syndrome.

METHODS

The authors report five patients, belonging to a younger age group, who presented with premature laxity of all the eyelid tissues. This caused medial and lateral canthal dystopia and eyelid malposition including ptosis, entropion and ectropion. Initial surgical correction was often followed by recurrence after some time.

CONCLUSIONS

The authors highlight the differences between lax eyelid syndrome, cutis laxa, floppy eyelid syndrome and the blepharochalasis syndrome and suggest that lax eyelid syndrome can be thought of as "progeria" or premature ageing of the eyelid tissues to distinguish it clearly from these other conditions.

Lower eyelid dermatochalasis with massive postural herniation of orbital fat

A severe degree of the aging process in the eyelid and orbital soft tissue complex can lead to extreme weakness or even dehiscence of the supporting fascia and other surrounding soft tissue, rarely leading to free mobility of the orbital fat pads and hence postural herniation into the eyelids as seen in this unusual case.

Incidental diagnosis of orbital lymphoma during blepharoplasty

PURPOSE

To describe the incidental diagnosis of orbital lymphoma in 3 patients, in whom unusual findings at the time of blepharoplasty led to the diagnosis of orbital lymphoma.

METHODS

A retrospective review of the medical records of 3 patients.

RESULTS

Two patients presented with bilateral dermatochalasis that obscured the upper visual field and was more prominent on one side. One patient presented with bilateral ptosis and dermatochalasis. All three patients underwent bilateral upper blepharoplasty. In one patient, bilateral ptosis repair was performed in addition to upper blepharoplasty. Blepharoplasty specimens were sent for histopathologic analysis because of the unusual appearance of the preaponeurotic fat at the time of surgery. Histopathology showed low-grade B-cell lymphocytic lymphoma in all three cases. Postoperative CT scan showed a mass in the lacrimal fossa in one patient. None of the patients had evidence of systemic involvement. Two patients were treated with external beam radiotherapy with good results. One patient recently diagnosed with orbital lymphoma was referred to the oncology clinic for further treatment.

CONCLUSIONS

Histopathologic evaluation of blepharoplasty specimens is highly recommended in cases in which the orbital fat has an unusual appearance, color, or consistency at the time of surgery.

A conservative blepharoplasty may be a means of alleviating dry eye symptoms

PURPOSE

Patients with dermatochalasis often complain of dry eye symptoms. In a prospective study, the influence of upper eyelid blepharoplasty on dry eye symptoms, tear film parameters and ocular surface morphology was evaluated.

METHODS

Patients with upper eyelid dermatochalasis were studied before and 3 months after upper eyelid blepharoplasty. Changes in ocular symptoms and physical examinations such as tear film break-up time, Schirmer test without local anaesthesia, impression cytology of the bulbar conjunctiva and inflammatory reaction were recorded.

RESULTS

Subjective dry eye symptoms were found in 11 patients (46%) preoperatively and in five patients (21%) postoperatively. Objective dry eye signs were present in eight patients (33%) before blepharoplasty and in nine patients (38%) 3 months postoperatively. Morphological findings did not change within the observation period. The inflammatory reaction shown by impression cytology decreased postoperatively.

CONCLUSION

Blepharochalasis may be associated with dry eye. Blepharoplasty might be a means of alleviating dry eye symptoms. The reason for this subjective alleviation might be due to reduced inflammatory reaction, changes in blink mechanism or the fact that patients are more confident about their appearance.

[Post-inflammatory cutis laxa. A case report]

Cutis laxa (CL) is a rare disorder in which the skin hangs in loose fields, so that affected individuals appear to be prematurely aged. The changes are more evident when effect the face with a prematurely-aged appearance. The acute form follows an inflammatory skin lesions. Its aetiology is not well known. We report a case of a head acute CL of a 17 years patient, secondary to a generalized skin eruption. The prematurely-aged appearance concern especially forehead, ear lobes and nasolabial folds. A two stages surgical treatment has associated: a forehead lifting associated to a Coleman lipofilling and an ear lobe reduction, a secondary Coleman lipofilling of the nasolabial folds. The skin biopsy confirm the diagnosis. The correction is stable and satisfactory after one year. The confrontation of our findings to those previously described confirm complexity of diagnosis and histological observations of this rare disorder.

A case report of cutis laxa in one of identical twins

A 29-year-old man with cutis laxa presented requesting surgery to improve his appearance. The patient had an unaffected identical twin brother which allowed us to compare how he had changed over the years in relation to his sibling and this also provided us with a gold standard for any surgery performed. The patient underwent staged surgery including upper lid blepharoplasties and two facelifts.

Stretching of the Mueller muscle results in involuntary contraction of the levator muscle

PURPOSE

Since the levator muscle involuntarily and tonically contracts against the weight and elastic resistance of the upper eyelid to maintain an adequate visual field, a mechanoreceptor such as a muscle spindle or a periodontal mechanoreceptor is thought to be essential for its functioning. It was surmised that the Mueller muscle might act as a serial kind of muscle spindle of the levator muscle.

METHODS

The response of the bilateral levator muscles evoked by stretching the Mueller muscle of each eyelid of 87 patients with dermatochalasis or aponeurotic blepharoptosis was electromyographically and photographically recorded.

RESULTS

Stretching of the unilateral Mueller muscle evoked contraction of the ipsilateral levator muscle in 18 and of the bilateral levator muscle in 69 of the 87 patients.

CONCLUSIONS

The Mueller muscle can be thought of as a large, serial kind of muscle spindle, so that stretching by voluntary phasic contraction of the levator muscle for initial eye opening may evoke an afferent impulse to the mesencephalic trigeminal nucleus. Subsequently, this nucleus may stimulate the central caudal nucleus of the oculomotor nuclear complex, leading to involuntary tonic contraction of the ipsilateral or bilateral levator muscles, in the form of a continuous stretch reflex, to maintain an adequate visual field.

Psychosocial implications of blepharoptosis and dermatochalasis

PURPOSE

To investigate, for the first time, the psychosocial implications of blepharoptosis and dermatochalasis.

METHODS

Two hundred ten individuals rated whole-face photographs of a series of patients on the basis of 11 different personal characteristics: intelligence, throat, friendliness, health, trustworthiness, hard work, mental illness, financial success, attractiveness, alcoholism, and happiness. Preoperative and postoperative photographs of both male and female patients with bilateral blepharoptosis and/or dermatochalasis were used. The paired t test was used to compare preoperative and postoperative ratings on the 11 characteristics.

RESULTS

The preoperative photographs were rated more negatively than the postoperative photographs (P < .01-P < .001) on all 11 characteristics for both male and female patients by the 210 study subjects.

CONCLUSIONS

Members of society seem to view individuals with blepharoptosis and dermatochalasis negatively. These psychosocial attitudes may lead to unjust bias toward affected patients, and surgical correction likely provides benefits beyond improved visual function.

The role of plastic surgery in congenital cutis laxa: a 10-year follow-up

The clinical features and the plastic surgery management of a 23-year-old woman with cutis laxa are presented. Two rhytidectomies were performed in this patient within 1 year. The first was associated with a SMAS flap; the second employed a prehairline incision. The evolution of the aging facial appearance 10 years after the last face lift was evaluated and compared with the preoperative situation. Repeated face lifts seem to be an interesting way to manage patients with cutis laxa. Unlike patients with other disorders of the connective tissue, those with cutis laxa have no vascular fragility and heal well. The role of plastic surgery and the clinical features and timing for operation are reviewed and discussed.

Eyelid kinematics following blepharoplasty

PURPOSE

This study characterizes the effects of blepharoplasty on blink dynamics in subjects with dermatochalasis. The authors evaluate the hypothesis that orbicularis oculi removal and the consequent alterations in blink are potentially harmful consequences of blepharoplasty.

METHODS

Sixteen patients were studied, before and after laser blepharoplasty, by a modified scleral search coil technique. Changes in lid position during blinks were recorded before surgery as well as 2 months, and 1 year postoperatively. Off-line analyses assessed blink down-phase amplitude, peak velocity, duration, and main sequence (peak velocity versus amplitude) relationships.

RESULTS

Despite muscle resection, there was no significant compromise of mean blink down-phase amplitude, peak velocity, or main sequence following blepharoplasty. Mean blink duration was likewise unchanged at either follow-up session from the preoperative state. Our data show that upper lid blepharoplasty does not cause any lasting decrement in lid function in blinking.

CONCLUSIONS

Blepharoplasty includes resection of a portion of the orbicularis oculi. It appears unlikely that the purposeful resection of preseptal portion of the orbicularis oculi that accompanies blepharoplasty is responsible for any functional complications such as dry eye.

A new approach for the treatment of recurrent large abdominal hernias: the overlap flap

In this article we report a new technique for the treatment of recurrent large abdominal hernias and skin laxity: the overlap flap. This technique combines abdominoplasty with hernia repair. Obese patients with recurrent large abdominal hernias and skin laxity could benefit from this operation. This operation could not be performed in patients with a wide absence of the abdominal wall. A total of six patients were treated with this technique in our clinic. Follow-up of the patients has ranged from 1 to 4 years. Cosmetic results were excellent in all patients. No recurrence of the hernias has been observed in any of the patients. Two flaps are prepared; the lower one is deepithelialized, and it is used as an autogenous mesh in place of a prosthetic material to reinforce the abdominal wall, and the upper flap is prepared and overlapped on this lower one.

Generalized elastolysis (cutis laxa): case study illustrating associated medical and surgical conditions

Cutis laxa is grouped with the other hyperelastic skin conditions, but it shows almost total lack of skin elasticity. Numerous other medical and surgical conditions may coexist with the skin problem, since it is a generalized affliction of the supporting connective tissues. Our patient had cutis laxa proved by skin biopsy. All surgical procedures were done without any wound complications. He had many associated medical conditions and so served as an excellent opportunity to review the condition of cutis laxa.

Atypical mycobacterial wound infection after blepharoplasty

Images

Menkes' syndrome: wound healing in a long-term survivor

A rare case of a long-term survivor of Menkes' syndrome who was treated early and had excision of bilateral axillary skin excess is presented. Primary wound healing was observed and skin histology showed fragmentation of the elastic fibers. Two years after surgery, the scars appeared atrophic with evidence of early recurrence of the skin excess. The relationship between Menkes' syndrome and the other copper-related syndromes (X-linked cutis laxa, occipital horn syndrome, and Ehlers-Danlos syndrome type 1X) is also described.

Congenital cutis laxa: a case report and review of loose skin syndromes

Congenital cutis laxa is a deforming disease that may present for plastic surgical consultation during childhood. Failure to differentiate cutis laxa, with near normal wound healing, from the other forms of hyperelasticity syndromes with poor wound healing, has historically led to conflicting recommendations regarding the surgical management of patients presenting with loose skin. A face-lift and direct nasolabial fold excision was performed in a 10-year old patient with congenital cutis laxa with a good result. The other major syndromes presenting with loose skin as a clinical feature are reviewed and distinguished from cutis laxa. Plastic surgical procedures can be aesthetically and psychologically beneficial in children with congenital cutis laxa, and can be recommended without overt fear of wound disruption, poor scarring, and medical catastrophies that can occur with other hyperelasticity syndromes.

Dermatochalasis and dry eye

The medical records of 141 patients with dermatochalasis seen during the 32-month period of January 1989 through August 1991 were reviewed. Patients were classified on the basis of symptoms and mode of treatment and were examined for effectiveness of blepharoplasty in ameliorating these symptoms. Seventy-three patients (51.8%) had symptoms similar to those found in keratoconjunctivitis sicca, including mattering, burning, itching, redness, epiphora, foreign-body sensation, and photophobia. Of these 73 patients, 38 (52.1%) underwent upper eyelid blepharoplasty. Subjective improvement in symptoms was achieved in 33 of these patients (86.8%) postoperatively. Upper eyelid blepharoplasty may represent an effective component in the treatment of patients with dermatochalasis and dry-eye symptoms.

Eyebrow loss, eyelash loss, and dermatochalasis

The eyebrows, eyelashes, and eyelids are important protective structures for the eye and are also of considerable cosmetic value. The dermatologist should understand the available cosmetic and surgical techniques for helping patients with eyebrow loss, eyelash loss, and dermatochalasis.

[The aging eyelid]

The ocular adnexal tissues share the progressive loss of tone and bulk, common to many aging tissues. As a result of these progressive involutional changes lid anatomy is altered inducing senile ptosis, ectropions, entropions, canthal laxity and epitheliomas. A better understanding of these conditions allows more appropriate surgical management. Senile ptosis is an acquired ptosis usually due to dehiscence or disinsertion of the levator aponeurosis (below the orbital septum); surgery aims to reattach it to the tarsal plate via either anterior or posterior approach. Senile ectropions and entropions share several aetiologic factors: horizontal laxity, lid retractors, laxity migration of the preseptal orbicularis for senile entropion; stretching of the canthal tendons, secondary skin retraction and conjunctival thickening for senile ectropion. The entropion requires the association of horizontal lid shortening, lower eyelid retractors shortening, skin blepharoplasty with deep sutures (between preseptal and pretarsal orbicularis). In some cases of senile ectropions, the horizontal shortening of the eyelid by a full-thickness pentagon resection with shortening of the lower eyelid retractors must be associated with a medial canthal tendon plication and skin graft.

Primary hereditary systemic amyloidosis (Meretoja's syndrome): clinical features and treatment by plastic surgery

The characteristic, bloodhound-like appearance, which degenerates gradually, of patients with primary hereditary systemic amyloidosis, also called Meretoja's syndrome (MS), is attributable to amyloid degeneration of the craniofacial skin and peripheral facial nerves, but apparently also to amyloid deposits in the muscles; a finding not previously described. A material of five patients treated with plastic surgery is presented, and the peculiarities and differences of this rare disease in comparison with other peripheral neuropathies is discussed from a reconstructive viewpoint.

Blepharochalasis syndrome

Patients with chronic forms of blepharochalasis often develop eyelid deformities characterized by blepharoptosis and prolapse of the orbital fat and lacrimal gland. Some individuals have an acquired form of blepharophimosis, secondary to the dehiscence of the canthal tendons. In this late stage of the condition, the tendons still adhere to the periosteum of the orbital rims and loss of fixation occurs at the distal attachment between the tendons and the eyelid tissues. This results in a horizontally shortened palpebral fissure and a rounded deformity of the lateral canthal angle. Surgery remains the primary treatment.

Granulomatous slack skin

A 39-year-old man had a two-year history of three indurated plaques that progressively underwent a cutis laxa-like transformation. Histopathologically a granulomatous, deep, dermal infiltrate was observed. It was composed mainly of numerous histiocytes and many multinucleate cells and foam cells. The case has the clinical and microscopic features of granulomatous slack skin (GSS), which may be considered to be a peculiar form of localized elastolysis. To date, there is no effective therapy for GSS.

Simultaneous treatment of lower eyelid dermatochalasis and abnormal-appearing skin

Abnormal, thin, crinkly, or pigmented nasal lower eyelid skin is sometimes associated with dermatochalasis (excessive skin). In these cases, excision of temporal lower eyelid skin by conventional cosmetic blepharoplasty draws and diffuses this abnormal skin temporally and worsens the appearance of the lower eyelid skin. A new procedure in which excessive abnormal skin is excised nasally rather than temporally draws and diffuses the more normal temporal skin nasally and improves the appearance of the lower eyelid skin. This approach simultaneously resolved dermatochalasis and abnormal-appearing lower eyelid skin in six eyelids of three patients without complications.

[Surgical treatment of skin changes in cutis laxa (author's transl)]

Cutis laxa is an extremely rare genetic disorder of connective tissue. The striking dermatologic features are loose skin folds and skin laxity. Due to these folds the patients appear to be prematurely aged. Plastic surgery can improve these changes. This treatment is especially indicated in patients with the autosomal dominant type of cutis laxa where internal manifestations do not occur. We report the case of a seventeen years old boy with cutis laxa and surgical therapy.

Unilateral blepharochalasis

True blepharochalasis occurring in young adults and associated with recurrent bouts of eyelid swelling and eventual lid laxity is an uncommon entity. We report the case of an 18-year-old woman who had a nine-year history of unilateral blepharochalasis. A skin biopsy specimen that showed the absence of stainable elastic tissue confirmed the clinical impression, and appropriate surgical correction was carried out.

[Late-onset cutis laxa (generalized elastolysis)]

Cutis laxa is a heterogeneous disease of elastic fibres, divided into three congenital and two acquired forms. Its aetiology is unknown except for the X-linked recessive form. A late form with slow progression in a 52-year-old woman and a probably postinflammatory form in a 29-year-old woman are reported. In both cases histological examination revealed severe damage of the elastic fibres of the skin, in the first one also calcium deposits and (electronmicroscopically) damage to collagen fibres. Treatment is entirely symptomatic, but in severe cases plastic surgery may help cosmetically.

Eye disorders. Treatment of baggy eyelids

Blepharochalasis is a redundancy of the eyelid skin. It may be associated with herniation of orbital fat, and the eyelids may have a baggy appearance. They may become heavy and reduce the visual field. Blepharoplasty, in which the excess skin and fat are removed, can not only improve appearance but can also improve ocular function. The most common serious complication of surgery is overcorrection of the lower eyelids. Skin grafting may be required to repair the resulting ectropion. Since visual compromise is a rare but possible complication, complete preoperative ophthalmologic evaluation is advisable.