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Acute Lymphedema of the Eyelid after Major Reconstruction of the Medial Canthus: The Role of the Lymphatic Drainage Pattern

Aveta, Achille M.D.; Tenna, Stefania M.D., Ph.D.; Segreto, Francesco M.S.; Cagli, Barbara M.D.; Brunetti, Beniamino M.D.; Marangi, Giovanni Francesco M.D.; Persichetti, Paolo M.D., Ph.D.

Plastic and Reconstructive Surgery: October 2011 - Volume 128 - Issue 4 - p 370e–372e
doi: 10.1097/PRS.0b013e3182268846

Plastic and Reconstructive Surgery Unit, Campus Bio-Medico University of Rome, Rome, Italy

Correspondence to Dr. Tenna, Department of Plastic and Reconstructive Surgery, Via Alvaro del Portillo 200, 00128 Rome, Italy

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We read with great interest the article by Pan, Le Roux, and Briggs about the variations of the lymphatic drainage pattern of the head and neck.1 The lymphatic system was first described by Gasper Aselli2 in 1627, but it is only in recent years that it has been accurately identified. Because of new techniques in molecular biology and imaging, a detailed characterization has been achieved also in unknown regions such as the orbit.3 We therefore congratulate the authors for their work and would like to add further clinical evidence to their experimental findings by reporting an unusual complication that occurred in a 66-year-old white male patient treated for a recurrent basal cell carcinoma of the upper third of the nasal dorsum involving the left medial canthus. After a wide skin excision (upper two-thirds of the nasal dorsum, medial third of both eyelids, the glabella, and the head of the left eyebrow), the medial canthal tendon, the left nasal bone, the nasal process of the frontal bone, and the medial adipose compartments of the upper and lower eyelids were removed; the frontal sinus was opened; and the lacrimal sac was excised (Fig. 1, left). Reconstruction was achieved by using a right forehead flap and a rotational cheek flap with lateral cantholysis and tarsoconjunctival sliding; an iliac crest graft was used to obliterate the frontal sinus (Fig. 1, right). Ten days later, an acute lymphedema of the left upper eyelid occurred (Fig. 2, left). Lymphedema of the eyelid is an uncommon condition that presents in most cases as a chronic form associated with acne rosacea, irradiation, and ocular surgery.4 According to Pan and colleagues, the lymphatic drainage of the eyelids is conveyed by two major collecting vessels to the outer and inner canthus with, in some cases, one more vessel arising from the middle inferior region of the lower eyelid. In our patient, the medial drainage was interrupted by the radical excision and the lateral path was compromised as a consequence of the rotational cheek flap. In this situation, no compensation was possible and the patient developed lymphedema of the upper eyelid. It is likely that the lower eyelid showed no swelling because of the presence of the previously cited inferior branch or other anastomotic branches. The patient was treated twice, every 5 days, by skin and orbicularis muscle incisions to allow a partial reduction of edema. Multiple manual lymphatic drainage massages were also necessary every other day to obtain resolution of the swelling at 90 days postoperatively (Fig. 2, right). We believe that our case adds clinical evidence to the experimental findings of Pan et al., highlighting the importance of taking into account the paths of lymphatic drainage in the preoperative planning of reconstructive eyelid surgery.

Fig. 1

Fig. 1

Fig. 2

Fig. 2

Achille Aveta, M.D.

Stefania Tenna, M.D., Ph.D.

Francesco Segreto, M.S.

Barbara Cagli, M.D.

Beniamino Brunetti, M.D.

Giovanni Francesco Marangi, M.D.

Paolo Persichetti, M.D., Ph.D.

Plastic and Reconstructive Surgery Unit, Campus Bio-Medico University of Rome, Rome, Italy

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The authors have no commercial associations that might pose or create a conflict of interest with information presented in this communication.

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The patient provided written consent for the use of his images.

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1. Pan WR, Le Roux CM, Briggs CA. Variations in the lymphatic drainage pattern of the head and neck: Further anatomic studies and clinical implications. Plast Reconstr Surg. 2011;127:611–620.
2. Aselli G. De Lactibus Sive Lacteis Venis. Milan, Italy; 1627.
3. Dickinson AJ, Gausas RE. Orbital lymphatics: Do they exist? Eye (Lond.) 2006;20:1145–1148.
4. Chalasani R, McNab A. Chronic lymphedema of the eyelid: Case series. Orbit 2010;29:222–226.
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