CHAPTER

8 PALPEBRAL ANOMALIES

J C van der Meulen

EPICANTHUS

Congenital epicanthal folds are a normal racial characteristic in Asia and the Americas. In the western part of the world they are con­sidered an abnormality. Two explanations can be offered.

The first is laxity of skin over the nasal roof. In support of this are the facts that some of the folds disappear before the age of 6

8.1 Different techniques for correction of epicanthus.

103

years and that obliteration of the folds is observed by insertion of an implant or by pinching up of the nasal skin.

The second is that the folds are caused by an intrinsic shortage of skin, for which evidence can be found in the facts that different types of epicanthal folds have been distinguished and that correc­tion of these can be obtained by redistribution of skin using one of the various methods that have been advocated (8.1).

Blair

Spaeth~

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PALPEBRAL .ANOMAUES

Unfortunately, some of these procedures produce more scar tissue than others because of difficulty in planning the direction of the inci-

sions and consequently the orientation of the scars. Careful selec­tion and execution of the technique is therefore imperative (8.2, 8.3 ).

8.2 Correction of epicanthus. a Design of V-Y plasty. b Result of V-Y advancement. c Preoperative appearance. d Postoperative appearance.

8.3 Correction of epicanthus. a Design of double Z-plasty. b Result of Z-plasty procedure. c Preoperative appearance. d Postoperative appearance.

104

BLEPHAROPHIMOSIS

TELECANTHUS

An increase in width between the medial canthi as a solitary phe­nomenon is rare. The anomaly is one of the characteristics of Waardenburg's syndrome and is a dominant featu re in blepharo­mosis. The normal intercanthal width is almost exactly half of the interpupillary distance, and telecanthus is caused by an abnormal insertion of the medial canthal tendons or by abnormal length of these tendons.

If telecanthus appears to be the only abnormali ty present, it should be distinguished from teleorbitism by careful measurements of the interorbital distance. Since there a re no complicating epi­canthal folds, correction is straightforward and can always be achieved by means of a transnasal canthopexy (8.4, 8.5).

BLEPHAROPHIMOSIS

Blepharophimosis is a rare congenital anomaly. The word phimosis or stenosis refers to the short and narrow, almost slit-like palpebral fissure or meatus, which forms a sharp contrast with the general flatness of the orbital region. This flatness is due to the absence of distinct convexities formed by the nasal roof and orbital roof, or prominent concavities such as a palpebral fold or canthal fossa. The palpebral aperture usually shows an antimongoloid slant, though occasionally the slant is mongoloid.

Epicanthus inversus, telecanthus, and ptosis of the upper eyelid form the tr iad that is most characteristic of this striking anomaly.

However, abnormalities of the lateral canthus and the lower eyelid may also be observed. Closer inspection of the orbital region reveals the signs described below.

UPPER EYELID

A palpebral fold is virtually non-existent and ptosis is always pre­sent. The dimensions of the eyelid are short in every direction. The skin seems to be somewhat thicker than normal, and hirsutism is occasionally observed.

THE MEDIAL CANTHUS

Telecanthus is invariably observed, but the canthal drift is frequently masked by an epicanthal fold, which differs from a simple epican­thus in that its direction is more obliquely oriented. An epicanthus in versus is thus produced, rounding out the commissure, hiding the caruncle, and blending with the medial part of the lower eyel id, where it forms an epiblepharon.

THE LOWER EYELID

In contrast with the medial part of the lid, where an epiblepharon may create the impression of congenital entropion, the lateral half is frequently somewhat everted. Indeed the whole lid has the appear­ance of having shifted somewhat laterally, causing the canaliculi to lengthen, the lacrimal punctum to drift laterally, and the eyelid rim

8.4 Correction of telecanthus by medial canthopexy. a Preoperative appearance. b Postoperative appearance.

® 8.5 Correction of telecanthus by medial canthopexy. a Preoperative appearance. b Postoperative appearance. Note the presence of palpebral folds.

IOS

PALPEBRAL ANOMAUES

to lose contact with the globe. As a result, epiphora may occur. These phenomena can be explained by the uninhibited pull of the orbicu­laris muscle in a lateral direction, made possible by the medial can­thal drift. Shortage of skin, particularly in the lateral part of the lid, and hypoplasia of the orbital septum may also play a role, however.

THE LATERAL CANTHUS

Laxity of the lateral canthus or canthal dystopia is occasionally observed. These contribute to the formation of an antimongoloid slant and to the distortion of the lower lid and shortening of the palpebral fi ssure.

TREATMENT

The birth of a child with blepharophimosis is a traumatic experi­ence for the parents, because the impression of mental retardation is easily created. It often takes some time before this suspicion dis­appears. The anomaly is ra re and few physicians are familiar wi th it. Advice to the parents is frequently confusing or controversia l.

Once treatment is suggested, the surgeon is compelled to confess that complete success can never be guaranteed, because the causative mechanisms of the different abnormalities are still not sufficiently understood. There seem to be skeletal abnormalities, including hypoplasia of the orbital roof and the latera! orbital wall, but three­dimensional CT reconstruction of the orbit has failed to provide evi­dence for this hypothesis, and the impression of enophthalmus even seems to contradict it . The soft tissue abnormalities are, however, better understood, making it possible to improve the static and dynamic conditions in the orbital region to some degree.

Although the similarity of patients with this syndrome is strik­ing, particularly when they belong to the same family, important variations in appearance may be observed. The degree in severity of each of the symptoms may differ, creating a wide spectrum of abnor­mali ties, which becomes even more complex when there is distur­bance of other oculomotor functions, thereby causing underaction of the superior or inferior rectus muscles, exotropia, esotropia, or nystagmus.

Better surgical techniques and the fact that growth of the nasal dorsum and increased activity of t he frontalis muscle will support the surgeon in his efforts justify the view that, with time, substan­tia l improvement can be obtained by correction of the telecanthus first and the ptosis secondarily.

The medial canthus Correction of the canthal drift has priority and it can be achieved only by a transnasal canthopexy. Some surgeon perform this pro­cedure in combination with one of the many techniques t hat can be used to correct an epicanthus. If this approach is preferred, redis­tribution of skin should be achieved with a minimum of incisions to avoid conspicuous scarring. The various methods that may be used are shown in 8.1.

Blairs technique Blair's technique involves the use of one or tvvo unequal Z-plas­ties. It has given good results in our hands (8.6), but we now believe that, in the majority of cases, better results with less scarring can be obtained if no redistribution of skin is performed and all efforts are concentrated on reconstruction of the canthal depression by means of the transnasal canthopexy.

8.6 Correction of epicanthus. a Design of flaps. b Result of transposition. c Preoperative appearance. d Postoperative appearance.

106

BLEPHAROPHIMOSIS

Author's technique This technique is illustrated in 8.7 an d 8.8. A transverse incision is first made over the lax medial canthal tendon. This incision is extended over a small distance into the medial part of the lower eyelid, where the epiblepharon is seen. All the fat and muscle between skin and periosteum in the canthal area are then carefully removed. This step is important because resection of this surplus of tissue allows for accurate and intimate fixation of the skin to the underlying skeleton once a deep canthopexy has been performed in the manner described in Chapter 3.

The canthal depression can thus be reproduced and the need for extensive redistribution of skin is eliminated, because the epicanthal convexity is turned into an endocanthal concavity. The procedure

8.7 Correction of epicanthus and telecanthus by canthopexy. a Design of transverse incision in medial canthal region with lateral extension parallel to the rim of t he eyelid. b Resection of fat in medial cant hal

also tends to correct eversion of the lower eyelid and to narrow the palpebral fissure temporarily.

The lateral canthus Laxity of the lateral canthal insertion or canthal dystopia is best treated by means of a camhopexy.

Canthopexy (see Chapter 3) A short transverse incision is made just lateral to the outer canthus. Through this incision, the lateral orbital wall is first exposed. The periosteum overlying the skeletal rim is then incised in a cranial and caudal direction over some distance allowing for adequate release of the lateral canthus together w ith the periorbita and orbital

region. c Traction on transnasal sut ures in order t o t urn a canthal convexity int o a concavity. d Result of canthopexy and linear closure.

8.8 a Preoperative appearance of a patient w ith blepharophimosis. b Postoperative appearance of a patient on w hom t he author's t echnique w as used.

107

PALPEBRAL ANOMALIES

septum. Once sufficient mobility is obtained, the lateral canthus is raised and a canthopexy is performed in the manner described in Chapter 3 .

The lower eyelid Correction of lower lid eversion is usually obtained by adequate medial and lateral canthopexies. If necessary, transposition of a small laterally based V-flap from the upper to the lower eyelid is used in conjunction with the canthopexies. Eversion may, however, be so extreme that its correction by means of a skin graft is con­sidered. It should be remembered that the colour match of a retroau­ricular graft, although good, never equals the eyelid skin itself.

The upper eyelid Attempts to correct the ptosis by means of one of the various lev­ator shortening procedures are frequently doomed to fail , from a functional point of view, because the levator muscle is almost non­existent or hypoplastic. Nevertheless cosmetic improvement is occa­sionally seen when the tenodesis effect of the procedure results in the restoration of a palpebral fold or the widening of the palpebral fissure.

In the majority of patients however it will be necessary to per­form a frontalis suspension. It is true that the direction of pull by

this muscle is abnormal and that the eyelid initially may even lose its contact with the globe, but definite functional and cosmetic improvement is almost always obtained .

Operative technique The procedure used (8.9) is a personal modification from the many techniques that have been advocated in the past. Two short incisions are first made, one at the site of the upper rim of the tarsus, the other immediately above the eyebrow. A tunnel is then made connecting the two incisions. Through the upper incision the surface of the frontalis is carefully dissected over some distance in all directions.

The inferior edge of the frontalis muscle, beneath the eyebrow, is then incised transversely over a distance of approximately 1.5 em and dissection is continued between the muscle and the periosteum in a cranial direction. A rectangular muscle flap is finally formed by means of two parallel, cranially directed incisions that start at the exposed inferior edge.

The flap thus formed is then pulled through the tunnel and attached to the tarsus by means of several interrupted sutures. The immediate effect may be that the eyelid loses contact with the globe. This rapidly improves, however, owing to the balancing action of the orbicularis muscle (8.10, 8.11).

8.9 Correction of ptosis by frontalis plasty. a Dissection of frontalis muscle f lap. b Delivery of frontalis muscle flap through tunnel. c Preoperative appearance. d Postoperative appearance.

108

BLEPHAROSCHJZIS

BLEPHAROSCHIZIS (COLOBOMA)

The term coloboma refers to full-thickness defects of the eyelids. The anomaly is rare. It can be unilateral or bilateral, and all degrees of severity are seen. The configuration of the defect may be triangular or quadrilateral. The cornea is often exposed, which causes severe risks for normal vision, owing to corneal opacities or ulcerations. These risks are particularly great when the condition involves the centre of the eyelid and normal mobility of the eye is restricted by the presence of tethering bands. Urgent treatment is then indicated.

Colobomas of the eyelid may occur: • As a solitary anomaly. • As part of a syndrome that includes a complex variety of skele­

tal and soft tissue anomalies. These complex colobomas may be typical or atypical for the syn­

drome involved.

TREATMENT OF SOLITARY COLOBOMAS

Solitary colobomas are almost exclusively confined to the central and medial parts of the upper eyelid. The reason for this is not known. The size of these defects can be difficult to estimate because the edges are pulled in opposite directions by the separated parts of the orbicularis muscle. Careful examination under anaesthetic is indicated before the best method of treatment can be selected. For this purpose, the edges of the colobomas are approximated wi th skin hooks to define the true size of the defect. In the colobomas involving less than one-third of the eyelid rim, correction is per­formed by excision of the edges followed by direct apposition of the two segments in separate layers. Since straight line closure may result in considerable contraction, the incorporation of an additional Z-plasty is advocated.

8.10 Correction of severe blepharophimosis by medial canthopexy and frontalis suspension. a Preoperative appearance. b Postoperative appearance.

8.11 Correction of ptosis following adequate canthopexy. a Preoperative appearance. b Postoperative appearance. Note the strong frontalis muscle action.

109

PALPEBRAL ANOMALIES

Colobomas involving one-third or more of the eyelid rim require a different approach. Several principles have been advocated by var­ious authorities, but the technique that seems simplest and most effective is the transfer of a skin flap lined with a mucosal gra ft.

Unfortunately, the selection of flaps is limited, because the integri­ty of the lower eyelid deserves to remain intact and the quantity of available skin in the upper eyelid may be small. Nevertheless restora­tion of the eyelid is feasible in the majority of patients (8.12, 8.13 ).

8.12 a Coloboma of the upper eyelid. b Dissection of edges and closure of conjunctival defect with buccal graft. c Design of transposition f lap. d Resurfacing of buccal graft by transposition of the f lap.

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8.13 a Coloboma of the upper eyelid. b Reconstruction of the eyelid by closure of conjunctiva l defect w ith buccal graft and resurfacing of graft by transposition of flap. Long­term result. Note that the appearance of an eyelid following correction of a co loboma can be improved by secondary resection of a hairless eyelid rim or by 'make-believe' cilia using dermatography.

BLEPHAROSCHJZIS

TREATMENT OF COMPLEX COLOBOMA$

In the correction of complex colobomas, two alternatives based on slightly different principles can be considered (8.14).

The firs t principle concerns the transfer of a composite flap from the latera l part of the upper eyelid to close a defect in the central or medial part. The lateral segment is first mobilized by a cantho­tomy and then transferred in conjunction with a temporal exten­sion. This transfer is facilitated by the inclusion of a Z-plasty in the extended skin incision . Closure of the conjunctival defect that has been produced by the canthotomy may require the insertion o f a mucosal graft. The straight line closure of the coloboma may demand incorporation of a Z-plasty to prevent or correct contrac­ture.

The second principle concerns the transfer of a semicircular or semiquadrilateral skin flap raised in the lateral part of the eyelid and the palpebrotemporal area. Medial rotation of the flap is facilitat­ed by the inclusion of a Z-plasty in the lateral extension of the inci-

8.14 Principles for closure of complex coloboma. a Medial transposition of latera l eyelid segment using a lateral canthotomy and closure of the resulting conjunctival defect w ith a mucosal graft. The rotation is f acilitated by t he incorporation of a Z-plasty. (A 1 and A2 show closure of a coloboma in the upper eyelid; A3 and A4 show closure of co loboma in the lower eye lid.)

sion. The coloboma is first closed with a mucosal graft , inserted under some tension, and the skin flap is then used to cover the graft.

Complex colobomas a re usua lly associated with an underlying skeletal anomaly or cleft. These clefts were described and numbered by Tess ier. Circling the orbit in different degrees of severity a dis­tinct pattern can be observed.

An explanation for this was offered by van der Meulen et al. , who postulated that the skeletal anomalies have their origin in dysostoses of the various ossification centres, resulting in typical ho urglass deformities of the soft tissues (hairline, eyebrow, and eyelids). The size of the associated eyelid colobomas may be of such magnitude that more extensive transfers of tissue involving adjacent areas of skin are involved.

Fortunately, complex colobomas of the upper or lower eyelid are extremely rare. T he principles of correction are, however, similar. Redistribution of skin is extensive (8.15, 8.16) and the incorpora­tion of a Z-plasty in the medial part of the periphery of the flaps is imperative if secondary contracture is to be avoided.

b Closure of the conjunctiva l defect with a mucosal graft and medial transposit ion of lateral eyelid skin. This rotat ion is facilitated by the incorporation of a Z-plasty. (B 1 and B2 show closure of coloboma in upper eyelid; B3 and B4 show closure of coloboma in lower eyelid .)

III

PALPEBRAL ANOMALIES

8 .15 a Severe co loboma of upper eyelid. b Dissection of edges. c Closure of conjunctiva l defect by insertion of bucca l graft and design of transposition flap- the incorporation of a Z-plasty in the lateral part of the periphery of the flap permits rotation of the flap and closure of the

II2

smal l donor defect. d Resurfacing of t he bucca l graft by transposition of the flap and design of a V-flap that is used for a second Z-plast y in the medial part of the periphery of the flap directly over the buccal graft. e Result of second Z-plasty.

8.16 Severe facial and palpebral clefting (Tessier IV maxi llary dysplasia). a Preoperative appearance. b Postoperative appearance.

EPIDLEPHARON

EPIBLEPHARON

The term epiblepharon refers to the presence of an eyelid fold. Such a fold partia lly covering the rim of the eyelid may be observed in both eyelids. In spite of the similarity in appearance, the causative mechanism of each of these folds is different.

UPPER EYELID EPIBLEPHARON

In the upper eyelid, epiblepharon appears to be due to the protru­sion of orbital fat over the levator aponeurosis. This occurs because of a more caudally situated fusion between orbital septum and lev­ator aponeurosis (8.17). This condition is common in Orientals but it is rare in Caucasians, in whom fusion of levator aponeurosis and orbital septum is normally formed above the superior border of the tarsal plate (see 8.17).

8.17 a Frontal view and b lateral view of an epiblepharon.

Correction is relatively simple . The surplus of fat is resected through an incision at the site of the super ior border of the tarsus and a fold is created by the insertion of some sutures that produce strong adhesions between skin and levator aponeurosis.

LOWER EYELID EPIBLEPHARON

In the lower eyelid, epiblepharon is caused by a shortage rather than by an excess of tissue. Testimony to this is the combination of epi­canthus inversus and epiblepharon in patients wi th blepharophi­mosis and the fact that epiblepharon as a solitary phenomenon in the lower eyelid usually disappears with increasing laxity of skin. As a ru le treatment is not required, but in some patients the fold may induce a congenital entropion that demands correction.

II3

PALPEBRAL ANOMALlES

EURYBLEPHARON

The term euryblepharon refers to a congenitally long and wide palpebral fissure caused by extreme shortage of eyelid skin. The mal­formation may be associated with a lateral ectropion of the lower eyelid. Correction can be achieved only by the insertion of skin (8.18 ).

CONGENITAL ENTROPION

The combination of epiblepharon and congenital entropion is occa­sionally seen in children. It is rare in adults (8.19) because the mal­formation tends to disappear after a few years.

The entropion seems to be caused by a band of orbicularis muscle underlying the skinfold and overriding the tarsus. When there are no complaints of photophobia or recurrent conjunctivitis, conser­vative treatment with lubricating ointments is recommended.

®

There are some cases, however, that should be corrected by surgery. Release, relocation or resection of the muscular band, removal of a small crescent shaped segment of skin (less than 2 mm) and repositioning of the rim of the eyelid by the use of a few evert­ing buried sutures is usually sufficient (8.20).

CONGENITAL ECTROPION

This anomaly is usually seen as part of blepharophimosis or eury­blepharon. It is rare as a solitary malformation (8.21 ). Its cause is difficult to define. Factors that may play a role include: • Laxity of the canthal tendons, in particular the medial tendon. • Shortness of the orbital septum. • Horizontal lengthening of the rim of the eyelid. • Lack of skin.

Methods of correction involve canthopexies, lid shortening, and septal release. Serious effort should be made to avoid the insertion of skin grafts because the colour match is never satisfactory.

8.18 a Severe euryblepharon caused by extreme shortage of skin. b Correction by insertion of full-th ickness skin graft.

8.19 a Frontal view and b lateral view of a congenital entropion associated with epiblepharon in an adult.

114

CONGENITAL E CTROPION

8.20 Congenita l entropion associated with epibl epharon in a child. a Before correction. b After correction.

8.21 Congenital ectropion . a Right eye. b Left eye.

BIBLIOGRAPHY

CONGENITAL ANOMALIES

Blair VP, Brown JB, Hamm WG. Surgery of the inner canthus and related structures. Am j Ophthalmol1932;15:498.

Callahan A. In: troutman RC, Converse JM, Smith B (eds) Plastic and reconstructive surgery of the eye and adnexae. London: Butterworth's 1962, pp. 169-174.

Desmarres E. Trait theoretique et pratique des maladies des yeux. Paris I:468, 1854.

Fuento del Caampo A. Surgical treatment of the epicanthal fold. Plast Reconstr Surg 1984;73(4 ):566-570.

H an K, Kang J. Tripartite frontalis muscle flap transposition for ble­pharoptosis. Ann Plast Surg 1993;30:224-232.

Johnson CC. Epicanthus. Am j Ophthalmol 1968;66:939- 946. Johnson CC. Epicanthus and epiblepharon. Arch Ophthalmol

1978;96:1030-1033. Karlin DB. Congenital entropion, epiblepharon and anti-mongoloid obliq­

uity of the palbepral fissure. Am] Ophthalmol 1960;50:487. Lemke BN, Stasior OG. Epiblepharon- an important and often missed

diagnosis. Clin Pediatr 1981;20:661-662. McCord CD. Congenital euryblepharon. Ann Ophthalmol 1979;1217.

IIS

McCord CD. The correction of telecanrhus and epicanrhal folds. Ophthalmic Surg 1980;11:446-454.

M ustarde JC. Epicanrhal folds and the problem of telecanrhus. Trans Ophthalmol Soc UK 1963;83:397-411.

Mustarde JC. Congenital ectropion syndrome. Symposium on plastic surg­egy in the orbital region. In: Tessier DL, Callahan A, Mustarde JC Salyer KE (eds). St Louis: CV Mosby 1976, pp. 203-205.

Pang HG. Surgical formation of upper lid fold . Arch Ophthalmol 1961;63: 783-784.

Roveda JM. Epicanthus et blepharorphimosis. Notre technique de correc­tion. Ann d'Oculist 1967;200:551.

Salyer KE, Vasconez HC. Down's syndrome- surgical management. In: Mustarde JC, Jackson IT (eds ). Edinburgh: Churchill Livingstone, 1988, pp. 159-164.

Song R, SongY. Treatment of blepharoprosis: direct transplantation of the frontalis muscle ro the upper eyelid. Clin Plast Surg 1982;9:45-48.

Spaeth EB. Further considera tion of the surgical correction of ble­pharophimosis and epicanthus. Am J Ophthalmol 1956;41:61.

PALPEBRAL ANOMALIES

Tessier P. Anatomical classification of facial, craniofacial, and laterofacial clefts. In: Symposium on Plastic Surgery in the Orbital Region. St. Louis, CV Mosby, 1980.

Zhou LV, Chang TS. Frontalis myofascial flap from eyebrow region for the correction of ptosis of the upper eyelid: review of 133 cases. Eur] Plast Surg 1988;11,73-77.

Zide BM. Anatomy of the eyelid. Clin Plast Surg 1981;8,623-634.

EURYBLEPHARON

Feldman E, Bower SF, Morgan SS. Euryblepharon: a case report with pho­tographs documenting the condition from infancy to adulthood. ] Pediatr Ophthalmol1980;17,307.

Gupta AK, Ramanurthy S, Shukan KM. Euryblepharon. A case report. J Pediatr Ophthalmol1972;9,173.

Gupta AK, Saxera P. Euryblepharon with associated ocular anomalies. J Pediatr Ophthalmol1976;13,163.

Gupta JS, Kumar K. Euryblepharon with ectropion. Am J Ophthalmol 1968;66,554.

Hopen JM. Congenital eversion of the upper eyelids. Arch Ophthalmol 1955;53,118.

Keipert JA. Euryblepharon. Br] Ophthalmol1975;5957. Mazahar M. Congenital eversion of the upper eyelids. Br] Ophthalmol

1955;39,702. McCord CD, Chappell J, Pollard ZF. Congenital euryblepharon. Ann

Ophthalmol1979;1 L1217. Ostriker PJ, Lasky MA. Congenital eversion of the upper eyelids. Am]

Ophthalmol1954;37,779. Wolter JR. Familial euryblepharon. Pediatr Ophthalmol1972;9,175.

OTHER FURTHER READING

Elliott D, Wallace AF. Ptosis with blepharophimosis and epicanthus inver­sus. Br] Plast Surg 1986;39,244-248.

Flowers RS, Caputy GG, Flowers SS. The biomechanics of brow and frontalis function and its effect on blepharoplasty. Clin Plast Surg 1993;20,255-268.

Jackson IT, Adham MN, Marsh WR. Use of the galeal frontalis myofascial flap in craniofacial surgery. Plast Reconstr Surg 1986;77;905-910.

Kawamoto HK. The kaleidoscope world of rare craniofacial clefts. Order out of chaos (Tessier Classification). Clin Plast Surg 1976;3:529.

Mustarde JC. The treatment of ptosis and epicanthal folds. Br J Plast Surg 1960;12,252.

Mustarde ]C. Epicanthus and telecanthus. Br] Plast Surg 1963;10:346. Mustarde ]C. Repair and Reconstruction in the Orbital Region, 2nd edi­

tion. Edinburgh: Churchill Livingstone, 1980:342. Mustarde ]C. Congenital soft tissue deformities. In: Smith BC, Della Rocca

RC, Nesi FA, Lisman RD (eds). Ophthalmic Plastic and Reconstructive Surgery. St Loui" CV Mosby, 1987,1238-1261.

Nakajima T, Yoshimura Y, Onishi K, Sakakibara A. One-stage repair of blepharophimosis. Plast Reconstr Surg 1991;87:24-31.

Tessier P. Colobomas: vertical and oblique complete facial clefts. Panminerva Medica 1969a;11:95.

Tessier P. Fentes orbito-faciales verticales et obliques (colobomas), com­pltte5 et frustres. Annales de Chiurgie Plastique 1969b;14:301.

Van der Meulen JCH. Oblique facial clefts: pathology, etiolog and recon­struction. Plast Reconst Surg 1985;76:213.

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