Aim-To describe a series of patients who have undergone a medial canthal reconstruction with a rhomboid flap. Methods-A non-comparative interventional case series of 27 patients with medial canthal defects after Mohs excision of medial canthal basal cell carcinomas who underwent reconstruction using a rhomboid-shaped transpositional flap of adjoining skin and subcutaneous tissue. 25 cases were performed under local anaesthesia. The remaining two cases were combined with major lid reconstruction and performed under general anaesthesia. The outcome measures were closure of the defect, the cosmetic result, complications, and re-operations. Results-Primary closure of the defect was achieved in all cases. The cosmetic result was highly satisfactory in all cases. There were no major complications or re-operations. Two cases had minor webbing of the medial upper lid. Conclusions-The rhomboid flap is an eVective, quick, and simple technique for medial canthal reconstruction. It provides excellent cosmesis and is associated with minimal complications. It can be modified according to the nature of the periorbital skin and the location, size, and depth of the defect. (Br J Ophthalmol 2001;85:556-559) The medial canthus is the second most common location for periorbital basal cell carcinomas.

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A 57-year-old woman presented with intensely pruritic generalized eruptive keratoacanthomas affecting cutaneous and mucosal surfaces (Grzybowski syndrome). She derived marginal benefit from anti-pruritic agents, acitretin and methotrexate. However, cyclophosphamide 100 mg daily for 1 month followed by 3 months at 200 mg daily resulted in remarkable improvement and eventual remission without further treatment. The disease resulted in severe ectropion of upper and lower eyelids bilaterally. Two years after the onset of her disease, the lower lid ectropions were repaired using skin grafting. There was no evidence for papillomavirus infection.

In our series, 7 cases required explantation of the original titanium implant. In these cases a vigorous fibrotic reaction had taken place between the orbital contents and the titanium mesh implant. We postulate that the fibrous reaction between the implant and the orbital contents caused the eye movement restriction and the lid retraction. Implant materials used in orbital floor fracture surgery should be inert with a flat profile rather than a mesh to prevent adhesions through the mesh that may cause cicatricial eye movement restriction and eyelid retraction.

Periocular basal cell carcinomas can grow rapidly, and many have aggressive histological subtypes. Rapid growth is more likely in recurrent tumours, larger tumours and in men.

The maximal Hughes procedure is a safe and effective procedure that may be performed with patients under local anesthesia and may avoid the need for more extensive techniques for surgical repair of maximal defects of the lower eyelid.

Previous series suggest that significant delays between injury and surgery lead to poorer outcomes in young patients with orbital blowout fractures. The data from this series show that despite delays, excellent outcomes can be obtained.

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