|Year : 1983 | Volume
| Issue : 4 | Page : 331-337
New techniques and fresh concepts in eyelid surgery
Department of Ophthalmology, Caernarvonshire and Anglesey General Hospital, Bangor, (Gwynedd), Wales, United Kingdom
H K Mehta
F.R.C.S, Derwen Deg, Bangor, Gwynedd.
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mehta H K. New techniques and fresh concepts in eyelid surgery. Indian J Ophthalmol 1983;31:331-7
With the exception of extensive orbital surgery, not a single surgical procedure practiced by a competent ophthalmic surgeon can directly constitute a hazard to the patients' life. The postoperative restrictions- including the practice of keeping the patients admittea to the hospital-are therefore directed towards minimising the possible ocular and visual complications of current surgical techniques. The progressive evolution of finer surgical techniques in conjunction with the availability of finer instruments and suture materials has helped provide impressive advances in surgical techniques that yield consistently good results. However, the non-surigcal aspects of patient management have not advanced pari passu. The aim of this presentation is to provide useful innovations of surgical techniques, and some personal concepts the simplify the postoperative management yielding excellent results with reduced cost. The reduction in cost is achieved by simplified dressings, and treating patients as day cases.
| A NEW TECHNIQUE OF FULL-THICKNESS SKIN GRAFTING|| |
The use of local pedicle skin flaps for reconstruction of defects of the eyelids or the peripalpebral region has the disadvantage of temporary or permanent distortion of the usually visible part of the adjacent facial donor site. A full-thickness skin graft obtained from a remote and not readily visible donor site is therefore preferable. Such skin grafts can be used for making good superficial defects as well as for full-thicknes reconstruction of the lower eyelid when used in conjunction with a tarso-conjunctival sliding flap from the upper eyelid as reported by Holmstrom et a1. or in conjunction with a free buccal mucosal graft as reported by Mehta. 1979.
The conventional method of securing a fullthickness skin graft is by the "tie-over-bolus" technique. Apart from achieving the impaction of the graft to its bed, the use of the bolus allows the margins of the surgical wound to be stretched, thus accommodating a larger graft to compenste for subsequent shrinkage. A firm pressure bandage is usually necessary to re-inforce the stability of the graft. To ensure that the graft and its bed retain their relative immobility, patients are usually admitted to hospital. The larger the graft, the more the restrictions. Fox advocated that the patient be kept in bed for 24 hours, and then be allowed only bathroom privileges for the next 48 hours. He advises that all dressings be left in situ far 5 to 6 days. If the graft is large and a "take" precarious, Fox imposes restriction of activity for 6 days. Reeh et al advise that the pressure dressing should be applied by the surgeon himself, and that the dressing should not be removed for about 5 to 6 days, Miff, Miff & Iliff do not use a tie-over bolus. They recommend a dressing carefully applied with tape. Their patients are admitted to the hospital and are discharged after 48 hours. They advocate immobilisation for about 2 to 5 days, and warn that even the slight movement of changing a dressing can produce a haematoma under the graft. Mustarde advocates a tieover bolus, a pad and conforming bandageall of which are left undisturbed for a week.
To obviate the disadvantages of the tieover bolus technique, I devised a new technique, of full-thickness skin graft fixation [Figure - 1] using central and paracentral sutures in addition to the usual marginal sutures. I now use a continuous marginal suture as it considerably reduces time and effort. Over 300 patients have received full-thickness skin grafts by this technique of central sutures. The largest graft in the series was 20 x 55mm. In all these patients, there has been a l00% take of the graft with good colour match, texture, surface regularity and pliability [Figure - 2]. It would appear that the ideal technique for fixation of a free graft should, if anatomically possible, provide intrinsic_fixation-and intra-operative transfixion that can be maintained until cutocutaneous union occurs-without any reliance on external factors (like pressure dressing or a tie-over bolus) to maintain the crucial constant approximation between the graft and its bed during the first six days when vascular linkup is being established. Shearing strains that rupture or even prevent vascular linkup occur when there is relative mobility between the graft and its bed. With my central sutures the "graft and its bed" is rendered a single unit. Any movement of the graft bed therefore imparts a similar, simulta neous and equivalent motion to the graft. This movement is union prevents any tendency of shearing forces from becoming operative. Vascular link-up therefore proceeds unhampered despite the patients activity, All my patients undergoing skin grafting are allowed unrestricted activity starting immediately after the operation. My central fixation suture technique would appear to have the following advantages over the tie-over bolus technique:
(1) Full-thickness or partial thickness grafts of much larger size can be used thus eliminating the need to use local flaps, which have their disadvantages. (2) Grafts of irregular shapes in awkward sites-like the nasocanthal region or the outer canthus-can be used with excellent results. (3) Assured constant approximation and immobility of the graft relative to its bed prevents a dead space that would otherwise be filled by hematoma and fibroblastic invasion. The ultimate results are therefore of a consistently good quality. (4) As there is no need for a pressure dressing, a cartella shield is the only protective dressing needed to prevent accidental mechanical molestation. Visual obstruction can be prevented by improvising a hole of about 1015 mm in diameter in the shield. (5) As the central sutures assure relative immobility between the graft and its bed, there is no need to restrict the activity of the patients after the operation. They are therefore treated as day eases.
| Spontaneous reformation of the eyelids|| |
In the surgical management of tumours involving the upper or lower eyelid, full-thickness excision of an appropriate portion of the eyelid is necessary if the malignancy involves, or is likely to involve the eyelid margin. After such margin-including excisions immediate surgical reconstruction has been assumed to be mandatory. If the defect is less then one-third of the horizontal span of the eyelid, it is customary to repair it with direct multi-layer suturing. For larger defects a multitude of techniques of varying complexities has bcen advocated. If may be neither possible nor desirable to implement immediate reconstructive surgery in some patients for reasons of health or other considerations. In 2 such patients of mine full-thickness excision of the medial half of the lower eyelid was left to heal spontaneously The extremely satisfactory results obtained in these 2 patiets prompted a study that was reported recently by the author.' Since that report of 11 patients, further 37 patients with lower eyelid lesions, 6 patients with upper eyelid lesions, and 12 patients with periorbital lesions, have undergone management by simple excision and spontaneous rapair [Figure - 3].
In all the 55 patients the wounds healed completely in about 6 weeks, though the cosmetic appearance continued to improve over further 6 to 8 weeks. No patient had any of the possible complications of sepsis. secondary haemorrhage, non-healing or delayed healing of the wound, ocular irritation, exposure keratopathy, epiphora, trichiasis entropion, symblepharon or loss of eyelid due to failure of healing. A secondary surgical procedure was needed in 3 patients who had large tumours needing extensive excisions. The final cosmetic and functional results in all these 55 patients are satisfactory.
Apart from demonstrating the feasibility of spontaneous reformation of margin-including full-thickness resections of lower eyelid, this study shows that even if left "open" without any dressings such wounds heal normally in about 6 weeks. The cartella shield in these patients was used merely to prevent accidental mechanical molestation of the vulnerable fragile fronds of granulation tissue. The improvised central hole in the shield obviated visual obstruction. Conventionally such wounds are managed with dressings of tulle gras and pad and pressure bandage, which demand expert nursing attention, are inconvenient to the patient, and are more expensive. In these 55 patients the application of the antibiotic ointment and reapplication of the same cartella shield was carried out by the patients themselves or their relatives. This, coupled with the patients' having been treated as day cases resulted in significant savings in the cost of materials and manpower. It appears that the petroleum jelly base of the antibiotic ointment aided by natural lacrimal secretion prevented descication of the wound.
It is surprising that none of the patients reported here was concerned about the cosmetic outcome, though all were anxious to have complete removal of the tumour. As some of the surgical procedures for reconstruction of the lower eyelid are extensive and possibly multistage procedures that leave noticeable evidence of surgical repair. I believe that it is unreasonable to subject all patients to such surgery to achieve results about which the patients themselves may be indifferent. It is even more unreasonable if the surgery is undertaken predominantly to gratify the aesthetic sensibility of the surgeon. The potentially invasive nature of malignant tumours affecting the lower eyelid does make their treatment imperative. The potential of satisfactory spontaneous repair of full-thicknes excisions of up to half of the lower eyelid renders their primary surgical reconstruction optional.
| Fresh personal concepts in surgery for ptosis and retraction of the upper eyelid|| |
The author recently demonstrated the validity of Hering's Law in levator surgery, and postulated that compensatory retration of the fellow upper eyelid is the rule in truly unilateral levator ptosis irrespective of the cause of ptosis [Figure - 4]. These observations have the following clinical implications:
Firstly, in some patients, this compensatory retraction of the fellow upper eyelid constitutes as much a cosmetic blemish as does the ptosis in the primarily affected eye.
Secondly, just as surgical operation on the extra-ocular muscles of one eye has effects on the actions of the corresponding muscles of the fellow eye, (a phenomenon repeatedly exploited in the surgical management of patients with strablismus), so does a similar phenomenon operate in corrective surgery for ptosis. It can be utilised to "balance" the position of the 2 upper eyelids as follows: (a) The improvement of unilateral ptosis by levator resection is frequently accompanied by reduction in the compensatory retraction of the unoperated fellow upper eyelid. This latter contributes as much to the improved cosmesis as does the reduction of ptosis by surgery, (b) In some patients in whom gross surgical over correction of unilateral ptosis has caused unsightly ipsilateral upper eyelid retraction, the unoperated fellow upper eyelid develops a compensatory ptosis. When the overcorrection is relieved by levator recession surgery, the compensatory ptosis of the contralateral upper eyelid is also is relieved [Figure - 5].
Thirdly, in cases of bilateral ptosis, when unilateral surgical correction is carried out, the improvement of the ptosis of the operated eye is accompanied by worsening of the ptosis of the untreated upper eyelid [Figure - 6]. The patients should therefore be warned that they are committing themselves to bilateral surgery.
Of the 130 adult patients undergoing levator surgery in my unit during the past 7 years, only 4 patients were admitted for social reasons. In adults, levator resection is almost invariably carried out under local anaesthesia. with facial nerve block (4 ml), retrobulbar block (2 ml), and frontal nerve block (1 ml), with bupivacaine 0.5°,, with adrenalin (Marcain). Levator resection and 2 mm tarsectomy is carried out by the conjunctival approach. Before incising into the conjunctiva and the tarsal plate, cautery is applied to the palpebral conjunctiva along the entire width of the eyelid at the sites of proposed incision (2 mm proximal and 2 mm distal to upper tarsal border) to minimise bleeding and to facilitate dissection The emergence the mattress sutures at the pre-marked line on the skin at the upper border of the tarsus gives an excellent lid fold. This gives a cosmetically better result than that obtained with emergence of the sutures just above the lash line. I have not found it necessary to use a contact lens for corneal protection during surgery. Nor do I use Frost sutures after surgery. Cartella shield with a pad on its superficial aspect is the only dressing. The patients are allowed home within an hour of the operation, and are seen for first dressing at 48 hours, and then on the 7th post-operative day for removal of sutures. There has not been corneal injury or exposure keratopathy in any of these 130 patients, despite the non-use of contact lens and Frost sutures.
| References|| |
Holmstrom, H., Bartholdson, L., and Johanson, B, 1975, Scand. J. Plast. Reconstr. Surgery 9: 107.
Fox. S,A., 1976, Ophthalmic Plastic Surgery, 5th ed, P.91 Grune & Stratton, New York.
Reeh, M.J., Beyer, C.K., and Shannon, G.M., 1976, Practical Ophthalmic Plastic & Reconstructive Surgery 1st edn. P.10. Lea and Febiger, Phildelphia,
Iliff, C.E., Iliff, flow, J. and I1iff, N.T., 1979 Oculoplastic Surgery, 1st edn., P.10, W.B. Saunderes Philadelphia,
Mustarde, J.C., 1980 Repair & Reconstruction in the Orbital Region, 2nd edn. P. 378. Churchill-Living stone, Edinburgh.
Mehta, H.K., 1977, Trans, Ophthalmol. Soc. U.K. 97:117.
Mehta, H.K., 1979. a,b,c., Brit. J. Ophthalmol. 63:120,125,578.
Mehta, H.K., 1981, Brit. J. Ophthalmol. 63 202
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]