61E.H. Black et al. (eds.), Smith and Nesi’s Ophthalmic Plastic and Reconstructive Surgery,DOI 10.1007/978-1-4614-0971-7_2...
62 G.J. Lelli Jr. et al.not to use these for 1 or 2 weeks before surgery. However, forpatients with certain medical condit...
632 Basic Principles of Ophthalmic Plastic Surgeryfor lamellar passes through tissues such as sclera and tarsus(Fig. 2.2)....
64 G.J. Lelli Jr. et al.with the outer limits placed deep and the inner limits placedsuperficially through the skin alone. ...
652 Basic Principles of Ophthalmic Plastic Surgeryremoved after several days to weeks. They tend to cause lessinflammation ...
66 G.J. Lelli Jr. et al.may be delayed by hematoma, or the desired result may notbe accomplished. Uncontrolled postoperati...
672 Basic Principles of Ophthalmic Plastic SurgeryReductionCautery is the mainstay of intraoperative hemostasis. It istarg...
68 G.J. Lelli Jr. et al.although some believe that a small inflammatory reactionmay ensue. Other readily available material...
692 Basic Principles of Ophthalmic Plastic SurgeryDetumescence occurs as the scar heals. A depressed scar isavoided by car...
70 G.J. Lelli Jr. et al.necrosis or poor wound healing. The length of the flap cansafely be up to 2.5 times the width of th...
712 Basic Principles of Ophthalmic Plastic SurgeryFig. 2.17 (a–c) Tongue-in-groove advancement flap withBurrow’s triangles ...
72 G.J. Lelli Jr. et al.Z-plastyZ-plasty is an important surgical option to release acontracted scar. It is a transpositio...
732 Basic Principles of Ophthalmic Plastic SurgeryFig. 2.24 (a) Central incisionthrough line of traction with armline offs...
74 G.J. Lelli Jr. et al.Fig. 2.25 (a) Cicatricial band causing vertical shortening of the upperlid. (b) Central line throu...
752 Basic Principles of Ophthalmic Plastic Surgeryangle the flaps more acutely to allow the flaps to work withinthe availabl...
76 G.J. Lelli Jr. et al.Transmarginal Repair of the EyelidAll incisions or lacerations of the eyelid margin requiresurgica...
772 Basic Principles of Ophthalmic Plastic SurgeryFig. 2.29 (a) Correction ofelevated brow by Z-type incision.(b) Transpos...
78 G.J. Lelli Jr. et al.surgeon’s personal experience and the patient’s ability toheal. Since the dense connective tissue ...
792 Basic Principles of Ophthalmic Plastic SurgeryFig. 2.39 Final closure of incisions after lateral canthotomy andinferio...
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Smith and nesis ophthalmic plastic and reconstructive surgery

  1. 1. 61E.H. Black et al. (eds.), Smith and Nesi’s Ophthalmic Plastic and Reconstructive Surgery,DOI 10.1007/978-1-4614-0971-7_2, © Springer Science+Business Media, LLC 2012IntroductionOphthalmic plastic and reconstructive surgery combines theprecision of ophthalmic microsurgery with plastic and recon-structive surgical principles, allowing for subspecialized careof the eyelid, orbital, and lacrimal system. A foundation inophthalmology allows the oculoplastic surgeon the knowledgeand skills to safely and successfully protect the globe whileachieving functional and aesthetic results. Certain basic oph-thalmic and plastic surgical considerations form the necessaryframework for the successful practice of oculoplastic surgery.Preparation of the PatientConsistent surgical outcomes depend on optimal preoperativepreparation and patient counseling. The patient’s oculoplastic,ophthalmic, psychological, and general physical conditionmust be evaluated and documented. The surgeon needs tounderstand the concerns that have caused the patient to seekconsultation. Every patient deserves a discussion of the goalsof treatment (medical or surgical), along with an honestappraisal of the expected outcomes and potential pitfalls thatmay prevent the patient from achieving the desired results.The patient’s preoperative condition must be assessed anddocumented in a manner consistent with the risk and com-plexity of the proposed procedure. This may include a gen-eral physical examination, an ocular examination, and anophthalmic plastic examination, as indicated. A typical pre-operative oculoplastic evaluation includes a problem-specificexamination of the eyes, eyelids, and adnexal structures. Itmay include specialized testing such as lacrimal probing andirrigation, ocular photography, or orbital imaging.Laboratory and ancillary evaluation should adequatelysatisfy the patient’s needs and be consistent with the diagno-sis and planned intervention. This may include completeblood count (CBC), electrolyte panel, prothrombin time(PT), partial thromboplastin time (PTT), chest radiograph,electrocardiography, magnetic resonance imaging (MRI),and/or orbital computed tomography (CT).Many nonorbital oculoplastic procedures are now per-formed with local anesthetic and intravenous sedation asneeded, with monitored anesthesia care provided by an anes-thesiologist. These cases may not require any ancillary test-ing if the patients are under 40 years of age and without ahistory of diabetes, diuretic use, or coagulopathy. In someinstances, a CBC and coagulation panel is performed,depending on the patient’s age and comorbidities and theproposed procedure. Patients who are diabetics require mea-surement of their glucose level. Patients on a diuretic needmeasurement of their potassium level. A recent electrocar-diogram is usually necessary for patients older than 40 years.The same procedure performed in the office setting withlocal anesthesia and oral sedation usually does not requireany laboratory evaluation.When possible, medications that decrease clotting shouldbe stopped before oculoplastic surgery. Ideally the patient isgiven a list of all aspirin-containing medications, both pre-scription over the counter and homeopathic, and instructedBasic Principles of OphthalmicPlastic SurgeryGary J. Lelli Jr., Christopher I. Zoumalan,and Frank A. Nesi2G.J. Lelli Jr., M.D.Division of Ophthalmic Plastic, Reconstructive, and Orbital Surgery,Department of Ophthalmology, Weill Cornell Medical College,New York-Presbyterian Hospital, 1305 York Avenue, 12th Floor,New York, NY 10021, USAe-mail: gary.lelli@gmail.comC.I. Zoumalan, M.D.Department of Ophthalmology, Division of Ophthalmic Plasticand Reconstructive Surgery, Keck School of Medicine of USC,1975 Zonal Avenue, Los Angeles, CA 90089, USAF.A. Nesi, M.D., F.A.C.S. ( )Oculoplastic Surgery, Oakland University William Beaumont Schoolof Medicine, Royal Oak, MI, USAe-mail: llion1@comcast.netDepartment of Ophthalmology, Kresge Eye Institute,Wayne State University School of Medicine, Detroit, MI, USAConsultants in Ophthalmic & Facial Plastic Surgery, P.C.,29201 Telegraph Road, Suite 324, Southfield, MI 48034, USA
  2. 2. 62 G.J. Lelli Jr. et al.not to use these for 1 or 2 weeks before surgery. However, forpatients with certain medical conditions, such as a mechani-cal heart valve or cardiac stent, it is not always advisable tostop anticoagulation. Working in coordination with thepatient’s primary care doctor or cardiologist will allow anindividualized decision based upon the cardiac history andthe surgical risk of bleeding [1]. When abnormal bleedingcannot be avoided during surgery, the surgeon and the patientneed to reevaluate the relative necessity of the surgery andthe inherent risks involved.All patients with periocular or remote trauma need to havetheir tetanus immunization status evaluated. Any patient whohas been previously immunized for tetanus but was lastimmunized over 5 years ago needs to have a booster for teta-nus toxoid. Any patient with a contaminated wound and noprior tetanus immunization needs to have a tetanus immuneglobulin injection immediately followed by a complete teta-nus vaccination sequence.Perioperative AntibioticsPerioperative antibiotics have limited usefulness in most ocu-loplastic procedures. Infection is very unlikely following ocu-loplastic surgery, and preoperative antibiotics have not beendemonstrated to reduce the incidence of postoperative infec-tion in most oculoplastic procedures [2, 3]. Although there isno consensus, antibiotics may be useful in cases of trauma,particularly bite wounds (with anerobic coverage needed), andin cases of preoperative infection. Antibiotic selection shouldbe directed to the most likely category of bacterial contamina-tion, such as gram-positive organisms from the skin and anaer-obes from the sinuses. When deemed appropriate and if thepatient is not allergic to penicillins or cephalosporins, 1 g ofcefazolin covers the most common pathogens.Tissue ManipulationInstruments for oculoplastic surgery are larger and sturdierthan instruments for eye surgery but are generally smallerand more delicate than instruments for general plastic sur-gery. Appropriately sized instruments allow the surgeon tohold the tissue without damaging it. The carbon dioxide lasercan be used to incise skin and dissect tissues as well. SeeChap. 3 for additional details on instrumentation in ophthal-mic plastic surgery.Wound ClosureClosure of incisions in the periocular area usually requiressutures. Staples and tissue adhesives are generally poorchoices for the eyelids and surrounding areas owing to thegreat mobility of the skin and surrounding structures. Greatcare must be taken with suture placement and suture tension.A tight suture can cheese-wire (pull) through thin eyelid skinand can cause necrosis, especially in association with signifi-cant edema (Fig. 2.1). Attention must be paid to needle typeand size, suture type and thickness, and suture placement andtension. All of these factors have a significant effect on thesurgical result.Suture NeedlesThe choice of needles is critical in eyelid surgery. The typeof needle determines the ease with which the needle pene-trates the tissue. The size and shape of the needle influencethe amount of trauma induced by passing the suture. Cuttingor reverse cutting needle configurations are the most usefulin ophthalmic plastic surgery. Spatulated needles are helpfulFig. 2.1 Depressed scar causedby overly tight suture
  3. 3. 632 Basic Principles of Ophthalmic Plastic Surgeryfor lamellar passes through tissues such as sclera and tarsus(Fig. 2.2). Round or tapered needles, often used in vascularsurgery, have a limited role in ophthalmic plastic surgery, butcan be used to decrease bruising in certain procedures, suchas temporary eyelid closure (tarsorrhaphy).The size and curvature of the needle is also important.Slightly curved needles are helpful for suturing eyelid skinand tarsus. Highly curved (semicircle) needles are helpfulfor tight spaces such as the medial or lateral canthus or deepersuture passes in dacryocystorhinostomy surgery.Suture PlacementSutures should be used when clearly indicated. For skinclosures, correctly placed sutures slightly pucker the woundedges.A simple, interrupted suture is a single rectangular totrapezoid-shaped loop that can approximate tissue well whenthere is little tension on the wound. The base of the loopshould be wider than the top to ensure skin edge eversion(Fig. 2.3). A vertical mattress suture creates a U-shaped loopFig. 2.2 (a) Spatula needle.(b) Cutting needle. (c) Reversecutting needleFig. 2.3 Correctly placed inter-rupted superficial closure withskin edges slightly puckered aftertying
  4. 4. 64 G.J. Lelli Jr. et al.with the outer limits placed deep and the inner limits placedsuperficially through the skin alone. The vertical mattresssuture is used to ensure an approximated and everted skinedge for a wound where there is significant tension (Fig. 2.4).A figure-of-eight suture is a variant of the vertical mattresssuture (Fig. 2.5). A horizontal mattress suture is created bytying two connected simple sutures together (Fig. 2.6).A horizontal mattress suture is commonly used to reattachthe lateral canthal tendon to the inner aspect of the lateralorbital rim during lower eyelid tightening. The horizontalmattress suture, like a continuous, locking, running suture, isa means of reducing the number of knots and the timerequired to tie them (Fig. 2.7). Subcuticular sutures form anS-shaped chain linking the dermis. Such sutures, largely bur-ied, suit a skin closure with little tension in which the sur-geon wishes to reduce the effect of suture materials onepidermal scarring. The subcuticular sutures are exteriorizedat the wound ends and left free, and tied or sutured to skin atthe ends (Fig. 2.8).Suture MaterialsBoth absorbable and nonabsorbable sutures are useful,depending on the desired effect. The sizes for ophthalmicplastic surgery are usually between 4–0 (largest) and 8–0(smallest). The naturally occurring materials such as catgutand collagen are usually monofilaments and are degraded byenzymatic action that is somewhat variable between indi-vidual patients (Table 2.1). Therefore the effectiveness ofthese suture materials is somewhat unpredictable, but theyare shorter acting than the synthetic materials. The syntheticmaterials such as polyglactin are usually braided and aredegraded by hydrolysis, which is more predictable but takeslonger to complete. The braided sutures make the most effec-tive knots but also have spaces between the braids that aretoo small for white cells to enter while allowing bacterialproliferation. Sutures that inhibit bacterial colonization byimpregnation with triclosan are now available (Ethicon plussutures, Ethicon, Somerville, NJ).Nonabsorbable sutures usually last at least for severalyears or longer. When externalized, they are frequentlyFig. 2.4 Vertical mattress suture provides excellent deep and superfi-cial support and helps to evert wound edges. A far-far, near-near suturepass is utilizedFig. 2.5 (a) Buried suture usedto close deeper layers. Superficiallayer closed with interruptedsuture. (b) Figure-of-eight sutureused to achieve same closure
  5. 5. 652 Basic Principles of Ophthalmic Plastic Surgeryremoved after several days to weeks. They tend to cause lessinflammation than absorbable sutures because they are moreinert and relatively ignored by the body’s immune system. Silksutures are the principal exceptions to the above-mentionedguidelines. Silk causes significantly more inflammation thanthe synthetic monofilament sutures, but offers excellent easeof use. Supramid, polyester, and silicone are used predomi-nantly for eyelid suspensions and canthal reconstructions.Steel wire is used for joining bones and for canthal recon-struction but is rarely used now with the wide availability ofplating sets (Fig. 2.9).HemostasisThe eyelids and ocular adnexa are richly vascularized witharcades oriented in the eyelid in predictable locations.Although this generous blood supply reduces the risk ofnecrosis and infection, it makes perioperative hemostasismore difficult. Excessive bleeding obscures the surgical fieldand can prolong intraoperative time. The final surgical resultFig. 2.6 Horizontal mattress suture allows speed of placement second-ary to less tying and is useful for wounds under tension, as in reapproxi-mation of the lateral canthal tendon during the lateral tarsal stripprocedureFig. 2.7 Continuous locking sutureFig. 2.8 Buried running subcuticular closure affords excellentcosmesis and ease of removal
  6. 6. 66 G.J. Lelli Jr. et al.may be delayed by hematoma, or the desired result may notbe accomplished. Uncontrolled postoperative bleeding canlead to orbital hemorrhage and vision loss [4].PreventionThe possibility of abnormal bleeding always exists. Historicalclues should be sought preoperatively such as easy bruisingwith minor trauma or excessive bleeding during prior sur-gery, including dental surgery. This issue must be thoroughlyreviewed with the patient, who frequently may not recall thisinformation even with specific prompting. The patient’smedication list should be carefully evaluated. Preoperativebleeding studies may be considered such as platelet countand a coagulation profile (PT/PTT/INR). In rare instances, ableeding time may be beneficial.Control of perioperative blood pressure is an importantpreventive measure to avoid excessive bleeding during andafter surgery. This is best accomplished by having the patienttake his or her usual medication with a small drink of waterthe morning of surgery. Of particular note, the patient shouldtake their midday medications if they are on the afternoonsurgery schedule. If necessary, the patient can be given anadditional long-acting oral agent to control the blood pres-sure on arrival to the surgical preoperative holding area.Additional systemic measures can decrease the chance ofhemorrhage in the perioperative period. They include use ofantitussives as needed and the use of antiemetics to preventvalsalva during or after a procedure.Careful attention to perioperative hemostasis is a criticalelement of any oculoplastic surgery. Injection of local anes-thetic with a vasoconstrictor, such as epinephrine (1:100,000or 1:200,000), is extremely helpful. It is important to payparticular attention to the time of injection, as epinephrinerequires approximately 10 min for its effects to occur and hasits maximal effect between 20 and 60 min after injection.Ideally the critical part of the surgery will be completedwithin this time. Additionally, epinephrine significantly pro-longs the action of lidocaine and other similar anesthetics.Phenylephrine is an acceptable alternative when epinephrineis contraindicated owing to cardiac or other reasons. It can beadded to a local anesthetic to achieve similar hemostasis asepinephrine without as much cardiac stimulation.Conjunctival and mucosal bleeding frequently can be min-imized or prevented by proper preoperative planning. When aconjunctival incision is planned, the application of phenyleph-rine drops 20 min before the incision can frequently eliminatemost if not all of the bleeding typically encountered from thistype of incision. Likewise, the use of 0.5% phenylephrinenasal spray before a dacryocystorhinostomy can dramaticallyreduce the amount of nasal mucosal oozing.Table 2.1 Commonly used suture materials in oculoplastic surgerySuture Characteristics Strength retention Typical useNylon Synthetic, monofilament Permanent Skin closureProlene Synthetic, monofilament Permanent Skin closureSilk Natural, multifilament 2 years Lid margin repairPlain gut Natural, monofilament 7–10 days Skin and conjunctival closureChromic gut Natural, monofilament 2–3 weeks Deep buried wound closure, tarsal suturesPolyglactin Synthetic, multifilament 3–4 weeks Deep buried wound closure, tarsal suturesPolydioxanone Synthetic, monofilament 4–6 weeks Deep suspension sutures, tissue flap supportFig. 2.9 (a) Wire is twisted tohold it in position; it is not tied.(b) After the wire is twisted, thefree end is bent toward the boneand deeply buried. Wire causesvery little tissue reaction if theend is well buried
  7. 7. 672 Basic Principles of Ophthalmic Plastic SurgeryReductionCautery is the mainstay of intraoperative hemostasis. It istargeted and works immediately. When used properly it tendsto cause minimal associated thermal damage while closingthe bleeding vessels. There are three types of commonlyused cautery: (1) hot wire, (2) high-frequency radio waves,and (3) laser. All three methods use heat to coagulate theblood vessel and adjacent tissue to stop the bleeding.Hot-wire cautery is generally accomplished with a hand-held, battery-operated instrument. They are available in lowand high temperature varieties. Low-temperature cauteryusually contains a single AA battery and reaches a tempera-ture of 1,000°C. The wire does not glow red. It is often usedfor ocular and periocular surgery. The high-temperature cau-tery usually contains two AA batteries and reaches a tem-perature of 2,200°C. The wire glows orange red. The color ofthe tip glow indicates the temperature of the cautery; a brightorange is the maximum temperature. This temperature ishelpful for dissection. Temperature and heat are differentmeasures of the same phenomenon and should not be con-fused with each other. Temperature is determined by the rela-tive speed of the molecules in an object. Heat is a product ofthe relative speed of the object’s molecules and the object’smass. Although the two batteries in the cautery can raise thetemperature of the wire to several thousand degrees, the totalheat in the wire is small, even when the tip is glowing orange.Therefore it is important to apply the cautery with the tipglowing. This method allows maximum cauterization at thesurface with minimal deep thermal effects. If the cautery isapplied to the tissue before the wire glows orange, the cau-tery will be inefficient. The temperature does not rise muchbecause the tissues absorb the extra energy and a deeper, lesseffective burn occurs that unnecessarily damages normaltissue.High-frequency electrocautery is extremely useful in ocu-loplastic surgery. It is useful for dissecting as well as cauter-izing tissue. The relative action of the instruments iscontrolled by the frequency and shape of the electrical wavethat emanates from its tip. The power level controls the inten-sity of these effects. It can be used as a unipolar or bipolarinstrument. In the unipolar mode, it is a very effective dis-secting instrument and can coagulate vessels that are smallerthan 1 mm in diameter by direct obliterative cautery. In thebipolar mode, it is a poor dissecting instrument but an unpar-alleled coagulator of larger vessels that are difficult to con-trol with any other means. The bipolar mode seals largervessels by also cauterizing and recruiting the surroundingconnective tissue into the zone of coagulation and collagenshrinkage (Fig. 2.10).Bipolar cautery is very helpful for shrinking prolapsedorbital fat. During orbital surgery, fat frequently prolapsesinto the surgical field. One option for managing this problemis bipolar cautery. The surface of the fat is lightly moistenedwith saline. The bipolar cautery power is set relatively low.The tips are applied to the fat’s surface in a painting motionwith the power on and the waveform set to coagulate. The fatconsistently contracts out of the field without the need toincise it and without the risk of causing bleeding.The carbon dioxide laser can function as a scalpel or cau-tery, or both. When the laser’s energy flux or density is veryhigh, it vaporizes tissue without leaving any heat in theremaining tissue to coagulate it. In this fashion the lasermakes an excellent scalpel, but there is tremendous bleedingassociated with its use. Conversely, the laser can be adjustedto heat tissue without cutting it, but causing tissue necrosisfrom the thermal effects. Most of the time, the carbon diox-ide laser is used to simultaneously cut and coagulate. Therelative effects are controlled by varying the intensity andduration of the beam.Adjuvant AgentsSome bleeding is so diffuse that cautery is impractical orunwise. This happens frequently with mucosal surface bleed-ing, especially when preoperative hemostasis has not beeneffective before a dacryocystorhinostomy. In these caseshemostasis is augmented nicely by several different materi-als. An excellent option is to utilize one of the charged col-lagen products such as Helistat or Collistat. These materialsare sheets containing many ends of charged collagen simu-lating a cut tissue surface. These sheets strongly inducethrombogenesis. They may be left in the operative field,Fig. 2.10 Bipolar cautery is applied directly to a blood vessel after theforceps are placed in apposition
  8. 8. 68 G.J. Lelli Jr. et al.although some believe that a small inflammatory reactionmay ensue. Other readily available materials include absorb-able gelatin foam (Gelfoam), oxidized cellulose (Surgicel),and microfibrillar collagen (Avitene). Gelfoam and Avitenecan be left in the surgical field. Surgicel may cause too muchinflammation to be left in the eyelids or orbit.Bleeding from bone is best controlled with direct applica-tion of bone wax into the bleeding sites. It is very difficult tocontrol bone bleeding with cautery of any kind even with awell-defined bleeding site because the vessels do not havemuch surrounding connective tissue that can be incorporatedinto the coagulated area.IncisionsIncisions in and around the eyelids demand precision butoffer the attentive surgeon the possibility of completely hid-ing well-constructed wounds in the natural skin folds andcreases around the eye [5]. To make successful skin incisionsinto the eyelids requires an understanding of their muscular,fibrous, and vascular anatomy as well as that of all of theadjacent structures. It also requires knowledge of the surgicalprinciples involved.Whenever possible the incisions should be placed in orparallel to skin folds and skin tension lines. These skin linesoften coincide with lines of facial expression and are espe-cially prominent around the eyes. Subtle skin tension linescan be identified by compressing the skin at 90° angles andobserving the indentation pattern. Incisions in or along peri-ocular rhytids help decrease wound tension, thereby creatingthinner scars (Fig. 2.11).Lymphatic drainage from the eyelids can be adverselyaffected by poor incision placement. Poor lymphatic drainagecan significantly delay wound healing and can lead to asuboptimal long-term result. The normal lymphatic channelsof the eyelid extend obliquely, posteriorly, and inferiorlyfrom the lateral eyelids to the preauricular and submandibu-lar lymph nodes. Vertical incisions in the lateral canthus tendto disrupt the flow of lymph fluid and heal poorly. Verticalincisions in the medial canthus do not affect the lymphaticsas much as those in the lateral canthus. Simultaneous verticalincisions in the medial and lateral canthal regions of the sameeyelid may cause chronic eyelid lymphedema.Skin DefectsPrimary ClosureSmall skin defects without significant tension are closed bestby direct apposition. If the skin edges are under significanttension, the surgeon can undermine the skin from the under-lying tissue by sharp dissection; the surgeon is effectively cre-ating a small sliding advancement flap. This approach allowsthe edges of the incision to be advanced without creating trac-tional forces that will tend to broaden the scar as it heals(Fig. 2.12). Small eyelid skin lesions can be excised withelliptic incisions that easily convert to linear closures withminimal tissue distortion (Fig. 2.13). As with all incisions, itis important to evert the wound edges as they are closed. Alltissue margins are swollen during the wound closure.Fig. 2.11 Suggested incision sites in the periocular regionFig. 2.12 Undermining of wound edges with slight eversion of the wound margin
  9. 9. 692 Basic Principles of Ophthalmic Plastic SurgeryDetumescence occurs as the scar heals. A depressed scar isavoided by carefully and consistently everting the woundedges during the closure (Fig. 2.14). Each layer of skin shouldbe approximated to the equivalent layer in the opposite woundedge to avoid creating a bump in the scar. If a raw edge issutured to an epidermal surface, an elliptic abnormality in thescar will result because the two will not properly seal.Dog EarsDog ears are created by redundant tissue at the terminationof an incision. Unequal incision lengths and incisions joinedat an angle that is too acute frequently cause dog ears.Creating incisions of equal length and joining them atappropriate angles minimizes dog ears. Dog ears are elimi-nated by creating a flat, unpuckered incision before closure(Fig. 2.15).FlapsThe oculoplastic surgeon must be able to adjust the surgicalplan as the intraoperative situation dictates. What is per-ceived preoperatively as a simple excision of a mass anddirect closure may become more difficult because of unan-ticipated tissue loss in an attempt to achieve clear surgicalmargins. Therefore, familiarity with the technique of creat-ing skin flaps is important. The specific flap is based on theextent and location of the defect.One of the most helpful techniques to facilitate wound clo-sure is undermining the edges. In most instances it is straight-forward to undermine the adjacent tissue in the subcutaneousplanes beginning at the wound margins. The surgeon mayhave to dissect a significant distance to decrease the tension ofthe tissue to an acceptable level. During the dissection, thewound edges are repeatedly grasped with toothed forceps anddrawn together until the surgeon is satisfied that the woundcan be closed relatively tension free. In effect, a simpleadvancement flap is created without any skin incisions. If thewound is closed with significant, persistent skin tension, thescar will broaden postoperatively and will tend to either hyper-trophy or atrophy. This is particularly true if the scar has repet-itive stretching forces on it, such as a scar in the upper eyelid.When undermining is insufficient to relieve incisionalstress, more advanced techniques are necessary. The next stepis a simple advancement flap with skin incisions. This is par-ticularly helpful for square or rectangular defects (Fig. 2.16).Careful measurement of the defect to determine the size andshape of the tissue is necessary to fill the defect, following thewoodworker’s dictum of “measure twice and cut once.” Theflap is outlined and the skin incisions are made sufficientlydeep to include the vascular bed that nourishes it. Failure toinclude the bed can lead to loss of the flap through tissueFig. 2.13 Elliptic defect closed with interrupted suturesFig. 2.14 Poorly placed suture is too far from the wound and caused inverted wound edges
  10. 10. 70 G.J. Lelli Jr. et al.necrosis or poor wound healing. The length of the flap cansafely be up to 2.5 times the width of the flap. With great caretaken by the surgeon to retain the vascular integrity of the tis-sue, the flap is dissected until it can slide easily into the defectwith minimum tension. With this maneuver, an area of stressmay appear along the edges of the advancing flap that mayimpede the successful advancement of the flap. The eyelidsare a privileged sight with great vascularity; therefore it is rareto see tissue slough. Nevertheless, these priciples apply to theperiorbital regios as well as other sites. Small releasing trian-gles, called Burrow’s triangles, may be made at these stresspoints to lessen the tension and minimize scarring (Fig. 2.17).After the flap is advanced into position and the apparent stressis acceptable, it is sutured into position. In those areas withlarger flaps, buried absorbable sutures may be used to joinopposing subcutaneous tissue and obliterate the surgical deadspace (Fig. 2.18). These buried sutures also decrease the ten-sion on the skin and distribute it more evenly.An alternative method of tension reduction is the V-Yplasty (“V to Y plasty”). Determining the force vector on theskin is critical for this flap. Once the direction of the mainvector is known, a V-shaped incision is made along themeridian of the main vector bisecting the V. The area lateralto the V is undermined. This results in a release of the V inone direction, and the former base of the V lengthens. Thisarea is then closed by suturing the former base of the V in alinear fashion. The arms of the V are automatically convertedinto a Y (Fig. 2.19). It is also possible to make a Y into a Vby a reverse process. These techniques are most helpful inthe reconstruction of the medial and lateral canthi.A rotation flap is very helpful for rotating tissue around afixed base to fill in a defect. A flap of tissue is dissected freeof the subcutaneous tissue, as in a simple advancement flap.The flap is rotated into position, and the defect is closed byFig. 2.15 Correction of dog ears requires stretching the redundant skinedges and excising the redundancy in the line of the incision. A singlecut treats both edges simultaneously; folding the redundancy and cut-ting with one blade inside the fold treats each edge separatelyFig. 2.16 (a) Wound margin is undermined in shaded region to achievesliding flap closure. (b) Simple linear advancement flap. (c) Rotationflap with triangle removed to facilitate closure. (d) Combined slidingand advancement flap. (e) Transpositional flap used to close nonadja-cent defects
  11. 11. 712 Basic Principles of Ophthalmic Plastic SurgeryFig. 2.17 (a–c) Tongue-in-groove advancement flap withBurrow’s triangles excised fromthe end of the incisionFig. 2.18 Elimination of surgical dead space with flap advancementFig. 2.19 V-Y plastyFig. 2.20 Transposition flap from nonadjacent areabeginning at both ends to minimize undue tension (Fig. 2.20).Those areas of puckered tissue can be excised as a triangleand closed with interrupted sutures.The Limberg or rhomboid rotational flap is a useful varia-tion of the standard rotational flap for situations that make aless complicated flap insufficient to close the defect [6]. It isparticularly helpful for closing diamond-shaped incisions orelliptic incisions that have been converted to a rhomboid shape.The configuration of the flap is shown. The critical elementsare the 120° and 60° angles, as indicated, so that the flap sitssnugly into position (Fig. 2.21). The key to success is the ori-entation of the excision site. Before demarcating the lesion, thesurgeon should determine in which direction the skin is mostextensible. This line becomes the lateral aspect of the channel.This approach ensures minimal wound tension at the conclu-sion of the procedure. The guideline cannot be perpendicularto the lid margins because this position may cause abnormaltension and result in malposition of the eyelid (Fig. 2.22). Theprocedure lends itself well to use in the orbital adnexal areas.After creation of the defect, the flap is formed with the topextending from an imaginary line bisecting the 120° angle. Itis the same length as the corresponding side of the diamond.To complete the flap, the lateral incision is formed by placingit at a 60° angle and parallel to the bottom or top side of thediamond, depending on which way the flap will be rotated.Meticulous dissection is used to properly undermine and iso-late the flap until it can be rotated into the defect. After it isrotated, near-far, far-near sutures are used to secure it.
  12. 12. 72 G.J. Lelli Jr. et al.Z-plastyZ-plasty is an important surgical option to release acontracted scar. It is a transpositional flap, and it is used todecrease the tension on a scar. It is also possible to com-pletely excise the scar or a mass within the central incision ofthe Z-plasty by enclosing it within a spindle-shaped exci-sion. The combination of a Z-plasty with a spindle-shapedexcision of a mass is called an O-Z plasty (Fig. 2.23). Theflap is started by orienting the long or central arm of the Zthrough the scar or lesion and parallel to the principle line oftension. After the central incision is oriented and sized, theoutside incisions are created with an equal length to the cen-tral incision and are angled at 60° to the central incision. Thiscreates two flaps shaped like equilateral triangles of equalsize. The flaps are undermined extensively so they can berotated into position and joined together without significanttension (Fig. 2.24). This process is facilitated by creatingflaps of equal size that are mirror images of each other acrossthe central incision.Once the triangular flaps are formed, the subdermal tissueis examined. Subcutaneous fibrous bands may be presentthat the surgeon had not appreciated preoperatively. Thesebands must be excised completely because failure to releasethem may result in an inadequate surgical result. The flapsare joined by anchoring the bases of the flap first and thenFig. 2.21 Limberg rotational flapFig. 2.22 Lines of direction altered to preserve eyelid functionFig. 2.23 O-Z plasty
  13. 13. 732 Basic Principles of Ophthalmic Plastic SurgeryFig. 2.24 (a) Central incisionthrough line of traction with armline offset by 60° angles.(b) Flaps dissected free andelevated. (c) Fibrotic bandexcised and flaps ready fortransposition. (d) Flaps havebeen transposed. (e) Flapssutured into positionevenly distributing the tension along the remainder of theflap with multiple interrupted sutures. It may be appropriateto use buried sutures to minimize the effects of late scar con-tracture. Sometimes it is necessary to anchor the flap apexeswith vertical or horizontal mattress sutures to distribute thetension better along the flap edges. Undue stress caused byinequality of the flaps promotes poor or incorrect woundhealing. Such problems may actually exacerbate the underly-ing condition rather than improve it. If it is not possible tomake these flaps of equal angles, there should be no morethan 20° of difference between them.The use of the Z-plasty may range from apparently simpleapplications to extremely complex situations. It is useful forrelieving vertical contracture in the eyelids after trauma. It isalso helpful for long, complicated scars of the face.To correct a vertical shortening of the upper eyelid fromscar contracture, the tension-relieving incision or excision ismade vertically through the cicatrized area of the lid. Thetwo arms of the Z are made at 60° angles to the central inci-sion to form the two equilateral triangles. The flaps are com-pletely mobilized. All of the underlying scar tissue is excised.Any scar tissue that remains will compromise the desiredsurgical result. The flaps are carefully transposed. A signifi-cant lengthening of the vertical dimension of the eyelid willresult. It is frequently possible to increase the vertical dimen-sion of the eyelid by one-third of the length of the scar(Fig. 2.25). To enhance the early healing process, a tractionsuture should be placed through the upper eyelid margin andtaped to the cheek for approximately 1 week. A double-armed 6–0 silk suture with cutting needles is placed through
  14. 14. 74 G.J. Lelli Jr. et al.Fig. 2.25 (a) Cicatricial band causing vertical shortening of the upperlid. (b) Central line through scar with arms offset at 60° angles. (c)Flaps dissected free and ready to be transposedFig. 2.26 Upper lid placed on stretch with bolsters after completion ofthe Z-plastythe eyelid margin directly below the Z-plasty, over a bolstermaterial of the surgeon’s choice (Fig. 2.26). At the surgeon’sdiscretion, the suture may be brought through the lower eye-lid margin to completely close the eyelids for the week thatthe suture is in place. By keeping the eyelid stretched for thefirst week, the initial wound contraction is controlled and thevertical elongation of the eyelid is enhanced. Gentle massageof the area can soften the subcutaneous scar.Z-plasty can also be used for more-complex types offacial scars. Multiple Z-plasties can be used for long scarsthat would not respond well to a single large Z-plasty. Theinitial, central incision is made through the center of the scar.The first two arms are created at 60° to the central incision tocreate the first two equilateral triangles of tissue for the flaps.Additional arms are created as necessary to completely treatthe scar (Fig. 2.27). Great care must be taken to ensure thatthese incisions parallel the original offset incisions. It is easyto become slightly disoriented, and each mistake will resultin successive mistakes in placement of the incision. Thenumber of pairs of incisions depends on the length of the scarand adequate distribution of the wound tension. Each pair ofoffset incisions that forms a Z-plasty is treated as describedabove.Z-plasty is also helpful to rotate the eyelid or brow mar-gin. In this role it can be a useful alternative to skin grafting.When caring for burn patients, there is minimal skin avail-able for grafting, and avoiding a graft can be critical. Toenhance incision placement and accuracy, the surgeonplaces the eyelid on stretch before the incision. This canbe accomplished with a 4–0 silk suture. The incision is madethrough the skin 2–3 mm outside of the ciliary margin. Thearms of the Z are completed on the side of the eyelid thatthe tissue flaps will be moved toward (Fig. 2.28). The flapsare meticulously dissected, and all fibrotic bands are excised.In cases of lateral or medial canthal transposition, the angleof the flaps may not be at 60° angles. It may be necessary to
  15. 15. 752 Basic Principles of Ophthalmic Plastic Surgeryangle the flaps more acutely to allow the flaps to work withinthe available space. It may also be necessary to incise andreattach the lateral canthal tendon before final placement ofthe flaps.A similar problem such as elevation of the lateral canthuscan be solved by adapting this technique. The flap is takenfrom the lateral portion of the lower eyelid and used to rotatethe lateral canthus downward. The level of the medial canthusis used as a guide to estimate the optimal placement of thelateral canthus. In this adaptation, the central portion of the Zis marked first. It is placed 3 mm below the cilia line. Parallelto the lid margin, it extends from the middle of the lowereyelid to the angle of the malpositioned lateral canthus, notthe future site of the new lateral canthus. Then the incisionsweeps medially, superiorly, and obliquely toward the supra-tarsal crease of the upper lid. The inferior arm of the Z isbrought laterally and ends at the desired position of the newlateral canthus. This step is extremely important. The cicatrixcreating an abnormal canthal position is excised segmentallyuntil the lateral canthus freely drops into the desired position.The inferior angle is then transferred to fill the superior defect.Skin hooks or delicate atraumatic forceps are extremely helpfulduring these manipulations. The wound is then closed.An elevated brow can also be corrected by a Z-plasty. Theincisions are marked out while keeping in mind that thefuture position of the elevated brow will be determined by itsplacement in the temporal and inferior arm of the Z(Fig. 2.29). The site is estimated by comparison both to thecontralateral brow and the medial aspect of the ipsilateralbrow. The absence of cilia in the elevated brow or aberrantgrowth should be noted. If they are found, placement of thebrow should be adjusted accordingly. The central portion ofthe Z is placed under and parallel to the arch of the affectedbrow. The superior arm is then offset to follow the curve ofthe superior orbital rim. The inferior arm of the Z is placedparallel to the superior incision. It may be necessary to extendthe lateral aspect of the inferior incision slightly in order tolessen wound tension and accommodate the transposition.This frequently makes the Z resemble the number 2. Theflaps are dissected carefully to minimize the risk of injury tothe lash follicles. The flaps are transposed as shown andsutured into position.Fig. 2.27 (a) Multiple Z-plasty marked out and incised. (b) Flaps carefully transposed and sutured into position
  16. 16. 76 G.J. Lelli Jr. et al.Transmarginal Repair of the EyelidAll incisions or lacerations of the eyelid margin requiresurgical repair to restore the structural integrity of the eyelid.This is true even if the involvement is only partial thickness.This type of surgical repair can be performed with a generalor local anesthetic as the situation dictates. As always, whenusing a general anesthetic for eyelid surgery, it is very helpfulto infiltrate local anesthetic with epinephrine into the opera-tive area for short-term pain control and vasoconstriction. Thetechnique of pentagonal wedge resection can be used to closea horizontal lid defect regardless of the underlying cause.The medial wound edge is first straightened with a super-sharp knife or a No. 11 Bard-Parker scalpel (Fig. 2.30). Thisallows a more precise closure and removes debris from theincision. The eyelid margin is grasped with toothed forceps.While keeping the eyelid under tension, the blade is insertedthrough full-thickness eyelid. It is brought upward in onecontinuous motion to remove all of the irregular tissue whilecreating a smooth wound edge. The lateral wound edge istreated in a similar fashion. Attention is directed to closingthe wound edge without leaving a notch in the eyelid margin.The center point of this effort is placing three 6–0 silk suturesthrough the eyelid margin. The sutures should be passedthrough the meibomian gland orifices, the gray line, and thelash line approximately 2–2.5 mm from the wound marginon either side (Fig. 2.31). The first suture passed should bethrough the gray line, just anterior to the mucocutaneousjunction. A double throw is placed in the suture and the eye-lid margin is evaluated. The eyelid margin should be wellapproximated with a solid mirror-image pass. If the woundedges are symmetrically joined, the suture is completed withtwo more throws to make square knots and the suture is cutlong and placed within a hemostat which is rested on thepatient’s brow and aids in retraction for the next pass. If thewound edges are not symmetrically joined, the above-mentioned process needs to be repeated. The second sutureis placed through the lash line by starting the needle 2–2.5 mmfrom the wound edge and passing it in a smooth, symmetricfashion through the opposite side of the wound at the samelevel. This suture is tied, cut long and placed in a hemostat,and retracted inferiorly (rested over the patient’s cheek) toaid in retraction for the last lid margin suture. The thirdsuture is passed in between the first two (along the meibo-mian gland orifices), usually in one single pass which isaided by the retraction provided by the initial two sutures.This suture is also cut and left long (Fig. 2.32). All three lidmargin sutures are then placed in the same clamp which isrested on the brow and provides retraction for the deep, tarsalclosure. Absorbable 5–0 or 6–0 sutures are used to close thetarsal plate. They are passed anteriorly through the tarsus ina lamellar fashion to approximate the tarsal edges during theFig. 2.28 (a) Z-type incision prepared to correct lower lid deficiency.(b) Upper lid flap transposed to fill deficiency and sutured into place.(c) Central incision made along lid margin in attempt to lower lateralcanthus. (d) Lower lid flap transposed to upper lid and sutured in place
  17. 17. 772 Basic Principles of Ophthalmic Plastic SurgeryFig. 2.29 (a) Correction ofelevated brow by Z-type incision.(b) Transposed brow withplacement at temporal endof lower armFig. 2.30 Freshening of wound edgesFig. 2.31 Correct placement of sutures for full-thickness eyelid repairFig. 2.32 Closure of posterior lid margin sutures away from thecorneahealing phase and to avoid any exposure of the suture on theconjunctival side. By placing sutures in the tarsus, the woundstress is more evenly distributed, the likelihood of a dehis-cence is decreased, and the risk of a lid notch is minimized(Fig. 2.33). The skin is closed with interrupted 6–0 sutures,and the lid margin sutures are tied inferiorly into one of theskin sutures to avoid corneal-suture touch. The patient isinstructed not to rub the eyelid and to wear a shield wheneversleeping for the first 2 weeks after surgery to avoid inadver-tently rubbing the eyelid during twilight sleep (Fig. 2.34).The lid margin sutures are left for 7–14 days. The patient isusually seen at 7 days, and a determination is made at thattime regarding optimal suture removal. The decision of whento remove the lid margin sutures is greatly influenced by the
  18. 18. 78 G.J. Lelli Jr. et al.surgeon’s personal experience and the patient’s ability toheal. Since the dense connective tissue of the tarsus requires9–10 days to heal, removal of these sutures is most oftenperformed at about 10 days from surgery.After suture removal, the lid margin should be slightlyeverted. The eversion resolves with complete resolution of thepostoperative edema. It is also acceptable to have the lid mar-gin smooth and flat. A small depression developing at the inci-sion site will fill in with epithelium. If a depression larger than2 mm develops, it will probably require surgical revision.Sometimes the defect is too large to allow direct closure.In these cases, it is necessary to obtain additional tissue torelieve the tension on the wound, otherwise the wound willstretch and separate in the early postoperative period.The simplest way to obtain additional tissue is through alateral canthotomy. A straight mosquito hemostat is placedaround the lateral canthus, with the blades straddling thehorizontal raphe. The hemostat is advanced until the inner tipreaches the cul-de-sac at the level of the bony rim. The can-thal tissue is crushed (Fig. 2.35). The area is then incised withminimal bleeding. The eyelid has now gained several milli-meters of additional horizontal length. If this is sufficient, thewound is closed and the canthal incision is closed with inter-rupted sutures. If additional tissue is required to close theincision, the appropriate crus of the lateral canthal tendon canbe partially or completely lysed. The tendon is isolated fromthe orbicularis anteriorly and the conjunctiva posteriorly bycarefullydissectingwithinthecanthotomyincision(Fig.2.36).The tendon can be incised in a graded fashion to provide pro-gressively more horizontal lid tissue until the tendon is com-pletely severed (Fig. 2.37). Complete severing of the inferiorcrus of the lateral canthal tendon creates approximatelyFig. 2.34 Completed wound closureFig. 2.35 Formation of lateral canthotomyFig. 2.36 Isolation of inferior crus of the lateral canthal tendonFig. 2.33 Closure of vertical wound’s subcutaneous layer whichincludes the tarsal layer closure
  19. 19. 792 Basic Principles of Ophthalmic Plastic SurgeryFig. 2.39 Final closure of incisions after lateral canthotomy andinferior cantholysis for lid margin reconstructionFig. 2.37 Lysis of the inferior crus of the lateral canthal tendonFig. 2.38 Sliding full-thickness eyelid into place medially after lysisof the inferior crus of the lateral canthal tendon8–10 mm of additional eyelid length (Fig. 2.38). Whenproperly dissected away from the surrounding tissues, sever-ing the tendon does not significantly affect the position orfunction of the eyelid. The primary wound is closed firstfollowed by the canthal incision (Fig. 2.39). When the inferiorcrus of the lateral canthal tendon has been completely lysed,deep sutures are useful from the lateral aspect of the eyelidorbicularis and tarsus to the inner aspect of the lateral orbitalrim, to serve as lower eyelid support and reforming sutures.References1. Custer PL, Trinkaus KM. Hemorrhagic complications of oculoplas-tic surgery. Ophthal Plast Reconstr Surg. 2002;18(6):409–15.2. Lee E, Holtebeck AC, Harrison AR. Infection rates in outpatienteyelid surgery. Ophthal Plast Reconstr Surg. 2009;25(2):109–10.3. Baran CN, Sensoz O, Ulusoy MG. Prophylactic antibiotics in plasticand reconstructive surgery. Plast Reconstr Surg. 1999;103(6):1561–6.4. Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. Incidence ofpostblepharoplasty orbital hemorrhage and associated visual loss.Ophthal Plast Reconstr Surg. 2004;20(6):426–32.5. Courtiss EH, Longacre JJ, Destefano GA, Brizio L, Homstrand K.The placement of elective skin incisions. Plast Reconstr Surg.1963;31(1):31–44.6. Lister GD, Gibson DT. Closure of rhomboid skin defects: the flapsof Limberg and Dufourmentel. Br J Plast Surg. 1972;25:300–14.
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