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Lid reconstruction
- 1. Lid reconstruction PRESENTED BY: DR.VANDANA SHARMA
- 2. Surgical anatomy Skinthinnest in eyelids No subcutaneous fat No or fine hairs present Attached to medial lateral palpebral tendons Dimensions of palpebral fissure: Vertical: 8 – 11mm Horizontal: 25 – 30 mm
- 3. Lateral canthuslies 1-3 mm above medial canthus Highest point of palpebral fissure is at junction of medial and central thirds Structures of lid margin: Cilia Grey line Meibomian ducts
- 4. Intermarginal striphas sharp posterior border Tarsal plate is firmly attached to connective tissue and skin at lid margin Muscles of the lids: Orbicularis oculi Levator palpebre superioris Corrugator supercilii Muller’s muscle
- 5. Orbital septum Unites tarsal plate to supra and infra orbital margins Not uniform in thickness Pierced by vessels and nerves Medial palpebral tendon: Connects both tarsal plates with medial wall of orbit on lacrimal crest Gives origin to orbicularis oculi
- 6. Lateral palpebraltendon Closely connected to tarsal plates, lateral raphe of orbicularis oculi and lateral expansion of LPS Attaches on a tubercle about 3 mm posterior to orbital margin
- 7. General considerations beforesurgery Final shape and outline of features should be comparable on both sides Patient’s general state of health should be known Local condition of the wound should be noted Skin defects in the lids should be covered by sliding adjacent skin or using flap from redundant skin
- 8. Lid marginshould be preserved as much as possible Orbicularis muscle should be disturbed as little as possible Palpebral conjunctiva cannot be slided Line of skin sutures should not directly overlie cartilage and bone grafts
- 9. Technique of suturing All blood clots and debris should be removed Sutures should be applied with 6 – 0 braided silk with spatulated curved eyeless needle Slight eversion of cut edges should be done when sutures are tied Colour of skin edge should remain pink Sutures should be placed about 6 mm apart Skin wound of 3 – 4 mm along skin crease needs no suturing Wound of orbicularis at right angles to the muscle should be sutured with 6- 0 absorbable suture
- 10. Closure of fullthickness lid margin incision or wound Should be closed in layers Notching of lid margin should be avoided
- 12. Absorbable 6 –0 suture is placed as close to lid margin as possible Single knot is tied and approximation is assessed 2 more absorbable sutures are passed through tarsal plate Silk 6 – 0 suture is passed through grey line and left loose 1st absorbable suture is then tied Orbicularis is sutured Grey line suture is tied and left long Lash line is sutured Skin is sutured and long ends of previous sutures are caught in them
- 13. Deep subcutaneous knots Buryinga subcutaneous knot Figure of 8 stitch
- 14. Reconstruction of eyelids,socket and orbit Local flaps Rotation Transposition Advancement Island Free grafts Skin Split skin Full thickness
- 15. Hair bearing Mucous membrane Other like fat, bone, cartilage etc Pedicle grafts Expanded grafts Muscle grafts Free flaps
- 16. Local flaps Mainsources are Forehead Glabella Cheek Transposition flaps such as Z plasty may be done Advancement flap such as V Y operation may be used In island flap, skin is raised in subcutaneous pedicle along with blood supply from the pedicle and advanced over short distances
- 17. Free grafts Skingrafts: Split skin grafts: Preparation of donor site Usually medial aspect of upper arm or thigh General anaesthesia is used Harvesting the graft Donor site lubricated with sterile liquid paraffin or petroleum jelly Donor skin stretched with skin graft boards Graft taken with skin graft knife
- 18. Dressing donorsite Dressed with tulle gras and melolin Light gauze bandage is applied Left undisturbed for 10 days Hemostasis achieved at recipient site Fixation of graft Graft stitched to edges of defect with fine silk Dressing with tulle gras and proflavine wool is sutured with the graft
- 19. Post opcare Inspection of dressing at 24 and 48 hrs Removal of sutures after 10 days
- 20. Full thicknessgrafts May be taken from Redundant skin in upper eyelid post auricular skin Pattern of recipient area is taken Full thickness graft is taken and donor site is closed Skin flap is defatted Edges of graft are sutured to edges of the defect Proflavine bolster sutured
- 21. Anchoring suturesmay be applied Daily inspection of graft to ensure no seroma or hematoma is formed Stitches removed after 7 – 14 days
- 22. Hair bearinggrafts: Full thickness free grafts containing hair follicles Local scalp flaps containing hair
- 23. Temporal island flapfor reconstruction of eyebrow
- 24. Mucous membrane: Conjunctiva Free conjunctival flaps Local transposition of conjunctival flap Buccal mucosa To cover defects in palpebral and bulbar conjunctiva after injury, burns excision of neoplasms May be taken from inner aspect of lower lip or cheek
- 25. Fat: Freefat grafts shrink to almost half of their size So not preferred for contour reconstruction Used to repair depressed scars Cartilage: Thin cartilage grafts needed to reconstruct tarsus taken from auricle or nasal septum Cartilage grafts for reconstruction of orbital margins taken from rib
- 26. Bone: Reconstructionof orbital floor is done with bone graft from iliac crest Periosteal layer should be retained with the grafts Fascia: Used in ptosis surgery Taken from fascia lata or extensor tendon of little toe
- 27. Pedicle grafts Consistsof skin, and subcutaneous tissue along with its own blood supply Skin of temporofrontal region is commonly used in eyelids Good color match May be hair bearing Have to be advanced in stages
- 28. Expanded flaps Tocover large defects, flaps are expanded with tissue expanders More complications are seen with these
- 29. Muscle grafts Microvasculartransplantation of muscle will ensure its survival at transplanted site Function can be retained by preserving nerve supply
- 30. Free flaps Transferof skin flaps with their own arterial and venous supply Direct anastomosis of arteries and veins is done under operating microscope Large areas of skin, muscle and cartilage can be transferred
- 31. Lateral canthotomy Indications: To decompress orbit in cases with orbital cellulitis Correction of partial ankyloblepharon or blepharophimosis In cataract surgery for better exposure of globe as in deep socket Procedure: Skin at lateral canthus is made taut and lifted up Hemostasis is achieved by crushing with mosquito forcep
- 32. One bladeof a blunt ended scissors is passed into lateral fornix Scissors is closed thereby cutting the tissue Closure of canthotomy: One interrupted silk suture passed through the two cut ends is sufficient
- 33. Cantholysis Indications: Reconstructionof full thickness defect for quarter of length of lid or more Facilitate forward movement of lids in tarsorraphy Procedure: Dicision of one or both bands extending from tarsal plate to lateral canthal tendon Division of orbital septum from orbital margin may also be done
- 34. Canthoplasty Lateral canthotomyis done Bulbar and froniceal conjunctiva is undermined Sliding flap of conjunctiva is carried through the skin 4 mm lateral to extent of canthotomy Mattress sutures are passed between skin and conjunctival flaps to cover the raw surfaces If conjunctiva is insufficient, free flaps may be taken
- 35. Canthal tendon operations Division and fixation of medial canthal tendon: Medial canthal tendon may get damaged due to injury or DCR May lead to downward displacement of medial canthus Repair:
- 36. Tendon is exposed Anchoredinto a pre bored tunnel in frontal process of maxilla If the tendon is short, a non absorbable suture passed at end of the tendon is passed into the tunnel, back into the tendon and sutured
- 37. Replacement of medial canthal tendon Narrowlamellar pedicle is cut from upper tarsal plate Reflected back on itself medially over lower canaliculus Free end is sutured to periosteum over anterior iliac crest
- 38. Division oflateral palpebral tendon: Done in rapidly progressive exophthalmos Procedure: Lateral canthotomy is done Lateral margin of orbit is identified Blunt ended scissors is spread posteriorly upto orbital tubercle Scissors is turned so that the blades open in vertical direction Tendon is engaged and cut
- 39. Reconstruction oflateral palpebral tendon Fascia lata may be used Procedure: 1.5 cm long incision is made at lateral canthus along skin crease Orbicularis is retracted Lateral ends of upper and lower tarsal plates are identified Vertical incisions are made into each tarsus 4 mm long, 3 mm from its ends Tunnel of diameter 4 mm is drilled into orbital wall after retracting orbital contents medially
- 40. Strip of fascialata is split into ‘Y’ Base of y is passed into orbital tunnel and emerging free end is sutured over itself Each arm of y is passed in the buttonholes of the tarsal plates and sutured over itself Orbicularis incision is sutured over itself with absorbable sutures Skin is sutured with non absorbable sutures
- 41. Closure of liddefects Small defects: Closed by advancement of adjacent skin or V – Y plasty Full thickness defect for quarter of length or less: Modified Wheeler’s operation is done Full thickness defect for more then quarter of length: Mustarde’s operation Upper lid rotation from lower lid Loss of more than half of eyelid Cheek rotation flap for reconstruction of lowerlid Lower lid rotation and cheek rotation flap for upper lid reconstruction
- 42. Modified wheeler’s operation forlid defects
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- 46. Mustarde’s cheek rotationflap for lower lid reconstruction Lower lid is reconstructed from cheek skin, nasal septum cartilage and nasal mucosa
- 47. Mustarde’s cheek rotation flap Mobilisationof cheek flap Nasal mucous membrane and septal cartilage graft • size of mucous membrane graft: 2.5 cm long and 1.5 cm wide Fixation of cheek flap
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- 50. Reconstruction of upperlid Severe damage to upper lid is rare Immediately jeopardizes safety of the eye Points to be considered while reconstructing upper lid Should be lined with conjunctiva or buccal mucosa Should contain a supporting plate Should have a muscle action if possible in form of orbicularis or LPS attachment
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- 52. LPS maybe torn in trauma Retraction is prevented by lateral attachments of the muscle Repair: Local anaesthetic is injected Site of torn aponeurosis is revealed by asking the patient to look up Aponeurosis is held in a clamp and sutured to anterior surface of tarsus with 4 – 0 absorbable sutures If primary repair has not been done timely, 6 – 12 months should be allowed to elapse before attempting repair
- 53. Mustarde’s operation forreconstruction of upper lid in 2 stages Broad based full thickness flap of lower lid is made Rotated into the defect as far as possible and sutured 2 weeks later base of flap is cut and remaining flap sutured to remaining defect Lower lid is reconstructed with cheek flap and nasal septal cartilage and mucous membrane Principles for creating lower lid flaps: If remnant of upper lid is present: hinge made on same side If defect is total or central: hinge is placed laterally Lacrimal punctum is not included in the flap
- 54. Mustarde’s operation for reconstruction of upperlid in 2 stages
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- 57. Neoplasm excision Proliferativetype of BCC does not invade deeper tissues Lesions over lid margins also do not tend to involve tarsal plate 2 different sets of instruments should be used for excision of tumor and plastic repair Excision of neoplasm: Proliferative lesion 3 mm from lid margin: lid margin structures should be preserved Deeply infiltrative lesions: full thickness resection has to be done
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- 59. Collar stud excision withpartial tarsectomy Done when main mass of lesion lies away from lid margin with possible involvement of tarsus at lid margin Tarsal coloboma is closed with interrupted absorbable sutures Cantholysis may be used
- 60. Tarsal sutures aretied Orbicularis bridge flap is sutuered Full thickness skin flap is placed over the defect
- 61. Medial canthusreconstruction: When plane of excision is not upto periosteum: full thickness skin grafts are used When plane of excision is upto periosteum: V Y advancement of frontoglabellar flap for defect upto 10 mm Midline frontal pedicle for defect more than 10 mm
- 62. Frontoglabellar flap Inverted Vincision is given Flap is mobilized Defect is closed Flap is sutures in Y shape Free conjunctival or buccal mucosal flap is attached to undersurface Medial end is sutured to periosteum Flap is cut in centre to create upper and lower lid
- 63. Midline frontal pedicleflap Incision is given on glabella and flap is raised Anterior end of flap is divided so as to fit upper and lower lid defects Anterior end is lined by free conjunctival or buccal mucosal flap Anterior end of flap is sutured to the defects Vertical incisions on forehead are undermined, approximated and sutured Medial limit of graft is marked Tulle is passed beneath the pedicle bridge After 18 days, pedicle is cut at marked site Fibrous tissue from undersurface is excised and it is sutured back to frontal region Medial edge of graft is sutured
- 64. Total loss oflower lid and partial loss of upper lid Lower lid is reconstructed using cheek flap If medial half of upper lid is lost, midline frontoglabellar pedicle flap is used If lateral half of upper lid is lost, temporofrontal flap is used
- 65. Total loss ofupper lid and partial loss of lower lid If lateral part of lower lid is conserved it is rotated to medial side of upper lid Lateral part of upper lid is reconstructed with temporofrontal flap Lower part of lid is reconstructed with cheek flap When medial part of lower lid is conserved Lateral defect closed with cheek flap Upper lid reconstructed with supraorbital flap
- 66. Total loss ofboth eyelids Four stage repair is done Stage 1: Remnants of conjunctiva mobilized and sutured with absorbable suture to cover the cornea Thin shaving of auricular cartilage may be placed to replace tarsus Bridge pedicles of orbicularis are placed over the eye Split skin graft is placed
- 67. Stage 2: After 1 month, split skin graft is replaced with full thickness skin graft Stage 3: Eyebrow bearing transplants may be used for creating lash line 1 – 2 mm skin is kept between the two lash lines Stage 4: After 3 – 4 months after 1st operation, tarsorraphy is divided
- 68. Bibliography Stallard’s eyesurgery;7th edition Lids, orbits, extraocular muscles, volume 1; Von noorden