ANESTHESIA

In most cases, local infiltrative anesthesia augmented with intravenous sedation can be used. With local anesthesia, the patient can be asked to open his or her eyes and look in various directions during the course of the reconstruction. In this way, the curve of the upper lid and the tension of the lower lid during different positions of gaze can be better evaluated. Since some eyelid reconstructive procedures last 2–3 hours, intravenous sedation is often a significant adjunct to the local anesthesia.

The author’s preferred anesthetic mixture is 2% lidocaine hydrochloride with epinephrine. If the anesthetic is given 20 min prior to the surgical procedure, it will be absorbed sufficiently so as not to distort the tissues, and the epinephrine will decrease the amount of bleeding.

If an eyelid margin is to be incised, one must remember to inject the anesthetic in the adjacent cul-de sac so that all of the conjunctival nerves are anesthetized. Care must also be taken not to anesthetize the levator muscle if upper lid function is to be evaluated during the course of the reconstruction. In order to decrease the discomfort of the injection of local anesthetic, the patient can be given intravenous sedation just prior to the administration of the lidocaine.

If use of epinephrine is contraindicated due to a cardiovascular problem, 2% lidocaine hydrochloride without epinephrine mixed with 0.5% bupivacaine hydrochloride without epinephrine can be used. With this combination, the surgeon should anticipate a significant increase in bleeding, resulting in frequent use of the cautery and significantly more swelling during the procedure.

REFERENCES

1.Pollack SV (1991). Electrosurger y of the Skin. Churchill Livingstone, New York, pp. 21–23.

2.NIOSH (1996). Control of smoke from laser/electric surgical procedures. USDHHS CDC; Publication 96–128.

3.Older JJ (2002) Review: The value of radiosurgery in oculoplastics. Ophthalmic Plastic and Reconstructive Surgery

18(3): 214–218.

SMALL CENTRAL LID MARGIN DEFECTS

If the defect is 5–10 mm (0.2–0.4 in) in horizontal diameter and if the edges can be manually brought together with the minimum amount of tension, a primary closure can be performed (196–200).

After tumor removal, the defect in the lower lid should be square or rectangular. Once all the margins are read as free of tumor, a triangle of skin and subcutaneous tissue inferior to the original defect is removed. This is done to eliminate wrinkling when the closure is performed. The triangle is base-up with the base of the triangle being the inferior margin of the defect.

Two or three absorbable sutures are placed within the tarsus so that the knots face away from the cornea. The needles are placed through the posterior aspect of tarsus, but not through conjunctiva, so that when the tarsal elements are re-approximated the sutures will not rub on the cornea. A half-circle needle is helpful in placing these sutures. Absorbable 6-0 polyglactin 910 or 5-0 chromic gut can be used.

One or two 6-0 silk sutures are placed in the lid margin, and a third is passed just inferior to the lash line and through tarsus. The absorbable sutures may be tied prior to the placement of the silk sutures, or the surgeon may choose to tie them after the silk sutures are placed. The silk suture that closes skin and muscle below the lash line includes the long ends of the other three silk sutures. This maneuver is performed to keep the ends of the lid margin silk sutures from rubbing on the cornea. The skin and subcutaneous tissue inferior to the tarsus are then closed with a running nonabsorbable suture such as nylon or polypropylene. If there is any significant tension on the wound, vertical mattress sutures of 6-0 nylon or subcutaneous sutures of 5-0 chromic gut can be placed so that the skin will approximate easily.

SMALL LATERAL OR MEDIAL LID MARGIN DEFECTS

If the defect in the lower lid has tarsus on one edge and no tarsus on the other because the defect is near a canthal tendon, the tarsus is sewn to the medial or lateral canthal tendon using interrupted 5-0 polyglycolic acid or polyglactin 910 sutures. Care must be taken to approximate the lid margin properly, realizing that the eyelid with tarsus will be thicker than the area of the canthus to which it is being sewn. Therefore, this must be considered when re-approxi- mating the skin in order to give a smooth closure. Skin can then be re-approximated with 6-0 silk, 6-0 nylon, or 7-0 polypropylene sutures.

Lesions in the medial lower lid may lie directly over the canaliculus. If the majority of the canaliculus is sacrificed, an attempt at reconstruction of the tear drainage system is best left to a later date. In many patients, especially those over 60, tearing will not be a problem because of the lower tear production. The upper canaliculus might be enough to drain the tears. If epiphora is a problem three months after surgery, repair such as conjunctivodacryocystorhinostomy (CDCR) should be considered.

A triangle of skin inferior to the defect can be removed as needed to allow for a smooth skin closure.

If part of the canaliculus of the lower lid is sacrificed during tumor resection, the remaining canaliculus may be marsupialized so that it drains the inferior aspect of the lacrimal lake (201). The end of the remaining canaliculus is incised along its superior posterior border for approximately 2–3 mm (0.15 in). The edges of the wound are then sewn in such a way that the canaliculus will remain open. A silicone tube is placed in the canaliculus; the eyelid defect is repaired, and the silicone tube is then stitched to the skin of the lower lid. The end of the tube is knotted so that the tube will not migrate into the canaliculus and, perhaps, into the nasolacrimal system. The author’s preferred size of tubing is 0.3 mm (0.012 in) inside diameter by 0.6 mm (0.025 in) outside diameter. This tube can be left in place for 1–2 weeks and then be removed.

If the majority of the canaliculus has been sacrificed during tumor removal, it is unlikely that marsupialization of the medial 3–4 mm (0.15 in) will allow the canaliculus to remain open. Therefore, if <6 mm (0.25 in) of canaliculus remains, the chances of reconstructing a patent canaliculus are small, and a CDCR should be considered if epiphora is a problem three months after tumor surgery.

MEDIUM LOWER LID DEFECTS EXTENDING TO THE MEDIAL CANTHAL ANGLE

If the medial aspect of a medium-sized defect extends past the punctum but no further than the medial canthal angle, the remaining lower lid can be brought medially by using the lateral advancement flap. If the lateral aspect of the advancement flap has no conjunctival lining, a modified tarsoconjunctival flap could be brought down to line the lateral part of the advancement flap (modified Hughes procedure). The remaining tarsus of the lower lid can be sutured to the remains of the lower limb of the medial canthal tendon. If part of the lower canaliculus is preserved, the repair can be accomplished as described under small defects which extend medial to the punctum (201).

201 Canalicular reconstruction. a: Defect in the medial aspect of the lower lid showing partially excised inferior canaliculus. b:The posterior superior aspect of the remaining canaliculus is incised for approximately 2 mm (0.1 in) to give a large opening. c: A silicone tube is passed into the remaining lower canaliculus and stitched to the lower lid skin in an attempt to keep the canalicular opening patent during healing.

If the defect in the lower lid is too large to be closed as in (196), but tarsus exists on either side, the eyelid that remains lateral to the area of excision can be brought medially by making an incision in the lateral canthal angle, and extending this incision laterally for 20–30 mm (0.8–1.2 in) and forming an advancement flap (202–215). The inferior horn of the lateral canthal tendon should be

incised. If the conjunctival layer is left intact at the lateral canthal angle, pulling the lower lid medially might tend to bring the lateral aspect of the upper lid medially and cause rounding of the lateral canthal angle. A full canthotomy can be performed so that the lower lid will slide past the upper lid, without distorting the canthal angle.

A base-up triangle of skin and underlying tissue should be removed inferior to the eyelid defect, and the tarsal edges and skin can be approximated as described for small defects (196).

After the tarsus is re-approximated, the subcutaneous

tissue of the advancement flap is attached to the periosteum just below the superior aspect of the wound. The attachment is made with one or several 5-0 polyglactin 910 sutures. This maneuver will keep the lateral aspect of the lower lid from pulling downward, thereby preserving the proper angle of the lateral canthus. The lateral canthal angle can then be re-approximated with 6-0 silk sutures, and the rest of the lateral wound is closed with a running 6-0 nylon suture. A triangle of excess skin may be removed if necessary, to allow a smooth skin closure.