REFERENCES

1.Cutler NL, Beard C (1955). A method for partial and total upper lid reconstruction. Am. J. Ophthalmol., 39(1): A-7.

2.Wesley RE, McCord CD Jr (1980). Transplantation of eyebank sclera in the Cutler–Beard method of upper eyelid reconstruction. Ophthalmology, 87(10): 1022–1028.

310 Opposite. Primary closure in a lesion not involving the lid margin. a: Circular defect with dotted lines indicating triangles to be removed. b: Defect ready for closure. c: Primary closure using interrupted 6-0 silk or running 7-0 polypropylene sutures. Deep layers may be closed with interrupted 5-0 chromic gut sutures.

311 Opposite. Upper lid circular defect not involving the margin. a: Circular defect with dotted lines indicating triangles of skin and subcutaneous tissue to be removed. b: Defect ready for primary closure. c: Primary closure with interrupted 6-0 silk or running 7-0 polypropylene sutures. Deep layers are not closed since this wound should be approximated without any tension.

GENERAL CONSIDERATIONS

When repairing soft tissue defects of the eyelids that do not involve the eyelid margins, the general principles of skin reconstruction must be modified so that the eyelid function is properly preserved. For instance, a defect in the lower lid might be closed in a horizontal manner so as to hide the scar within a line of facial expression. However, if the defect is greater than the amount of available skin, this type of repair might result in lower lid ectropion. Ectropion of the upper lid is less likely to occur following a horizontal closure since upper lid skin is usually more plentiful. Tarsal kinking can occur in either the upper or lower lid if a vertical closure is done without sufficient attention to the effect on the tarsus.

Skin color and texture is best preserved if a flap of skin can be rotated or advanced into a defect from an adjacent area. The laxity of the surrounding skin and the potential eyelid deformity from the effects of healing will usually determine which method of repair is used. In many cases, several methods will be equally acceptable.

Increased tension on a wound might result in a widened

scar. Subcutaneous absorbable sutures can be used to decrease this tension. An alternative method to take tension off the wound is to place a horizontal mattress suture across the wound. These sutures can be tied over bolsters of cotton or other nonirritating material.

Skin can be closed with interrupted 6-0 silk or 7-0 nylon sutures or running 6-0 or 7-0 nylon sutures, depending on the strength needed for the wound closure. 6-0 or 7-0 polypropylene can also be used for wound closures, as a running suture with loops on either end. To remove this suture, one loop is cut and the suture is pulled through from the other end. 7-0 polypropylene slides very easily.

PRIMARY CLOSURE

A circular defect can be converted to an ellipse in order to eliminate ‘dog ears’ in a primary closure. This type of closure can be used in the upper lid, lower lid, or either canthal area. In deciding in which way to orient the ellipse, the general principles mentioned above must be considered (310, 311).

ADVANCEMENT FLAPS

If the defect appears to be too large to respond to primary closure, advancement flaps should be considered as the

next procedure of choice. The adjacent area with the most lax skin is the place to fashion the advancement flap. In some cases, an advancement flap can be taken from both sides of the defect, rather than doing extensive undermining to get a rotation flap from only one side (312–322).

312 Horizontal advancement flaps.Tension is taken off the skin wounds by attaching flaps to deeper tissues.

313–318 Reconstruction using horizontal advancement flap. 313: Basal cell carcinoma on the right lower lid of a 40-year-old male. 314: One day postoperative showing the advancement flap which was brought from the lateral lid into the defect. 315:Thirteen days postoperative showing healing with some residual edema in the lower lid. 316: Middleaged female with a basal cell carcinoma in the lateral left lower lid.

317: Same patient one week after advancement to repair defect.The flap is outlined by the sutures that are still in place. 318: Four years after surgery the wound has healed well and the lid margin is in the proper position.

314

Skin muscle island flaps are a type of advancement flap, but in these cases the uninterrupted blood supply comes from the underlying muscle that is left intact. The skin is completely freed from attachments on all sides, brought into the defect, and then the donor area is closed primarily.

319

Advancement Flaps 109

Along with the blood supply from the underlying muscle, there will be new vessel formation from the surrounding skin and subcutaneous tissue (323).

As a general rule, the surgeon should form advancement flaps in a horizontal direction in the upper and lower

319–322 Lateral advancement flap for large lower lid defect not involving the lid margin. 319: Small pigmented lesion in a 37-year-old female. Clinical diagnosis was lentigo, but histological examination showed melanosis with a focus of severe atypical melanocytic hyperplasia.This type of lesion might progress to a malignant melanoma. 320: Defect shown after wide resection of the tumor. 321: Closure of lateral advancement flap. 322: Patient shown six months after tumor removal.

320

321

322

323

a

b

c

323 Myocutaneous island flap. a: Circular defect with dotted lines indicating the outline of the island flap. b: Flap is brought into the defect. The muscle layer in the superior part of the triangle is left attached as the primary blood supply (216b). c:The triangle is trimmed to fit the defect, and the donor site is closed primarily.