Ординатура / Офтальмология / Английские материалы / Tumors of the Eye and Ocular Adnexa_Char_2001

30 TUMORS OF THE EYE AND OCUALR ADNEXA

squamous cell carcinoma, slightly lower tumor control rates have been achieved; Fitzpatrick and colleagues noted a 5-year control rate of 93 percent.56

In our limited experience with KS, approximately 90 percent of lesions responded to a single 800-cGy fraction of orthovoltage or electrons, and results appeared to be as good as with fractionated doses totalling 1,500 to 3,600 cGy.57 Lid or conjunctival KS lesions are usually more diffuse than evident on clinical examination; they should be treated with a relatively wide surround. An example of a lid and conjunctival KS prior to and after irradiation is shown in Chapter 4, Figures 4–42 and 4–43. While other options, including intralesional vinblastine sulfate (Velban), cryotherapy, and surgical resection, have been reported, single-fraction radiation seems to be the most effective with the least morbidity.58,59

We have not used radiation as a primary therapy for sebaceous gland carcinomas of the eyelids. The results with radiation in the literature have been variable. Some early failures were due to insufficient radiation; however, some recurrences have been described despite treatment with as much as 119 Gy of radiation.32,34,60 One of three patients treated with primary radiation developed nodal metastases 6 months after treatment.61

This author’s bias has been to use surgery for basal, squamous, or sebaceous cell carcinoma or melanoma confined to the lid, and to limit the use of radiation to diffuse tumors that have sufficient orbital or bone involvement to preclude conventional surgical resection. In some of these latter cases, wide-field radiation has either cured the tumor or produced sufficient shrinkage to allow surgical removal of the residual mass.

After successful radiation of any lid tumor, epitheliitis develops and peaks approximately 10 to 20 days after treatment and subsides in 2 to 4 weeks. Tumor destruction is usually complete by 2 months.

A number of complications have been reported after eyelid radiation. Most of the serious complications have occurred after treatment of large upper lid tumors. Lederman noted an overall complication rate of 10 percent.53,54 In a large French series, < 4 percent had serous ocular side effects.40 Almost all irradiated lids develop keratinization of the palpebral conjunctiva (Figure 2–8). Patients radiated for

tumors in the middle of the upper lid are more prone to develop ocular complications, even when the cornea is shielded. Radiation complications include lid atrophy, skin necrosis, ectropion, lid telangiectasia (Figure 2–9), epiphora, lash loss (Figures 2–9, 2–10), keratitis, and cataract.52,53,62 An example of a disastrous complication after an appropriate dose and fractionation of radiation for a basal cell carcinoma of the upper lid is shown in Figure 2–11. Anterior exenteration was eventually required in this case. A lower incidence of significant complications occurs with external beam technique versus iridium wire technique, and most complications occur in patients with large tumors.51,56,63,64

Cryotherapy

Cryotherapy is an effective alternative treatment for small, localized basal cell carcinomas.65–68 It is especially useful in debilitated patients or others in whom there are systemic contraindications to surgery.56–59 An advantage of cryotherapy, compared with radiation, for the treatment of small basal cell carcinomas is that cryotherapy can be performed in one session versus the 3- to 5-week course needed for external beam radiation. Overall, there is about a 10 percent recurrence rate after cryotherapy, mostly due to inadvertent inclusion of morpheaform, diffuse, or multicentric lesions in the treatment session. In addition to diffuse tumors, other contraindications to this technique include conjunctival fornix involvement, bone involvement, denervated lid, or tumors in dark-skinned patients.60

Figure 2–8. Keratinization of the palpebral conjunctiva after radiation of a lid tumor.

To effectively treat a basal cell carcinoma, the entire tumor must be frozen to –30°C. Liquid nitrogen is the most effective freezing agent to obtain this temperature, especially in thick tumors. It is necessary to monitor intratumor temperature with a thermocouple or similar device (Figure 2–12). While some investigators rely on visual appearance to gauge temperature, it has been the experience of the group at the University of California, San Francisco, that only with a thermocouple can one be certain that adequate freezing has occurred, and that excessive morbidity from an unnecessarily low temperature is limited.

A typical cryotherapy treatment apparatus is shown in Figure 2–13A, B. Lesions can be treated with either a direct liquid nitrogen spray or an applicator tip that has liquid nitrogen circulating through it. Prior to treatment, the treatment area is injected with

a 1:1 mixture of 0.5 percent marcaine and 1 percent lidocaine (Xylocaine) with l:100,000 epinephrine. The lateral and medial aspects of the field are masked off with tape if the liquid nitrogen spray is used. We place a plastic retractor between the lid and the bulbar conjunctiva to avoid inadvertent ocular freezing. A thermocouple in a 22-gauge needle is placed in the center of the tumor (Figure 2–14). Treatment is performed to reach a –30°C temperature through the entire malignancy and a cycle of freeze-thaw-freeze- thaw is used. As with any type of thermal injury, there is transient redness, swelling, and usually ulceration. These changes subside in 10 to 21 days. Often, there is permanent depigmentation, not noticeable in lightskinned patients.

Fraunfelder and colleagues reported a 5-year control rate of 97 percent for basal cell carcinomas, with

nodular lesions < 10 mm in diameter. A similarly high control rate was noted in a Swedish series of 222 tumors.69 However, with lesions larger than this, approximately 15 to 17 percent of tumors recurred.70 A number of complications have been observed with cryotherapy, and overall, approximately 25 percent of cases have some type of complication.71 Depigmentation of the treated area severely limits the use of this technique in dark-skinned patients, since results are not cosmetically acceptable. There is universal epilation of eyelashes in the treatment field. Visual loss, lid notching, hypertrophic scar, ectropion, pseudoepithelial hyperplasia, hyperpigmentation, chronic granulation, devitalized bone, rectus paresis, lacrimal drainage obstruction, trichiasis, symblepharon, activation of herpes, and corneal ulcer have all been reported.71 In the author’s experience, pseudoepithelial hyperplasia, noted in approximately 5 percent of cases, is the most difficult to manage, in that only with repeat biopsy can one exclude recurrent tumor, especially if the patient

was treated for a squamous cell carcinoma. In one of the author’s patients, this complication developed 4 years after cryotherapy. Repeat biopsies were negative for malignancy, but eventually the author reconstructed the lid to repair the cosmetic defect. As Visnes has stressed, there may be recurrences, and so patients require careful monitoring after treatment. Some investigators have used cryotherapy for recurrent tumors, although we have preferred surgical resection in that setting.72

Experimental Therapies

Many other approaches have been used to treat eyelid tumors. Three additional modalities discussed below have limited use. The author has used these treatments in the management of patients who have a cancer diathesis, such as xeroderma pigmentosum or basal cell nevus syndrome, and have recurrent lid tumors after multiple surgical procedures, radiation, and cryotherapy.

Figure 2–14. The lid carcinoma and the contiguous normal structures are draped prior to treatment of a lid tumor with cryotherapy. The thermocouple is in place, and the tape is used to try to limit the spread of the freeze to normal structures.

Hematoporphyrin derivative (HpD) photochemotherapy has been used to successfully treat a number of bladder and lung malignancies. As discussed under basal cell carcinomas, few patients with lid carcinomas have been treated with reasonable results.19,73 Preliminary results with newer sensitizers have suggested that there may be less morbidity, but there is a paucity of controlled trial data.19 Dermatologists have noted the beneficial effects of vitamin A for over 40 years. Since l978, retinoids have been used to treat some malignancies, including basal cell, squamous cell, and adnexal carcinomas.74–76 In patients with high risk of multiple eyelid tumors, these approaches may afford some prevention. Immunotherapy has similarly been used to treat some of these disparate lid cancers, with occasional success.77,78 These approaches are not routinely used for lid tumors and are well discussed in the references listed.

Two other newer experimental treatments should be briefly discussed. As mentioned in Chapter 1, the standard treatment of pediatric capillary hemangiomas is steroid injection; if this is not effective, local surgical debulking is sometimes indicated. In large capillary hemangiomas, especially around the airway, the use of systemic interferon-alpha 2b has been tried with good success. One case with orbital involvement has been treated in this manner; significant morbidity precludes the routine use of this agent.79,80 Hyperthermia is being used to treat a number of tumors, and some centers are using it for superficial malignancies.81

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26.Wieman TJ, Shively EH, Woodcock TM. Responsiveness of metastatic basal-cell carcinoma to chemotherapy. A case report. Cancer 1983;52:1583–5.

27.Khandekar JD. Complete response of metastatic basal cell carcinoma to cisplatin chemotherapy: a report on two patients. Arch Dermatol 1990;126:1660.

28.Putterman AM. Conjunctival map biopsy to determine pagetoid spread. Am J Ophthalmol 1986;102:87–90.

29.Kass LG. Role of cryotherapy in treating sebaceous carcinoma of the eyelid. Ophthalmology 1990;97:2–4.

30.Mashburn MA, Chonkich GD, Chase DR. Meibomian gland adenocarcinoma of the eyelid with preauricular lymph node metastasis. Laryngoscope 1985;95: 1441–3.

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32.Doxanas MT, Green WR. Sebaceous gland carcinoma. Review of 40 cases. Arch Ophthalmol 1984;102: 245–9.

33.Pardo FS, Wang CC, Albert D, Stracher MA. Sebaceous carcinoma of the ocular adnexa: radiotherapeutic management. Int J Radiat Oncol Biol Phys 1989;17:643–7.

34.Nunery WR, Welsh MG, McCord CD Jr. Recurrence of sebaceous carcinoma of the eyelid after radiation therapy. Am J Ophthalmol 1983;96:10–5.

35.Matsumoto C, Nakatsuka K, Matsuo K, et al. Sebaceous carcinoma responds to radiation therapy. Ophthalmologica 1995;209:280–3.

36.Day CL Jr, Mihm MC Jr, Sober AJ, et al. Narrower

margins for clinical stage I malignant melanoma. N Engl J Med 1982;306:479.

37.Urist MM, Balch CM, Soong S, et al. The influence of surgical margins and prognostic factors predicting the risk of local recurrence in 3445 patients with primary cutaneous melanoma. Cancer 1985;55:1398–402.

38.Avril MF, Charpentier P, Margulis A, Guillaume JC. Regression of primary melanoma with metastases. Cancer 1992;69:1377–81.

39.Kirkwood JM, Ibrahim JG, Sondak VK, et al. Highand low-dose interferon alfa-2b in high-risk melamoma: first analysis intergroup trial E1690/S9111/C9190. J Clin Oncol 2000;18(12):2444–58.

40.Schlienger P, Brunin F, Desjardins L, et al. External radiotherapy for carcinoma of the eyelid. Report of 850 cases treated. Int J Radiat Oncol Biol Phys 1996;34:277–87.

41.Moore PS, Chang Y. Detection of herpes virus-like DNA sequences in Kaposi’s sarcoma in patients with and without HIV infection. N Engl J Med 1995;332: 1181–5.

42.Stanowsky A, Krey HF, Kopp J, et al. Irradiation of malignant eyelid melanoma with iodine 125 plaque. Am J Ophthalmol 1990;100:44–8.

43.Buatois F, Coquard R, Pica A, et al. Treatment of eyelid carcinomas of 2cmm or less by contact radiotherapy. J Fr Ophthalmol 1996;19:405–9.

44.Amdur RJ, Kalbaugh KJ, Ewald LM, et al. Radiation therapy for skin cancer near the eye: kilovoltage X- rays versus electrons. Int J Radiat Oncol Biol Phys 1992;23:769–79.

45.Kishi K, Shirai S, Sonomura T, et al. Lead contact lens for crystalline lens shielding in electron therapy for eyelid tumors. Radiat Med 1996;14:107–9.

46.Shiu AS, Tung SS, Gastorf RJ, et al. Dosimetric evaluation of lead and tungsten eye shields in electron beam treatment. Int J Radiat Oncol Biol Phys 1996; 35:599–604.

47.Rodriguez-Sains RS, Robins P, Smith B, Bosniak SL. Radiotherapy of periocular basal cell carcinomas: recurrence rates and treatment with special attention to the medial canthus. Br J Ophthalmol 1988;72: 134–8.

48.Leshin B, Yeatts P, Anscher M, et al. Management of periocular basal cell carcinoma: Mohs’ micrographic surgery versus radiotherapy. Surv Ophthalmol 1993;38:193–212.

49.Cobb GM, Thompson GA, Allt WE. Treatment of basal cell carcinoma of the eyelids by radiotherapy. Can Med Assoc J 1964;91:743–8.

50.Fayos JV, Wildermuth O. Carcinoma of the skin of the eyelids. Arch Ophthalmol 1962;67:298–302.

51.Fitzpatrick PJ, Jamieson DM, Thompson GA, Allt WE. Tumors of the eyelids and their treatment by radiotherapy. Radiology 1972;104:661–5.

52.Lederman M. Discussion of carcinomas of the conjunctiva and eyelid. In: Boniuk M, editor. Ocular

and adnexal tumors. St. Louis, MO: CV Mosby; 1964. p. 104.

53.Lederman M. Radiation treatment of cancer of the eyelids. Br J Ophthalmol 1976;60:794–805.

54.Nordman EM, Nordman LE. Treatment of basal cell carcinoma of the eyelid. Acta Ophthalmol 1978;56: 349–56.

55.Hirshowitz B, Mahler D. Incurable recurrences of basal cell carcinoma of the mid-face following radiation therapy. Br J Plast Surg 1971;24:205–11.

56.Fitzpatrick PJ, Thompson GA, Easterbrook WM, et al. Basal and squamous cell carcinoma of the eyelids and their treatment by radiotherapy. Int J Radiat Oncol Biol Phys 1984;10:449–54.

57.Ghabrial R, Quivey JM, Dunn JP Jr, Char DH. Radiation therapy of acquired immunodeficiency syn- drome-related Kaposi’s sarcoma of the eyelids and conjunctiva. Arch Ophthalmol 1992;110:1423–6.

58.Dugel PU, Gill PS, Frangieh GT, Rao NA. Treatment of ocular adnexal Kaposi’s sarcoma in acquired immune deficiency syndrome. Ophthalmology 1992; 99:1127–32.

59.Heinemann MH. Medical management of AIDS patients. Ophthalmic problems. Med Clin North Am 1992;76:83–97.

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63.Call NB, Welham RAN. Epiphora after irradiation of medial eyelid tumors. Am J Ophthalmol 1981;92: 842–5.

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SURGICAL TECHNIQUES

Regardless of surgical technique, the removal of a tumor must be carefully monitored. The inclusion of the entire tumor in the treatment field and the histologic control of the tumor edges are crucial to the success of any surgical strategy. There are two options for surgical resection of eyelid tumors: Mohs’ micrographic technique and standard surgery with frozen section control of tumor margins. There are advantages and disadvantages with each approach.

Standard Resection with Frozen Section Control

The major advantages of standard resection with frozen section control are its good control of tumor margins, its availability in almost all hospitals, and its high cure rate.1 There are, however, three major disadvantages of standard frozen section control: (1) it is a more time-consuming procedure than the Mohs’ micrographic procedure for the ophthalmic surgeon;

(2)Especially in a teaching institution (ie, where residents perform frozen sections), the level of pathologic expertise is generally less than if tumor resection is monitored by a trained Mohs’ surgeon; and

(3)in many cases, a larger amount of normal tissue must be sacrificed to obtain free margins, especially if the tumor has areas of small islands or pseudopod extensions of malignant cells.

A number of publications have reported that lid tumor resections without frozen section control, but with an arbitrary 3- to 5-mm margin, have between a 23 and 50 percent incidence of incomplete tumor removal.2–7 In cases of incomplete

resection, approximately 35 percent of basal cell carcinomas have been reported to recur.7 These numbers vary markedly; Frank noted that 18 of 21 “incompletely excised tumors” had no residual neoplasm on repeat excision.8

In an institution with excellent pathologists, the incidence of tumor recurrence with frozen section control is less than 2 percent.5,9 If a tumor is to be excised under standard frozen section control, orientation is vital. We routinely orient all specimens on a sterile tissue map (Figure 3–1). Even an experienced pathologist is often confused regarding small lid tumor resection margins. This confusion can be decreased if the main tumor mass is sent to the pathologist separately from carefully oriented small marginal sections that represent the presumably normal tissue margins surrounding the malignancy. As a further precaution, placing a 5-0 marker suture in one edge of each margin specimen and listing its location on the map are useful for orientation. Finally, this author often uses a blue surgical marking pen to highlight the side of the margin away from the neoplasm so that it can be optimally oriented to make frozen sections. Occasionally, it is important to accompany the material to the pathology laboratory.

It is difficult to be certain that the histologic material is processed correctly, and failure to do so can result in an incorrect assessment of tumor extension. For example, at UCSF we have had a case in which the pathology resident used a transverse section through the lateral margin instead of sampling the entire length of the horizontal and both vertical resection margins. He thought erroneously that the margins were clear, when, in fact, they were involved with tumor. This case illustrates the need

for close communication with the pathologist. Similarly, a tissue block can be inadvertently reversed so that the lateral free margin is thought to be the margin closest to the tumor and is not studied, while the margin closest to the tumor was sampled as the “free margin” and thought to be contaminated by tumor. When the correctly oriented tissue was analyzed, the distal margin was tumor free. Finally, tangentially cut sections can result in confusion between hair follicle epithelium, rete ridges, and carcinoma.

Regardless of the pathologist’s experience, the delineation of a sebaceous cell carcinoma margin, given its propensity for both pagetoid spread and multicentricity, is difficult.10 Similarly, frozen section control for cutaneous melanomas has a significant false-negative rate.11

Mohs’ Micrographic Technique

In 1941, Mohs described a different approach to monitor skin tumor resection.12 A number of alternative terms have been used to describe his procedure, but the current nomenclature is “Mohs’ micrographic technique.” Previous terms include chemosurgery, microsurgery, Mohs’ microsurgery, and Mohs’ technique.13,14 Three major advantages to Mohs’ technique are the use of two different teams to separately resect and reconstruct the eyelid to avoid inadequate tumor resection margins, the sparing of the ophthalmic surgeon’s time by not having to wait in the operating room until tumor-free margins are obtained, and the low incidence of tumor recurrence. The major disadvantages of this technique are cost to the patient for two separate procedures, the need for a trained Mohs’ surgeon, and the possibility of excess lid resection.

The goal of the micrographic technique is to accurately delineate the tumor margins, while sparing normal tissue. As in an archeologic excavation of an elevated mound, once the major tumor mass is removed, a layer-by-layer approach is used by the Mohs’ chemosurgeon to carefully outline the position of the remaining tumor and remove it. As shown in Figure 3–2, the undersurface of tangential small sections of each tissue layer is histologically studied for residual tumor, and further dissection and micrographic survey are carried out only in those areas

where tumor is found. These tissue blocks are approximately 5 to 10 mm in diameter and 2 to 4 mm in thickness. The Mohs’ procedure is probably more accurate than frozen section control in detecting small pseudopod extensions of tumor, but the technique may be less conservative in sparing tumor-free tissue. Unlike standard frozen sections that are perpendicular to skin, Mohs’ technique is, by definition, tangential. Tangential sections obtained through either normal hair follicle epithelium or rete ridges can often simulate basal cell carcinoma. It has been the impression of many dermatopathologists that

A

B

Figure 3–1. A, Sterile tissue map used for specimen orientation during standard tumor lid surgery. B, Example of specimen oriented on the sterile tissue map.

38 TUMORS OF THE EYE AND OCULAR ADNEXA

some patients treated with the Mohs’ technique have more tissue sacrificed than is necessary. Conversely, in other cases, Mohs’ technique does limit the area of neoplastic resection, since only tumor-containing areas are removed, instead of straight cuts through both involved and uninvolved lid structures.

The initial micrographic technique was based on in situ tissue fixation, followed by removal and histologic examination of successive tissue layers,12–15

A

B

Figure 3–2. A, Schematic representation of standard frozen section control. B, Mohs’ micrographic technique of histologic analysis.

although lid tumor micrographic surgery is now performed using a fresh tissue technique.16 Local anesthesia is used, minor hemostasis is achieved with oxidized cellulose, and larger vessels are electrocoagulated. Thin, precisely oriented specimens are examined, with the sides of each specimen color coded with red or blue dyes. A technician cuts the flat undersurface of each specimen with a frozen section. Further sections are taken only in areas in which residual tumor is found.

The fixed tissue technique is used for two types of ophthalmic adnexal tumors: (1) in the management of malignant melanoma, Mohs felt that in situ fixation was less likely to spread viable melanoma cells;15 and (2) better anatomic detail is obtained with tissue fixed in situ, and tumors that extend into the deep orbit or that involve bone are more accurately resected with the fixed tissue technique.15,17

Mohs advocated granulation (secondary intention healing) after tumor resection.18 While this laissezfaire reconstruction technique is adequate, especially in large medial canthal lesions, most ophthalmic surgeons reconstruct eyelid defects created by the Mohs’ approach.1,19–22 Overall, in Mohs’ personal experience with the micrographic approach, > 98 percent of eyelid squamous cell or basal cell carcinomas have no noted recurrence 5 years after resection. Lateral canthal lesions have a lower cure rate (91% for basal cell, 87.5% for squamous cell) than tumors in other locations. Similarly, recurrent tumors have a slightly lower success rate (92.4% for basal cell, 98.5% for squamous cell). Tumors > 30 mm in size have only a 50 percent cure rate.16 Smaller series, presumably in centers with less voluminous experience, have reported slightly lower control rates.23,24

GENERAL PRINCIPLES OF LID

RECONSTRUCTION

There are many operations that have been created to repair surgical lid defects. As in most areas of medicine, many procedures have been re-invented or are very slight modifications of procedures described previously and therefore they have not been discussed here. The anatomy is altered differently by every lid tumor resection, and each reconstructive procedure is unique. It is almost impossible to

describe the judgment on which subtleties of repair of lid and canthal tumors is based.

There are four general principles that guide surgical lid defect reconstruction: (1) the lid consists of two components, an anterior and posterior lamella; both must be present or be replaced to have a competent lid repair. The anterior lamella consists of myocutaneous tissue. The posterior lamella requires a mucous membrane on a stiff cartilaginous material to prevent the lid from turning in or out; (2) if one lamella is replaced with a free graft, the other layer must have a good vascular supply and therefore requires a transpositional, rotation, advancement, or bridge pedicle flap; (3) there are limited sources of good graft tissue. The anterior lamella of either lid can be best matched for color and texture with skin from the contralateral or vertically opposite lid; next in order of preference is skin from the retroauricular and supraclavicular areas. Myocutaneous tissue can be obtained as a free graft; a bridge, pedicle, advancement, or rotational flap; or a myocutaneous island.25 The blood supply to the underside of the skin in the periocular region is good enough that a flap of just subcutaneous tissue attached to overlying skin is usually moveable with adequate vascular support; and (4) the posterior lid lamella can be obtained from a pedicle or advancement flap of tarsus and conjunctiva, a free nasal-septal graft, a free tarsoconjunctival (posterior composite) graft, or a hard palate graft (for lower eyelids only). All combinations of these anterior and posterior lamella reconstruction options, with the exclusion of free grafts for both lid layers, have been used to repair lid defects.

Those surgical procedures that the author has found to be both simple and effective in the reconstruction of over 90 percent of lids after complete tumor resection have been described here. Undoubtedly, this choice reflects the bias of the author’s training and experience. A number of other procedures could be substituted with similar results. The heroic multispecialty surgeries for tumors that extend outside of usual ophthalmic boundaries have not been addressed here deliberately.

LOWER LID RECONSTRUCTION

Four procedures can be used to reconstruct almost all lower lid defects: (1) primarily, apposition of the

resected lid margins, (2) a lateral cantholysis with a lateral advancement flap (Tenzel and Reese procedures), (3) a tarsoconjunctival pedicle flap (Hewes-Beard procedure),29 or (4) an upper lid tarsoconjunctival advancement flap (Hughes procedure).30 The choice of procedure depends on the size of the defect and the patient’s age. Patients under 40 years of age generally have little skin laxity, and less of the lid can be resected and closed primarily.

After the tumor has been completely removed with adequate margins, two Bishop-Harmon toothed forceps are used to grasp the medial and lateral lid remnants to determine if the lid defect can be closed either primarily or with lateral cantholysis and a mucocutaneous advancement flap (Figure 3–3A). If the ends of the lid defect cannot be brought together without too much pressure (Figure 3–3B), even after lateral cantholysis, then a tarsoconjunctival pedicle flap, an upper lid tarsoconjunctival advancement procedure or a free posterior lamellar graft with a pedicle skin graft must be considered.

Primary Closure of Lower Lid Defects

While historically halving procedures were used to approximate the lid margins, most surgeons now align the tarsus with either a single vertical suture, as shown in Figure 3–3B, or with two horizontal sutures. The ends of the tarsus must be perpendicular and its margins aligned to obtain a good cosmetic closure. The choice of suture material is not critical. Tarsal or periosteal sutures must retain strength for over 14 days, while conjunctival sutures only require 5 to 7 days of integrity. The materials normally used in our procedures are given below, but others could be used with equal results.

A 4-0 or 5-0 chromic gut suture is placed in the tarsus so that the knot is distal to the lid margin. Prior to tying this tarsal suture, a running 6-0 plain gut conjunctival suture is fashioned; it is necessary to bury the knots so they do not contact the surface of the mucous membrane. We generally close the subcuticular lid in two layers, with deeper 5-0 chromic gut sutures horizontally bolstering the tarsal closure. The skin is closed with interrupted 7-0 silk (Figure 3–3C). The cut ends of interrupted sutures at the gray line and lash margin are deliberately left