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

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long, and the ends of these sutures are then tied into the first and second interrupted sutures along the anterior edge of the lid skin to avoid abrading the cornea (see Figure 3–3C).

A number of complications can occur with primary lid closure. As in any surgical procedure, infection or untoward reaction to suture material may be a problem. Most commonly, incorrect apposition of the tarsal margins results in lid notch (Figure 3–4). This problem cannot be overstressed. Probably, if only the tarsal sutures were used to close an eyelid defect, cosmesis would be excellent. In contrast, a poorly aligned tarsus almost guarantees a poor cosmetic result. If the lid defect is too large for primary closure, wound breakdown or entropion is likely to occur. It is not uncommon for conjunctival edema to occur from an overly tight lid, especially in the first 2 weeks after surgery.

A

Figure 3–4. Lid notch resulting from an incorrect apposition of tarsal margins.

Lateral Cantholysis and

a Lateral Advancement Flap

(Tenzel and Reese Procedures)

Generally, lesions involving 33 to 60 percent of the lower lid cannot be closed primarily; a lateral myocutaneous advancement flap with cantholysis is advised in these cases. Two variations of this procedure have been widely used. The initial procedure, by Reese, was a straight lateral horizontal incision.28 The author has used it with good results.

Figure 3–5 shows a 6-month postoperative view of a Reese procedure to correct resection of 60 percent of the lower lid. Tenzel modified this approach by making a highly curved incision with the convex apex running laterally above the brow.26,27 The rationale for the latter approach is to decrease the likelihood of lower lid ectropion by bringing a correctly oriented flap into the lower lid.31 This procedure is shown in Figure 3–6A.

Figure 3–3. A, Primary lower lid closure — initial surgical defect. B, The tarsus is approximated with a 4-0 chromic gut suture. C, The suturing material is left long at the gray line and lash margins, and it is tied into the stitches lower on the lid margins to prevent the ends from abrading the cornea. (See discussion in text)

Figure 3–5. Postoperative view of a 60 percent lower lid resection and repair using a Reese procedure.

The inferior crus of the lateral canthal tendon is palpated and cut through the lateral conjunctival fornix (Figure 3–6B). After the tendon is severed, the lateral inferior lid remnant should be easily mobilized. A curvilinear incision arched upward is created, and the ends of the lid remnants are apposed, as in primary lid closure. In closing the lateral aspect of this incision, it is important to first reconstruct the lateral canthus (Figure 3–6C) and correctly place the lateral conjunctival fornix in relation to the posterior edge of the new canthal skin area. This avoids both symblepharon formation and rounding of the canthus. Interrupted 5-0 chromic

sutures are used to close the subcutaneous layers (Figure 3–6D). A length of 7-0 running silk is used to close much of the lateral defect after a few interrupted 7-0 silk sutures are placed to approximate the medial lid position (Figure 3–6E). If the lateral canthal tendon has been sacrificed, the posterior aspect of the lateral lid is either sutured to the periosteum inside the entrance to the lateral orbit, or, if that has also been resected, the lid is sutured with wire to a hole drilled into bone. Failure to anchor the lateral lid posteriorly may result in lid sag or lateral ectropion. The two most common complications with this procedure are failure to completely sever the inferior

42 TUMORS OF THE EYE AND OCULAR ADNEXA

lateral canthal tendon and poor reconstruction of the lateral canthus. In the former situation, the lateral lid remnant cannot be adequately mobilized. If the inferior crus has not been cut, tension remains on the tendon, and it can be palpated like a guitar string on stretch. Failure to correctly align the lateral advancement flap with the lateral conjunctiva and upper lid results in rounding of the lateral canthus. Good cosmesis is achieved with the Tenzel curvilinear incision; however, the results with a straight lateral skin incision are acceptable (see Figure 3–5). Spinelli and Jelks noted that canthal abnormalities were responsible for over 50 percent of the major complications in their series of patients who had lid reconstruction after removal of a lid tumor.32

Tarsoconjunctival Pedicle Flap

(Hewes-Beard Procedure)

Either a Hughes or a Hewes-Beard procedure can be used for simple reconstruction of the entire lower lid.29,30 The goal of surgery is to create a relatively rigid mucous membrane–lined posterior lamella and to cover it with either a free or an advancement skin graft. If the lid defect involves more than 60 percent of the lower lid (unless it is predominantly the medial portion of the lid), and if the lateral canthus is not involved, a Hewes-Beard procedure can be used (Figure 3–7A). The author prefers the tarsoconjunctival pedicle flap to the Hughes procedure because the former does not require temporary closure of the involved eye. If the Hughes procedure is used, the eye must be occluded for 2 to 6 weeks after surgery. Either of these procedures is preferable to other lower lid reconstructions, such as a Mustardé procedure, for two major reasons: (1) these are simpler procedures for an ophthalmic surgeon to perform; and (2), in our experience, the results are excellent.

In the Hewes-Beard procedure, a tarsoconjunctival pedicle flap is created. The upper lid is everted over a Desmares retractor (Figure 3–7B). The medial remnant of the lower lid is grasped and pulled laterally, and its relative horizontal position is identified by a vertical scratch incision in the upper tarsus. If only a small remnant of the lateral lower lid remains, we usually sacrifice it. A No. 67 Beaver blade is used to make an incision in the upper lid tar-

sus and conjunctiva. Horizontal incisions are made to create a 4-mm wide tarsoconjunctival flap. The tarsal incision closest to the lash margin is approximately 4 mm away from it, while the superior horizontal tarsal incision is made approximately at the upper margin of the tarsus. The length of the tarsoconjunctival pedicle is predicated on the amount of surgical lid defect remaining after the lid remnants are grasped with forceps and pulled together. The tarsal flap should fit this defect; too large a pedicle uniformly results in lower lid ectropion. The tarsoconjunctival flap is then mobilized using toothed forceps and sharp scissors. We attempt to minimize cauterization of bleeding from the flap, especially at its lateral aspect, to lessen damage to its vascular supply. While the author is uncertain whether there is a good blood supply to the entire length of the flap, Beard feels strongly that it has at least some circulation (personal communication).

The tarsoconjunctival pedicle flap is mobilized at the lateral aspect of the lid and rotated so that the conjunctival side of the flap faces the inferior bulbar conjunctiva (see Figure 3–7B). The distal ends of the tarsoconjunctival pedicle flap are sutured with two interrupted 5-0 chromic sutures to the tarsus of the medial remnant of the lower lid (Figure 3–7C). An interrupted 5-0 chromic suture is used to anchor the inferolateral aspect of this pedicle to the remnant of the inferior canthal tendon. A running 6-0 plain gut suture anastomoses the conjunctiva on the inferior edge of the pedicle flap to the remnant of conjunctiva in the lower lid defect.

A number of options exist for creating an anterior lid lamella, the best of which is an advancement myocutaneous or “bucket handle” flap from below. A free skin graft can be placed on top of the pedicle flap, but its chances for survival may not be as good. In order of preference, the graft should be taken from the upper lid, retroauricular skin, or, least desirably, the supraclavicular fossa. If the last area of skin is used as a donor site, we usually create an advancement bridge flap from the lower cheek to cover the margin of the reconstructed lower lid; we then place the supraclavicular skin in the inferior defect. Regardless of the donor site, the skin graft should be approximately 25 percent larger than the defect to be filled to allow for shrinkage. All donor

skin should be turned over and the subcutaneous tissues removed prior to transplantation.

After 6-0 cardinal sutures are placed at the superior, inferior, lateral, and medial edges of the skin graft, the superior edge of the graft is sutured to the superior edge of the tarsoconjunctival pedicle flap, using a continuous 6-0 plain gut suture. We attempt to have the edge of the tarsoconjunctival pedicle graft slightly higher than the skin to avoid abrading the cornea (Figure 3–7D). A number of small, linear cuts are made in the graft with a scalpel to avoid post-transplantation exudation. The eye and orbit are pressure-patched with an antibiotic ointment for 24 hours and pressure-patched again for an additional 24 hours after the surgical site is dressed again. In some large cutaneous grafts, the ends of

the sutures are tied over cotton bolsters to put additional pressure on the graft.

A number of complications are associated with the tarsoconjunctival pedicle flap reconstruction of the lower lid defect. First, if the tarsal pedicle flap is too long, an ectropion invariably occurs (Figure 3–8). In order to avoid this problem, it is imperative that the tarsoconjunctival flap be short enough to create reasonable tension along the lower lid. This necessitates measuring the horizontal length of the flap with the medial lid remnant stretched laterally with a forceps. Second, with any form of lower lid reconstruction, there is loss of eyelashes. In the author’s experience, lash grafts have been uniformly disappointing in correcting this relatively minor cosmetic defect. Third, in some patients, the pedicle is

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Figure 3–8. Ectropion caused by a tarsoconjunctival pedicle graft that was too long.

left in situ, which yields a rounded lateral canthus (Figure 3–9). In most patients, approximately 6 weeks after surgery, 2 percent lidocaine (Xylocaine) and 1:100,000 epinephrine are injected into the pedicle in the lateral intrapalpebral fissure, and then it is incised in the office.

The two major contraindictions to the HewesBeard procedure are tumors involving the entire lower lid, canthus, and lateral upper lid region, and malignancies involving only the medial lower lid.

Tarsoconjunctival Advancement Flap

(Hughes Procedure)

The Hughes procedure was an early approach to correcting a 50 to 100 percent lower lid defect.30 The author has not used this approach for the last 10 years because the tarsoconjunctival pedicle flap is equally effective and does not require eye closure during the recuperative period. Performance

Figure 3–9. Rounded lateral canthus after a tarsoconjunctival pedicle graft.

of a Hughes procedure is relatively straightforward. Instead of a pedicle flap, the inner lamella of the lower lid defect is reconstructed, using an advancement flap of tarsus and conjunctiva from the upper lid.

As shown in Figure 3–10, a tarsoconjunctival advancement from the upper lid is brought down to fill the lower lid defect. After the upper lid is everted on a Desmares retractor, a scalpel is used to mark the tarsal extent of donor tissue (Figure 3–10A). As with a tarsoconjunctival pedicle flap, the remnants of the lateral and medial lower lid defects should be positioned as close together as possible to minimize the amount of upper lid material needed to cover the defect. The incision should be approximately 4 mm from the lash margin to prevent upper lid instability. Blunt dissection of the tarsus and conjunctiva from the more superficial layers of the upper lid is performed. Care should be taken to avoid damage to Müller’s muscle and the flap’s vascular supply. The tarsoconjunctival advancement flap is sutured to the respective conjunctival and tarsal surfaces of the lower lid defect using interrupted 5-0 chromic sutures for the tarsus and running 6-0 plain gut for the conjunctiva (Figure 3–10B). A free skin graft or an advancement bridge flap is then sutured in the defect to recreate the anterior lamella of the lower lid (Figure 3–10C). The skin graft should be approximately 25 percent larger than the defect. The surgical technique of graft placement is described under the Hewes-Beard procedure.

Approximately 1 to 6 weeks after initial surgery, the tissue of the upper lid is incised just above the reconstructed lower lid edge (see Figure 3–10C), using a convex superior curved incision. By angling the scissors anteriorly and making a convex incision, retraction and scarring leave an even tissue surface with a slight excess of conjunctiva; this method also results in a lower incidence of secondary corneal abrasions. Other authors have recommended cutting the conjunctiva flush with the skin. They believe that this modification results in improved cosmesis.33 If there is too much conjunctiva in the anterior surface of the reconstructed lower lid, it can either keratinize or be cauterized.

A number of complications have been reported in association with the Hughes procedure. If too lit-

tle upper lid tarsus remains, an upper lid entropion with trichiasis can result. Similarly, secondary retraction of the upper lid can occur if the conjunctiva superior to the tarsus in the upper fornix is not dissected free from Müller’s muscle when the advancement flap is created from the posterior lamella of the upper lid. As with the tarsoconjunctival pedicle flap, if too large a donor graft is placed in the lower lid defect, the occurrence of a lower lid ectropion is likely; if the graft is too small, entropion can occur. If insufficient conjunctiva is left on the anterior edge of the lower lid, fine residual hairs can abrade the cornea. The reconstructed lower lid is less mobile than normal. Some authors have suggested using an orbicularis muscle advancement as a modification of this procedure to increase mobility.34,35 Less commonly used lower lid procedures (glabellar flap, Mustardé, laissez faire) and the Gorney procedure are discussed at the end of the chapter.

Posterior Free Tarsal Graft

Recently, many surgeons are using more free grafts to replace the posterior lamellae of the lower eyelid. The two most used donor sites are either ipsilateral

Figure 3–11. A posterior lamellar graft is obtained from the everted upper eyelid.

46 TUMORS OF THE EYE AND OCULAR ADNEXA

Figure 3–12. A large hard palate graft harvested. Care is taken to avoid both the midline and the soft palate.

or contralateral posterior upper eyelid (Figure 3–11) or hard palate (Figure 3–12).36–40 The author prefers the variant of the composite or posterior lamellar graft shown in Figure 3–11. The upper eyelid is everted on a Desmares retractor with a 4-0 silk traction suture. The length of the tarsus needed (with the edge of the surgical defect relatively tightly apposed to measure this length) is marked with a scalpel. We take care to leave 2 to 3 mm of tarsus near the lash line. Sutures are used, as described for the previous two procedures, to attach this conjunctival tarsal tissue to create the posterior lamella of the reconstructed lower lid. The anterior lamella is reconstructed with a sliding or bridge flap. Hard palate grafts (see Figure 3–12) for lower eyelid defects also work well, but it is more difficult for the ophthalmologist who performs this type of procedure only rarely to obtain such tissue.

UPPER LID RECONSTRUCTION

The principles of upper lid reconstruction are similar to those of lower lid repair but with three important caveats. First, since the normal Bell’s phenomenon is usually preserved, the placement of buried knots in the central portion of an upper lid reconstruction is crucial to avoid corneal abrasions and pain. Even with correct closure of upper lid defects, occasionally we find it necessary to use a soft bandage contact lens to protect the cornea in the first few weeks after surgery. Second, while the upper lid tarsus is excellent for providing a stable posterior lamella in lower lid reconstructions, the much smaller and less stable lower lid tarsus does not provide equal support

or utility for reconstruction of an upper lid defect. Third, the hard palate is probably not a good substitute for upper eyelid tarsus. We have seen a number of referred patients who have had this procedure performed with significant corneal damage.

In small upper lid defects (usually less than 33 percent of the lid), a direct apposition of the medial and lateral remnants is performed in the same manner as primary closure of the lower lid. In older patients, a defect as large as 60 percent of the lid can be closed by cutting the superior crus of the lateral canthal tendon. To close an upper lid defect, it is cosmetically more effective to have the convexity curved inferiorly, instead of having the convexity of the lateral skin incision point superiorly. The surgical techniques to perform these procedures are identical to those described in the lower lid and do not need further description.

Lateral Cantholysis and Sliding Tarsal Flap

A moderate-sized lid defect can be closed with a combination of a lateral cantholysis sliding procedure and a transposition tarsal flap from the remnant or remnants of the medial, lateral, or upper tarsi.34,41,42 This approach is shown in Figure 3–13.

In this procedure, after maximum sliding is obtained with lateral cantholysis, a full-thickness tarsal incision is made from the superior edge of the tarsus to within 1 mm of the inferior border and 2 to 3 mm from the cut tarsal edge (Figure 3–13A). This tarsal strip is rotated to create a posterior lamella in the upper lid defect. The superior conjunctiva is mobilized and brought down as an advancement flap and sutured with 6-0 plain gut to the upper edge of the transposed tarsus, and a free skin graft is placed over the entire defect, as shown in Figures 3–13B and C. Figure 3–14 shows a slight modification of this technique in a 40-year-old man with sebaceous gland carcinoma. In this case, the tarsal transposition flap from the medial lid remnant was sutured to a raised strip of orbital periosteum.43 Schematically, this procedure utilizes a rotated tarsal strip attached to the raised piece of periosteum of the lateral orbital rim. This procedure is schematically shown in Figure 3–15.

In patients with a carcinoma that only involves the distal 2 to 5 mm of the eyelid near the eyelashes,

another approach to closure is shown in Figure 3–16. The remaining tarsus is brought down to fill the posterior defect and a free skin graft is placed anteriorly. It has not been necessary to alter the normal levator aponeurosis-tarsal relationship with this small advancement.44 We have not had a problem with eyelid retraction postoperatively.

Cutler-Beard Procedure

The reconstruction of a defect involving more than 60 percent of the upper lid is best accomplished using a Cutler-Beard procedure.45 The surgery is

straightforward, but the technique requires some functional levator aponeurosis as well as a two-stage repair. The surgical upper lid defect is trimmed to rectangular shape, and a full-thickness lower lid donor flap is fashioned approximately 4 to 5 mm inferior to the lower lid margin (Figure 3–17A). The length of the horizontal lower lid incision should parallel the amount of defect present in the upper lid. As discussed above under “Lower Lid Reconstruction,” this upper lid defect should be minimized by creating moderate traction with forceps on both the lateral and medial lid remnants. A flat ribbon retractor is placed in the inferior cul-de-sac, and a No. 15 Bard-

48 TUMORS OF THE EYE AND OCULAR ADNEXA

A

B

C

Figure 3–15. A, Schematic approach to closure of a upper lid lateral defect with a rotational tarsus graft. B, A tarsal graft is mobilized as discussed previously. It is sutured to the raised strip of periosteum from the lateral orbital rim. C, This tarsal-periosteal anastomosis is used as a reconstruction point for the posterior lamellae of the upper lid.

Parker blade is used to make the horizontal incision through the entire lower lid onto the anterior surface of the retractor. The medial and lateral edges of the lower lid advancement flap are incised with sharp scissors, and the full-thickness flap is passed under the bridge of the margin of the lower lid (Figure 3–17B). A three-layer closure of conjunctival, then subcutaneous, and finally skin tissues is used to unite

the flap with the tissues at the edges of the upper lid defect. The corners of the conjunctiva are approximated with 6-0 interrupted gut, and the remainder of the conjunctiva is closed with a running 7-0 plain gut suture. The subcutaneous tissues are closed with 5-0 chromic gut suture, and the skin is approximated with interrupted and continuous 7-0 silk sutures (see Figure 3–17B). Some surgeons believe that insertion of eye bank sclera between the conjunctiva and the myocutaneous layers produces a more stable reconstructed upper lid margin.46

While some authors have advocated closing the open remnant of the lower lid bridge, we usually do not; instead, we place an eye pad, cut in half, on each side of the lower lid margin, put antibiotic on its surface, and pressure-patch the entire area. There have been rare, isolated reports of necrosis of the lower lid bridge, but we have never observed this.

The eye must remain closed for between 4 and 12 weeks after surgery to allow stretching of the advancement flap and re-establishment of vascular as well as lymphatic supply. It is not rare to have transient lymphedema in the advancement flap (Figure 3–18B).

The second stage of the reconstructive procedure is done under local anesthesia, using 2 percent lidocaine and 1:100,000 epinephrine. Two muscle hooks are used to elevate the lid away from the bulbar conjunctiva, and an inferiorly pointing convex incision is made with angled scissors to leave the conjunctiva slightly longer than the skin of the upper lid (see Figure 3–17C). An incision is made approximately 2 mm below the intended upper lid margin to allow for normal shrinkage. If the incision is cut straight across, retraction results in an unsightly scar and possible exposure. The slight increase in conjunctiva length to overlap the shorter skin edge decreases the likelihood of corneal abrasion (see Figure 3–17C). The upper lid margin is closed with a 6-0 plain gut suture. The inferior aspect of the marginal lower lid remnant is freshened with either a scalpel or scissors, and the severed lower lid bridge flap is resutured in three layers using a 6-0 plain gut to appose conjunctiva, 5-0 chromic interrupted suture for the subcutaneous layer, and 7-0 silk for the skin. Figures 3–18A to C show the use of a Cutler-Beard procedure to reconstruct an 85 percent defect in the upper lid after resection of a melanoma. Figure 3–18D

demonstrates the final result of a squamous cell carcinoma defect in a 50-year-old man who had lid repair with a Cutler-Beard procedure.

In our experience, the major complication associated with the Cutler-Beard lower lid advancement

technique has been the loss of lashes. Retraction of both the upper lid and lower lid scars can occur, but it is unlikely. Rarely, delicate hairs on the advanced lower lid skin can abrade the cornea. A number of modifications of the Cutler-Beard procedure have