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Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 334 - файл
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8 Eyelids
Fig. 8.15 Tenzel ap. (a) Markings for excision and ap, (b) Excision defect, (c) Flap raised and
lateral canthotomy and inferior cantholysis, (d) Periosteal strip marked for lateral tarsal reconstruction, (e) Periosteal strip raised, (f) Periosteal strip sutured into place, (g) Final closure
Lower Eyelid
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Fig. 8.15 (continued)
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8 Eyelids
Hughes Flap
Indications: Large defects.
Technique: The defect is modied to obtain wound margins that are perpendicu-
lar to the lid margin. The defect is measured, and the tarsoconjunctival ap from the
upper eyelid designed to be marginally shorter to maintain adequate tension following closure. The upper eyelid is everted with Desmarres retractors and the ap
marked on the posterior surface of the eyelid, preserving 4mm of the tarsal plate
adjacent to the lid margin, to maintain upper lid support. Vertical marking is made
from its extremities. The incision is made through the conjunctiva and tarsal plate
and the ap raised on the surface of the levator palpebrae superioris, which is preserved. Superiorly, above the tarsal plate, the plane of dissection is between the
conjunctiva and Muller’s muscle. The mobilised ap is sutured into the lower lid
defect in layers, with particular attention paid to approximation of the tarsal plates.
The anterior lamella is reconstructed with a musculo-cutaneous advancement ap
(Fig.8.16a–g, i–o).
The second stage is performed about 4weeks later. The ap is divided about
2mm above the intended lower lid margin. The new lower lid margin is freshened,
and the conjunctiva sutured to the skin margin (Fig.8.16h). The remaining ap is
sectioned at its attachment to the upper lid, and the defect left to continue to heal by
secondary intention.
Tips: The patient should be counselled appropriately about the two-stage proce-
dure and “closure” of the eye during this period of time. Periosteal aps will have to
be considered if there is no remaining lower lid at the extremities of the defect (See
Fig.8.15d–f). Skin graft can be used to reconstruct the anterior lamella.
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Fig. 8.16 Hughes ap. (a) Markings for excision, (b) Excision defect, (c) Markings for tarsocon-
junctival ap in upper eyelid, (d) Flap transposed into lower eyelid defect to reconstruct posterior
lamella defect, (e) Skin advancement ap to reconstruct anterior lamella defect, (f) Tarsoconjunctival
ap sutured in situ, (g) Skin closure with intact upper eyelid pedicle, (h) Final result after second
stage division of pedicle, (i) Markings for excison and lateral transposition ap, (j) Excision
defect, (k) Upper eyelid tarsoconjunctival ap sutured insitu, (l) Lateral transposition ap sutured
in situ, (m) Early post operative appearance of rst stage procedure, (n) Appearance after second
stage division - eyes open, (o) Appearance after second stage division- eyes closed
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Fig. 8.16 (continued)
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Fig. 8.16 (continued)
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Suggested Algorithm
Upper Eyelid
Anterior Lamellar Defects
1. Primary closure (horizontal/vertical)
2. Advancement ap
3. Fricke ap
4. Skin graft
Full-thickness Defects
Small
1. Primary closure (vertical)
Medium
1. Primary closure with lateral canthotomy and superior cantholysis
2. Tenzel ap
Large
1. Cutler beard ap
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Medial Canthus
1. Healing be secondary intention
2. Glabella transposition ap
3. Glabella island ap
4. Skin graft
Lower Eyelid
Anterior Lamella Defects
Small
1. Primary closure (vertical)
2. Tear drop
Medium
1. Advancement ap
2. Tripier ap
3. Rotation/transposition ap
Large
1. McGregor ap
2. Mustarde’ ap
Suggested Algorithm
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Full-Thickness Defects
Small
1. Primary closure
Medium
1. Primary closure with lateral canthotomy and inferior cantholysis
2. Tenzel ap
Large Defects
1. Hughes ap
2. McGregor ap
3. Mustarde’ ap
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Auricular Reconstruction
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Subunits andAnatomical Considerations
The pinna is a structure made up of a complex three-dimensional cartilaginous
framework and draped by skin on the lateral and medial aspects. The underlying
elastic cartilage principally determines the shape of the ear. The skin on the anterior
aspect is rmly adherent to the underlying cartilage and reveals the contours of the
underlying cartilage, with minimal subcutaneous tissue. The skin of the posterior
aspect is more loosely attached and contains more subcutaneous tissue.
The pinna lies between horizontal lines drawn from the superior orbital rim and
the nasal spine. It protrudes from the scalp at an angle of 25°–35°.
The skin on the lateral surface is thin and densely adherent to the underlying
cartilage, whereas the posterior skin in thick and more mobile. The auricular cartilage is supple and can be easily deformed by wound tension and scar contracture.
Scars can be camouaged in the many undulations of the pinna. Local ap reconstruction often results in a decreased height of the pinna, but when the shape is
maintained, is surprisingly inconspicuous.
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© Springer Nature Switzerland AG 2024
V. Ilankovan et al., Local Flaps in Facial Reconstruction,
https://doi.org/10.1007/978-3-031-49464-2_9
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9 Auricular Reconstruction
The goal of reconstruction is to try and preserve the shape, size and position of
the pinna. Knowledge of the different parts of the pinna is essential for reconstruction (Fig.9.1). When it comes to reconstructing auricular defects, it is more practical to analyse it in terms of (1) location, (2) extent and (3) composition of the defect.
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