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Eyelid
Surgery
A Fresh Perspective
on Correcting Common
Conditions
Vladimir Thaller
123
Eyelid Surgery
Vladimir Thaller FRCOphth, FRCS
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Vladimir Thaller
https://t.me/medicina_free
Eyelid Surgery
A Fresh Perspective on Correcting
Common Conditions
Vladimir Thaller
https://t.me/medicina_free
Royal Eye Infirmary
Plymouth, UK
ISBN 978-3-031-31526-8 ISBN 978-3-031-31527-5 (eBook)
https://doi.org/10.1007/978-3-031-31527-5
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse
of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and
transmission or information storage and retrieval, electronic adaptation, computer software, or by similar
or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or
the editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
To my teacher, mentor, and friend, Richard
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Collin, in gratitude for showing me the way.
Foreword: Keeping Eyelid Surgery
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Simple—A Surgical Manual
Many medical texts attempt to cover all issues and repeat concepts prevalent at
the time of writing—including those ideas that are ill-conceived or, in some cases,
clearly wrong. As thoughts change slowly with time, this leads to most textbooks
becoming out-of-date fairly soon and requiring frequent revision if to remain of
value.
It therefore is particularly refreshing to have a manual of eyelid surgery using
a frank and logical teaching of principles and practice, this arising through the
author’s evolution as a surgeon and based on decades of practical experience. A
lesson is usually best remembered where teaching is presented with a touch of
humour, and in a well-explained fashion: To do the latter requires an enquiring
and objective mind (as mathematician Alfred North Whitehead said, “It requires
a very unusual mind to undertake the analysis of the obvious”), and to provide
the former requires a slight sense of mischief and humour. For the 40 years we
have been acquainted, Ok Thaller has certainly shown both the analytical and a
humorous mindset!
The author is not afraid to discuss experience learnt through both good and
bad results, and many of his ideas were ahead of their time, challenging the common attitude of “that is the way it has always been done”? Einstein said, “the
only source of knowledge is experience”, and this condensation of the author’s
life experience provides an invaluable—and enjoyable—resource for both trainee
and more experienced surgeons. We must congratulate and thank Ok Thaller for
condensing the broad spectrum of eyelid surgery into a practical and highly readable manual, and remember that “a person who never made a mistake never tried
anything new” (Einstein). It is very clear that the author has tried many new things,
very wisely learnt from any such misjudgements, and has had the courage to pass
on this knowledge to the next generation. We “all build on the shoulders of giants”,
and this book is not only a delight to read, but also a particularly thoughtful foundation on which we can continue to build a better future for those trusting in our
care.
January 2023 Geoffrey E. Rose, D.Sc., FRCOphth
vii
Preface
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Why?
Experience is simply the name we give our mistakes.
—Oscar Wilde
I admit to not being an avid reader of textbooks, probably because I still read in
the way I was taught to as a child. In mitigation, it may be that most textbooks
were not written to be read, merely consulted. Either way, what follows is a basic
surgical manual, not a textbook!
Similarly, I have yet to outgrow the annoying childhood habit of always asking
“Why?”. Often, I am surprised by the lack of clear answers. Now, at the end of a
career’s worth of surgical “experience”, I feel honour bound to attempt at least to
pass on my few, hard gained, answers. Although we are each destined make our
own mistakes, all must start from somewhere. I consider this manual to be as good
a starting point as any. May it set you on the right path.
Plymouth, UK Vladimir Thaller, FRCS, FRCOphth
Acknowledgements I thank my many teachers for all they have taught me and for their kind
forbearance at my endless questions. I include patients among my teachers. I have learnt much from
them. The National Health service, for all its imperfections, is a wonderful altruistic organisation
whose dedicated staff have supported me throughout my career and made me look forward to each
working day. And last but not least I thank my dear wife Linda for her unwavering support and
understanding.
ok.thaller@outlook.com
ix
Contents
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1 Introduction ........................................................ 1
1.1 Overview . ................................................... 1
1.2 Congratulations .............................................. 1
1.3 The Target (Fig. 1.1) . . . ...................................... 1
1.4 “Common Things are Common…Save Common Sense” ...... 2
1.5 Less is More . ............................................... 2
1.6 The Truth, NOT the Whole Truth, and Nothing
But the Truth! ............................................... 2
1.7 A Matter of Principle . . ...................................... 3
1.8 Heresy, Not Hearsay . . . ...................................... 3
1.9 Concept or Cookbook? ...................................... 3
1.10 10,000 hour Expert? . . . ...................................... 4
1.11 Challenge ................................................... 4
1.12 The Good Outcomes Secret . ................................. 4
1.13 Style and Structure .......................................... 4
1.14 Exceptions Prove the Rule . . ................................. 5
1.15 Warning . . ................................................... 5
2 The Basics .......................................................... 7
2.1 Overview . ................................................... 7
2.2 Do Least Harm! . . . .......................................... 7
2.3 Surgery is Directed Scarring ................................. 8
2.4 The Healing Response . ...................................... 8
2.4.1 Primary Intention Healing . ......................... 8
2.4.2 Secondary Intention Healing . . . .................... 8
2.5 Stages of Wound Healing . . . ................................. 8
2.6 Thermal Burns .............................................. 9
2.7 Tension, Expansion, Migration, and Contraction . . . ........... 9
2.7.1 Tissue Expansion . ................................. 9
2.7.2 Suture Migration . . ................................. 9
2.7.3 Contraction (Hydrocortisone Ointment
2.8 The Dog Ear Dilemma (Waste Not, Want Not!) (Fig. 2.3) . . . . 12
2.9 Active v Passive Surgical Mechanisms (Fig. 2.5) . . ........... 14
and Massage) ...................................... 10
xi
xii Contents
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2.10 The Kit (Instruments) .. ...................................... 15
2.11 Anaesthesia . . . ............................................... 15
2.12 Haemostasis . . ............................................... 16
2.12.1 Vasoconstriction . . . ................................. 16
2.12.2 Positioning (Fig. 2.6) . . ............................. 16
2.12.3 Diathermy . . . ...................................... 17
2.12.4 Cut Uphill . . . ...................................... 17
2.13 Plication v Resection . . ...................................... 17
2.14 Post-operative Antibiotics and Padding .. . .................... 17
2.14.1 Steps .............................................. 18
2.15 Fail-Safe Redundancy (Fig. 2.7) . ............................. 18
2.16 Take Home Message . . . ...................................... 19
3 Sutures and Suturing ............................................... 21
3.1 Overview . ................................................... 21
3.2 Suture Characteristics . . ...................................... 22
3.2.1 Absorbable v Non-absorbable . . .................... 22
3.2.2 Suture Tension ..................................... 22
3.2.3 Suture Gauge (Table 3.1) . . ......................... 22
3.2.4 Knotting . .......................................... 23
3.2.5 Monofilament v Braided . . . ......................... 23
3.2.6 Suture Needles (Fig. 3.1) . . ......................... 23
3.2.7 Needle Shape (Fig. 3.2) . . . ......................... 24
3.3 Suturing Techniques . . . ...................................... 25
3.3.1 Interrupted v Continuous (Fig. 3.3) . ................ 25
3.3.2 Suture Bite Spacing (Fig. 3.4) . . .................... 26
3.3.3 Suture Spaghetti . . ................................. 26
3.3.4 Simple v Mattress (Fig. 3.5) ........................ 27
3.3.5 Horizontal v Vertical Mattress (Fig. 3.7) ............ 28
3.3.6 The Humble Horizontal Mattress (Fig. 3.8) . . ....... 30
3.3.7 The ‘Magic Suture’ (Fig. 3.9) . . .................... 30
3.4 The Cotton Bud: An Aid to Suturing ......................... 33
3.4.1 Steps (Fig. 3.11) . . ................................. 33
3.5 Take Home Message . . . ...................................... 34
Reference . . . ........................................................ 34
4 Pertinent Anatomy ................................................. 35
4.1 Overview . ................................................... 35
4.2 The Lid Skeleton (Fig. 4.1) . ................................. 35
4.2.1 Canthal Tendons . . ................................. 35
4.2.2 Orbital Septum (7 Veils) . . ......................... 36
4.3 Lid Layers (or Lamellae) (Fig. 4.2) . ......................... 36
4.3.1 Anterior Lamella (Fig. 4.2a) ........................ 36
4.3.2 Posterior Lamella (Fig. 4.2b) . . . .................... 37
4.3.3 In-Between . . ...................................... 37
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