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2. Bluntly dissect proximally on the under surface of the conjunctiva while holding
the inferior conjunctival edge on upward stretch (Fig. 9.7b).
3. Insert toothed Jayles forceps into the dissected pocket and grab and with-
draw the retractor fascia. Tag it with a 6/0 absorbable suture before letting
go (Fig. 9.7c).
4. Check the retractor pull by putting the suture on gentle upward traction while
the patient is looking up, and then asking the patient to look maximally downwards. You should feel a tug on the suture. If it is not felt, repeat the manoeuvre
but this time asking the patient to follow your hand into downgaze. If there is
still no pull on the suture, remove and replace it.
5. Bring the suture needle out through the edge of the tarsal plate and conjunctiva,
and then back into the wound through the inferior conjunctival edge (Fig. 9.7d).
The tarsal bite should be placed 5 mm medially of centre in anticipation of a
subsequent lateral lid margin shortening.
6. Tie the suture tightly and cut the ends to 2 mm. Encourage them to retract
into the wound so that the knot becomes fully buried. This single suture both
plicates the retractors to the tarsal plate and closes the conjunctival incision.
7. Proceed to perform a lid margin shortening (lateral wedge resection and Bick
repair) (Fig. 9.7e).
9.7.3.4 Note
•
Retractor plication alone is only of marginal benefit if performed without lid
shortening.
•
Alternatively, the retractors may be plicated via an anterior approach (see
Fig. 8.8b–d). Use this approach when you need to perform anterior lamellar
augmentation.
9.7.4 Free Skin Graft (Fig. 9.8)
9.7.4.1 Principle and Considerations
Take a full thickness patch of colour and texture matched donor skin from an
available donor site and suture it into the anterior lamellar deficit. Stabilize the
graft bed with a lid margin traction suture and the graft with a pressure dressing.
9.7.4.2 Case Selection
Anterior lamellar deficit (actual or secondary to mid face drop).
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9.7.4.3 Steps
1. Incise the lower lid skin and orbicularis 5 mm below the lid margin and
perform lid margin tightening if one is required (Fig. 9.8a). It usually is!
2. Put the recipient bed on stretch and dry it. Blot the area with a piece of paper
to obtain a blood-stained imprint of the defect. Remove the paper and cut
a b
c d
x
y
x + y ≥ 20 mm
e
Fig. 9.8 Anterior lamellar graft. a Incise the lower lid skin and orbicularis 5 mm below the lid
margin and perform lid margin tightening if required. b Blot the recipient bed with a piece of paper
to obtain a blood-stained imprint of the defect to create a paper template. c Use the template to mark
theareaofskintobeharvested.d Transfer the skin graft to the donor bed anchoring it at either end.
e Use the anchoring sutures to suture the graft in place with a continuous suture. Suture the donor
site
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around the imprint to create a paper template of the defect. Check this against
the wound and refine it as necessary (Fig. 9.8b).
3. Place the paper template on the gently stretched donor site and mark the area
of skin to be harvested. If you choose the upper lid as the donor site, ensure
that you leave sufficient skin behind to allow full eyelid closure. As a rule of
thumb, leave at least 20 mm of skin between the lid margin and the lower
edge of the eyebrow (Fig. 9.8c).
4. Intumesce the donor site with a sub-dermal injection of local anaesthetic with
adrenaline. This assists haemostasis and makes it easier to harvest a thin graft.
5. Incise the full thickness of the skin along the marked line with a scalpel.
6. Grasp one edge of the donor skin with toothed forceps to keep the skin on
traction and carry out a sharp dissection in the superficial subcutaneous plane
with the tip of the scalpel blade or with scissors. Check frequently that you
are not perforating the graft.
7. Wrap the harvested skin graft around your index finger, subcutaneous side
out, and trim off any excess subcutaneous tissue remaining on the graft with
Westcott scissors.
8. Anchor the skin graft to the donor bed at either end with a 6/0 absorbable
suture but do not cut the suture ends (Fig. 9.8d).
9. Use the anchoring sutures to suture the graft in place with a continuous suture.
Do this in two stages using one of the anchoring sutures for one half and the
other for the second half. Tie each suture to the free end of the other one to
complete (Fig. 9.8e).
10. Suture the donor site.
11. Tape the lid margin traction suture securely to the forehead (for the lower lid)
or cheek (for the upper lid) to keep it on traction and so immobilize the graft
bed.
12. Apply a non-stick film, copious antibiotic ointment, and a firm pressure dressing to the closed eye. Leave this undisturbed for 5–7 days to keep the graft
immobile while it revascularizes.
9.7.4.4 Notes
•
Take care when removing the pressure dressing not to pull on the graft as not all
dressings marketed as ‘non-stick’ live up to their name. Remove the lid margin
traction suture.
•
Apply twice daily antibiotic ointment to the graft for a further week to keep it
soft and moist.
•
Thereafter the patient should massage the graft gently towards the lid margin,
twice daily, with a thin smear of hydrocortisone 1% skin ointment. This helps
to reduce postoperative graft shrinkage.
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9.7.5 Upper to Lower Lid Skin Pedicle Flap (Fig. 9.9)
9.7.5.1 Principle and Considerations
Skin may be transferred to the donor site on its own vascular pedicle. This has the
theoretical advantage of ensuring flap survival. In practice, there is little additional
benefit over a free graft because the periocular region is so well vascularized.
When possible ‘set in’ the flap pedicle to avoid the need for a second operation.
a
c
a
b
c
b
x
y
x + y ≥ 20 mm
d
a
c
b
e
Fig. 9.9 Anterior lamellar pedicle flap. a Create a paper template of the defect. b Use the template
to mark the pedicle flap. c Raise the flap and transfer it to the recipient site. d Anchor the tip of the
flap in its new position with a 6/0 absorbable suture and anchor the lateral corner of the recipient
skin (point c) into the lateral end of the donor incision (point a). e Suture the flap into place with
a continuous suture and close the upper lid donor bed
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9.7.5.2 Case Selection
Anterior lamellar deficit (actual or secondary to mid face drop) when sufficient
upper lid donor skin is present.
9.7.5.3 Steps
1. Put the recipient bed on stretch, using a 4/0 monofilament lid margin traction
suture, and dry it. Blot the area with a piece of paper to obtain an imprint of
the defect. Remove the paper and cut around the blood stain to create a paper
template. Check this against the wound and refine it, as necessary (Fig. 9.9a).
2. Place the paper template on the chosen skin donor site. Ensure that the skin is
gently stretched before marking the area to be harvested (Fig. 9.9b). Mark also
the pedicle on which this donor skin will be transferred. This should not be
narrower than the flap. Take particular care to align the upper and lower ends
of the pedicle base (points a and b) vertically, one above the other (Fig. 9.9c).
This ensures that when transferred the pedicle beds in aesthetically.
3. Intumesce the donor site with a superficial injection of local anaesthetic with
adrenaline. This helps with haemostasis.
4. Incise the full thickness of the skin along the marked line with a scalpel.
5. Grasp the tip of the flap and dissect the flap free of its bed with Westcott
scissors. The dissection plane can either be between the skin and the orbicularis, or the orbicularis can be included as part of the flap. The latter results
in an easier dissection, better vascularity and slightly more ‘support’ from the
pedicle.
6. Anchor the tip of the flap in its new position with a 6/0 absorbable suture (do
not cut the ends) (Fig. 9.9d).
7. Anchor the lateral corner of the recipient skin (point c) into the lateral end of
the donor incision (point a) with a second suture to complete the alignment.
8. Suture the flap into place with a continuous suturing technique, using the uncut
anchoring sutures (Fig. 9.9e).
9. Finally, close the upper lid donor bed with a continuous absorbable suture.
10. Tape the lid margin traction suture securely to the forehead to immobilize the
flap bed and keep it on traction.
11. Apply a non-stick film, copious antibiotic ointment, and a firm pressure dressing to the closed eye and leave this undisturbed for 1–7 days. It is not strictly
necessary to keep a flap padded for as long as a graft. However, a pad does
protect the surgical site from the patient’s wandering hands during the early
healing phase.
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9.7.6 Permanent (Overlap) Lateral Tarsorrhaphy (Fig. 9.10)
9.7.6.1 Principle and Considerations
Adding a short (4 mm) permanent lateral tarsorrhaphy transfers some of the upper
lid levator pull to lift the lower lid laterally. This imparts an active component to
an otherwise passive ectropion repair. This is especially important when correcting
paralytic ectropion.
9.7.6.2 Case Selection
Atonic lower lid ectropion. Usually combined with lid margin shortening and with
medial canthoplasty.
9.7.6.3 Steps
1. Make a 4 mm long incision in the lower lid grey line up to the lateral canthus
(Fig. 9.10a).
2. Based on the grey line incision, excise a semicircle of anterior lamella below
it, including skin, lashes, and orbicularis, to expose the underlying tarsal plate
(Fig. 9.10b). Ensure that the exposed tarsal plate surface is free of connective
tissue. Gentle diathermy may be applied if required to enhance adhesion.
3. Evert the upper lid margin and mark out a corresponding semicircle on the
sub-tarsal conjunctiva ensuring that it also starts at the lateral canthus. Apply
gentle diathermy to this area to destroy the conjunctiva without significantly
damaging the tarsal plate (Fig. 9.10c). Wipe off any loose necrotic conjunctiva.
4. Insert a 6/0 absorbable suture through the middle of the exposed lower lid
tarsal plate margin.
5. With the same suture take a bite of the upper edge of the adjacent diathermied
area of the everted upper lid tarsal plate (Fig. 9.10d).
6. Tie this suture and cut its ends short, so that they do not irritate the eye.
7. Insert a 4/0 monofilament suture on a round bodied needle through the upper
lid skin, just above the lashes so that it exits the denuded tarsal plate close to
the lateral canthus.
8. With the same suture now take a strong, partial thickness, bite to span the
exposed lower lid tarsal plate.
9. Complete this suture by taking it through the upper lid tarsal plate at the
medial end of the denuded tarsal crescent, so that it exits through the skin just
above the lashes (Fig. 9.10e).
10. Cut a piece of silicone tubing the length of the distance between the suture
entry and exit points and thread it onto the suture. It will act as a bolster. Clip
the untied suture ends together.
11. Place one or two 6/0 absorbable sutures to bring together the upper lid meibomian orifice line and the cut edge of the lower lid orbicularis and skin. Tie
the suture(s) (Fig. 9.10f).
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a
b
c d
e f
Fig.9.10 Permanent lateral tarsorrhaphy. a Make a 4 mm long incision in the lower lid grey line
up to the lateral canthus. b Excise a semicircle of anterior lamella to expose bare tarsal plate.
c Evert the upper lid and diathermy a corresponding area without significantly damaging the tarsal
plate. d Insert a 6/0 absorbable suture between the middle of the exposed lower lid tarsal plate
margin and the upper edge of the adjacent diathermied area of the everted upper lid tarsal plate
and tie it. e Insert a 4/0 monofilament suture on a round bodied needle through the upper lid skin,
just above the lashes so that it exits the denuded tarsal plate close to the lateral canthus and take
a strong, partial thickness, bite of exposed lower lid tarsal plate. Complete this suture by taking it
through the upper lid tarsal plate to exit the skin just above the lashes. Thread it through a piece
of silicone tubing. f Place two 6/0 absorbable sutures to bring together the upper lid meibomian
orifice line and the cut edge of the lower lid orbicularis and skin together
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12. Tighten and tie the preplaced 4/0 monofilament suture to hold the raw tarsal
plate surfaces in firm apposition, so that they unite during healing.
13. Before cutting the 4/0 suture ends, thread one end back through the tubing,
using the blunt end of its needle. By pulling on this suture the knot can be
pulled to lie inside the tubing for the patient’s comfort. Cut both suture ends
close to the tubing.
14. No dressing is required. Remove the non-absorbable suture and bolster at two
weeks. The remaining sutures are allowed to dissolve spontaneously.
9.7.6.4 Notes
•
Such tarsorrhaphies are well camouflaged by the upper lid lashes.
•
They are permanent and cannot be reversed without causing distortion of the
lid margin.
•
They are often combined with a medial canthoplasty which provides medial lift
to the lower lid.
9.7.7 Medial Canthoplasty (Fig. 9.11)
9.7.7.1 Principle and Considerations
Medial canthoplasty is a tarsorrhaphy carried out medially to the lacrimal puncta. It
transfers upper lid levator pull to a paralytic lower lid adding an active component
to a paralytic ectropion correction. Take great care not to damage, or suture closed
the lacrimal canaliculi during this procedure as they lie close to the tendon.
9.7.7.2 Case Selection
Atonic lower lid ectropion. Usually combined with lid margin shortening and with
lateral tarsorrhaphy.
9.7.7.3 Steps
1. Insert ‘0’ gauge Bowman lacrimal probes into the upper and the lower canali-
culi and ask an assistant to keep them in the lacrimal sac by pressing them
gently against the side of the nose (Fig. 9.11a).
2. Carefully make a ‘U’ shape skin incision around the medial canthus from
punctum to punctum and 1–2 mm outside the probes (hence also the canaliculi).
3. Separate the orbicularis under the incision by blunt dissection using pointed
scissors.
4. Using a 6/0 absorbable suture on a curved needle take a strong horizontal bite
of the firm medial canthal tendon tissue adjacent to the canaliculus (Fig. 9.11b).
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a b
c d
Fig.9.11 Medial canthoplasty. a Insert ‘0’ gauge Bowman lacrimal probes into the upper and
the lower canaliculi and make a ‘U’ shape skin incision around the medial canthus from punctum to punctum and 1–2 mm outside the probes. b Using a 6/0 absorbable suture on a curved
needle place 2 ‘box’ sutures. c Withdraw the Bowman probes and tie both sutures firmly. Place
two 6/0 absorbable horizontal mattress sutures across the wound, engaging both the skin and the
orbicularis. d Tie the skin sutures to evert the skin edges
The tendon is identified by its resistance to distraction rather than by its visibility. Start at the medial canthus. If you touch metal with your needle tip it
has penetrated the canaliculus and should be withdrawn.
5. Take a similar bite of tendon with the same suture through the opposing lid in
the opposite direction to make a ‘box’ suture. Clip the two suture ends together.
6. Place a second suture adjacent to the first so that the bites extend to the lateral
ends of the incisions, close to the lacrimal puncta.
7. Withdraw the Bowman probes and tie both sutures firmly. In doing so the lid
margins become inverted so that there is no epithelium between the raw surfaces
of the upper and lower limbs of the medial canthal tendon.
8. Place two 6/0 absorbable horizontal mattress sutures across the wound, engag-
ing both the skin and the orbicularis. As you tie them, they will evert the skin
edges (Fig. 9.11c, d).
9. No dressing is required. Leave the sutures to dissolve spontaneously.
9.7.7.4 Notes
A medial canthoplasty hides the caruncle. Usually this is not a major aesthetic
issue particularly as in paralytic ectropion the pre-operative medial canthus is
excessively widened.
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9.7.7.5 Problems
Lid margin tightening and anterior lamellar flaps and grafts rely on static mechanisms of action and are therefore prone to ectropion recurrence. Recurrence
is particularly likely if a small anterior lamellar deficit has gone unnoticed and
uncorrected.
9.8 Take Home Message
•
Surgical correction of involutional ectropion requires substantial lid margin
shortening ± anterior lamellar supplementation with a skin graft or flap.
•
Ectropion recurrence is common because the surgery mostly relies on passive
mechanisms.
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