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150 11 Dermatochalasis and Blepharoplasty
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3. Repeat step 2 medially and laterally at several points along the lid as the
amount of loose skin varies (there is usually more laterally). These marks
represent the maximum amount of skin that may be safely removed without
impairing eyelid closure.
4. Complete the skin marking by drawing an ellipse that falls within the
upper skin markings and is based on the skin crease marking from step 1
(Fig. 11.1d).
Note: The ellipse must extend laterally, past the lateral canthus as there is
usually more excess skin laterally than medially. Try to stay within the orbital
region as outside the orbital area scars become more visible.
5. To cross check, measure the distance between the lower edge of the eyebrow
and the upper skin ellipse line centrally. Add this value to the planned skin
crease height. The sum of these two measurements should exceed 20 mm to
ensure that sufficient skin remains for normal blinking.
6. Inject local anaesthetic with adrenaline into the sub-orbicularis plane ballooning the skin along the whole length of the ellipse.
7. Place a metal eye protecting plate in the upper fornix to avoid accidental eye
damage and ensure that an assistant holds it in place up against the superior
orbital rim.
8. Incise the skin and orbicularis along the markings with a no. 15 scalpel blade
(Fig. 11.1e). Remember to cut ‘uphill’ to prevent blood from running down
and obscuring your skin markings.
Note: Keep the skin stretched tightly between the thumb and fingers of your
other hand while performing this incision. This makes it easier to follow the skin
marking. Lax skin is difficult to cut accurately.
9. Lift the outer corner of the skin ellipse with St. Martin’s toothed forceps and
use Westcott spring scissors to finish cutting through the orbicularis to start
raising a flap in the sub orbicular plane (Fig. 11.1f).
10. Extend in this plane to remove the entire skin and orbicularis ellipse. Keep
the skin stretched throughout to make the dissection easier.
Note: An alternative to scissor dissection is to use a high temperature disposable
cautery. This reduces bleeding but takes a little practice. It is essential to pull
and lift the skin flap away from the eye to avoid accidental damage. The cautery
tip must glow to cut tissue. Because it is immediately cooled by tissue contact
develop the technique of making frequent small dabs with the tip to maintain cutting. I strongly advise the inexperienced surgeon against using radio frequency
cutting diathermy as this provides no tactile feedback and makes inadvertent
globe penetration frighteningly easy.
11. Place a single interrupted absorbable orbicularis suture just above and lateral
to the outer canthus to start closing the incision (Fig. 11.1g). This approximates the wound edges and creates an angle. Check the alignment of the skin
edges before proceeding.
12. Complete the skin closure using a 6/0 or 7/0 absorbable continuous suture
(Fig. 11.1h).
11.7 Take Home Message 151
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Note: Geometrically the upper skin wound edge is longer than the lower one.
Therefore ‘gather’ the excess along the whole length of the closure. In the central
lid portion of the closure alternate bites should engage the levator aponeurosis
to ensure that a strong skin crease develops. This adds an ‘active’ component
to the operation which reduces the likelihood of an early recurrence.
13. Apply antibiotic eye ointment and a pressure dressing overnight to reduce the
almost inevitable lid swelling and bruising.
Note: Having both eyes padded is disorientating and unpleasant even if only for
one night. Some surgeons do not pad and prefer instead to recommend that the
patient applies ice packs to reduce the postoperative swelling. This is neither
easy for the patient nor comfortable.
11.6 Notes
•
It is possible to remove only skin and to leave the orbicularis intact. However,
the subcutaneous plane is harder to dissect than the sub-orbicularis plane as the
skin and orbicularis are bound together by the orbicular fascia.
•
If only skin is removed the skin crease will reform without the need of levator
aponeurosis suture bites.
•
Removing skin but leaving the orbicularis risks creating a ‘stuffed sausage’
appearance with too much orbicularis filling for the remaining skin.
11.7 Take Home Message
•
Plan your skin excision carefully to leave enough behind for full eyelid closure.
Lid Lumps and Bumps
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12.1 Overview
•
Cyst excision.
•
Meibomian cyst incision and curettage.
•
Marking tumour surface extent and gauging its depth.
•
Choosing the type of biopsy, and the size of clear margin.
•
Full thickness lid margin tumour resection technique.
Eyelid bumps are either caused by cysts or by tumours. Both may distort the
lid and interfere with function through their mass effect.
12
12.2 Cysts
Cysts are closed epithelium lined sacs which tend to enlarge as they fill up with
shed cells or secretions. They may be developmental, as in the case of dermoid and
epidermoid cysts, or occur as inclusion cysts from epithelium accidentally buried
during surgery. If they leak, their contents incite a marked local inflammatory reaction. When symptomatic, such cysts should be excised intact, by careful dissection,
to ensure all their epithelial lining is removed or they can reform. Blocked eyelid
sweat glands form clear fluid filled cysts of Moll which transilluminate. Blocked
grease glands form white cysts of Zeiss. Both occur superficially under the skin
and can easily be lanced. If they reform, they should either be de-roofed and left
to granulate or excised intact.
But by far the commonest lid bump results from a blocked meibomian gland
and is known as a meibomian cyst or Chalazion.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
V. Th a l l e r, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_12
153
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12.2.1 Meibomian Cyst Incision and Curettage (I & C)
12.2.1.1 Case Selection
The majority of meibomian cysts settle on conservative treatment with hot
compresses. Large, persistent, or recurrent meibomian cysts require surgical
drainage.
12.2.1.2 Principle
Because meibomian glands are part of the tarsal plate they cannot easily be
excised. Incise them instead and remove the gland’s epithelial lining by thoroughly
curetting the cavity.
12.2.1.3 Steps
1. Evert and carefully inspect the meibomian orifice line and sub-tarsal surface
of the affected lid under magnification to identify the affected gland or glands.
Often the offending gland looks darker or redder than its neighbouring glands
(Fig. 12.1a). If you are unable to identify blocked gland incise at the point of
maximum swelling and hope for the best.
2. Anaesthetise the eye with proxymetacaine drops and the affected lid with
adrenaline containing local anaesthetic injections.
3. Apply a large, oval meibomian clamp to the lid to encompass the affected part
and tighten it to prevent bleeding (Fig. 12.1b).
Note: If you use a small clamp there is a high chance of missing the true position
of the cyst or part of it.
4. Evert the lid using the clamp.
5. Incise the length of the suspected gland (or area of maximum intumescence),
taking care to avoid damaging the lid margin (Fig. 12.1c).
Note: At this point you will hopefully see the gelatinous lipo-granulation contents
of the cyst emerge (Fig 12.1d). If you do not obtain the typical contents, you
may have missed the cyst. Consider performing a second incision to one side
and parallel to the first. When present, the contents are pathognomonic of a
meibomian cyst. However, they are not always found, particularly in chronic
cases where fibrosis has supervened the granulation stage.
6. Vigorously curette the cyst cavity to remove the lining to remove it and any
remaining contents (Fig. 12.1e).
7. Remove the clamp and apply firm pressure until the bleeding stops.
8. Clean the eye, removing any blood and clots, and instill antibiotic ointment.
There is no need to apply a dressing providing you have waited for the bleeding
to stop.
12.2.1.4 Warning
Beware of atypical meibomian cysts or ones that recur after incision. They might
be meibomian carcinomas! Take a biopsy of one edge when repeating the I & C.
12.3 Tumour Excision (Fig. 12. 2) 155
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a b
c d
e
Fig.12.1 Meibomian cyst incision & curettage. a Identify the responsible gland. b Apply and
tighten a large meibomian clamp. c Incise the tarsal plate from the conjunctival surface. d Look
for release of the pathognomonic lipo-granulomatous cyst contents. e Curette the cyst cavity
12.3 Tumour Excision (Fig. 12.2)
The obvious priorities of tumour surgery are to cure the patient while minimizing
collateral damage. The former requires knowledge of the tumour type and its true
extent. The latter involves excising the minimum tissue necessary to effect the cure.
The likely tumour type is inferred from its appearance and rate of growth (learnt
pattern recognition), combined with probability (95% of malignant lid tumours
are basal cell carcinomas). The tumour’s true extent may be obvious, as in a well
demarcated nodular basal cell carcinoma. However, infiltrative tumour margins are
difficult to discern. Therefore, use all the available clues: appearance, palpation,
and mobility (is it fixed to underlying tissues).
To determine a tumour’s surface extent, stretch the surrounding skin in all
directions. This makes it easier to see the tumour boundary by making surface
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Fig.12.2 Butcher. Tumour
surgery is destructive
texture, colour, and contour changes easier to spot. Use magnification (a slit lamp
or illuminated loops) to see details more clearly. Look specifically for:
•
Skin hair or lash loss (indicates tumour infiltration of the follicles).
•
Skin texture alteration viewed by surface reflection of oblique illumination (loss
of the normal fine skin wrinkles and semi-matt surface; tumours tend to be
smooth and shiny).
•
Surface contour change.
•
The capillary network. In tumours it is different from that of normal skin.
Time spent carefully marking the tumour margins saves wasting time later with
avoidable re-excisions.
12.3.1 First is Best
It is said that the first excision attempt has the highest cure rate. This is of course a
self-fulfilling prophecy as failure at the first attempt is likely to be due to uncertain
margins which will be no clearer the second time around. But there is also some
truth in the saying: previous attempts at excision leave scars and distort tumour
margins and tissue planes, making re-excision less certain.
12.3 Tumour Excision (Fig. 12. 2) 157
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12.3.2 Clear Cutaneous Margins
Because of the difficulty in determining a tumour’s boundary with certainty it is
standard practice to excise a ‘clear safety margin’ around the tumour. For presumed
benign lesions 1–2 mm surface margins suffice. For presumed malignant lesions
4 mm margins are a reasonable compromise between incomplete excision and an
unnecessarily large tissue defect (views on this vary considerably (3–5 mm)).
12.3.3 Stretch
Eyelid skin is both mobile and elastic. This makes skin marking difficult as the
marker pen drags and distorts the skin. Clear margin measurement must be standardized to have any meaning. Get around both problems by having an assistant
keep the skin stretched during measuring, marking, and incising.
12.3.4 Deep Excision
The depth of a tumour’s extension is gauged differently from its surface markings.
Grasp the tumour and pull it to and fro noting its mobility over the underlying
tissues. If mobility is restricted, then there is likely to be deep extension. Fortunately, most tumours are reluctant to cross tissue planes unless encouraged to do
so, for example by incisional biopsy. Consequently, most cutaneous lid growths
do not penetrate the orbicularis plane. So, for complete excision excise the surface
marked tumour and include an intact layer of underlying orbicularis in the specimen as the deep safety margin. If the tumour appears fixed, the specimen should
include the underlying tarsal plate or periosteum (depending on its location).
12.3.5 Waste Not, Want Not
It is customary to excise lesions as elliptical specimens to avoid lax ‘dog ear’
folds at either end of the closure scar (see Chap. 2). This practice results in excess
healthy tissue being sacrificed on the altar of cosmesis. I recommend removing
only the actual tissue necessary to achieve a cure for two reasons. Firstly, the so
called ‘dog ears’ tend to remodel and vanish within a year of surgery and seldom
require subsequent treatment. Secondly, the tissue spared may come in useful for
the present or for future reconstructions.
The same dictum is true when choosing reconstruction procedures. I am suspicious of reconstructions which require you to discard a significant quantity of
skin.
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Fig.12.3 Beware canthal
tumours. Tumours at the
canthi can spread into the
orbit silently along the
canthal tendons
BEWARE!
12.3.6 Beware the Canthi (Fig. 12.3)
At the eyelid margin a tumour readily invades the tarsal plate but cannot penetrate
deeper than the conjunctival surface. However, at the medial and lateral canthi
the canthal tendons provide a direct highway for tumour spread to the orbital rim
periosteum, from where it can quietly invade the orbit unnoticed.
12.3.7 Biopsy: Excision V Incision
Single stage or ‘one stop’ surgery is preferred by patients and is an efficient use
of resources. Therefore, excision biopsy with direct defect closure should be your
default management. However, if serious doubt exists about the nature of a large
lesion, perform an incisional biopsy first to establish the diagnosis. This biopsy
should include part of the tumour margin rather than being taken from the centre. The former shows the tumour invading normal tissue. This is helpful to the
histologist. Histological confirmation that a lesion is benign avoids excessive clear
margin excision.
12.3.8 Histology First!
Delay reconstruction of presumed malignant tumour defects until you have histological proof of tumour clearance. The only exceptions to this rule are direct defect
closure or directed laissez-faire. With these all the tumour margins are included in
the single scar. Should the subsequent histology report recommend a re-excision,
simply excise the scar with the appropriate additional safety margin.
12.4 Full Thickness Lid Margin Tumour Resection (Fig. 12. 4) 159
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12.3.9 One Stop Management
There are only three options for safe ‘one stop’ management:
1. Excision and direct closure
2. Excision and ‘laissez-faire’
3. Excision with ‘on table’ frozen section histology followed by reconstruction.
This last option is time and resource intensive making it costly. Furthermore,
frozen section histology is less reliable than paraffin sections. Mohs’ surgery
is a form of sequential frozen section biopsy that may be useful in tumours
without any clear margins, but it is by no means infallible. Furthermore, it is
difficult to carry out periocularly because of the mobility of the thin tissue
planes relative to each other which makes the excision of an intact 2 mm thick
Mohs layer neigh impossible.
12.4 Full Thickness Lid Margin Tumour Resection (Fig. 12.4)
See Fig. 12.4.
a b
c d
Fig.12.4 Lid margin tumour resection. a Mark the visible tumour margins. b Mark a clear safety
margin. c Incise along the marking with a no. 15 scalpel. d Excise the specimen with scissors.
e Flatten the specimen on card and mark the edges with dyes for orientation
4 mm
e
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12.4.1 Considerations
Meaningful margins can only be measured with the tissues on stretch. Careful specimen marking and orientation during fixation avoid confusion when the
histological margins are reported.
12.4.2 Steps
1. Carefully mark the visible tumour edges with the lid held on stretch
(Fig. 12.4a).
2. Mark the planned clear margin (usually 4 mm) using a calliper (Fig. 12.4b).
3. Protect the eye with a metal plate under the lid and incise the skin along the
markings with a no.15 scalpel (Fig. 12.4c).
Note: Remember to cut ‘uphill’!
4. Complete the orbicularis ± tarsal plate incision with tenotomy scissors
(Fig. 12.4d).
5. Get an assistant to apply firm pressure to the area for haemostasis, while you
attend to the specimen.
6. Without releasing your hold, rinse and dry the specimen to remove blood.
Inspect all the edges and the deep surface to make sure no tumour is visible. If
it is, excise an additional specimen from that margin.
7. Place the specimen on a piece of card and spread it, unrolling the skin edges if
required.
8. Mark the specimen edges with histology marking inks for orientation
(Fig. 12.4e) and record the colours of the respective edges in the notes and
on the histology request form. Allow the inks to dry and the specimen to stick
to the cardboard for 5 min.
9. Slip the cardboard mounted specimen slowly into a formalin pot so that the
specimen remains flat during fixation. This makes the pathologist’s task easier.
12.5 Take Home Messages
•
Biopsy atypical or recurrent meibomian cysts.
•
Careful tumour margin marking pays dividends.
•
Await proof of clearance before undertaking complex reconstructions.
•
Beware of canthal tumours!
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