Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 850 - файл
.pdf
13.6 Permanent Surgical Tarsorrhaphy 171
https://t.me/medicina_free
13.6.1.3 Steps
1. Make a 4–5 mm long incision in the lower lid grey line up to the lateral
canthus (Fig. 13.7a).
2. Based on the grey line incision, excise a semicircle of anterior lamella below
it, including skin, orbicularis, and lash follicles, to expose the underlying
tarsal plate (Fig. 13.7b). Ensure that the exposed tarsal plate surface is free
of connective tissue. Apply gentle diathermy if required.
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. 13.7c). 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. 13.7d).
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. 13.7e).
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 into the upper lid meibomian orifice
line, bringing them down to engage the cut edge of the lower lid orbicularis
and skin. Tie the suture(s) (Fig. 13.7f).
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 reverse thread (using the blunt end of its
needle) one end through the tubing. By pulling on this suture, you can pull
the knot to lie inside the tubing for the patient’s comfort. Then cut both suture
ends close to the tubing.
14. No dressing is required. Remove the non-absorbable suture and bolster at two
weeks. Allow the remaining sutures to dissolve spontaneously.
Note: Such tarsorrhaphies cannot be reversed without causing distortion of the
lid margin and so should only be used when permanence is intended. They are
well camouflaged by the upper lid lashes.
172 13 Eye Protection
https://t.me/medicina_free
13.6.2 Permanent Medial Canthoplasty (Fig. 13.8)
13.6.2.1 Principle and Considerations
Medial canthoplasty is effectively a tarsorrhaphy carried out medially to the
lacrimal puncta where there is no tarsal plate to suture together. Instead, aim to
unite permanently the upper and lower limbs of the medial canthal tendons. Take
great care not to damage, or suture closed the lacrimal canaliculi during such
surgery as they lie adjacent to the tendon.
It is often combined with a lateral tarsorrhaphy.
13.6.2.2 Case Selection
•
Non-recovering facial palsy
•
Atonic lower lid ectropion
•
Lower lid retraction e.g., Thyroid eye disease (only when combined with
retractor recession).
a b
c d
Fig.13.8 Permanent medial canthoplasty. a Insert Bowman probes into the upper and the lower
canaliculi and make a ‘U’ shape skin incision around the medial canthus from punctum to punctum. b Suture firm medial canthal tendon tissue adjacent to the canaliculus together with two ‘box’
sutures. c Place two horizontal mattress sutures across the skin wound. d The posterior lamella is
inverted, and the anterior lamella everted to maximise the contact area
13.6 Permanent Surgical Tarsorrhaphy 173
https://t.me/medicina_free
13.6.2.3 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.
2. Carefully make a ‘U’ shape skin incision around the medial canthus from
punctum to punctum and just outside the probes (hence also the canaliculi)
(Fig. 13.8a).
3. Separate the orbicularis by blunt dissection using pointed scissors.
4. Using a 6/0 absorbable suture on a curved needle take a strong bite of the firm
medial canthal tendon tissue adjacent to the canaliculus (Fig. 13.8b).
Note: Identify the tendon by its resistance to distraction rather than by its visibility. Start at the medial canthus. If you feel the needle tip touch metal, then it is
intracanalicular and should be removed and replaced.
5. Take a similar bite 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 ends
of the incision, 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. 13.8c, d).
9. No dressing is required. Leave the sutures to dissolve spontaneously.
13.6.3 Lower Lid Lifting (Fig. 13.9)
The lifting of an atonic lower lid is best achieved by combining a medial canthoplasty with a small lateral tarsorrhaphy. Doing so transfers dynamic upper lid lift
(levator pull) to the lower lid. The effect can be enhanced by dividing the lower lid
retractors first (transconjunctivally) and placing the lower lid on upward traction
overnight with a central tarsal traction suture.
174 13 Eye Protection
https://t.me/medicina_free
Fig.13.9 Permanent medial canthoplasty and lateral tarsorrhaphy. Impart dynamic lift to a lower
lid with a small lateral tarsorrhaphy and medial canthoplasty
13.7 Take Home Message
•
Use the meibomian orifice line, not the grey line, for bolster-less lid margin
traction suture placement.
•
Use a meibomian orifice line suture tarsorrhaphy instead of a temporary surgical
tarsorrhaphy.
Lid Reconstruction
https://t.me/medicina_free
Post Tumour Excision Repair
The art of surgery (Fig 14.1).
14
Fig.14.1 Artist with a scalpel
14.1 Overview
•
Relative importance of the upper lid
•
Lid tension vectors and tissue expansion
•
Direct closure of lid margin defects
•
Direct closure of skin defects
•
Directed Laissez-faire
•
Upper to lower lid skin flap
•
Cheek pedicle flap
•
Mustardé lower lid switch flap
© 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_14
175
176 14 Lid Reconstruction
https://t.me/medicina_free
When faced with an eyelid reconstruction, ask first “Is reconstruction is really
necessary?” Our natural healing response has evolved over millennia to do just
that and is generally very effective. Remember the maxim “First do no harm”, as
all surgery involves further wounding, albeit with the best of intentions. So, always
attempt direct defect closure, and if that fails consider the option of doing nothing,
referred to as “Laissez-faire”. It can produce acceptable results in selected cases
and may be preferred by some patients as an alternative to further surgery.
A functioning lid requires both an anterior and a posterior lamella. Restore
both.
14.2 The Reconstruction Ladder (Fig. 14.2)
Reconstruction techniques are ranked in a hierarchy, sometimes referred to as
Gillies’ ladder (after Sir Harold Delf Gillies CBE FRCS 1882–1960). Rank the
best technique first and the most complex last:
•
Direct closure (best tissue match)
•
Directed laissez-faire (incomplete attempted direct closure)
•
Laissez-faire (involves no surgery)
•
Flaps (recruitment of adjacent tissue)
•
Grafts (free transfer of distant tissue)
•
Microvascular flaps (free grafts with a vascular re-anastomosis).
Fig.14.2 The reconstruction
ladder. A hierarchy of
reconstruction options with
the best at the bottom and the
most complex at the top.
With experience 80% of
reconstructions can be
satisfactorily managed using
the bottom two rungs
Reconstruction ladder
Microvascular Graft
Free Graft
Local Flap
Laissez-faire
Directed Laissez-faire
Direct Closure
80%
14.3 Upper Lid Essential, Lower Lid Optional! 177
https://t.me/medicina_free
Without doubt, direct closure gives the best outcomes. However, it is not always
possible. Consider leaving a wound partially closed when you cannot quite close it
completely (termed ‘directed laissez-faire’). Ultimately the size and nature of the
defect will dictate the most appropriate management choice. Consider patient preference, although that is in large part dictated by the way you present the options.
Never oversell. ‘Under promise and over deliver’ to avoid disappointment. Be
aware of the subconscious bias to promote unnecessarily complex repairs because
we as surgeons enjoy operating (or possibly derive additional financial benefit?).
I challenge you to incrementally increase your direct closure/directed laissez-
faire rate to 80% from the probable 30% at which I guess it currently stands.
14.3 Upper Lid Essential, Lower Lid Optional!
The relative functional importance of the upper lid compared with the lower lid is
often overlooked. Many papers and chapters are devoted to lower lid reconstruction using harvested upper lid tissue. This is not without risk to upper lid function
which is essential for clear vision. Without it the comfort and integrity of the eye
itself are in jeopardy. The upper lid is a ‘wash-wiper’, spreading a fresh optical
tear film across the upper 2/3 of the cornea with each blink (Fig. 14.3). Bell’s phenomenon (the upward rolling of the eye during blinking) ensures that the lower
1/3 of the cornea is also kept moist by the upper lid. This means that the lower
lid is mostly redundant, a fact born out following complete lower lid margin excision without reconstruction (laissez-faire healing). Never compromise upper lid
function when you use it as a donor site.
Fig.14.3 Wash-wiper. The upper lid spreads the tears on blinking to clean and replenish the precorneal tear film, a function essential for clear vision and for corneal survival
178 14 Lid Reconstruction
https://t.me/medicina_free
14.4 Proof of Cure
I contend that histological proof of malignant tumour clearance is mandatory
before you undermine or alter the defect margins in case a further wider excision is needed. Therefore, avoid performing flap or graft repairs at the time of
excision biopsy, unless on table frozen section histology is available and negative.
Consequently, the only safe primary management options are direct closure without undermining, partial direct closure (directed laissez-faire), or simply dressing
the defect (laissez-faire).
14.5 Eyelid Tension: Normal and Necessary
Eyelids require tension to hold them against the eye and keep them stable. When
a youthful eyelid margin is cut the tension is released and the wound edges
spring apart by about a centimetre. Loss of tension is an important factor in the
development of entropion and ectropion. Therefore, when reconstructing a lid,
restore lid margin tension ensuring that you direct it parallel with the margin.
A reconstruction that gives rise to perpendicular tension will cause lid margin
stretching and ectropion.
14.6 Don’t Undermine
The undermining of wound edges is common surgical practice. A skin flap must
be dissected free from the underlying tissues (undermined) to allow it to be raised.
However, our faces are naturally very mobile, anchored by facial ligaments in
only a few places. So, undermining wound edges for the direct closure of defects
is both unnecessary and creates avoidable scar planes. Contraction of these scar
planes during healing may cause undesirable tension vectors.
Detaching the mid face from the zygomatico-cutaneous ligament, as when lifting a cheek rotation flap, leads to late progressive mid face descent which spoils
an initially satisfactory reconstruction.
There is currently a vogue for dividing the confusingly named tear trough ligament from the inferomedial orbital rim in order to “re-drape” the lower lid fat
pads for aesthetic reasons instead of removing them. It will be interesting to see
what the long-term unintended effects of this will turn out to be.
14.7 Direct Closure 179
https://t.me/medicina_free
14.7 Direct Closure
The benefits of direct wound closure are obvious:
1. Primary repair at the time of tumour resection.
2. Edge to edge suturing gives the best skin colour and texture match.
3. Absence of a donor site and related morbidity.
Its limitations are:
1. Limited local tissue availability.
2. Temporary impairment of eyelid function due to raised lid margin tension.
3. Lid margin malposition (retraction, cicatricial ectropion) if the induced tension
vectors are wrongly aligned.
The direction of the closure tension is more critical than the orientation of the
resulting scar. Figure 14.4 illustrates the correct tension vectors’ orientation (black
arrows) for closing lid margin and periocular defects. The resulting closure scars
(yellow lines) end up at right angles or oblique to the lid margin, and cross skin
tension lines. The trio of vectors outside the canthi relate to the bony attachments
of the canthal tendons to which you should anchor the soft tissues.
But how is it possible to bring together the edges of a significant tissue defect?
1. Most tissues have an inherent degree of elasticity, skin and muscle more so
than tarsal plate and canthal tendon.
2. The naturally curved eyelid straightens when pulled. This change in geometry
from curve to the shorter straight line relies on the lid displacing the eye back-
wards and upwards within the orbit (Fig. 14.5), irrespective of whether it is the
upper or the lower lid that has been tightened.
3. The phenomenon of ‘tissue creep’ lengthens the lid per operatively. It comprises
the squeezing of fluid from the tissues and micro-tears of the collagen. The
more slowly you pull the tissues together, the more creep takes place.
These three mechanisms together give rise to significant lid length gain.
180 14 Lid Reconstruction
https://t.me/medicina_free
Fig.14.4 Direction of wound closure vectors. a The arrows indicate the desired closure tension
vectors for lid margin defects, the lines the direction of the resulting scars. b The arrows indicate
the desired closure tension vectors for defects peripheral to the lid margins, the lines the direction
of the resulting scars
14.7.1 Tissue Expansion (Fig. 14.6)
Living tissues under abnormal tension expand or grow to reduce that tension. After
all, no-one pops from getting fat or pregnant. Ophthalmologists are familiar with
lengthened eyelids in cicatricial ectropion and even more so in the floppy eye-
lid syndrome (surgery to correct these conditions requires significant lid margin
Соседние файлы в папке @xirurgi_2025