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14.7 Direct Closure 181
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a
B
A
c
b
d
e
Fig.14.5 Globe displacement by direct closure. a When a lid (A) is shortened to become a
straight line (B) the eye is pushed backwards. Direct closure of a lower lid defect b straightens the
lid margin upwards (small arrow) (c) and displaces the eye upwards (large arrow). Direct closure
of an upper lid defect d straightens the lid margin downwards (small arrow) e but still displaces
the eye upwards (large arrow)
shortening). Plastic surgeons have long used implanted subcutaneous balloons to
expand skin so that it can be used to reconstruct a defect. It is therefore surprising that few oculoplastic surgeons exploit the phenomenon of tissue expansion for
eyelid reconstruction.
Closing a large lid margin defect directly by pulling the wound edges together
creates tension that may prevent normal eyelid movement and displace the eye posteriorly and upwards within the orbit as already mentioned (Fig. 14.5). However,
these changes are short-lived. The displaced eye acts as an inbuilt tissue expansion balloon, applying sustained pressure to the reconstructed lid thus stimulating
it to stretch and grow. Often excessive lid tension after a significant direct closure
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Fig.14.6 Tissue expansion.
No-one bursts from getting
fat or pregnant!
prevents the eye from opening immediately. However, it is usually able to do so
again often by the second postoperative day and certainly within a week or two.
Within two months the vertical and horizontal palpebral aperture dimensions will
have returned to within 1 mm of those on the un-operated side [1, 2].
Consequently, ‘excessive tension’ is not a valid argument against direct wound
closure provided the lid tension vector rules in Fig. 14.4 are observed.
14.7.2 No Cantholysis
As explained above, raised lid margin tension is necessary for expansion to occur.
Relieving that tension by performing an elective cantholysis to enable direct closure is therefore counterproductive. Don’t do it! You end up with an unsightly web
of tissue at the cantholysis site devoid of the normal lid margin structures.
Note: Some surgeons recommend a cantholysis to allow remaining intact lateral
lid margin to move to a pre-corneal position to enhance the stability of the lid
reconstruction. This is a valid reason, but in my experience such a manoeuvre is
seldom required.
14.7.3 Closure Scar Lengthening
Direct closure wounds lengthen, a fact which is not widely recognised (Fig. 14.7).
Closing a circular defect results in a closure length approximately 1½ times the
defect’s original diameter. This is fortuitous as it counterbalances the naturally
occurring scar contraction during healing, which might otherwise pull on the lid
margin.
14.8 Direct Closure of Lid Margin Defect (Fig. 14.8) 183
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C
D
Circle circumference C = Π , where D is the circle
diameter.
D . Π
Closure length L = ½ C =
Fig.14.7 O to I closure. Directly closing a circular wound lengthens the closure scar by roughly
one and a half times the original defect diameter
≈ 1.5 x D
L
14.8 Direct Closure of Lid Margin Defect (Fig. 14.8)
14.8.1 Principles and Considerations
This technique is the same as that for lid margin repair (described in Chap. 5)
but relies on postoperative tissue expansion to restore the lid margin length. The
resulting margin is complete with eyelashes, albeit more spaced out, something no
other repair achieves. It uses absorbable sutures which, generally, do not require
removal.
The tarsal plate is the most important structure to suture as it forms the skeleton
of the lid margin.
14.8.2 Case Selection
Attempt direct closure on most defects, irrespective of size. With experience you
will start closing defects much larger than the 1/4 to 1/3 of the lid’s length that
textbooks quote.
14.8.3 Steps
1. Insert a 6/0 absorbable suture, mounted on a 1/2 circle needle, through the tarsal
plate on either side to span the wound. Place it as close to the lid margin as
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Fig.14.8 Lid margin reconstruction by direct closure. a Grasp the full thickness of the lid ‘sand-
wich’ perpendicularly to the margin with toothed forceps and evert the edge. b Enter the anterior
tarsal plate surface perpendicularly with your suture needle. c After engaging almost the full tarsal
plate thickness, take a similar bite on the far wound edge. d In the lower lid, place 2 further sutures
below the first one in a similar fashion, in the upper lid, 3 or 4. e to h). Place a 7/0 absorbable hor-
izontal mattress suture in the margin, burying its knot. f Tie and cut the preplaced tarsal sutures.
g Tighten and tie the lid margin mattress suture. h Ensure the margin pouts. i Repair the remain-
der of the skin wound. j With lateral defects use the cut lateral canthal tendon as the lateral suture
fixation point. k Close the skin and orbicularis
14.8 Direct Closure of Lid Margin Defect (Fig. 14.8) 185
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Fig.14.8 (continued)
possible. Take care to align the suture bites on each side to be equidistant from
the lid margin to avoid a margin step.
(a) Grasp the full thickness of the lid ‘sandwich’ perpendicularly to the margin
with toothed forceps, about 2–3 mm from the cut edge (Fig. 14.8a). Evert
the edge slightly to improve visibility and access.
(b) Use the flat surface of the suture needle to push the skin and orbicu-
laris away, so that the needle tip enters the anterior tarsal plate surface
perpendicularly (Fig. 14.8b).
(c) As soon as the needle tip engages the tarsal plate, rotate and advance the
needle so that it emerges close to the conjunctival surface on the cut edge
of the tarsal plate, i.e., after engaging almost the full tarsal plate thickness.
(d) Retrieve and remount the needle from this first bite and grasp the far side
of the lid margin with tissue forceps, as in step 1a.
(e) Insert the needle into the cut surface of the tarsal plate close to and parallel
with its conjunctival surface. Take special care to place this bite at the same
distance from the lid margin as the first bite on the other side of the defect
(Fig. 14.8c).
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(f) As soon as the needle tip engages the tarsal plate, rotate, and advance the
needle so that it emerges on the anterior surface of the tarsal plate 1½ mm
from the wound edge. Avoid engaging the orbicularis and skin (you may
have to lift them off the needle tip).
(g) Clip the two untied suture ends together with a bulldog clip and retract
them.
2. In the lower lid, place 2 further sutures below the first one in a similar fashion,
spaced about 1 mm apart (Fig. 14.8d). In the upper lid, 3 or 4 additional sutures
may be required as the tarsal plate is wider. Again, clip each pair of untied
suture ends together to aid later identification when tying.
3. Preplace a lid margin horizontal mattress 7/0 absorbable suture so that its knot
will become buried in the lash line. This configuration will cause the lid margin
repair to pout as intended when this suture is eventually tied.
(a) With the needle enter the wound edge through the orbicularis, just anterior
to the tarsal plate surface in line with the lashes (Fig. 14.8e).
(b) Rotate the needle so that it emerges from the skin within the lash line 1½
mm from the wound edge, having engaged the orbicularis and skin.
(c) With the same needle re-enter the lid margin perpendicularly through the
meibomian orifice line on the same side (Fig. 14.8f). Rotate and advance
the needle to exit the cut tarsal plate surface close to the margin. Take
special care not to accidentally engage the first preplaced tarsal plate suture
from step 1, as this would cause problems when tying the latter.
(d) Now insert the same suture through the far wound edge in reverse order i.e.,
entering the cut tarsal plate first, exiting the meibomian line, re-entering
through the lash line and finally exiting the orbicularis just anteriorly to the
tarsal plate (Fig. 14.8g).
(e) Clip the untied suture ends together (Fig. 14.8h).
4. Now tie firmly and cut the preplaced tarsal sutures in reverse order of placement
i.e., starting with the one furthest from the lid margin (Fig. 14.8i). Once tied, the
first suture takes up most of the wound tension. This makes tying the remaining
tarsal plate sutures easy and their first throws very unlikely to slip during tying.
By the end of this step the lid margin wound should be accurately and securely
closed.
5. Tighten and tie the lid margin mattress suture (Fig. 14.8j). Confirm that it causes
the lid margin join to pout (Fig. 14.8k). Cut its ends short enough for them to
retract into the wound.
6. Either repair the remainder of the skin wound with interrupted 6/0 or 7/0
absorbable sutures which incorporate the underlying orbicularis into each bite
or suture the orbicularis as a separate layer with a magic suture (see below)
(Fig. 14.8l).
14.9 The Trans Incisional Tarsal Traction Suture (Fig. 14.9) 187
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14.8.3.1 Notes
•
An accurately repaired lid margin will not leave a noticeable scar or notch.
However, for larger defects the scar may stretch.
•
Direct margin closure works equally well when a canthus is involved. Use
remaining canthal tendon, periosteum, or a bone screw to anchor the sutures
at the lateral wound edge (Fig. 14.8m, n).
14.9 The Trans Incisional Tarsal Traction Suture (Fig. 14.9)
14.9.1 Principle and Considerations
The direct closure of larger defects can be made easier by placing a modified
tarsal traction suture (see Chap. 5) across the defect to reduce the tension across
the wound. Its ends may be used to apply lid traction or converted into a suture
tarsorrhaphy (see Fig. 13.6).
a b
0
90
c
Fig.14.9 Trans incisional traction suture. a Enter the meibomian orifice line with d 4/0 monofil-
ament polypropylene suture. b Advanced the needle within the tarsal plate to exit in the wound.
c Re-insert the needle into the far wound edge to engage the tarsal plate and come out through the
meibomian orifice line. d Now continue with the direct closure of the lid
d
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14.9.2 Steps
1. Grasp the full thickness of the lid as parallel to the margin as possible with
large forceps (e.g., Toothed Adson’s) and evert the margin. As you squeeze the
lid the egress of meibomian secretions identifies the meibomian orifice line.
2. Enter the meibomian orifice line with a 4/0 monofilament polypropylene suture
on a 17 mm half circle, non-cutting needle with its tip held perpendicular to
the lid margin (Fig. 14.9a).
3. Slowly advanced the needle within the plane of the tarsal plate, allowing it
to follow its own curve to exit in the wound at the base of the tarsal plate
(Fig. 14.9b).
4. Re-insert the needle into the far wound edge to engage the tarsal plate and
come out through the meibomian orifice line (Fig. 14.9c).
5. Now continue with the direct closure of the lid defect as outlined in the previous
section (Fig. 14.9d).
6. Apply traction to the suture ends using an artery clip to approximate the wound
edges when you tighten and tie the repair sutures.
14.10 Direct Closure of a Skin Defect (Fig. 14.10)
14.10.1 Principle and Considerations
The principles of non-marginal lid wound closure are the same as for any surgical
wound: accurate alignment of the edges and closure in layers. The main difference
periocularly is the paramount importance of the tension vector (direction) which
has already been discussed. This is because the free lid margin edge is unable
to withstand any sustained radial traction. The technique below incorporates the
magic suture, described in Chap. 5.
14.10.2 Case Selection
Potentially applicable to any periocular wound. At best, full closure is achieved. At
worst, the defect has been minimized prior to an additional graft, flap or directed
laissez-faire.
14.10 Direct Closure of a Skin Defect (Fig. 14.10) 189
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14.10.3 Steps
1. Ensure adequate haemostasis.
2. Place a single, strongly anchored, buried, 4/0 or 6/0 absorbable suture in the
subcutaneous tissue layer (usually the orbicularis muscle) to span the maximum
wound diameter, orientated as in Fig. 14.4b (See also ‘The Magic Suture tech-
nique’ Chap. 5). Insert the suture so that the knot becomes buried when tied
(Fig. 14.10a).
3. Tighten this suture fully by lifting the first throw free of the tissues, rocking it
gently side to side to encourage it to slide through the tissue, and then snugging
down the throw (Fig. 14.10b). This manoeuvre may need to be repeated until
you bring the tissue edges completely together. Do not rush this step to allow
time for ‘tissue creep’ to occur.
4. Tie the suture on a bow and observe the effect that tightening has had on the
lid margin position. If there is any sign of margin retraction, remove the suture
and replace it in a more favourable alignment. Once happy with the orientation
tie it with a minimum of two additional throws.
a
10 mm
10 mm
b
c
Fig.14.10 Direct closure of a periocular skin defect. a Span the defect with a strongly anchored,
orbicularis muscle suture, orientated parallel to the lid margin. b Tighten this suture by lifting and
rocking the first throw side to as you pull. Once happy with the orientation tie it with a minimum
of two additional throws. c The skin edges should have been brought sufficiently close together to
suture
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5. Observe the effect that the first subcutaneous suture has had on the skin mar-
gins. The skin edges should have been brought sufficiently close together
to allow suturing without undue tension. If not, add additional subcutaneous
sutures in a similar fashion.
6. Close the skin with either interrupted or a continuous suture (Fig. 14.10c).
7. Apply a pressure dressing overnight to minimise oedema.
Notes: The tissue at either end of the closure will appear lax in comparison to the
central area of maximum tension. This can give rise to a ‘dog ear’ appearance.
Ignore this as it is very likely to resolve spontaneously by tissue remodelling.
14.11 Directed Laissez-Faire (Incomplete Direct Closure)
14.11.1 Principle and Considerations
Although direct eyelid defect closure remains the first choice, sometimes it is
impossible to achieve complete closure. In such circumstances, partially closing
the defect to reduce its size is still of benefit. Firstly, it aligns the closure tension
vector in the desired axis (see Fig. 14.4), rather than permitting the unmodified
concentric wound contraction of laissez-faire to occur. Secondly, because you have
greatly reduced the wound area left to heal by granulation, more rapid secondary
intention healing occurs. The closure sutures span and reduce the residual defect
(Fig. 14.10). Remember, they should only create tension that is parallel to the
eyelid margin, as already discussed ad nauseam. Apply antibiotic ointment and a
non-stick pressure dressing and leave it undisturbed for a week while awaiting histology. All the excision margins are available for re-excision should the histology
suggest incomplete tumour removal. Healing by secondary intention often gives
excellent results and further surgery may be unnecessary. At two to three months
post excision, decide whether the outcome is functionally and aesthetically acceptable or whether to perform a secondary reconstruction. If reconstruction proves
necessary, the tissue expansion that has already taken place in the interim will
make it less extensive.
14.11.2 Directed Laissez-Faire of a Lid Margin Defect (Fig. 14.11)
14.11.2.1 Steps
1. Preplace interrupted 6/0 absorbable sutures into the cut tarsal plate edge on
one side of the defect. Double armed horizontal mattress sutures hold strongly
and are easy to tie under tension. Two will suffice in a lower lid, three may be
needed in an upper lid. If you use simple sutures three will suffice for a lower
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