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14.11 Directed Laissez-Faire (Incomplete Direct Closure) 191
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a b
c d
e f
Fig.14.11 Directed laissez-faire margin reconstruction. a A large lid margin defect. b Attempt
direct closure, bringing the wound edges as close as tension allows. c Repair the orbicularis and
skin as much as you can. Leave the remaining defect to granulate. d Manage a large lateral margin
defect similarly. e Reduce the horizontal defect size with sutures. f Reduce the orbicularis and skin
defect. Wait for granulation to close the remaining defect
lid and 4–5 in the upper lid. If no tarsal plate remains, insert the sutures into the
cut edge of the canthal tendon (Fig. 14.11e). Should that also be absent place
them through the orbital rim periosteum (arcus marginalis). If no periosteum
remains insert a short, self-tapping, bone screw into the orbital rim and tie the
suture to that with a clove hitch knot.
2. Span the wound with the sutures and insert them in the cut far side tarsal plate
edge (Fig. 14.11b).
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3. Tie the sutures in turn, starting with the one furthest from the lid margin:
(a) When using simple sutures remember to lift the first throw, rock it a lit-
tle side to side to help it slide through the tissues and then snug it down
under tension. Ask an assistant to grasp and hold the tightened first suture
throw with the very tips of a pair of Moorfields forceps before releasing
the tension on the suture ends. Repeat this manoeuvre several times until
the wound edges stop coming any closer. Ignore the induced palpaebral
aperture distortion and globe displacement. Lock the knot with a second
single throw, asking the assistant to remove the forceps just before they are
trapped by the locking throw. Complete the knot with 1–2 further single
throws and cut the ends no shorter than 2 mm (to avoid unravelling).
(b) When using horizontal mattress sutures lift and pull the first throw, rock it
horizontally to and fro and then tighten it down snugly against the tissues.
Normally it is unnecessary to grasp the first throw as the suture tension
holds it down firmly against the tissues. The friction this causes prevents it
from slipping. Lock the first throw, as above, with 2–3 further throws and
cut the suture ends no shorter than 2 mm.
4. Repeat step 3 for the remaining suture(s). Do not rush these steps as tissue
creep is gradually occurring as you increase the tension.
5. Close the orbicularis and skin with interrupted sutures as far as the tissue
tension allows (Fig. 14.11c, f).
6. Apply a non-adherent dressing membrane, antibiotic ointment, and a pressure
dressing. Leave the dressing undisturbed for 5–7 days.
7. Continue twice daily antibiotic ointment thereafter until the remaining defect is
epithelialized. When a suture loosens, remove it to prevent irritation.
14.11.3 Directed Laissez-Faire of Skin Defect (Fig. 14.12)
This is almost identical to the direct closure of a skin defect, differing only in that
the defect is not fully closed at the end.
14.11.3.1 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(Seethemagic suture technique
in Chap. 5). Insert the suture so that the knot becomes buried when tied
(Fig. 14.12a).
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. 14.12b). This manoeuvre needs to be repeated several
14.11 Directed Laissez-Faire (Incomplete Direct Closure) 193
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a
10 mm
10 mm
b
c
Fig.14.12 Directed laissez-faire of skin defect. a Place a magic suture across the defect. b Use it
to minimize the orbicularis defect. c Close the skin as much as tension allows. Allow granulation
to deal with the residual defect
times over a matter of minutes to encourage ‘tissue creep’, until the tissue
edges no longer advance.
Note: If your suture breaks consider using a stronger one. If it cuts out use a
horizontal mattress configuration instead.
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 ask
an assistant to grasp and hold the tightened first suture throw with the very tips
of a pair of Moorfields forceps to prevent it from slipping while you complete
the knot with a minimum of two additional throws.
5. Begin closing the skin with interrupted horizontal mattress sutures from either
end of the wound. Continue adding sutures until the skin edges can no longer
be advanced to meet (Fig. 14.12c).
6. Apply a non-stick film, antibiotic ointment, and a pressure dressing, leaving it
undisturbed for 5–7 days. The residual skin defect will granulate by secondary
intention healing.
7. Once you remove the dressing ask the patient to apply twice daily ointment to
the wound until it is fully healed. Reassure the patient that the appearance will
improve with time and that you will reassess the outcome at 2 months to decide
whether secondary reconstruction is required (it rarely is).
Note: The healing time depends on the size of the defect and on the individual’s
powers of healing.
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14.12 Flaps
Pedicle flaps are peninsulas of tissue attached to a blood supply sufficient to ensure
their on-going survival. They are used in eyelid reconstruction to bring additional
tissue into the area. They also bring in a blood supply and can therefore be used as
a bed for a free graft. Flaps are less prone to shrink than free grafts. They can be
thicker and include additional tissue layers e.g., the orbicularis muscle. They must
be planned so as not to leave a significant donor site deficit i.e., only take from
where there is redundant tissue. Where possible flaps should have their pedicle
inlaid to avoid the need for secondary pedicle division surgery. Eyelid flaps can
be used to add anterior lamellar or posterior lamellar tissue. Numerous flaps have
been described. Here I shall describe only three: two anterior lamellar and one
transferring the full thickness of the lower lid margin (Fig. 14.13). The first two
are straightforward and widely applicable. The third is rarely needed but I include
it as it is the only way of reconstructing a normal upper lid margin following total
or subtotal loss.
Note: I do not find simple advancement flaps useful for two reasons. Firstly, it is
usually possible to close such a defect directly. Secondly, as you pull a flap in one
direction it narrows perpendicularly, introducing a new, undesirable force vector
(Fig. 14.14a, b).
a b
Fig.14.13 Useful flaps. a Upper to lower lid pedicle flap. b Cheek pedicle flap. c Mustardé Lid
Switch Flap
c
14.12 Flaps 195
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a b
Fig.14.14 Advancement flap. a Advancement flap. b Stretching in one direction causes narrow-
ing at right angles
14.12.1 Paper Templates
It you need to transfer skin into a defect, first make a paper template of the defect
size from a piece of spare, sterile instrument wrapping paper.
14.12.1.1 Steps (Fig.14.15)
1. Get an assistant to gently stretch the wound to its full size.
2. Fold an appropriately sized piece of paper to make is easier to insert in a
concave area (Fig. 14.15a).
3. Dry the wound and then briefly press the paper against it, unfolding it as you
do (Fig. 14.15b).
4. Remove the paper, turn it over, and cut round the blood-stained wound imprint
with scissors (Fig. 14.15c).
5. Refine the template by putting it back in the wound and trimming its edges if
necessary (Fig. 14.15d).
6. Use this paper template to mark the gently stretched skin donor site.
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a b
c
Fig.14.15 Making a paper template. a Fold a piece of sterile paper. b Press and unfold on the
defect. c Cut around the blood stain. d Recheck the template and refine if necessary
d
14.12.2 Upper to Lower Lid Skin Flap (Fig. 14.16)
See Fig. 14.16.
14.12.2.1 Principle and Considerations
Transfer redundant upper lid skin into a lower lid defect on its vascular pedicle.
14.12.2.2 Case Selection
Lower lid defects where sufficient redundant upper lid skin is present.
14.12.2.3 Steps
1. Make a paper template of the lower lid skin defect (as described above)
(Fig. 14.16a).
2. Position the lower edge of the template on the upper lid skin crease and use
it to mark the body of the flap on the gently stretched upper lid donor skin
(Fig. 14.16b). Check that there will be sufficient skin remaining after the flap
has been transposed (minimum 20 mm between the lashes and eyebrow).
14.12 Flaps 197
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a
c
C
1
C
5 mm
A
1
A
B
D
e
1
A
A
B
C
b
A
1
A
B
C
d
1
A
A
B
D
C
1
C
f
Fig.14.16 Upper to lower lid skin flap. a Make a template of the defect. b Use it to mark a donor
flap on the upper lid. c Raise the flap and incise the skin to join the defect to the flap pedicle.
d Anchor the flap tip C into the defect C
f Complete the skin and margin closures
3. Join the donor skin to the intended pedicle base with two parallel lines
(Fig. 14.16b). The lower line should end about 5 mm lateral to the lateral
canthus (or 5 mm medial to the medial canthus) at the level of the canthus.
The upper line should finish vertically above the lower one. The pedicle width
should be similar to the maximum flap width.
4. Intumesce the donor area with a subcutaneous injection of local anaesthetic
with adrenaline.
5. Incise the skin with a no.15 scalpel blade along the flap outline while your
assistant ensures the eye is protected with a metal guard (Fig. 14.16c).
1
. e Anchor corner A1into the upper pedicle angle A.
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6. Lift the tip (or edge) of the flap and dissect it free from the underlying tissue,
either as a pure skin flap or as a skin and orbicularis flap.
7. Join the lower lid defect to the base of the pedicle flap, B-D with an incision
(Fig. 14.16c). This will allow you to inlay the pedicle.
1
8. Anchor the tip of the flap C into the far edge of the lower lid defect C
with
a 6/0 absorbable suture (Fig. 14.16d). Do not trim the suture ends or cut off
the needle.
1
9. Anchor the corner of the lateral canthal skin A
into the upper pedicle angle
A (Fig. 14.16e). This effectively transposes the pedicle downwards. Do not
cut off the needle.
10. Use the already placed anchoring sutures to finish suturing the flap into the
recipient site (Fig. 14.16f) and tie the running suture to the short arm of an
available knot.
11. Suture the donor site closed with a running absorbable suture.
12. Ensure that the recipient bed remains stretched and immobilized, usually with
a lid margin traction suture, and apply a non-adherent film, antibiotic ointment,
and a pressure dressing. Leave the dressing undisturbed at least overnight, but
preferably for 5–7 days.
14.12.2.4 Notes
There may be a tendency for a narrow pedicle to ‘tube’ because of interface fibrous
contraction. Initial lid margin traction and subsequent massage help to avoid this
complication.
14.12.3 Cheek Pedicle Flap (Fig. 14.17)
14.12.3.1 Principle and Considerations
The thicker cheek skin can be used to construct an anterior lamella for a lower lid
replacement when there is no tarsal plate remaining. Its thickness imparts a degree
of stiffness to the reconstruction. The posterior lamella can be made of advanced
fornix conjunctiva or a free mucosal graft.
14.12.3.2 Case Selection
Total lower lid loss requiring reconstruction.
14.12.3.3 Steps
1. Estimate the skin flap length needed by pulling the lid margin edges together
and measuring the length of the reduced defect (Fig. 14.17a). Alternatively,
use an unfolded gauze swab to measure the defect and then, keeping it held
firmly at the lateral canthus, swing the tip of the swab down like a compass
and mark the skin (Fig. 14.17b).
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Note: A common error is to make the flap too long which leads to the
reconstructed margin sagging.
2. Measure the vertical width of the defect without tension in order that the
reconstructed lid develops no radial tension to later cause an ectropion. Draw
the flap, based at the lateral canthus. Check that there is sufficient cheek laxity
to close the intended donor defect by pinching the skin at the flap base before
raising the flap.
3. Decide whether sufficient conjunctiva can be mobilized for the posterior
lamella by undermining the inferior conjunctival fornix. If this is not possible
consider harvesting a lower lip mucosal graft.
4. Incise the skin and raise the flap in the subcutaneous plane (dissecting deeper
risks damaging the facial nerve) (Fig. 14.17c).
5. Preplace a 7/0 absorbable suture at the lateral canthus (for later suturing of
the reconstructed margin).
6. Rotate the flap and anchor its tip B to the far end of the lid margin defect B
with a 6/0 absorbable suture (Fig. 14.17d). Do not cut this suture as it will be
used to suture the inferior flap edge to the defect.
1
7. Close the donor defect by anchoring point A
to the pedicle angle A with a
6/0 absorbable suture (Fig. 14.17e). Then suture the vertical defect with the
same suture (Fig. 14.17f).
8. Suture the lower flap edge to the defect edge with the suture from step 6.
9. Suture the free conjunctival edge to the skin to recreate the margin with the
preplaced 7/0 suture (Fig. 14.17g). Tie it to the end of the anchoring suture.
10. Apply antibiotic ointment and pad the eye firmly closed overnight.
1
14.12.3.4 Notes
•
The cheek donor scar remains visible. The recreated lid margin is rounded and
lacks the stiffness of a normal lid margin. There is a risk of fine skin hairs
irritating the cornea.
14.12.4 Mustardé Lower Lid Switch Flap
Inclusion of the lid switch flap in this manual is an anomaly as it is neither
commonly needed nor is it a simple technique to perform. However, no better technique exists for restoring a normal functioning upper lid margin (including lashes).
Despite this it is not widely known and so I make no apology for including it for
the rare occasions when you may find it invaluable.
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a b
c
A
1
1
A
B
B
e
A
1
A
B
1
B
g
d
A
B
1
1
A
B
f
h
Fig.14.17 Cheek pedicle flap. a Measure the length of the reduced defect. b Or use an unfolded
swab as a compass to mark the flap. c Raise the flap and swing it into the defect, point B to B
d Anchor the flap in place. e Anchor point A to corner A
skin. g Suture the mucosal edge to the flap to create a new lid margin. h Put the flap on traction
using a bolster
1
to close the donor defect. f Suture the
1
.
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