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2 1 Introduction
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Fig. 1.1 Target audience
1.4 “Common Things are Common…Save Common Sense”
Lid surgery, like many other things, follows the 80–20 rule (known as the Pareto
principle). Eighty percent of your surgery is for the mere 20% of conditions that
are common. This book aims to help you get that 80% of common operations right
the first time by promoting simple, safe, and above all, effective techniques. It is
not comprehensive making no attempt to cover less usual conditions or critique
the myriad of alternative operations. Established texts already do this admirably.
However, in my humble opinion some popular operations fail the common-
sense test, so here I only describe techniques which make sense to me.
1.5 LessisMore
You will discover that I favour a minimalist approach to surgery to do “the least
harm”. As an enthusiastic novice I had a naïve faith in the benefits of surgery.
Experience tempered that enthusiasm with the realization that surgery is always a
trade-off, and the risk of complications is ever present.
1.6 The Truth, NOT the Whole Truth, and Nothing
But the Truth!
This book builds on sound foundations handed down by generations of innovative
surgeons. Everything I have included is based on my personal experience and I
currently believe it to be true. But learning continues and beliefs change. So, ‘my
current truth’ cannot be the whole truth and will, in time, be superseded by new
knowledge. I challenge you to add to that knowledge base, as I have tried to do.
1.9 Concept or Cookbook 3
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1.7 A Matter of Principle
Look for the principles behind each operation. Your chosen procedure should
address all the factors you believe to be causing a particular problem. Analyse
your current and future surgical repertoire on this basis, to help you discern the
best of several options. Doing so may even stimulate you to develop your own
improvements.
1.8 Heresy, Not Hearsay
Some of what I describe is unorthodox and does not appear in or even contradicts
existing textbooks. I challenge some popular practices e.g., use of the lateral tarsal
strip procedure, or employing complex reconstructions when direct closure would
suffice. Some regard this as heresy. The following heresies are currently unique to
this manual:
•
Meibomian orifice line superiority over the grey line
•
Suture tarsorrhaphy as a replacement for temporary surgical tarsorrhaphy
•
Maximizing the use of direct closure, directed laissez-faire, and tissue expansion
in eyelid reconstruction
•
The magic suture subcutaneous closure
•
Medial canthal thermoplasty
•
Control of active thyroid eye disease with depot orbital steroid injections
•
Full orbital volume replacement of after eye removal
•
Modified Bick lid margin resection in preference to the lateral tarsal strip for
lid tightening
•
Transverse release-plasty of radial traction bands.
1.9 Concept or Cookbook?
Individual learning styles vary. Some of us will always practise ‘painting by numbers’ surgery. The step-by-step instructions in this manual should cater to your
taste. Like a recipe, these ‘cook-book’ instructions generally give good outcomes.
They are the best way for a novice to learn.
Those of an artistic or inquisitive nature will gain more from understanding the
principles outlined and adapt the procedures described to suit specific situations.
4 1 Introduction
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1.10 10,000 hour Expert?
No book can take the place of ‘hands on’, supervised, surgical experience. However, the saying “practice makes perfect” only holds true if you practise the right
things. This manual guides you in that ‘right direction’.
1.11 Challenge
In this book I sometimes question accepted treatments. I challenge you to do the
same and analyse alternative operations critically, particularly when you try new
techniques. You can only do this by auditing your own outcomes.
1.12 The Good Outcomes Secret
Good outcomes are more likely when you operate on patients who by the nature of
their condition should do well. For example, a ptosis patient with normal levator
function should do better than one with poor levator function. Case selection may
be a luxury for a veteran but is essential for the less experienced surgeon who
needs positive outcomes in order to acquire the confidence needed to progress.
This book aims to build that confidence by promoting simple and safe procedures
for appropriately selected patients.
1.13 Style and Structure
I have chosen a didactic, first-person style for this manual. Most chapters loosely
follow the structure below:
•
Overview
•
Introduction
•
Principle and considerations
•
Case selection (indications)
•
Steps (technique, method)
•
Notes (variations / discussion / surgical pitfalls / what can go wrong /
complications)
•
Take home message
You will notice much repetition for which I make no apologies. Firstly, should
you delve in mid-way I would not want you to miss important points mentioned
previously. Secondly, the repetition helps to reinforce the message.
I have included few references because references are not the authority behind
this volume. My personal experience is. The selected references which are included
are there to support some of my more contentious assertions.
1.15 Warning 5
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1.14 Exceptions Prove the Rule
Occasionally I have broken my own rule by including uncommon procedures
because they are so important, e.g., Emergency lateral canthotomy and upper lid
reconstruction using the Mustardé lid switch flap.
1.15 Warning
As a single author work this book is necessarily biased. It is neither comprehensive,
nor a typical surgical textbook. Beware, you may find some of the unorthodox
concepts and techniques which I promote useful and possibly infectious. My not
so hidden agenda is to help you to improve your surgical outcomes.
The Basics
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2.1 Overview
•
Surgery = directed scarring
•
Primary v secondary intention healing
•
Tension, expansion, migration and contraction
•
Active v passive operations
•
Surgical instruments
•
Anaesthesia
•
Haemostasis
•
Plication v resection
2
2.2 Do Least Harm!
The famous exhortation to physicians to “First do no harm”, sounds laudable but is
impossible for a surgeon. Fundamentally, all surgery involves judicious wounding,
albeit with altruistic intent. So, while we cannot avoid harm, we should strive to
limit our wounding to the minimum required to achieve our goal, for example by
not undermining unnecessarily the naturally mobile skin around the eye. Similarly,
do not use a flap or graft to repair a lid defect that you can close directly. Virgin
tissue is always better than an additional avoidable scar.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
V. Tha l l er, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_2
7
8 2TheBasics
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2.3 Surger y is Directed Scarring
Having first wounded the patient, the benefits of surgery derive from ensuring that
the tissues heal in the desired way. To achieve this, we direct the healing with
sutures. In lid surgery the direction of the suture induced tension is all important.
2.4 The Healing Response
Millennia of evolution have equipped us with amazing powers of healing. All
wounds heal in one of two ways, referred to as primary intention and secondary
intention healing.
2.4.1 Primary Intention Healing
Primary intention healing occurs when a wound’s edges are brought together and
held, usually with sutures, long enough for healing to take place. On the face such
wounds heal very quickly and are usually secure within 5 to 7 days. However, it
may take 6–8 weeks for them to attain maximum strength. Align wound edges
‘anatomically’ (layer by layer) to restore the best function and appearance.
2.4.2 Secondary Intention Healing
Evolution has ensured that gaping wounds still heal even when their edges are not
brought together. Such healing takes longer, the length of time depending on the
degree of wound edge separation. The process by which this occurs is known as
healing by secondary intention. It results in larger scars, and therefore we use it
less. But, in many cases, the ultimate result is acceptable. It is a viable alternative
to a graft or flap repair which are both more complex and create additional donor
site scars. Note that secondary intention scars contract radially in all directions
creating forces that a free lid margin is unable to resist. This results in lid margin
retraction.
2.5 Stages of Wound Healing
The stages of wound healing are similar for both types of healing. They are:
1. Haemostasis. Fibrin clot formation occurs within seconds to minutes of wound-
ing and, apart from assisting haemostasis, provides the scaffold for stage 3. As
surgeons we are often impatient and assist haemostasis by coagulating vessels
that continue to bleed with heat in the form of diathermy or cautery. Keep this
to a minimum as burns cause further tissue damage and incite fibrosis. Simply
applying local pressure and waiting a few minutes can be as effective.
2.7 Tension, Expansion, Migration, and Contraction 9
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2. Inflammatory. Starting immediately, this phase continues for several days. It
involves leakage of intravascular fluid into the tissues causing swelling, pain,
and redness. The relevance of this phase for the reconstructive surgeon is that
the suture holding strength of inflamed tissues is significantly reduced and they
are more prone to bleed at operation. This makes early delayed wound repair
more difficult. Therefore, if wound repair must be delayed it is better to delay
it by several days until the acute inflammatory phase has subsided.
3. Proliferative. This phase starts at about three days and continues for sev-
eral weeks. Myofibroblast invade the clot and contract to pull the edges
together and make the wound smaller. Type III collagen is laid down. Surface
epithelialisation occurs during this phase.
4. Maturation/remodelling. Scar remodelling begins at 3–4 weeks and continues
for 1–2 years. The type III collagen is converted to type I and the scars soften
and thin. When possible, delay any revision surgery you plan until this phase
is well under way. The surgery will be easier to perform and its outcome more
predictable.
2.6 Thermal Burns
Thermal burns sometimes incite an ongoing scarring (cicatricial) process which
can be difficult to manage. Use diathermy and cautery sparingly and avoid them
on the skin to minimize visible scarring.
2.7 Tension, Expansion, Migration, and Contraction
2.7.1 Tissue Expansion
Tissues subjected to sustained tension relieve that tension by elongating. You see
an example of this in cicatricial ectropion. In this condition the sustained pull of
a tight skin scar causes the lid margin to lengthen and sag so that it no longer sits
against the eye. The expanded lid margin does not return to its original position
after the traction has been surgically released. The phenomenon of tissue expansion
is underused in lid reconstruction.
2.7.2 Suture Migration
We use sutures to pull and hold tissues together during healing. If you tighten a
suture too much it will either exceed its own tensile strength and break or tear
through the tissue. What few people realise is that all sutures migrate. This is a
process that allows a suture to move through tissues until all its tension is lost
(Fig. 2.1). Individual cells in front of a tight suture temporarily divide and then
10 2TheBasics
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a
b
Fig. 2.1 Suture migration. Sutures dissipate tension by migrating through tissues
reunite behind it. This allows the suture to pass through tissues without visible
inflammation or scarring.
The fact of suture migration calls into question the rationale behind using so
called ‘permanent’ non-absorbable sutures. They may last permanently but their
tension is most definitely transient, lasting only a matter of weeks. Consequently,
the only two reasons for choosing non-absorbable sutures are their relative inertness (e.g., polypropelene v polygalactin) and their higher tensile strength. For
eyelid surgery these differences are rarely relevant.
2.7.3 Contraction (Hydrocortisone Ointment and Massage)
Linear scars shorten, wounds and grafts shrink concentrically. Because the lid margin is unattached it is unable to resist the pull of scar contraction and becomes
distorted (Fig. 2.2a and b). These are facts of life. Can anything be done to reduce
this? Yes, massage! Tissues under strain grow by ‘tissue expansion’ and ‘biological
creep’. Therefore, repeatedly stressing tissues in a desired direction will lengthen
them in that direction. Firmly massaging a scar can, to some extent, mitigate the
inevitable contraction that is an integral part of the healing process. This contraction takes place within the first 6–8 weeks of healing. Massage is most helpful
during this critical period. Thereafter tissue remodelling softens the scar naturally.
2.7 Tension, Expansion, Migration, and Contraction 11
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a
b
Fig. 2.2 Scar contraction. a Linear lid margin scars contract along their length to cause a lid
margin notch. b Tissue defects and scar planes contract radially, distorting the free lid margin
The same phenomenon takes place in scar planes which contract in two dimensions. The interface between a graft or skin flap and its recipient bed is such a
scar plane. Scarring is the reason that the linear dimensions of full thickness skin
grafts and flaps contract by about one third of their linear dimensions. Regular
firm massage reduces this shrinkage. Start massage a week or so after surgery,
to allow time for revascularization to occur. Use oils or ointments to protect the
skin during massage. Whether the type of lubricant plays a role in the process is
unclear. I recommend the sparing application of 1% hydrocortisone ointment as
the lubricant for scar massage. The additional benefit of using a steroid ointment
remains to be proven. However, this weak steroid does not carry significant risk
during prolonged topical use. Hydrocortisone does help to reduce healing associated inflammation and can work wonders on the eczematous component of an
ectropion prior to surgery. Very occasionally, massage with hydrocortisone alone
can cure the ectropion, avoiding surgery altogether.
12 2TheBasics
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2.8 The Dog Ear Dilemma (Waste Not, Want Not!) (Fig. 2.3)
You create tension across a wound whenever you close it. This tension is maximal at the widest point of the original wound, progressively decreasing towards its
end(s) (Fig. 2.4a). As you pull the wound edges together the tension at the ends
becomes negative compared to that at the centre. This pushes the slack tissue forward to form so called ‘dog ears’ (Fig. 2.4b). It is customary to extend defects into
ellipses by removing additional skin at the ends, to smooth the tension transition
and minimize dog ears (Fig. 2.4c and d). However, this extends the scar length and
discards healthy skin. This is counterintuitive in periocular reconstruction where
lid skin is in short supply. Fortunately, tissue tension acts to remodel scars and
periocular dog ears usually disappear within a matter of months. So, I recommend
ignoring dog ears and reassuring the patient that they are likely to vanish.
Fig. 2.3 Dog-ears
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