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2.8 The Dog Ear Dilemma (Waste Not, Want Not!) (Fig. 2.3)13
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b
a
cd
Fig. 2.4 Dog-ears. Direct wound closure a results in closure scar tension b that is maximal cen-
trally and reverses at each end to create dog ears of loose tissue. Converting a circular excision into
an ellipse by excising extra tissue c lengthens the scar but smooths the tension transition d reducing
dog ear formation
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2.9 Active v Passive Surgical Mechanisms (Fig. 2.5)
The mechanism by which any given operation achieves its purpose is active, passive, or a combination of both. By active we mean a procedure which reattaches
a muscle or its tendon/aponeurosis or one that modifies the direction (vector) of a
muscle’s action. Every time the muscle contracts it actively exerts its effect e.g., the
levator muscle in ptosis correction. Such operations continue to work indefinitely.
Passive operations on the other hand work by transferring or tightening non
muscle connected tissues and do not involve altering muscle function e.g., lid
margin resection and skin blepharoplasty (although both may involve functionally
insignificant orbicularis muscle resection). Such passive operations fail in time
as the tissues involved stretch under load (exceptions being bone, ligaments, and
tendons).
It is instructive to analyse the mechanism by which an operation achieves its
effect.
Fig. 2.5 Active v passive mechanisms active operations rely on muscle action to achieve their
effects
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2.10 The Kit (Instruments)
Few surgical instruments are required in a basic lid set. The following list includes
the essentials:
1. Large-toothed tissue holding forceps e.g., Toothed Adsons
2. Fine toothed tissue holding forceps e.g., Jayles forceps (long handled) and St
Martins forceps (short handled)
3. Moorfields (non-toothed) tissue forceps. Used for holding conjunctiva, tenons
fascia and silicone tubes
4. Fine Needle holders e.g., Castroviejo, locking
5. Scissors:
a. Spring scissors e.g., Curved Westcott tenotomy, –for dissection
b. Straight tenotomy, –for cutting tougher tissues
c. Straight pointed, –for suture cutting and blunt dissection
6. Retractors e.g., 3 Desmarres (small, medium, and large)
7. Squint hooks e.g., 2 Squint hooks&1Chavasse hook. Can double as retractors
8. Eye protecting plate e.g., Berke-Jaeger lid plate
9. Straight bipolar diathermy forceps
10. Cotton buds (used as a surgical instrument for blunt dissection and counter
pressure during suturing)
11. Artery clips (haemostats). Curved and straight
12. Bulldog (aneurysm) clips for holding pairs of suture ends together prior to
tying.
Additional specialist instruments are required for specific tasks e.g., Wright’s fascia needle for ptosis sling insertion or Thaller tarsal forceps (A6360 Altomed) for
easy lid margin traction suture placement (see Chap. 13).
2.11 Anaesthesia
Most eyelid surgery can be performed under direct infiltration local anaesthesia.
Lacrimal surgery is easier under general anaesthesia for both the patient and the
surgeon.
For lid surgery use local anaesthetic combined with adrenaline. The adrenaline
induced vasoconstriction prolongs the duration of anaesthesia by slowing anaesthetic absorption. This doubles the total safe dose that may be administered,
although toxicity is rarely a concern with the small volumes used for lid surgery.
The true reason we use adrenaline is the vasoconstriction it causes which
reduces bleeding and improves surgical field visibility. Unfortunately, adrenaline
containing local anaesthetics sting more on injection as they are acidic.
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2.12 Haemostasis
Surgery relies on accurate anatomical orientation and dissection. Visualization is
facilitated by good haemostasis.
2.12.1 Vasoconstriction
Full vasoconstriction, following local adrenaline injection, takes longer to manifest
than one might expect (about 15 min).
2.12.2 Positioning (Fig. 2.6)
Position your patient with their upper body slightly raised on the operating table
to reduce venous congestion and reduce bleeding. The head should be at least as
high as the highest point on the patient’s chest or abdomen. This posture both
aids venous return and reduces abdominal content pressure on the diaphragm, so
improving breathing. This is important as hypercapnia causes vasodilation and
bleeding.
Fig. 2.6 Patient posturing. Ensure the patient’s head is higher than the chest and abdomen to
reduce bleeding
2.14 Post-operative Antibiotics and Padding 17
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2.12.3 Diathermy
Use bipolar diathermy for the eyelid (in preference to monopolar) and set it to
the minimum power that works. To control coagulation further adjust the spacing
between the bipolar forceps tips. The closer they are together, the stronger the
current. Remember that once the tips meet, they short-circuit and cease to work.
2.12.4 Cut Uphill
Cutting causes bleeding. Cutting in an ‘uphill’ direction causes the blood to flow
away from the skin markings that you are trying to cut along. This makes life
easier for you and less stressful for your assistant.
2.13 Plication v Resection
‘Plication’ means to tuck or pleat a tissue. The dissection and suturing involved
produce relatively mild wounding and therefore little stimulus for the scarring
(healing) needed to permanently hold the tissues in their new configuration.
Resection means cutting and removing tissue (excision). This creates raw edges
which are more likely to heal together strongly and permanently.
2.14 Post-operative Antibiotics and Padding
The applications of postoperative antibiotic ointment (usually Chloramphenicol)
and a pressure dressing are deeply ingrained in oculoplastic practice. As neither
has a strong evidence base, it is only right that we should now question their
use. Despite this I strongly recommend postoperative pressure dressing following
periocular surgery. The laxity of periocular tissues gives them a great propensity
to swell. I believe that applying pressure to the surgical site reduces haematoma
formation, bruising, and inflammatory phase exudation, leading to less strain on
suture lines and faster rehabilitation. Furthermore, the dressing hides the surgical
site from the patient’s view, reducing their immediate postoperative anxiety, and
providing protection from interfering fingers.
I find it harder to argue in favour of antibiotic ointment over an aseptic lubricant
even though the traditional use of chloramphenicol ointment at the end of surgery
has stood me in good stead over many years. More evidence is needed.
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2.14.1 Steps
1. Wash and dry the surgical site to remove any residual antiseptic skin-prep and
blood.
2. Apply a thin coating of tincture of benzoin solution (Friar’s Balsam) to the
surrounding skin and allow it to dry. This improves surgical tape to skin
adherence.
3. Place a non-stick paraffin gauze or non-adherent film such at Tegapore® (3 M
Health Care Ltd) over the surgical site. Fold the latter if it is too large as cutting
it to size impairs its non-stick properties.
4. Apply Chloramphenicol ointment freely over the film.
5. Place one folded eye-pad over the orbital area followed by two more unfolded
pads.
6. Tape this dressing in place with several overlapping strips of 1
adhesive surgical tape to apply pressure. Press on the tape for a few seconds
until it adheres fully. If your patient has a history of allergy to elastic surgical
tape use a hypoallergenic stretchy alternative tape such as Blenderm® (3 M
Health Care Ltd).
(2.5 cm) elastic
2.15 Fail-Safe Redundancy (Fig. 2.7)
Many of the operations described in this manual use more sutures than are strictly
necessary to achieve the desired result, thus adding to the cost and duration of the
procedure. While this goes against my ‘minimalist’ philosophy, the extra sutures
are deliberately redundant to provide a degree of safety. Two sutures in a lateral
canthal repair mitigate against a critical suture failure. Three levator aponeurosis
sutures in ptosis correction are not only a fail-safe but also add a degree of control
over the lid curve. Additional skin suturing after the wound is effectively closed by
the retractor sutures allows for selective early retractor suture removal to resolve
an overcorrection without fear of the wound opening. After all, would you go
skydiving without a reserve parachute?
2.16 Take Home Message 19
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Fig. 2.7 Fail-safe redundancy. Back-ups can avert disaster
2.16 Take Home Message
•
Surgery is judicious wounding followed by suture directed healing.
•
Even permanent sutures have only a temporary effect.
Sutures and Suturing
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3.1 Overview
•
Suture characteristics
•
Suturing techniques
•
Mattress sutures
•
The magic suture.
Although a plethora of surgical sutures exist, you can carry out most eyelid surgery
using only four types of suture:
•
6/0 Polygalactin 910 (Vicryl®) on an 8 mm ½ circle, spatulate cutting needle,
(Ethicon W9756)
•
7/0 Polygalactin 910 (Vicryl®) on an 8 mm 3/8 circle, spatulate cutting needle,
(Ethicon W9561)
•
4/0 Polygalactin 910 (Vicryl®) on a 20 mm ½ circle, spatulate cutting needle,
(Ethicon W9113)
•
4/0 Polypropelene (Prolene®) on a 17 mm ½ circle round-bodied taper-point
needle (Ethicon W8557).
3
Choose your suture according to the properties you require for the particular task.
© 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_3
21
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3.2 Suture Characteristics
3.2.1 Absorbable v Non-absorbable
Much is made of the differences between non-absorbable (permanent) and
absorbable sutures. Modern absorbable sutures usually take about two months
to absorb fully. This is more than enough to allow satisfactory wound healing.
Suture longevity is consequently an irrelevant characteristic except for the fact
that non-absorbable sutures may require removal.
The only significant difference between absorbable and non-absorbable sutures
is the degree of inflammation that they incite. Absorbable sutures stimulate more
inflammation due to enzymatic hydrolysis. In practice, for eyelid surgery, this difference is rarely important and polygalactin sutures may safely be used in the
skin.
3.2.2 Suture Tension
Sutures must be tied under sufficient tension to hold the tissues together. This
tension dissipates within a matter of weeks as the suture migrates through the tissues. So, although non-absorbable sutures persist as foreign bodies and retain their
strength, after a few weeks they no longer fulfil any useful function. Consequently,
they are no more effective than absorbable sutures.
3.2.3 Suture Gauge (Table 3.1)
Suture gauge refers to the cross-sectional area of the suture which correlates positively with the suture’s tensile strength. When you need more strength use a thicker
suture. The suture diameter also correlates positively with its tissue holding ability.
A thin suture cheese-wires through tissues more easily.
Tab le 3.1 Commonly used
suture gauges in relation to
their metric diameters
a
USP
7–0 0.05
6–0 0.07
4–0 0.15
a
USP = United States Pharmacopeia
Ømm
3.2 Suture Characteristics 23
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3.2.4 Knotting
Silk is a naturally occurring polymer and braided silk sutures hold knots extremely
well. A silk surgical knot will hold securely with only two successive single
throws.
Most other sutures are synthetic and prone to knot slippage and unravelling.
Tie synthetic suture knots with a minimum of three single throws. I often add an
‘hysterical 4th’ throw to help me sleep better.
Cut the knot suture ends no shorter than 2 mm to avoid spontaneous unravelling.
3.2.5 Monofilament v Braided
Braided multifilament sutures are more compliant (bendy) and have less memory
(springiness). The cut ends of monofilament sutures are sharp and can cause pricking under the skin. On the other hand, monofilament sutures are less likely to wick
in bacteria and secretions that can cause a suture abscess.
3.2.6 Suture Needles (Fig. 3.1)
Most surgical sutures are now supplied swaged to ‘atraumatic’ needles. In this
context an ‘atraumatic needle’ is defined as an eyeless surgical needle with the
suture attached to a hollow end. The needles however are far from ‘atraumatic’
to the tissues that they penetrate. They are in effect tiny knives with a point and
Fig. 3.1 Suture needle tip profiles. a Triangular cutting, b Spatulate cutting, c Taper point non-
cutting
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