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5.4 The Magic Suture (Fig. 5.4) 55
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7. Now, tighten, tie firmly and cut the two preplaced tarsal mattress sutures in
reverse order of placement, i.e., starting with the one furthest from the lid margin. Lift and pull each pair of suture ends laterally, to close the wound using the
pulley effect, before snugging down the first throw. Once tied, the first suture
takes up most of the wound tension. This makes it easy to tie the second suture
tightly (Fig. 5.3i). By the end of this step the lid margin wound should be
accurately and securely closed.
8. Tighten and tie the pre-placed lateral canthal margin mattress suture (Fig. 5.3j).
Cut its ends short enough for them to retract into the wound. The canthus is
now reformed.
9. Repair the remainder of the skin wound with interrupted 6/0 or 7/0 absorbable
sutures which incorporate the underlying orbicularis into each bite (Fig. 5.3k),
or suture the orbicularis first, as a separate layer with a magic suture.
5.4 The Magic Suture (Fig. 5.4)
A long reach, subcutaneous, suture, placed across the centre of a tissue defect can
transform a gaping wound into a narrow slit “as if by magic”, hence its name. It
is an extremely useful technique for two reasons:
•
Temporarily tying this first stitch simulates the ultimate effect that your chosen closure direction will have on the eyelid margin position. Should it cause
ectropion or retraction, the suture is quick and easy to replace in a better
orientation.
•
Secondly, by aligning and approximating the skin edges this suture speeds up
the remainder of the wound closure.
a b
Fig. 5.4 Magic suture direction. a In the right lower lid, the suture is placed at an oblique wound
axis. In the left brow along the long wound axis. b When tightened the suture tension is parallel to
the respective lid margin tangent and transforms the wound’s geometry
56 5 Fundamental Procedures
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5.4.1 Principle and Considerations
Bringing the subcutaneous tissue layer together carries the overlying skin with it.
The salient properties of any suture bite are its direction, length and depth, and
the tissue it engages. With the magic suture all three properties differ from those of
conventional subcutaneous sutures. The most critical factor is the suture direction.
In conventional wound closure the sutures are placed across the short axis of a
defect. For a magic suture, by contrast, the direction of the closure tension must
be parallel to the tangent at the nearest point on the lid margin, irrespective of the
short axis of the actual defect (Fig. 5.4a). This ensures that the repair does not
pull on the lid margin to cause retraction. Consequently, the resulting closure scar
tends to lie more perpendicularly to the lid margin though not necessarily at right
angles. Place the Magic suture very roughly centrally on each side of the wound,
as this is the point at which maximum closure tension develops. However, Fig. 5.4
illustrates that with oblique and irregular wounds this is not necessarily the case.
Therefore, align the suture parallel to the lid margin, irrespective of the wound’s
orientation. Do not worry if you don’t get it right the first time. The suture is quick
to replace. The suture bites should start and end in the depth of the wound to bury
the suture knot when tied.
The suture material used for this technique is not critical. However, as suture
tension invariably dissipates by suture migration, I recommend an absorbable
suture on a half-circle needle. You gain no advantage by using non-absorbable
sutures. 6/0-gauge sutures work well within the eyelid area. Stronger 4/0-sutures
are preferable more peripherally.
5.4.2 Case Selection
Widely applicable to most wounds.
5.4.3 Steps
1. From the depth of the wound engage the subcutaneous tissue roughly at the
midpoint with a suture on a ½ circle needle (Fig. 5.5a). Within the periocular
area the subcutaneous tissue is mostly orbicularis muscle.
Note: Do not to engage immobile structures, such as the orbital septum inadvertently, as this would limit wound edge movement. Occasionally one may
deliberately choose to engage a canthal tendon in the knowledge that this side
of the repair will remain fixed, and all the mobility must come from the opposite
bite.
2. The bite length on each side of the wound should be no less than 5 mm within
the pre-tarsal area and no less than 10 mm in the surrounding tissue. Make
this bite deep enough to strongly engage the subcutaneous layer (usually the
orbicularis).
5.4 The Magic Suture (Fig. 5.4) 57
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a
Periocular 10 mm
Eyelid 5 mm
Skin
Orbicularis
b
Skin
Orbicularis
Periocular 10 mm
Eyelid 5 mm
c d
Fig. 5.5 The magic suture. a From the depth of the wound engage the subcutaneous orbicularis
muscle. b Bring the needle tip up until it is just visible through the skin, rotate by 90° and advance
subcutaneously to the wound edge. Traverse the wound and take a similar bite on the far side.
c Place the first double throw of the knot and tighten. d Complete the knot with three additional
single throws
3. At the required distance, bring the suture needle tip up until it is just visible
through the skin. At this point rotate the needle by 90° towards the wound
edge.
4. Advance the needle within the subcutaneous plane close to the skin until it
exits at the wound edge.
5. Traverse the wound and enter the subcutaneous plane on its far side.
6. Advance the needle within this plane for 5 or 10 mm, as for the first bite, and
then rotate the tip down to penetrate the muscle layer.
7. Rotate the needle out through the deep wound edge (Fig. 5.5b).
8. Place the first double throw of the knot (Fig. 5.5c).
Note: When tying the suture, it is helpful to have an assistant push the two sides
of the wound towards each other, temporarily reducing the wound tension. Lift
this first double suture throw clear of the tissues by lifting and pulling on both
the suture ends. Rock the knot side to side during this step to encourage the
suture to slide through the tissues as you pull them together.
9. While maintaining the suture tension, snug the knot down. Repeat this
sequence of lifting, rocking, and tightening several times until the wound
edges stop coming closer. The phenomenon of ‘tissue creep’ is gradually
occurring as you do this so do not rush this step.
10. Complete the knot with three additional single throws (Fig. 5.4d). Ask an
assistant to hold the first throw with the very tips of Moorfields forceps to
stop it slipping while you lock it with the second throw.
58 5 Fundamental Procedures
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5.4.4 Notes
•
Occasionally more than one magic suture is required. If you need even stronger
tissue holding use a buried horizontal mattress suture configuration instead.
However, the placement steps essentially remain the same.
•
A ‘magic suture’ enables the direct closure of larger defects than at first appears
possible. Use it as a first step to minimize any defect, even if you are planning
a flap or graft repair. Once it is in place reconsider your options. You may find
that direct closure has now magically become possible.
5.5 Tarsal Traction Suture (Fig. 5.6)
You will often need to pull on a lid with a suture either during an operation or
during the early healing phase. Traditionally you would do this by placing your
traction suture into the grey line and out through the skin, tarsorrhaphy tubing or
over a bolster to spread the load over a larger area, and back into the skin to exit
the grey line. The following method is a surer, longer lasting and more comfortable
alternative.
a
Grey Line
Meibomian Orifice Line
Meibomian Gland
b
0
90
c d
Fig. 5.6 The tarsal traction suture. a Lid margin landmarks. b Perpendicular needle entry into the
Meibomian Orifice Line. c Needle advanced within the tarsal plate. d Taping the lid margin suture
on traction
5.5 TarsalTraction Suture (Fig. 5.6)59
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5.5.1 Principle and Considerations
The tarsal plate is the strongest part of the eyelid despite 70% of it being meibomian gland tissue. Consequently, it is the best structure into which to anchor
a traction suture. Although the tarsal plate is only 1–2 mm thick the meibomian gland orifices provide a convenient surface landmark for the mid-tarsal plane
(Fig. 5.6a).
Tarsal plate has few nerve endings so a suture pulling on it causes no pain.
Eyelid skin, by contrast, is sensitive to suture pressure, even if you pass your
traction suture over a bolster or through tubing.
A tapered, non-cutting needle causes minimal tarsal damage because it separates, rather than cuts as it passes. Do not use a cutting needle for fear of shredding
the relatively thin tarsal plate, weakening it with each pass.
A 4/0 monofilament polypropylene suture on a 17 mm half circle, non-cutting
taper-point needle (Ethicon Prolene W8557) makes an excellent traction suture. It
is both strong and inert.
This way of applying lid traction is applicable to either lid, anywhere along its
margin. It is the basis of the ‘bolster-less suture tarsorrhaphy’ (see Chap. 13).
5.5.2 Case Selection
Any lid requiring sustained traction per operatively or postoperatively up to several
weeks e.g., to immobilize a graft bed or protect an eye.
5.5.3 Steps
(1) Grasp the full thickness of the lid as parallel to the margin as possible with
large forceps (e.g., Toothed Adson’s or the specifically designed Thaller Tarsal
forceps [Altomed A6360]) 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 the round bodied needle tip held
perpendicularly to the lid margin (Fig. 5.6b).
(3) Slowly advance the needle within the plane of the tarsal plate, allowing it to
follow its own curve to exit once more through the meibomian orifice line
some 10 to 12 mm from its point of entry (Fig. 5.6c). If the needle exits
prematurely, too anteriorly through the lash line or too posteriorly through the
conjunctival surface of the tarsal plate, partially withdraw the needle, alter the
angle at which you are holding the lid margin and re-advance the needle until
the tip exits the meibomian orifice line as intended. Even if you have to repeat
this a few times the non-cutting needle does minimal damage.
(4) Finally inspect the lid to ensure that the suture has not breached the conjunctiva
or skin during its long passage.
(5) Apply traction as required (Fig. 5.6d).
60 5 Fundamental Procedures
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5.5.4 Notes
•
Premature failure results through cutting out if you engage an insufficient length
of tarsal plate or inadvertently miss it. This is caused by not entering the
meibomian gland orifice line perpendicularly.
•
Eventual failure by suture migration out of the lid is inevitable but takes sev-
eral weeks. It occurs gradually and is only an issue with long-term suture
tarsorrhaphy. If this occurs, simply replace the suture.
•
A correctly placed tarsal traction suture causes no pain or inflammation while
in place, nor scarring after removal.
5.6 Emergency Cantholysis (Fig. 5.7)
Emergency lateral cantholysis is rarely required but I include it here because it
is a sight saving procedure when raised intra-orbital pressure threatens vision. It
heals spontaneously and seldom needs to be repaired. It can be performed in any
setting.
a b
Fig. 5.7 Emergency cantholysis. a At the lateral canthus crush the lid downward and laterally at
45°. b Cut downward and laterally at 45° through the crush mark dividing the full thickness of the
lid. c Extend the incision until the lower lid is completely detached
c
5.7 Take Home Message 61
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5.6.1 Principle and Considerations
Release the lid from its attachment to the lateral orbital rim by making a diagonal
full thickness cut at the lateral canthus. Cutting at an oblique angle, rather than
horizontally, avoids damaging the lateral canthal tendon.
5.6.2 Case Selection
Emergency decompression of a tense orbit following trauma, haemorrhage or
infection.
5.6.3 Steps
(1) Grasp and hold the lower lid close to the lateral canthus with strong toothed
forceps (Adson’s).
(2) Insert one blade of a pair of straight artery forceps under the lower lid mar-
gin at the lateral canthus and crush the lid downward and laterally at 45°
(Fig. 5.7a).
(3) Remove the artery forceps and insert one blade of a pair of strong scissors
(e.g., Steven’s tenotomy scissors) under the lower lid margin at the lateral
canthus and cut downward and laterally at 45° through the crush mark dividing
the full thickness of the lid (Fig. 5.7b).
(4) If the lower lid is not completely detached from the canthus, extend the
incision further until it is (Fig. 5.7c).
5.6.4 Note
•
Cantholysis may be performed on either the upper or the lower lid, or even on
both.
5.7 Take Home Message
•
Accurately align a lid margin repair.
•
A single, correctly aligned, subcutaneous suture can positively transform a lid
defect.
•
Place sutures in the meibomian orifice line, not the grey line.
•
Emergency cantholysis saves sight.
Eyelid Malposition
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Fig. 6.1 Lid malposition
6
6.1 Overview (Fig. 6.1)
•
Factors affecting eyelid position and stability.
The palpebral aperture, being the gap between the upper and lower lid margins,
is affected by both vertical and rotational lid margin malposition. Vertical eyelid malpositions comprise blepharoptosis (usually abbreviated ‘ptosis’) and eyelid
retraction. The rotational malpositions are entropion (inward turning of the margin)
and ectropion (outward turning of the margin).
© 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_6
63
64 6 Eyelid Malposition
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6.2 Lid Stability (Fig. 6.2)
6.2.1 Tarsal Plate Width
The lower lid is prone to rotational malposition as its tarsal plate is narrow (4 mm
wide) making it inherently less stable about its long axis than the upper lid (tarsal
plate width 8–10 mm).
6.2.2 Orbicularis Tone
The lids gain stability by being held flat against the globe. The active force doing
this is the orbicularis muscle tone. Usually this is spread evenly thanks to the
orbicular attachments to skin. With aging these attachments weaken allowing the
pre-septal orbicularis to move to a pre-tarsal position during contraction. This
creates net inward pressure on the lid margin which can cause entropion.
6.2.3 Lid/Globe Apposition and Volume Deflation
Passive stability stems from the geometry of the bony attachments of the lids (via
the canthal tendons) relative to the pupillary plane. For the lid to gain support it
must be bowed forwards by the eye.
Aging leads to facial and orbital volume loss (deflation). The resulting enophthalmos gives less lid support and the lid becomes lax relative to the eyeball
(‘eyelid/globe disparity’). In severe enophthalmos a space can develop between
the lower lid margin and the sunken eye.
Fig. 6.2 Lower lid stability
Factors contributing to lower
lid margin instability
Centre of rotation
Gravity
8-10 mm
4 mm
Enophthalmos
Narrow Tarsus
Retractor Laxity
6.3 The Palpebral Aperture 65
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6.2.4 Gravity
Gravity presses the upper lid down against the eye improving stability. By contrast,
in the upright posture gravity pulls the lower lid downwards, away from the eye,
reducing stability.
6.2.5 Retractor Tethering
The above factors allow the lower eyelid to rotate more easily about its long axis
(length) and flip inwards under the pressure of orbicularis contraction during blinking and eye squeezing, or outwards if the orbicularis is atonic, as in facial palsy.
The lower lid retractors help to resist such rotation by tethering the inferior edge
of the tarsal plate. This stabilizing effect is lost if the retractors dehisce or become
relatively lax through volume deflation.
Visible lower fornix fat prolapse is a sign of retractor dehiscence. Pull the lower
lid down to the orbital rim and look for a fat bulge between the eye and the tarsal
plate [1].
6.3 The Palpebral Aperture
The horizontal palpebral aperture length depends on the integrity of the medial
and lateral canthal tendons.
The vertical aperture (degree of lid opening) is determined by:
(1) The dynamic balance between the opening muscles (retractors), the levator and
Müller’s muscle, and the closing muscle (protractor), the orbicularis oculi. The
tone in the levator is controlled by the upper division of the oculomotor (III)
nerve, that of Müller’s muscle by the sympathetic nervous system, and the
orbicularis by the facial (VII) nerve.
(2) Static factors acting on the lid:
a. Normally, gravity and posture have relatively little effect on eyelid position.
b. Lid mass and volume does affect the palpebral aperture. Increase in volume,
such as by oedema, retention cysts or tumour infiltration can push the lid
margin towards closing. In the upper lid the increased weight causes posture
dependent ptosis, an effect that is occasionally exploited by implanting gold
or platinum lid weights in facial palsy.
c. Tissue elasticity is reduced by aging, frequent eye rubbing, recurrent
inflammation, and scarring,
d. Anterior lamellar tissue loss or relative shortage due to scarring or mid face
descent causes retraction and/or ectropion. Posterior lamellar (conjunctival)
scarring leads to lid margin retraction and cicatricial entropion.
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