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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_688_Библиотеки_им_академика_М_И_Перельмана
.pdf
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7 Nose
a
c
b
d
e
Fig. 7.19 Skin graft. (a) Markings for excision, (b) Skin graft sutured in place, (c) Post operative
appearance, (d) Template skin graft harvest forehead, (e) Closure of donar site
Suggested Algorithm
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Two-Stage Melolabial Flap
(See Fig.7.17).
Suggested Algorithm
Dorsum
Small
1. Primary closure (vertical/horizontal).
Medium
1. Glabella advancement ap.
2. Glabella transposition ap.
3. Skin graft.
Nasal Tip
Small
1. Primary closure (Vertical/horizontal).
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Medium
1. Glabella advancement ap.
2. Bilobed ap.
3. Skin graft.
Columella
1. Primary closure.
2. Skin graft.
3. Two-stage melolabial ap.
Side Wall
Small
1. Primary closure (vertical).
2. Healing by secondary intention (upper).
Medium
1. Skin graft.
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Upper side wall
1. Glabella transposition ap.
Lower side wall
1. Bilobed ap.
2. Apron ap.
Ala
Small
1. Island advancement ap.
Medium
1. Bilobed ap (laterally based).
2. Bilobed ap (medially based).
3. Two-stage melolabial ap.
4. Apron ap.
Paramedian Forehead Flap
7 Nose
1. Large nasal defects involving multiple nasal subunits.
2. Large nasal tip defects.
3. Large ala defects.
4. Large dorsal defects.
5. Large side wall defects.
Eyelids
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Subunits andAnatomical Considerations
Eyelids perform many important functions, which include protection of the eye and
maintaining an adequate tear lm. The aesthetic eyelid unit is dened by the lower
margin of the eyebrow, lateral and inferior orbital rims and the nasojugal fold. A
sound understanding of anatomy and function is essential for eyelid reconstruction
and should only be attempted by an appropriately trained clinician.
The eyelids are complex multilayered structures supported by cartilaginous tar-
sal plates. The free lid margin contains eyelashes and secretory glands, and the
extension of the tarsal plates forms the medial and lateral canthal tendons.
Reconstruction could be more easily understood if the eyelids were considered
to consist of an anterior lamella composed of skin and orbicularis oculi and a pos-
terior lamella composed of conjunctiva, tarsal plate, orbital septum and the lid
retractors. The orbital septum is occasionally considered the middle lamella, and the
“grey line” along the lid margin represents the junction between the anterior and
posterior lamellae.
The eyelid aesthetic unit can be further subdivided from a reconstructive point of
view into upper lid, lower lid, medial canthus and lateral canthus subunits (Fig.8.1).
The skin of the eyelid is the thinnest in the body, and the RSTLs around the eye-
lids are horizontally oriented (Fig.8.2). However, excision parallel to the RSTLs,
especially in the lower eyelid, runs the risk of eyelid retraction and ectropion. It is
therefore preferable to orient excisions to be perpendicular to the lid margins, unless
there is signicant skin redundancy. Excisions along the RSTL in the adjacent lateral and medial canthus, eyebrow and glabella regions can be performed and will
provide relatively unobtrusive scars.
8
© Springer Nature Switzerland AG 2024
V. Ilankovan et al., Local Flaps in Facial Reconstruction,
https://doi.org/10.1007/978-3-031-49464-2_8
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8 Eyelids
Full-thickness defects require reconstruction of both the anterior and posterior
lamella, in which case it is mandatory that at least one of the reconstructed lamella
should contain its own blood supply. Involvement of the lid margins is another
important determinant of reconstruction.
Subunits andAnatomical Considerations
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Fig. 8.1 Eyelid subunits
Fig. 8.2 Eyelid and
surrounding RSTL’s
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8 Eyelids
Upper Eyelid
Anterior Lamella Defects
Primary Closure
Indications: Small defects.
Technique: The defect is modied into an ellipse with a vertical or horizontal
orientation. The wound margins often do not require undermining, and the defect is
closed (Fig.8.3a–c).
Tips: In patients with eyelid skin redundancy, horizontal ellipse along the RSTLs
could be undertaken, without the risk of ectropion.
Upper Eyelid
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a
b
c
Fig. 8.3 Horizontal excision and primary closure. (a) Lesion upper eyelid, (b) Excision defect, (c)
Final closure
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8 Eyelids
Advancement Flap
Indications: Medium defects.
Technique: The defect is modied to obtain parallel wound margins. Incisions
are made from the extremity of the defect, and the ap raised in the sub-muscular
plane. The wound margins are undermined, and the defect is closed in layers
(Fig.8.4a–c).
Tips: The base of the ap can be made broader to maintain a satisfactory vascu-
lar pedicle. The aps can be medially or laterally based and when based medially,
should not extend beyond the connes of the eyelid skin.
ab
Upper Eyelid
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c
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Fig. 8.4 Advancement ap. (a) Markings for excision and ap, (b) Excision defect and ap
raised, (c) Final closure
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