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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_688_Библиотеки_им_академика_М_И_Перельмана
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8 Eyelids
Fricke Flap
Indications: Medium and large defects (upper and lower eyelid).
Technique: It is an inferiorly based transposition ap harvested from the temple/
forehead skin situated lateral and superior to the orbit/eyebrow. The margins of the
defect are delineated, and the ap designed with its inferior medial margin lying
along the lateral margin of the defect. A trial transfer is carried out to determine the
length of the ap and should take into account loss of length due to rotation around
the pivot point. The ap is raised in the subcutaneous plane and transposed into the
defect. The donor site defect is closed initially followed by insetting the ap into the
defect (Fig.8.5a–d).
Tips: The length to width ratio should not exceed 4:1 to maintain adequate vas-
cularity. The medial extent of the ap should stop short of the supra-orbital neurovascular bundle. Care should be taken to avoid damage to the branches of the facial
nerve, which lie on the deep surface of the muscles. Thinning of the ap might have
to be undertaken, either during the initial transfer or at a later stage.
ab
cd
Upper Eyelid
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Fig. 8.5 Fricke ap. (a) Markings for excision and ap, (b) Excision defect and ap raised, (c)
Flap transposed into defect, (d) Final closure
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8 Eyelids
Supra-trochlear Island Flap
Indications: Medium defect medial canthus, medial upper eyelid.
Technique: An accurate template is made of the defect and marked out at the
donor site along the horizontal glabellar skin crease. The skin is incised all around
the ap up to the subcutaneous tissue. The incision along the superior margin of the
ap is deepened down to the periosteum, and the skin medial to the defect and inferior to the proposed ap is raised in the subcutaneous plane. The deep ap pedicle
consisting of subcutaneous tissue and muscle is gradually released in the supraperiosteal plane, to obtain the required mobility. The mobilised ap is sutured into
the defect and the donor site closed primarily, following undermining of the wound
edges (Fig.8.6a–h).
Tips: The thickness of the subcutaneous pedicle can alter the contour of the
medial canthus region. This can be corrected at the second stage if required. Care
should be taken to avoid damage to the pedicle during dissection and haemostasis.
ab
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c d
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Fig. 8.6 Supra-troclear island ap. (a) Markings for excision and ap, (b) Excision defect and
ap raised, (c) Flap transposed into defect, (d) Flap sutured into defect, (e) Final closure, (f)
Markings for excision and ap, (g) Excision defect, (h) Final closure
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8 Eyelids
e
g
f
h
Fig. 8.6 (continued)
Upper Eyelid
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Glabella Transposition Flap
Indications: Medium defects medial canthus/jugum nasi.
Technique: The defect is modied into a triangle with the base placed laterally.
A curvilinear incision is made from the superior edge of the defect and extended
superiorly into the glabella skin crease. A back cut is made from the summit, across
to the contralateral medial canthus. The nasal component of the ap is raised in the
sub-muscular plane and the glabellar component in the subcutaneous plane. The
wound margins are widely undermined and closed in layers. The secondary glabellar/nasal root defect is closed primarily and any excess skin in the superior aspect of
the ap discarded. Dog ear at the primary defect is corrected as required (Fig.8.7a–
d, e–h, i–m).
Tips: The ap often has to be thinned, to match the defect margins. Primary
closure of the glabella defect medialises the eyebrows and would have to be taken
into account, when considering this ap. Variations to the design of the ap can be
utilised to best accommodate the defect and the eventual scar (Fig.8.7e–h, i–m).
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8 Eyelids
a
b
d
c
e
f
Fig. 8.7 Glabella transposition ap. (a) Markings for excision and ap, (b) Excision defect and
ap raised, (c) Flap transposed into defect, (d) Final closure (e) Lesion medial canthus area, (f)
Excision defect and ap incision, (g) Flap transposed into defect, (h) Final closure, (i) Markings
for excision and ap, (j) Excision defect and ap raised, (k) Trial transfer of ap, (l) Appropriate
thining of ap, (m) Final closure
gh
kl
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i
j
Fig. 8.7 (continued)
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Fig. 8.7 (continued)
8 Eyelids
m
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Full-Thickness Defects
Primary Closure (See Lower Eyelid)
Indications: Small defects.
Technique: The lesion is excised to leave a shield-shaped defect, with parallel
sides towards the lid margin. The wound is closed in layers with sutures placed in
the tarsal plate, avoiding going through the palpebral conjunctiva. The orbicularis
oculi and skin layers are then closed.
Tips: Accurate approximation of the lid margin is essential to prevent notching
and can be helped with vertical mattress sutures along the grey line. It is often helpful to place all the sutures in the tarsal plate, prior to tightening.
Primary Closure withLateral Canthotomy andCantholysis (See
Lower Eyelid)
Indications: Medium defect.
Technique: The lesion is excised to leave a shield-shaped defect. A 1-cm inci-
sion is made through the skin and orbicularis muscle overlying the lateral canthus.
The lateral canthus is next divided (Canthotomy) horizontally between the upper
and lower limbs, up to the bony orbital rim. The upper lid is put under tension and
the superior limb of the lateral canthus transected (cantholysis) vertically, till it is
completely released from its lateral attachments. The primary defect is closed in
layers as is the skin incision overlying the lateral canthus.
Tips: The position of the lateral canthus can be easily identied / felt by putting
the lid margins under stretch. Completion of the cantholysis can be conrmed by
medial displacement of the lid margins with forceps, while vertically transecting the
canthal limb. Free movement of the lid margin is obtained, once the cantholysis is
complete. There is often webbing in the lateral extremity of the lid margin at the site
of cantholysis.
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