Application of helical composite sandwich graft for eyelid reconstruction

PURPOSE: To show the efficiency of the ear helix sandwich graft as a simple method for reconstruction of full-thickness eyelid defects. METHODS: A prospective case series of 13 patients requiring full-thickness upper or lower eyelid margin reconstruction was evaluated. Defects were reconstructed with a helical composite sandwich graft, and all patients were assessed for functional and aesthetic results and surgical complications. RESULTS: All patients were satisfied with their functional and aesthetic results. Three patients had marginal skin loss on the composite graft, which was treated with daily dressings. Donor site complications occurred in two patients; one had a local infection that was treated with daily dressings and the other had wound dehiscence treated with marginal debridement and primary closure. CONCLUSIONS: The helical composite sandwich graft is a good match for eyelids in terms of color, texture, and contour. The use of the helical composite sandwich graft is a simple, effective, and safe procedure for the reconstruction of full-thickness defects of the eyelid margins.     

Surgical management of deep chemical burns of the eyelids

Chemical burns of the eyelids are common, and this may lead to ocular damage. A direct insult of the eyes that result in permanent damage, is rare in facial burns. The majority of the chemical burns of eyelids are partial-thickness that heal spontaneously in 1 week. Whereas, 10 percent are full-thickness burns that require release of contractures and grafts. Wound contracture can cause ectropion of the eyelid, resulting in exposure keratitis, conjunctivitis, corneal ulcers, perforation, and even blindness. At our departments, thirteen patients with 28 chemical burns of eyelids of third-degree, were reviewed. The eyelids had burns wounds with granulation and necrotic tissue. All patients had severe cicatrical ectropion. The eyelids were released with incisions running along the eyelid margin, down to the orbicularis muscle, including the distal part of the levator palpebrae superioris muscle, when necessary. To cover the resulting defects, we use generous full-thickness skin grafts, if available, for both the upper and lower eyelids. Rarely has a tarsorrhaphy been required, and properly constructed dressing provides satisfactory eyelid margin immobilization and conjunctival hygiene. Eighteen full-thickness grafts in 10 patients are reported 8 to 12 weeks after grafting. In seven eyelids, 3 patients developed ectropion and required reconstruction of the eyelids. Our series demonstrates that the early grafting of eyelid burns with full-thickness grafts, can prevent the development of recurrent cicatrical ectropion. Split-thickness grafting should be limited to cases where we can not find the hairless donor site for full-thickness skin grafts.     

Rhegmatogenous Retinal Detachments in Patients with Acquired Immunodeficiency Syndrome

Lower eyelid blepharoplasty surgery has undergone a dramatic evolution over the last decade. As more patients have requested cosmetic lower eyelid surgery, this has been accompanied by a greater number of surgeons performing the surgery and a greater number of patients with complications of a varied nature. Ophthalmologists, the surgeons most familiar with the anatomy of the eyelids, orbit, ocular structures, and adjacent face, have been called on more and more regularly to evaluate patients before their having cosmetic surgery, performed by other specialists, and then to manage complications ranging from minor ocular irritation to severe visually threatening ocular and periocular problems after surgery. In addition, more ophthalmologists are performing cosmetic eyelid surgery today than ever. Lower eyelid surgery has always instilled fear in the hearts of cosmetic surgeons because of the unacceptably high frequency of lower eyelid malpositions after surgery and the difficulty of correcting these problems. Transconjunctival blepharoplasty, particularly in conjunction with laser skin resurfacing, has reduced these problems. Lateral canthal tendon-tightening procedures will frequently reposition the lower eyelid back to its normal anatomic position. In cases of severe lower eyelid retraction, hard palate mucosal grafts, in conjunction with eyelid tightening, can reposition the eyelid satisfactorily. Other complications, including lacrimal drainage-system lacerations, extraocular muscle injury with postoperative diplopia, and wound dehiscence, need to be prevented and, if they occur, need to be able to be treated by the cosmetic eyelid surgeon. Certain difficult postoperative problems, such as chemosis or lymphedema, will occasionally occur and, although their anatomic origin is not yet understood, they must be properly medically evaluated and treated.     

Incidence of host site complications in periocular full thickness skin grafts

AIM: To evaluate the complications of periocular full thickness skin grafts (FTSG) in patients treated with Mohs' micrographic surgery (MMS) for periocular malignancy. METHOD: This prospective, multicentre case series included all patients in Australia treated with MMS for periocular malignancy followed by reconstruction with FTSG, who were monitored by the Skin and Cancer Foundation, between 1993 and 1999. The parameters recorded were patient demographics, reason for referral, histological classification of malignancy and evidence of perineural invasion, duration of tumour, site, recurrences prior to MMS, preoperative tumour size, and postoperative defect size. FTSG donor sites included upper lid, preauricular, retroauricular, inner brachial, and supraclavicular. The primary outcome measures were FTSG host site complications (partial/complete graft failure, graft infection, acute bleeding/haematoma, graft hypertrophy, and graft contracture). RESULTS: 397 patients (229 males, 168 females), mean age 60 (SD 15) years (range 20-91 years). 92.7% were diagnosed with basal call carcinoma, 2.0% with Bowen's disease, and 3.3% with squamous cell carcinoma. Medial canthus was involved in 66.5% of patients, lower eyelid in 28.0%, and upper eyelid in 5.5%. Postoperative complications were recorded in 62 patients (15.6% of all patients), and consisted of graft hypertrophy (45.1% of complications), graft contraction (29.1%), and partial graft failure (12.9%). The only statistically significant association found was a higher rate of graft hypertrophy in medial canthal reconstruction (p = 0.007). CONCLUSION: Host site complications of periocular FTSG are not common. Graft hypertrophy accounted for most complications and was more common in the medial canthal area. No other variables such as patient demographics, tumour characteristics, or donor site factors were associated with a higher risk of complications.     

Spontaneous reformation of upper eyelid.

Twenty-six patients with lesions of upper eyelids were treated with simple surgical excision under local anaesthesia as day cases. Three other patients with eyelid injuries had full-thickness margin-inclusive lacerations of upper eyelids. In all these 29 patients the upper eyelid wounds were allowed to heal solely by spontaneous repair. The cautious study began with small extramarginal skin excisions and progressed gradually via moderate sized juxtamarginal excisions of skin and orbicularis lamella to full-thickness margin-inclusive excisions. The wounds healed satisfactorily in all the 29 patients without ocular or palpebral complications. The functional results were normal. Cosmetic results were excellent in 27 patients and acceptable in 2, one of whom subsequently underwent a secondary oculoplastic repair. This study demonstrates that, for upper eyelids, full-thickness margin-inclusive excisions of up to 10 mm in horizontal extent and 5-6 mm in height, and moderate sized 13 X 10 mm juxtamarginal excisions of the skin and orbicularis lamella, yield near normal results with solely spontaneous repair. Immediate surgical reconstruction of such wounds is assumed to be mandatory by current tenets of oculoplastic surgery.     

Reconstruction of the upper eyelid with flaps and free grafts after excision of Basal cell carcinoma

Purpose: To describe a reconstructive technique of the superior eyelid with flaps and free grafts after excision of a basal cell carcinoma. Methods: Single case report of a 79-year-old woman who presented to our hospital with a basal cell carcinoma of the upper eyelid margin with initial erosion. Results: A large and full-thickness excision of the carcinoma was performed. The reconstruction technique should be customized to the individual patient. In this case, the use of a full-thickness tarsal graft from the contralateral upper eyelid, followed by an ipsilateral bipedicled flap and finally by a skin graft, was an effective surgical procedure, performed in one stage, without complications, and with good functional and esthetic results. Conclusions: Malignant neoplasms represent the leading cause of plastic reconstruction in the orbital region. Surgical techniques must be individualized for each patient and for each type of carcinoma. Reconstructive techniques with free grafts and flaps yield excellent results in the orbital region, particularly when some advice and a few fundamental rules are followed, namely accurate hemostasis of the receiving graft bed by moderate use of diathermy, careful suturing of the edges, and application of a compressive dressing for at least 4 days. Postoperative complications are very rare.     

Management of eyelid burns

Burns are devastating injuries scarring patients, both physically and psychologically, for life. This remains particularly true for facial burns. Eyelid burns occur in about 10% of thermal injuries and is a considerable challenge for the reconstructive surgeon given the particular anatomy of the eyelids. Reconstruction of the eyelids following burn injuries has been performed by plastic surgeons since the earliest days of reconstructive surgery, yet a consensus on a treatment regime has not been reached and plastic surgeons are divided on the subject. Controversies exist regarding the excision and debridement of eschar, temporary suture and surgical tarsorrhaphy, timing of surgery for eyelid contraction, and the role of full and split-thickness skin grafts in eyelid reconstruction. This paper describes the particularities of the treatment of burned eyelids in our Burn Center.     

Functional results and complications of Mersilene mesh use for frontalis suspension ptosis surgery

AIMS: To assess the functional results and complications of Mersilene (polyester) mesh frontalis sling suspension to correct poor levator function ptosis. METHODS: Retrospective case series. 32 eyelids of 20 patients (12 children and eight adults). RESULTS: Follow up 1-69 months (mean 32). CHILDREN: eight patients had bilateral and four unilateral surgery (20 eyelids). Good long term functional results were achieved in 73% (8/11 children) and 77% (14/18) eyelids. Two children had early postoperative wound infection requiring removal of mesh in one; the other was lost to follow up following medical treatment. ADULTS: four patients had bilateral and four unilateral surgery (12 eyelids). Good long term functional results were achieved in 75% (6/8 patients, 9/12 eyelids). One postoperative wound infection and one mesh exposure were treated definitively by surgical excision of mesh. CONCLUSION: Mersilene mesh provides good functional results but up to 20% of patients have early soft tissue complications. Other materials such as monofilament suture or autogenous fascia lata should be considered.     

The arm as a skin graft donor site in eyelid reconstruction.

PURPOSE: To report the technique, success, and complications of using the arm as a donor site for full-thickness skin grafts used in eyelid and facial reconstruction. METHODS: The charts of 42 patients were reviewed. The arm was used as a donor site for harvesting full-thickness skin grafts in 52 procedures of eyelid or facial reconstruction. RESULTS: The size of skin grafts varied from 4.0 cm2 to 59.5 cm2. There were few recipient site complications: partial necrosis (n=2), severe contraction (n=2), and hair growth (n=4). Donor site complications included wound dehiscence (n=2) and hypertrophic scarring (n=2). CONCLUSIONS: The arm is an acceptable donor site for harvesting full-thickness skin grafts for use in eyelid and facial reconstruction when either traditional donor sites are unavailable or a large amount of skin is needed.     

Periocular Necrotising Fasciitis—A Case Report

Purpose: To document the step-by-step reconstructive surgical rehabilitation, over a 12-month period, of a patient with severe periocular necrotising fasciitis. Methods: This is a retrospective interventional case note review of a 68-year-old man who developed necrotising fasciitis a few days after an insect bite. He had severe facial cellulitis with subsequent necrosis of all four eyelids despite broad spectrum antibiotics. Results: The initial management included performing a wide surgical debridement, with the removal of infected and necrotic tissue extending bilaterally from the forehead to the mouth. Split skin grafts were used to cover the extensive tissue defects. Subsequent horizontal eyelid shortening and full-thickness skin was required to correct severe cicatricial ectropions, eyelid displacement and improve lagophthalmos. Conclusions: Necrotising fasciitis is an acute fulminant infection of the subcutaneous fat and deep fascia. The initial appearance may look like cellulitis but necrosis quickly follows. Facial disease with extensive periocular involvement represents a significant management challenge.     

表浅肌肉腱膜皮瓣联合硬腭黏膜移植修复全层眼睑缺损

目的探讨利用眼周表浅肌肉腱膜系统（SMAS）皮瓣联合硬腭黏膜移植修复中、重度全层眼睑缺损的临床疗效。方法对26例（26只眼）大于或等于眼睑全长1／2的全层眼睑缺损患者,采用硬腭黏膜移植替代眼睑后层,即睑板和睑结膜层;利用眼周血供丰富的SMAS皮瓣修复眼睑前层,即皮肤肌肉层。其中5例采用眼轮匝肌蒂皮瓣,5例为颞浅动脉皮瓣,7例为眉上皮瓣,9例为上睑皮肤轮匝肌双蒂瓣。手术操作中首先行硬腭黏膜移植,然后根据眼睑前层缺损的部位和范围设计眼周的SMAS转位皮瓣,术毕行睑缘缝合3个月。结果全部患者随访6～36个月,平均11个月。转位皮瓣全部成活,硬腭黏膜植片成活好,无收缩,眼睑外观及功能改善较满意。结论眼周SMAS皮瓣联合硬腭黏膜移植可一次性修复缺损的眼睑全层,效果肯定。     

风筝皮瓣修复眼睑前层及中面部皮肤缺损

目的 评价风筝皮瓣修复合并或不合并中面部皮肤缺损的眼睑前层缺损的疗效.方法 自2008年1月至2010年3月,以面部皮下组织为蒂,设计"风筝"皮瓣,联合或不联合硬腭黏膜移植,修复合并或不合并中面部皮肤缺损的眼睑缺损共10例.眼睑前层或和中面部皮肤缺损面积为(1.2～6.5)cm2、(0.7～4.0)cm2.其中下眼睑中央水平方向4/5、垂直方向完全全层缺损合并颧颊部皮肤缺损1例,下睑内侧水平方向1/2、垂直方向完全全层缺损、下泪小点下泪小管缺损合并中面部皮肤缺损1例,下睑水平及垂直方向均完全全层缺损合并下泪小点及下泪小管缺损1例,上下睑水平方向完全、垂直方向1/3全层缺损合并上下泪小点泪小管缺损1例,下睑中央水平方向4/5、垂直方向完全全层缺损合并颧颊部皮肤缺损1例,全上眼睑前层及颞部皮肤缺损1例,下睑内侧水平方向1/3、垂直方向1/5前层缺损1例,上下睑中央水平方向2/3、上睑垂直方向1/3,下睑垂直方向2/3全层缺损1例,上下睑内侧1/3前层及内呲内侧皮肤缺损合并上下泪小点缺损1例,外眦外侧前层及颞部皮肤缺损1例.结果 皮瓣均无张力修复缺损,皮瓣及硬腭黏膜均全部成活,眼睑外形、功能完全恢复.结论 风筝皮瓣是修复眼睑缺损及面部皮肤缺损的良好方法.

Abstract：

Objective To evaluate the effect of rehabilitating the anterior 1amella of eyelids and midfacial skin defects with kite flap.Methods From January 2008 to March 2010,with or without combination of a hard palate mucosal grafts,the kite flap on a subcutaneous pedicle have been used to repair defect in the anterior lamella of eyelids and midfacial skin in 10 patients.The area of the defect in the anterior lamella of eyelids and midfacial skin ranged from(1.2～6.5)×(0.8～4)cm.Among them,defects span central 4/5 in horizontal direction and complete in vertical direction in full-thickness lower eyelid and partes zygomatica skin in 2 patient,medial 1/2 in horizontal direction and complete in vertical direction and puncta and canaliculus in full-thickness lower eyelid and midface skin in 1 patient,complete lower eyelid and inferior puncta and canaliculus in 1 patient,complete in horizontal direction and 1/3 in vertical direction and puncta and canaliculus both in full-thickness upper and lower eyelids in 1 patient,complete anterior layer of upper eyelid and temples skin in 1 patient,medial 1/3 in horizontal direction and 1/5 in vertical direction in the anterior lamella of lower eyelid in 1 patient,central 2/3 in horizontal direction and 1/3 in vertical direction in full-thickness upper eyelid,and central 2/3 in horizontal direction and 2/3 in vertical direction in full-thickness lower eyelid in 1 patient,medial 1/3 of anterior lamella and puncta and canaliculus both in upper and lower eyelid and inside skin of medial canthus in 1 patient,outside skin of outer canthus and temples skin in 1 patient.Results All flaps and hard palate mucosal grafts were survived.All defects were repaired without tention.The cosmetic appearance and function of eyelids rehabilitated.Conclusions The kite flap provides a competitive method for repairing the anterior lamella of eyelids and facial skin defects.     

Histoacryl closure of eyelid skin grafts

Histoacryl is virtually an ideal tissue glue. It has found application in corneal surgery, oculoplastic surgery, as well as many other surgical fields. A clinical series of 18 patients requiring eyelid skin grafts is presented. Each of the patients had skin grafts placed with a combination of sutures and Histoacryl. No complications were encountered. The postoperative course and results were identical to the authors' experience with skin grafts closed with suture alone. The advantages of Histoacryl skin closure are discussed. Other uses of Histoacryl in oculoplastic surgery are also reviewed.     

The technique of cranial bone grafts in the correction of posttraumatic orbital deformities

The technique of split-thickness cranial bone graft for reconstructive orbital surgery, is reported in five patients who sustained extensive orbital trauma. This technique involves exposing the skull via a coronal scalp incision, after which the cranial bone is split in situ along the diploe. The outer table of the cranial bone is then used as a graft to correct orbital defects and other associated bony deformities. Cranial bone grafts have several advantages over other graft sites in orbital reconstruction, including more rapid postoperative recovery, close proximity of donor site to recipient site, and improved survival of cranial bone grafts in experimental studies. Cranial bone grafts are an important source of autogenous tissue for the reconstructive surgeon.     

Management of complications following dermis-fat grafting for anophthalmic socket reconstruction

Sixty consecutive cases of dermis-fat grafts for anophthalmic socket reconstruction were reviewed to examine the frequency, severity, and management of postoperative complications. In seven patients, the conjunctiva failed to resurface the graft and central ulceration developed. Ten cases resulted in enophthalmos. Two patients developed keratinized sockets with chronic discharge and desquamation. Three patients required excision of conjunctival granulomas. One patient developed a primary graft infection. A donor site hematoma occurred in one patient. Secondary surgical intervention was required in ten patients. Nine complications in eight patients were managed in the office; five complications in four patients were observed and subsequently resolved without surgical intervention. Most complications occurred in patients with severely traumatized sockets who had undergone extensive earlier ocular surgery, or who had a systemic disease contributing to defective wound healing.     

Unilateral invasive xanthelasma palpebrarum

We describe an unusual case of an aggressively invasive, recurrent xanthelasma palpebrarum which was unilateral in its occurrence. Despite characteristics that appeared malignantly invasive clinically, the lesion was benign. The surgical treatment consisted of wide excision and resurfacing of the eyelids with full-thickness skin grafts.     

Eyelid necrosis and periorbital necrotizing fasciitis. Report of a case and review of the literature

Necrotizing fasciitis is an uncommon and severe soft tissue infection characterized by cutaneous gangrene, suppurative fasciitis, and vascular thrombosis. The disease is usually preceded by trauma in patients that have systemic problems, most commonly diabetes and alcoholism. Streptococcus pyogenes and Staphylococcus aureus are the most frequent bacterial etiologies; however, combinations of numerous facultative and anaerobic organisms have also been isolated. Involvement of the face and periocular region is rare. A case is presented here, as well as a review of the clinical features of 15 other patients previously described, in whom eyelid necrosis due to periorbital necrotizing fasciitis developed. Early surgical debridement and drainage of necrotic tissues and appropriate parenteral antibiotics are the mainstay of therapy. The mortality rate in patients with periorbital spread was 12.5%, with the prognosis known to be adversely affected by delay in diagnosis and treatment and/or extension of infection from the face to the neck. Reconstruction of the eyelids with skin grafts was necessary in most cases to avoid such complications as cicatricial lid retraction, lid malpositions, and lagophthalmos.     

Surgical treatment of cicatricial ectropion in lamellar ichthyosis

BACKGROUND. Lamellar ichthyosis is a skin disorder that is frequently associated with cicatricial ectropion and lagophthalmos. The authors present the surgical management of cicatricial ectropion in a case with lamellar ichthyosis. PATIENT AND METHODS. A 2-year-old male presented with bilateral cicatricial ectropion of the upper and lower eyelids. He had lagophthalmos and corneal punctuate staining. His skin was totally involved with the disease process except his prepuce. The patient was circumcised, and after the correction of horizontal eyelid laxity, the penile skin graft was sutured into the defects in all four eyelids. RESULTS. 18 months following surgery the patient had no lagophthalmos or corneal exposure, but had slight ectropion at the temporal side of the left lower eyelid. He had no complications from the circumcision. CONCLUSION. Prepuce is an alternative donor tissue in male patients with no other available donor site. To our knowledge, this is the second report of cicatricial ectropion corrected with a penile skin graft.     

Surgical treatment of cicatricial ectropion in lamellar ichthyosis

BACKGROUND . Lamellar ichthyosis is a skin disorder that is frequently associated with cicatricial ectropion and lagophthalmos. The authors present the surgical management of cicatricial ectropion in a case with lamellar ichthyosis. PATIENT AND METHODS . A 2-year-old male presented with bilateral cicatricial ectropion of the upper and lower eyelids. He had lagophthalmos and corneal punctuate staining. His skin was totally involved with the disease process except his prepuce. The patient was circumcised, and after the correction of horizontal eyelid laxity, the penile skin graft was sutured into the defects in all four eyelids. RESULTS . 18 months following surgery the patient had no lagophthalmos or corneal exposure, but had slight ectropion at the temporal side of the left lower eyelid. He had no complications from the circumcision. CONCLUSION . Prepuce is an alternative donor tissue in male patients with no other available donor site. To our knowledge, this is the second report of cicatricial ectropion corrected with a penile skin graft.     

Donor site morbidity in free tarsal grafts

PURPOSE: To determine if harvesting free tarsal grafts from the upper eyelids is associated with significant morbidity. DESIGN: Prospective case series. METHODS: Consecutive patients managed with free tarsal grafts by three of the authors (D.S., D.G., R.G.) over a 4-year period. RESULTS: Ninety-one eyelids in 75 patients were operated on using the free tarsal graft for various eyelid pathologies. Mean follow-up period was 14.83 +/- 8.45 months (range, 4 to 42 months). Contour peaking in donor upper eyelid appeared in two eyelids (2.2%), lash ptosis in four eyelids (4.4%) of three patients, and donor site infection in one eyelid (1.1%). Four patients (5.3%) complained of a transient ocular discomfort. There were no cases of postoperative changes on the eyelid height, entropion, or keratopathy in the donor site eye. Most of the donor site complications were mild or transient and required no further surgery. In three patients who underwent subsequent surgery to treat preexisting ptosis or retraction of the donor eyelid, the results were less predictable and further procedures were required. CONCLUSION: Free tarsal grafts harvested from the upper eyelids, with preservation of at least 4 mm of the tarsal plate inferiorly, do not lead to significant donor site morbidity. However, subsequent procedures to alter the position of the donor eyelid may be less predictable.