Upper eyelid defect by dog bite reconstructed by an ipsilateral advanced tarsoconjunctival flap with skin graft

A technique for reconstruction of a traumatic upper-eyelid marginal defect utilizing a local tarsoconjunctival advancement flap with a skin graft is presented. A 22-year-old woman was bitten by a dog, resulting in a full-thickness loss of approximately the central half of her left upper eyelid. Debridement was performed under topical anaesthesia followed by one-stage upper eyelid reconstruction. The residual tarsal plate was used as a tarsoconjunctival advancement flap to reconstruct the posterior lamella of the defect. Skin from the posterior aspect of the left ear was grafted onto the reconstructed posterior lamella with two setting tarsorrhaphy sutures. One month postoperatively, the patient had an excellent cosmetic result with appropriate upper eyelid height and curvature, although cilia were not transplanted. The technique described offers a one-stage procedure with a simple surgical method providing on appropriate cosmetic and functional result.     

Surgery for involutional entropion

Surgery for involutional entropion must correct horizontal eyelid laxity, vertical laxity, and overriding of the tarsus by the infra-tarsal tissues. The surgery should give lasting functional and pleasing cosmetic results. These goals are achieved with: 1) a blepharoplasty incision and reflection of a skin-muscle flap; 2) excision of a wedge of eyelid tissue at the lateral canthus; 3) barrier sutures or tuck of the retractors; 4) reattachment of the lid to the lateral orbital rim; and 5) excision of excess skin.     

Simple technique for proper approximation and closure of peritoneal and rectus sheath defects at port site after laparoscopic surgery.

Complex intra-abdominal surgical procedures can now be performed with laparoscopy, and laparoscopic cholecystectomy has become the gold standard in the care of patients with cholelithiasis. This and other surgically challenging procedures involve use of multiple large (10-mm-15-mm) ports. A standard laparoscopic cholecystectomy employs two 10-mm trocar incisions. Development of incisional hernia from these port sites is well recognized unless the rectus sheath is closed properly. This makes proper closure of the incisions for larger ports critical, especially 10-mm to 15-mm ports. However, securing abdominal wall bleeding and closing facial defects through a small incision can be a cumbersome task. We have developed a simple technique using the regular curved needle and sutures for closure of rectus sheath defects through a small port-site incision.     

The aponeurotic approach to congenital ptosis

Using a surgical technique directed at the levator aponeurosis, we successfully corrected 228 cases of congenital ptosis. The advantages of this approach are: normal anatomic planes and structures of the eyelid are maintained; basic and reflex tear secretion, goblet cells, or meibomian glands remain undisturbed, allowing maintenance of the three-layered tear film; any aponeurotic defects may be explored and repaired relatively easily; all elevating structures are preserved (aponeurosis rather than muscular levator is removed, Mueller's muscle is left intact, Whitnall's ligament is not violated); posterior sutures, which may irritate the cornea, are avoided; no tarsus or conjunctiva are removed.     

Reducing the Incidence of Incisional Hernias following Open Gastric Bypass Surgery

Background Abdominal wall hernias are a common complication following open gastric bypass (RYGBP) surgery. In an effort to reduce the incidence of incisional hernias with our form of open RYGBP, progressively smaller, upper midline epigastric incisions have been utilized along with permanent sutures. The purpose of this study is to analyze whether incision location, size and choice of suture material affect the incidence of incisional hernias following open RYGBP. Methods Clinically evident incisional hernias and other wound complications and non-wound related complications were analyzed for 1,180 consecutive primary open proximal RYGBP procedures performed between August 2002 and June 2006. Progressively smaller, upper midline incisions were utilized during the time period of the study. Results Smaller incisions limited to the upper abdomen and approximated with permanent sutures were associated with significantly fewer hernias (P < 0.01), wound dehiscences (P < 0.03), eviscerations (P < 0.03) and wound infections (P < 0.03). Smaller incisions may also be associated with less postoperative discomfort. Conclusion A reduction in incision size, the avoidance of the periumbilical region and the use of nonabsorbable sutures has significantly reduced the incidence of incisional hernias and acute fascial disruptions with our form of open RYGBP. These findings are consistent with LaPlace’s law regarding wall tension and vessel radius. In addition, we found smaller incisions to be associated with fewer infections and seromas and less postoperative discomfort. A reduction in incision size has not been associated with an increase in morbidity or mortality or changes in the operative time.     

Eyelid reconstruction with acellular human dermal allograft after chemical and thermal burns

OBJECTIVE: To evaluate the efficacy of eyelid reconstruction with acellular dermal allograft in patients with eyelid defect after chemical and thermal burns. METHOD: Eyelid reconstruction was performed in 15 eyelids of 13 patients during the period of June 2001-October 2004 by a single senior surgeon (Chen). Among them five patients had thermal burns, and eight patients had chemical burns. The acellular dermal allograft was used as a tarsus substitute that was sutured into the place between the levator aponeurosis in upper lid or retractor in lower eyelid and the remaining tarsus. RESULTS: After a mean follow-up of 9 months, satisfactory function and cosmesis were obtained. No implant rejection or severe complications were observed. CONCLUSION: Acellular dermal allograft may be used safely as a posterior lamellar spacer graft after chemical and thermal burns; the allograft appears to be biocompatible and does not aggravate the inflammation in the injured eyelid.     

眼睑恶性肿瘤切除术后自体硬腭黏膜移植眼睑再造

目的 眼睑恶性肿瘤切除术后采用自体硬腭黏膜替代眼睑后层进行眼睑再造，并对其临床效果进行评价。方法1998年1月～2003年10月，对18例（18眼睑）患者行眼睑恶性肿瘤切除术后，局部旋转移位皮瓣或游离皮瓣联合自体硬腭黏膜替代眼睑后层的眼睑再造术。其中男10例，女8例，年龄35～67岁。18例均为重度眼睑缺损，其中眼睑全部缺损12例，2／3眼睑缺损6例。眼睑基底细胞癌10例，睑板腺癌6例，眼睑鳞状细胞癌2例。结果18眼睑术后外观及功能基本恢复正常，闭合完全，无内外翻。术后随访6个月～4年，平均3年2个月，眼睑形态及功能保持稳定，无植片感染及挛缩，无免疫排斥反应，无肿瘤复发。结论自体硬腭黏膜代替眼睑后层作眼睑恶性肿瘤切除术后的眼睑重建术，是一种简便易行、取材方便、术后并发症少、临床效果满意的眼睑再造术，硬腭黏膜优于传统的眼睑后层替代材料。     

Island orbicularis oculis myocutaneous flap from the upper eyelid for lower eyelid reconstruction

An island myocutaneous flap of orbicularis oculis for reconstruction of central lower eyelid defects is presented. This flap is able to cover anterior lamellar defects extending up to 2/3 of the lower eyelid. It is also suitable for full thickness defects when the posterior lamellar involvement is less than 1/3 and can be closed primarily. In our hands this flap proved to be a good alternative to the classic reconstructive methods for the lower eyelid, since in one operation it offers the same skin quality, exactly fitting the defect, with a low complication rate. This reconstructive method for lower eyelid defects is safe, relatively simple and provides good functional and aesthetic results. Received: 21 August 1996 / Accepted: 15 June 1997     

Single-stage repair of urethral fistula by vascular island groin flap

A new technique for the repair of a urethral fistula at the penoscrotal junction is presented. Under local anaesthesia we have successfully repaired six of these fistulae using a groin island pedicle flap. The urethra is repaired by mobilising the mucous lining around the fistula and closing it longitudinally, using absorbable 4/0 chromic catgut sutures. The groin island pedicle flap which is based on superficial circumflex iliac vessels is used to cover the repaired lining. The donor defect is closed primarily. In all six cases there was primary healing. This procedure is recommended for cases where the skin around the fistula is badly scarred or where previous attempts at closure have failed. Moderate defects of penile and scrotal skin can also be repaired by this type of flap.     

A new closure technique for limited thoracotomy where the ribs are spread minimally.

An alternative closure technique for limited thoracotomy incisions is described below. This technique consists of fixing the intercostal muscles with horizontal mattress sutures. Also the described technique can be applied where the ribs are spread minimally in such limited thoracotomy incisions.     

A tarsal resection procedure for senile entropion with lid retraction.

1. A method of tarso-conjunctival resection for correction of spastic entropion associated with lid retraction has been presented which prevents a) the presence of suture knots against the cornea, b) localized trichiasis, and c) tissue reaction to absorbable sutures. 2. These advantages are achieved through the use of several figure-of-8 silk sutures which are tied on the skin surface. 3. By keeping the apex of the excised triangle of tarsus 2 mm below the lid margin trichiasis may be avoided. 4. Twelve operations have been followed for 1 to 6 years. The retraction and entropion were markedly improved in eleven lids. One under-correction resulted. There were no other complications.     

A new posteriorly based chondrocutaneous flap for the repair of middle third marginal auricular defects

 A new chrondrocutaneous flap raised from the posterior area was used to reconstruct composite marginal ear defects of two patients. In this technique, a posterior rectangular advancement flap with a cartilage strip was advanced into the defectly horizontal. Two weeks later, the pedicle was divided and the flap was tailored. The donor area was covered with a skin graft. This flap provides both ideal skin cover and support for the cartilaginous framework. It can be transferred without delay and can be used in immediate or secondary reconstructions. It is recommended as an alternative method for the reconstruction of the middle third marginal auricular defects. Received: 14 July 1996 / Accepted: 24 March 1997     

Total upper eyelid reconstruction by single staged malar-cheek flap

We report a case of total upper eyelid reconstruction by a new technique after excision of an eyelid tumour. The eyelid was reconstructed by a horizontal, laterally based flap from just under the lower eyelid combined with a chondro-mucosal graft from the nasal septum. Surgical outcome was an excellent aesthetically reconstructed eyelid, which was mobile and properly gliding on the globe to achieve complete eye closure.KEY WORDS: Eyelid tumour, sebaceous carcinoma, upper eyelid reconstruction     

"风筝"皮瓣在眼睑前层缺损修复中的应用

目的探讨“风筝”皮瓣(亦称皮下蒂推进皮瓣)在修复眼睑前层(包括皮肤和眼轮匝肌)缺损的应用。方法于缺损邻接部位沿皮纹方向设计“风筝”皮瓣，按设计线切开皮肤，在眼轮匝肌下剥离形成以眼轮匝肌为皮下蒂的“风筝”皮瓣，推进转移修复皮肤缺损，用70无损伤缝线缝合。自1994年以来已用于14例，年龄15～64岁，缺损最大直径为上睑长度的1／3。结果皮瓣全部成活，切口Ⅰ期愈合，随访时间3个月至1年，眼睑形态满意，切口瘢痕不明显。结论对于眼睑前层范围较大不宜直接缝合，但尚有条件用局部皮瓣修复的中等大的缺损，用“风筝”皮瓣进行修复简单易行，效果可靠。其优点是，皮瓣通过推进转移的方式覆盖创面，没有旋转和变形，转移后局部平整，无“猫耳”等畸形产生，皮瓣蒂部宽广，血运良好，愈合后肤色与四周一致。     

Upper eyelid reconstruction: a short report of an eyelid defect following a thermal burn

While the principles of eyelid reconstruction are well-established, achieving good functional and aesthetic reconstruction remains challenging. This communication presents a technique that we used on a young patient with an eyelid defect following a thermal burn. The patient was operated on to reconstruct the entire upper eyelid using, as a posterior lamella, a mucochondrial autologous graft taken from the ala of the nose as a tarsus and conjunctiva substitutes that were sutured to the Elevator palpebrae superioris aponeurosis and muscle. On the other hand, to reconstruct the anterior lamella, which consists of skin and muscle, the surgeons used a myocutaneous temporal flap taken from the region immediately lateral to the external canthus of the palpebral region, and which, after being isolated following a drawing of the upper eyelid to be reconstructed, was rotated and then sutured to the posterior lamella using the orbicularis oculi muscle as a pedicle.     

A New Technique for Levator Lengthening to Treat Upper Eyelid Retraction: The Orbital Septal Flap

Correction of upper eyelid retraction can be achieved by numerous techniques. We have developed a new flap, the orbital septal flap, to interpose between the recessed levator complex and the tarsus to correct the retracted upper eyelid of a young girl. The orbital septum is a facial structure; it is readily available and easy to dissect. The flap acts like a vascularited spacer without the problem of resorption; normal anatomical continuity of the levator mechanism can be functionally restored. We believe the orbital septal flap is a promising technique for correcting upper eyelid retraction; however, more case studies are needed.     

Tarsal grafting for correction of cicatricial entropion.

A technique of tarsal grafting was used as a simple yet effective procedure for the correction of upper-lid cicatricial entropion. A tarsal graft, 3 to 4 mm in height, excised from the superior tarsus of the donor upper eyelid and placed in a marginal tarsotomy, vertically expands the posterior lamella of the involved lid. This graft also provides a base for suture fixation of the everted lid margin. One case of unilateral cicatricial entropion corrected with a contralateral tarsal graft and one case of bilateral cicatricial entropion corrected by ipsilateral tarsal grafting demonstrate results obtained with this technique. Functional and cosmetically satisfactory results have been achieved with this technique. No recurrence of cicatricial entropion has been noted. With this procedure, tarsus provides excellent graft material for correction of the eyelid deformities associated with cicatricial entropion.     

Linea Alba Closure: Determination of Ideal Distance Between Sutures

An experiment was conducted to determine the optimal distance between sutures in closure of abdominal midline incisions. Human cadaveric fascia was harvested soon after death and stored at—70°C until testing. Suture pullout tests were performed to determine the maximal force applied to the fascia before pullout. Fascia from the opposite side of the same cadaver was used as a control. In a first series of testing, we observed that the pullout force of two sutures dropped linearly as they were brought closer than 12 mm apart. In a second series we observed no increase in pullout force using multiple sutures closer together compared to fewer sutures 15 mm apart. The experiments suggest that the mechanical requirements of closing a midline abdominal incision are met by placing sutures 10–15 mm apart.     

A novel technique for repositioning lower eyelid fat via the transoral approach in association with midface lift

Background  

Orbital fat repositioning in association with subperiosteal midface elevation has been variably described via both the transconjunctival and skin muscle flap approaches. Poor visualization, middle and posterior lamellar cicatricial fibrosis, technical difficulty, and incomplete release are disadvantages commonly ascribed to the transconjunctival approach. Lower eyelid malposition and retraction also are commonly seen in association with skin muscle flap approaches. A simple technique using the intraoral approach to release the orbital septum and postseptal fat is described in this report. This procedure avoids complications associated with the violation of key lower eyelid anatomic structures and markedly improves visualization through an incision allowing a much larger access.     

Muscular Trauma Treated with a Ga-Al-As Diode Laser: In Vivo Experimental Study

The aim of the study was to verify in an experimental model the effects of laser therapy performed with Ga-Al-As diode lasers (780 nm, 2500 mW) on traumatised muscles. Forty adult New Zealand male rabbits were divided into four groups (A, B, C and D) of ten animals each. Each group of animals was further divided into two subgroups of five animals each. The animals were submitted to muscular trauma for 7 min by clamping the posterior muscles of the left thigh under general anaesthesia. Four days later, the rabbits in the B₁, B₂, C₁, C₂, D₁ and D₂ subgroups started daily laser therapy. The parameters utilised were: 150 J/cm² energy density, 3 W, 50 Hz in group B; 250 J/cm², 3 W, 100 Hz in group C; and 800 J/cm², 3 W, 0 Hz (continuous output) in group D. The animals in subgroups A₁ and A₂ were used as untreated controls and allowed to heal spontaneously. In order to prepare samples for histological, histochemical and histomorphometrical studies, dissection of the posterior muscle of the thigh was performed under general anaesthesia and before sacrifice, after five days of laser therapy in the subgroups B₁, C₁ and D₁ and after ten days of laser therapy in subgroups B₂, C₂ and D₂. The samples of untreated subgroups A₁ and A₂ were subjected to the same procedure and at the same times as the corresponding laser-treated groups. The following parameters were analysed on muscular samples: qualitative histological aspect (lactate dehydrogenase (LDH), cytochrome oxidase, acid phosphatase and alkaline phosphatase concentration with histoenzymatic methods) and quantitative histomorphometric evaluation of muscular damage and tissue repair. Blood samples were drawn from each subgroup before the trauma and again before sacrifice to measure the creatine phosphokinase (CK) and LDH levels. The results obtained in the tables are shown. Analysis of the results showed a better qualitative and quantitative healing process in traumatised muscles treated with Ga-Al-As diode laser therapy than in spontaneously healed ones. The results obtained with laser therapy were confirmed as haematic, histoenzymatic and histomorphometric values. According to these results, there is a positive relationship between the biostimulation properties of the laser and the healing of traumatised muscular tissue. Received for publication 15 August 1997; accepted following revision 17 March 1998