aCase 22

by Dr.Chua
 

In the Western countries, upper lid reconstruction is often performed following excision of skin tumours in particular basal cell carcinoma. In our centre, the majority of the upper lid reconstruction is performed for unsatisfactory repair of eyelid trauma. Most of these cases were performed by non-ophthalmologists or ophthalmologists who have insufficient  understanding of the unique features of the eyelid skin. We present two cases who have poor cosmetic and functional results following initial repairs.

Figure 1. Unsatisfactory left ocular appearance.

Figure 2. Cicatricial ectropion of the upper and lower lid

with misalignment of the upper lid margin.

This young man was assaulted with a sword. He sustained a left full thickness eyelid laceration of the upper and lower lids as well as the globe. The eyelid laceration was repaired by a junior ophthalmologist. He later underwent evisceration because of painful blind eye and a prosthetic eye was inserted. The patient was unhappy with his appearance. Examination revealed poor cosmesis with cicatricial ectropion and poor alignment of the upper eyelid margin. The prosthetic eye also appeared too big for his orbit.

a. How can the appearance be improved?

This patient's poor cosmesis resulted from:

a. poor closure of the lid margin and cicatricial ectropion of the upper and lower eyelid from perpendicular pulling of the scar tissues.

b. inappropriate prosthetic eye.

 

The normal contour of the lid margin is restored by realigning the upper lid margin and performing z-plasty to release the pull of the scar tissues (both upper and lower eyelids). The prosthetic eye is replaced with a smaller size prosthesis.

 

Figure 2b. Improved left ocular appearance following z-plasty, realignment of

the upper lid margin and replacement of the prosthetic eye ball.

A 22-year-old female backseat passenger sustained multiple facial cuts from broken windscreen during a road traffic accident. She was admitted to the orthopaedic ward for observation and the left eye was patched without ophthalmic consultation as her vision was normal. She was seen three days later for her facial lacerations. The eyelid was found to be necrotic with glasses embedded in the wound. The wound was debrided and the skin was sutured and shortage of skin was noted (Figure 3). Although the patient was able to close her left eye initially, the contracture of the scar tissues resulted in eyelid retraction and lagophthalmos (Figure 4 and 5).

Figure 3. Appearance of the left eye 4 days after the initial repair.

Figure 4. Appearance of the left eye two months after the initial repair.

Figure 5. Poor eyelid closure due to skin shortage and cicatricial ectropion.

b. How could this have been avoided and how would you manage her problem?

Early repair of the skin would have avoided the problem with skin loss by preventing tissue necrosis and skin shortage. The face has a good vascular supply and skin usually survives despite extensive laceration. 

 

In this patient, early surgery was carried out (at 2 months instead of the recommended 6 months from initial injury) because of lagophthalmos and ocular irritation. Skin graft was used to replace the lost tissue to allow normal eyelid closure. The source of skin graft in order of preference is the upper lid skin, retro-auricular skin (behind the ear) and supraclavicular skin (above the clavicle). In this patient, the retro-auricular skin was used.

 

Steps of the surgery involved:

• making an incision along the scar with the eyelid pulled downward by a 4/0 silk passing through the greyline.

• all subcutaneous tissue is excised.

• a template is made of the skin defect and used to determine the amount of retro-auricular skin required.

• the retro-auricular full thickness skin graft was harvested using a no.15 blade and scissors. The graft is trimmed to removed any subcutaneous fat which may interfere with graft survival

• the graft is sutured to the edge of the skin using a 6/0 vicryl and the graft is immobilized by suturing a stent such as xeroform to its surface using 4/0 silk.

• the stent was removed at one week and the sutures at 2 weeks.

Reference:

1. Surgery of the Eyelid, Orbit, and Lacrimal System : Volume 1 - 3 (American Academy of Ophthalmology Monograph Series) (Paperback).