CHAPTER IXBLEPHAROPLASTY(Surgery of the Eyelids)

Plastic operations about the eyelids are necessitated by and for:

I. Direct injury causing the loss of a part, one or both lids.II. Loss of tissue following excision of tumor.III. Loss of tissue, the result of gangrene or ulceration.IV. Injuries due to burn or acid wounds.V. The healing and cicatrization following lupus.VI. The cicatrization following inflammatory lesions of the orbital borders, especially those of the supra-orbital ridge. Since the upper lid lies below the supra-orbital ridge, the above cause is rarely met with.VII. For the removal of redundant tissue.

I. Direct injury causing the loss of a part, one or both lids.

II. Loss of tissue following excision of tumor.

III. Loss of tissue, the result of gangrene or ulceration.

IV. Injuries due to burn or acid wounds.

V. The healing and cicatrization following lupus.

VI. The cicatrization following inflammatory lesions of the orbital borders, especially those of the supra-orbital ridge. Since the upper lid lies below the supra-orbital ridge, the above cause is rarely met with.

VII. For the removal of redundant tissue.

The result of the above causes leads to eversion of the lid (ectropion). There may be cicatricial contraction of the conjunctiva leading to ectropion, however, but its correction is not strictly of a plastic nature and belongs principally to the oculist surgeon, and will therefore not be referred to herein.

Ectropion is not uncommon, and involves the lower lid only in the great majority of cases. It may be partialor complete, according to the extent of cicatricial changes in the skin.

Fig. 89.—Dieffenbach Method.

For the correction of partial ectropion a V-shaped incision is made on the lid with the base of the triangle, including the maximum eversion, as inFig. 89,a.

Fig. 90a.—Correction of Partial Ectropion.(Author’s case.)

The incisions are made downward from the tarsal border, just below the lashes, and converge to a point. The flap included therein is carefully dissected up, dividing all the scar adhesions, and ispushed upward until the tarsal border at the seat of the defect is overcorrected in this position. The incisions are united with No. 1 twisted-silk structures to form the letter Y, as shown inFig. 89,b.

As the lid has usually become elongated from prolonged eversion, a small, triangular piece of skin may be excised at the outer end of the lid, with its base turned upward. In bringing the two sides together in linear form, horizontal traction is made along the tarsal line, which aids much in bringing about the desired result.

In the case shown inFig. 90athe ectropion was the result of the application of nitric acid or caustic potash for the removal of a nevus. It was corrected by the method just described, the result being shown inFig. 90b.

Fig. 90b.—Correction of Partial Ectropion.(Author’s case.)

Dieffenbach Method.—In complete ectropion the entire lid between the canthi is included in the V-shaped incision just mentioned (Fig. 91) and the flap is sutured as shown inFig. 92.

In crowding up the detached flap the palpebral bordermust be overcorrected, since the contractions following union will reduce the effect even to the extent of necessitating later minor operations.

Fig. 91.Fig. 92.Complete Ectropion, Dieffenbach Method.

Fig. 91.Fig. 92.

Complete Ectropion, Dieffenbach Method.

To prevent this contraction the palpebral fissure may be united after the correction is made by fine sutures, which are removed in several weeks (Plessing). This is rather uncomfortable for the patient, but there is no question as to the efficacy of the method. A shield can be worn over the eye operated upon after the incisions have united until the lids are separated. This relieves the discomfort of the patient to some extent, while the constant conscious strain to open the eye is greatly overcome by the mere knowledge of the presence of the shield.

If the position, or the extent of the deformity, does not permit of the Dieffenbach method, the following may be employed:

Wolfe Method.—An incision is made parallel to the tarsal border just below the lashes. The scar tissue is then excised. The palpebral fissure is closed by several sutures, as already described, thus drawing up the everted portion and bringing the lids together and causing a large, open wound (Fig. 93).

After the hemorrhage has been controlled a piece of skin about one third larger than the defect is taken from the arm or temporal region of the patient. Next its reverse side is freed of all adipose tissue. It is then laid upon the freshly made open wound, covering it completely, and held in place by numerous fine silk sutures fixing it along the wound margin, as shown inFig. 94.

Fig. 93.Fig. 94.Wolfe Method.

Fig. 93.Fig. 94.

Wolfe Method.

There is more or less contraction of the flap, although primary union takes place. Less contraction of the flap is obtained in the Wolfe method when the subcutaneous fat is not removed, as mentioned above (Hirschberg).

Thiersch Skin-grafting Method.—To somewhat overcome the contraction of the single-graft operation of Wolfe, the Thiersch skin-grafting method may be resorted to as already described. Better results have been obtained with this method. The graft should be placed parallel to the tarsal border. A number of Reverdin grafts can be taken from the temporal region, just below the hair line, and used to cover the wound. These small grafts must be placed quite close together to obtain the best result (Von Wecker). Immobility of the lid is, of course, necessary, and the temporary fixation of the lid must be accomplished as already described. Contraction in this,as in any other skin-grafting methods, is to be looked for and remedied later by minor plastic operations.

Fricke’s Method.—The best results in blepharoplasty, after the extirpation of tumors, are undoubtedly obtained by Fricke’s method. A flap is obtained from the temporal region, with its base in line with the inferior border of the defect to be covered. The flap must be cut to about twice the size of the bared surface, because of the contraction that follows in healing, and also to permit of covering the defect in its longest diameter when twisted. The flap should be taken from the tissues at the outer angle of the eye and cut in the curved form depicted inFig. 95to overcome its distortion as much as possible in twisting. It is twisted upon its pedicle at an angle of 90° and sutured into the defect, as shown inFig. 96.

Fig. 95.Fig. 96.Fricke Method.

Fig. 95.Fig. 96.

Fricke Method.

The lids are temporarily sewed together, thus stretching the defect fully into which the flap is to be sutured. The pedicle is severed after thorough circulation in the flap has been established.

Owing to the free movement of the skin over the temporal fascia, the wound formed by the incision of the flap can be entirely closed by a single line of interrupted sutures.

Ammon and Von Langenbeck Method.—A very similar method, especially devised for the correction of extensive ectropion of the lower lid, is that in which the pedunculated flap is taken from the latter aspect of the cheek.

A curved incision is made just below the tarsal border, freely loosening the attached conjunctiva in this manner. The cicatricial tissue or other cause of the defect is thoroughly excised and the lids fixed together by suture.

The wound is then fully exposed. A curved incision, as shown inFig. 97, is now made, with its base in line with the superior line of the raw surface. It is carefully dissected up and twisted into position and held by suture (Fig. 98).

Fig. 97.Fig. 98.Ammon-Von Langenbeck Method.

Fig. 97.Fig. 98.

Ammon-Von Langenbeck Method.

The sides of the wound made by the excision of the flap are brought together by an interrupted suture.

The skin of the cheek is liable to contract more readily than that from the temporal region, because it is thicker. Again, it is less suitable for grafting because of its subcutaneous layer of adipose tissue.

Dieffenbach-Serre Method.—Where the defect is too large to be covered with any of the preceding methods, as is often the case following the extirpation of carcinomata, a rhomboid flap can be utilized as shown inFig. 99.

The extirpation incision is made in the form of a V. The faulty tissue or scar is removed, care being exercised to retain as much of the conjunctiva as possible.A rhomboid flap is then taken from the lateral aspect of the cheek and slid over the defect and sutured into place, as shown inFig. 100.

Fig. 99.Fig. 100.Dieffenbach-Serre Method.

Fig. 99.Fig. 100.

Dieffenbach-Serre Method.

The objection to this method is that the extensive contraction following the healing of the wound made by the raising of the flap causes the lid to be drawn outward. This wound is usually allowed to heal by granulation, but it is better to place Thiersch grafts over the area which cannot be closed by suture, either immediately or as soon as a good granulating surface has been obtained and the sutured portions have become healed.

The outer or free margin of the conjunctiva is sutured to the upper free border of the rhomboid flap or enough of the flap should be at first provided by incision to warrant the turning in of its superior or palpebral border after it is slid into place.

In such case, however, it is best to provide mucous-membrane grafts from the lip of the patient to overcome the loss of conjunctiva (Wolfer).

Because of the splendid success obtained with temporal flaps it is better to follow the method of Fricke in the above operation, changing the shape of the flap to suit the form of the defect to be covered.

Tripier Method.—For the restoration of an entire lid the method of Tripier is to be advocated. A bridge flap with both ends attached is taken from the healthy eyelid (Fig. 101). It is obtained by making the curved inferior incision in a line with the superior border of the tarsal cartilage, and the superior incision parallel to the first at a distance depending upon the size of the defect to be covered. The flap thus formed should include some of the fibers of the orbicularis muscles detached from the tarsal cartilage, making it really musculo-cutaneous.

Fig. 101.Fig. 102.Fig. 103.Tripier Method.

Fig. 101.Fig. 102.Fig. 103.

Tripier Method.

This bridge or musculo-cutaneous flap, attached at both ends, is then gently drawn forward with a tenaculum and slid downward over the upper lid upon the defect of the lower lid, and there retained by interrupted silk sutures (Fig. 102), the superior margin of the bridge flap being sutured to the conjunctival fold freed by the previous extirpation of the lower lid.

The retention of the fibers of the orbicularis palpebrarum in the flap covering the defects is intended to take the place of the part of muscle destroyed by the incision of the faulty tissue in the lower lid, and enables the patient to open and close the lid almost as well as in the normal state.

The margins of the wound made by the removal of the flap are snugly brought together and heal withoutthe least discomfort to the patient, inasmuch as the skin covering the lid is quite loose and elastic (Fig. 103).

Von Artha Method.—It sometimes happens that by the extirpation of tumors part of both eyelids has to be removed. To restore such defect the following method may be followed:

Two sickle-shaped flaps are raised from the skin bordering the outer margins of the primary incision, according to Von Artha, and sliding them about so as to reform the canthus of the palpebral fissure (Figs. 104 and 105).

Fig. 104.Fig. 105.Von Artha Method.

Fig. 104.Fig. 105.

Von Artha Method.

This method leaves little if any secondary effect, its immediate success depending upon the preservance of the conjunctiva at the time of extirpation.

As will be seen, the foregoing method only included operations about the lower lid. The majority of these operations are required only for the lower lid; where defects of the upper lid are to be corrected the flaps and incisions mentioned must be made to correspond to the defect, while in the V-Y method the incision must be inverted.

In the case of ectropion of both lids the palpebral tissue may be sutured for a period of several months with certain benefit, if no other operations can be decided upon.Or the method may be combined with any other plastic operation deemed serviceable for its correction. In most defects of the upper lid, however, if they are not too extensive, the loose skin of the lid itself can be utilized by sliding flap methods to cover the defect (Kolle).

This condition, in which a fold of skin stretches across from the inner end of the brow to the side of the nose covering the inner canthus, is met with principally in children. It usually disappears later in life. It may remain, however, owing to nondevelopment of the nasal bridge and is often met with in the colored races.

Bull Method.—This defect may be corrected by the excision of an elliptical piece of skin from the anterior aspect of the bridge of the nose, and sewing the wound together with interrupted fine silk sutures, as shown inFigs. 106 and 107.

Fig. 106.Fig. 107.Bull Method.

Fig. 106.Fig. 107.

Bull Method.

Paraffin Injection.—As the above operation leaves a linear scar on the anterior nasal line, the author has found it much better to correct the defect by building up the nasal bridge, or the entire anterior nasal line by the subcutaneous injection of one of the paraffin compounds, thus overcoming both the epicanthus and the nasal deformity. In fourteen cases, two Japanese and the rest negroes, the author has obtained excellent and permanent results.

The process herein referred to was first suggested in a general way by Gersuny, and has been extensively andsuccessfully utilized in many ways, especially in this country. A special chapter is given to the method elsewhere.

Following the injection of the substance employed there is slight swelling for a few days, which may or may not involve the eyelids. This disappears about the second or third day. The injected material becomes organized in two or three weeks’ time and gives no further trouble to the patient.

If the patient complains of a dull pain or soreness in the area thus operated upon, the application of cold extract of hamamelis is to be applied on little squares of sterilized gauze, which usually relieves the discomfort in a few hours.

Canthoplasty involves the lengthening of the palpebral fissure at the external canthus. The canthus is divided outward to the extent designed with a pair of angular scissors, probe pointed (Fig. 108), and to the extent as shown inFig. 109.

Fig. 108.—Probe-pointed Angular Scissors.

The contiguous ocular conjunctiva is dissected (Fig. 110) up and attached to the newly made skin margin with silk sutures to prevent its reunion, one suture uniting the angle of the wound with the raised tip of conjunctiva (Fig. 111).

The sutures are allowed to remain about five days.Traction with the fingers should be made several times each day to thoroughly separate the wound and to prevent the contraction of the conjunctival triangle, which would offset entirely the object of the operation. As a rule the fine silk sutures heal out of the mucodermal margins owing to the softening of the tissue through the increased lachrymal secretion caused by the irritation of their presence and the resultant reaction following the operation.

Fig. 109.Fig. 110.Fig. 111.External Canthoplasty.

Fig. 109.Fig. 110.Fig. 111.

External Canthoplasty.

A slight regional conjunctivitis usually follows this operation, yielding readily to simple treatment, often requiring no special care but the hygiene of secondary-wound antisepsis.

This is a drooping of the upper eyelid, due to congenital or paralytic causes. It may be unilateral or bilateral.

Apart from internal and proper external electrical and other treatment the simplest surgical method to be employed is to remove an elliptical piece of skin from the eyelid and to suture the margins of the wound together. Care should be taken not to take out too much tissue, as this would involve inability to close the lid.

A condition in which the two lid margins are united by cicatricial adhesion. These should be removed and the margin of the lids be rebuilt by any of the methods suggested if possible. Mucous-membrane flaps are naturally to be preferred.

A common condition after middle life, when not due to other causes than normal changes in the skin and subcutaneous tissue. Edematous pressure due to disease is a common factor.

The wrinkling may be marked or slight.

To correct the condition is to remove the redundant or baggy tissue by excision, as massage in any form accomplishes little if any benefit. The shape of the incision should be made to include the loose tissue and varied somewhat, as shown inFigs. 112 and 113.

Fig. 112.Fig. 113.Blepharoplasties, Author’s Method.

Fig. 112.Fig. 113.

Blepharoplasties, Author’s Method.

The superior line of incision in operations of the lower lid should be made as close to the tarsal line as is practical, so as to show as little of the resulting scar as possible. The best distance is about an eighth of an inch below the tarsal cartilage fold. Accuracy in making thesuperior line of the incision is furthered by outlining the flap to be removed with a very fine bistoury.

In operations about the upper lid a somewhat widened elliptical piece of skin is excised with its inferior margin about one fourth to one half inch above the tarsal line, so as to allow the line of union to lie above it and within the curved fold when the eye is open.

Fig. 114.—Curved Eye Scissors.

For the excision it will be found best to use a fine pair of curved eye scissors, beginning the incision by raising the skin at the outer canthus with a fixation forceps or tenaculum.

Another guide to outline the necessary amount of tissue to be removed is to mark the area, prior to operation, with India ink or an indelible pencil. The parts can then be snipped away readily without fear of causing ectropion. There is usually very little bleeding, and in most cases the tissue is exceedingly thin.

The margins of the wound are brought together with very fine twisted silk, using the continuous suture preferably on account of the ease with which it can be removed.

The wound is then powdered with a suitable antiseptic powder and covered with antiseptic adhesive silk plaster moistened with an antiseptic. The form of the plaster should be of suitable shape, not too wide, and nicked so as to permit of proper application.

There is more or less edema following the operation, associated with or without discoloration, which disappears usually without treatment in forty-eight hours. It is advisable to administer a saline laxative each morningfollowing the operation for several days. Small doses of magnesium sulphate answer the purpose very well.

The sutures are withdrawn in from twenty-four to forty-eight hours after having been carefully softened with warm boric-acid solution, or a ten-per-cent peroxid-of-hydrogen aqueous solution. The early removal of the sutures prevents stitch cicatrices. The part is again powdered as before and covered with the adhesive silk plaster, which answers both purposes of protection and splinting.

The resulting cicatrization is so surprisingly little as to be almost invisible in the great majority of cases. In patients of blond complexion the redness of the scar disappears as early as three weeks, but is more prolonged in persons of darker type. It is not advisable to do both upper and lower eyelids in one operation to avoid the discomfort of the edema which usually follows.

In rare instances there appears a hypertrophy of the scar line, which is best treated with strips of thiosinamin plaster mull, twenty per cent, applied nightly and removed the next morning. If irritation results the plasters should be discontinued for a day or two.

A yellow discoloration of irregular patchlike formation in the skin of the lids, usually about the region of the inner canthus.

The condition may involve both upper and lower lids symmetrically. The patches are generally slightly elevated and vary in size. They make their appearance usually late in life, and are due to the infiltration of the deeper layers of the skin with groups of cells overburdened with fat.

They are best removed by excision, following the method of the preceding operation. There may or maynot be a recurrence of the disease at an indefinite period, when the tissue must again be removed.

All of the above operations in blepharoplasty can be done under local anesthesia, using either the two- or three-per-cent cocain or, preferably, Beta-eucain solutions.

About ten minutes after each operation a sharp stinging sensation is experienced in the eyelid operated upon, which lasts for almost an hour or more, and indicates nothing alarming except the absorption of the anesthetic and a return to the normal state. A sponge dipped into cold sterile water relieves the parts considerably at the time.

It is advisable to inform the patients of this symptom beforehand to avoid unnecessary alarm on their part. Patients are easily frightened when cutting operations around the eye are undertaken, and should be apprised of what is to be done, and what to expect, especially when the operation has been done as a purely cosmetic one.

After the sutures are removed the patient is instructed to allow the plasters to remain until they fall off, which occurs usually in about two days, unless there be reasons for dressings for discharges due to infection, the result of carelessness in operating.

Should at any time, from carelessness or accident, the wound be torn open, the parts need only be brought together with adhesive silk plaster. Healing will go on, giving practically as good a result as with the suture. Bardeleben does not suture these wounds at all, yet the author believes it a safeguard and a psychological necessity in most cosmetic cases.

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