BLEPHAROPLASTY
(_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.
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
Ectropion is not uncommon, and involves the lower lid only in the great
majority of cases. It may be partial or complete, according to the
extent of cicatricial changes in the skin.
[Illustration: FIG. 89.—DIEFFENBACH METHOD.]
PARTIAL ECTROPION
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
in Fig. 89, _a_.
[Illustration: FIG. 90_a_.—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 is pushed 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 in Fig. 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 in Fig. 90_a_ the 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 in
Fig. 90_b_.
[Illustration: FIG. 90_b_.—CORRECTION OF PARTIAL ECTROPION. (Author’s
case.)]
COMPLETE ECTROPION
=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 in Fig. 92.
In crowding up the detached flap the palpebral border must be
overcorrected, since the contractions following union will reduce the
effect even to the extent of necessitating later minor operations.
[Illustration: 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 in Fig. 94.
[Illustration: 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 in Fig.
95 to 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 in Fig. 96.
[Illustration: 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 in Fig. 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).
[Illustration: 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 in
Fig. 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 in Fig. 100.
[Illustration: 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.
[Illustration: 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 without the 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).
[Illustration: 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.
ECTROPION OF BOTH LIDS
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).
EPICANTHUS
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 in Figs. 106 and 107.
[Illustration: 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 and successfully 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
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 in Fig. 109.
[Illustration: 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.
[Illustration: 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.
PTOSIS
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.
ANKYLOBLEPHARON
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.
WRINKLED EYELIDS
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 in Figs. 112 and 113.
[Illustration: 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 the
superior 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.
[Illustration: 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 morning following 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.
XANTHELASMA PALPEBRARUM
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 may not be a recurrence of the disease at an
indefinite period, when the tissue must again be removed.
_Remarks_
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.