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Reconstruction of both eyelids following traumatic loss
British Journal of Plastic Surgery (/97I), 24, 36x-364
R E C O N S T R U C T I O N OF BOTH EYELIDS FOLLOWING T R A U M A T I C LOSS By DAVIDHaY, M.B., B.S., F.R.C.S.(Ed.), F.R.C.S.(Glas.), M.R.C.S.(Eng.), L.R.C.P. (Lond.). Williamson Diamonds Limited, Mwadui, Tanzania T o lose both upper and lower eyelids yet retain an eye with normal vision and anatomy must be so rare as to be almost unique. Similarly the problems of repair must be nearly unique. No report of a similar case has been found in the literature.
A
5
C
I
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D
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F /
c
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Fxc,. 9, I
Total loss of both lids with an intact eye. A-F. Protection of underlying eye by suturing conjunctival flaps across cornea, and using mid-line forehead flap as cover. G. Substitution of skin graft for flap skin in region of upper lid. H. Division of ~lids' 9 weeks later. FIG. x P l a n o f repair ( r e p r o d u c e d f r o m M u s t a r d e , ]. C., " R e p a i r a n d R e c o n s t r u c t i o n in t h e Orbital R e g i o n " , L i v i n g s t o n e , I966).
Mustarde (I966) has referred to such an injury but has no knowledge of a case and emphasises the difficulties involved in reconstruction. However, he suggests an ingenious practical approach (Fig. I ) ; it was this approach which was used in the case to be described. That his method can succeed has been proved, but as Mustarde points out, 36r
362
BRITISH JOURNAL OF PLASTIC SURGERY
even this method does not provide anything like a perfect cosmetic result. N o n e the less, vision is preserved, ocular movements are full and the eye is safely covered in sleep and can be opened sufficiently to uncover the pupil. By further surgery it is hoped to improve upon the present result. FIG. 2
Fig. 2 . ~ O n a d m i s s i o n : globe intact : b o t h lids avulsed. Fig. 3 . - - A f t e r s u t u r e o f conjtmctival r e m n a n t a n d cover b y forehead flap. Fig. 4 . - - T h e bridge s e g m e n t r e t u r n e d to t h e forehead.
FIG. 3
FIG. 4
Case R e p o r t . - - A young African was set upon by thieves late at night. He was felled to the ground by a rock, and in the ensuing m~16e his money was stolen and one of his assailants succeeded in biting off both upper and lower left eyelids. The assailants and the lids have never been traced. On his arrival at hospital the patient was found to have an intact globe with normal vision. The only remnant of the lid tissue was a segment 3 ram. in length bearing the upper puncture (Fig. 2).
RECONSTRUCTION OF BOTH EYELIDS F O L L O W I N G TRAUMATIC LOSS
363
Under general anmsthesia, wound toilet was carried out. The conjunctiva attached to the globe was freed, turned forward, and brought together in from of the eye with a 6/0 silkworm gut running suture. A hole was left at the inner canthus for drainage. A midline forehead flap was then raised and rotated imo the total lid defect (Fig. 3). Healing was uncomplicated and at two and a half weeks the bridge segment was returned to the forehead (Fig. 4)-
FIG. 5 (A) Present stage---eyelids at rest. (B) Eyelids opened.
The flap was allowed to settle for 8 weeks when the upper half of the flap was excised (without disturbing the conjunctiva) and replaced by a thin post-auricular Wolfe graft which survived completely. The patient returned to work for 8 months and then, about IO months after injury, the new "lids " were separated and the conjunctival fornices deepened and lined by mucous membrane grafts. Satisfactory take and healing resulted in a fairly mobile upper lid and eye (Fig. 5), but despite splinting the grafts for 3 months with a plastic ring, contraction has been marked and it now seems necessary to carry out further grafting. When this is done it is also proposed to shorten the vertical length of the upper lid. COM~fENT T h e initial stage was technically not difficult. However, the final result depended for success upon a soft and mobile upper lid. Replacing the thick upper half of the flap with a relatively supple free graft was an improvement in this respect. T h e final stage of repair involved more than simple separation of the " l i d s " Movement of the upper " l i d ""is dependent upon its levator attachment (and in this instance there was very little of levator substance left at all) and upon the amount of conjunctiva in the fornices. Shortage of conjunctiva also tethers the globe and may prevent safe cover of the cornea in sleep because the eye cannot roll upwards in the normal way. When awake, head movements are necessary to compensate for this reduction in the range of ocular movements. For these reasons it was essential to provide additional tissue by mucous membrane grafts. T h e first grafts have produced a vast improvement in that the globe can now roll freely upwards ; further tissue will be provided at a later stage. Surprisingly there has been no epiphora. T h e stiff flap tissue remaining as the
364
BRITISH JOURNAL OF PLASTIC SURGERY
lower " l i d " is thick and well applied to the globe; it shows no tendency towards ectropion or entropion. It is not intended to provide eyelashes; there is nowhere straight hair in the African and curly hair would, if grafted, inevitably cause trichiasis. Cosmetically the n e w " l i d s " are far less than elegant and must be later improved ; however, binocular vision has been restored to a young man and he is very happy with the result as it stands. AD K N O W L E D G E M E N T S I am most grateful to Mrff. C. Mustardefor his exhaustive long-range advice on management. Dr S. G. Pandit provided excellent anaesthesia at each stage of reconstruction. REFERENCE MOSTAROE,J. C. (1966). " Repair and Reconstruction in the Orbital Region. " Edinburgh : Livingstone.
R E C O N S T R U C T I O N OF BOTH EYELIDS FOLLOWING T R A U M A T I C LOSS By DAVIDHaY, M.B., B.S., F.R.C.S.(Ed.), F.R.C.S.(Glas.), M.R.C.S.(Eng.), L.R.C.P. (Lond.). Williamson Diamonds Limited, Mwadui, Tanzania T o lose both upper and lower eyelids yet retain an eye with normal vision and anatomy must be so rare as to be almost unique. Similarly the problems of repair must be nearly unique. No report of a similar case has been found in the literature.
A
5
C
I
.zO:½ E
D
'. ".'v
F /
c
H /
Fxc,. 9, I
Total loss of both lids with an intact eye. A-F. Protection of underlying eye by suturing conjunctival flaps across cornea, and using mid-line forehead flap as cover. G. Substitution of skin graft for flap skin in region of upper lid. H. Division of ~lids' 9 weeks later. FIG. x P l a n o f repair ( r e p r o d u c e d f r o m M u s t a r d e , ]. C., " R e p a i r a n d R e c o n s t r u c t i o n in t h e Orbital R e g i o n " , L i v i n g s t o n e , I966).
Mustarde (I966) has referred to such an injury but has no knowledge of a case and emphasises the difficulties involved in reconstruction. However, he suggests an ingenious practical approach (Fig. I ) ; it was this approach which was used in the case to be described. That his method can succeed has been proved, but as Mustarde points out, 36r
362
BRITISH JOURNAL OF PLASTIC SURGERY
even this method does not provide anything like a perfect cosmetic result. N o n e the less, vision is preserved, ocular movements are full and the eye is safely covered in sleep and can be opened sufficiently to uncover the pupil. By further surgery it is hoped to improve upon the present result. FIG. 2
Fig. 2 . ~ O n a d m i s s i o n : globe intact : b o t h lids avulsed. Fig. 3 . - - A f t e r s u t u r e o f conjtmctival r e m n a n t a n d cover b y forehead flap. Fig. 4 . - - T h e bridge s e g m e n t r e t u r n e d to t h e forehead.
FIG. 3
FIG. 4
Case R e p o r t . - - A young African was set upon by thieves late at night. He was felled to the ground by a rock, and in the ensuing m~16e his money was stolen and one of his assailants succeeded in biting off both upper and lower left eyelids. The assailants and the lids have never been traced. On his arrival at hospital the patient was found to have an intact globe with normal vision. The only remnant of the lid tissue was a segment 3 ram. in length bearing the upper puncture (Fig. 2).
RECONSTRUCTION OF BOTH EYELIDS F O L L O W I N G TRAUMATIC LOSS
363
Under general anmsthesia, wound toilet was carried out. The conjunctiva attached to the globe was freed, turned forward, and brought together in from of the eye with a 6/0 silkworm gut running suture. A hole was left at the inner canthus for drainage. A midline forehead flap was then raised and rotated imo the total lid defect (Fig. 3). Healing was uncomplicated and at two and a half weeks the bridge segment was returned to the forehead (Fig. 4)-
FIG. 5 (A) Present stage---eyelids at rest. (B) Eyelids opened.
The flap was allowed to settle for 8 weeks when the upper half of the flap was excised (without disturbing the conjunctiva) and replaced by a thin post-auricular Wolfe graft which survived completely. The patient returned to work for 8 months and then, about IO months after injury, the new "lids " were separated and the conjunctival fornices deepened and lined by mucous membrane grafts. Satisfactory take and healing resulted in a fairly mobile upper lid and eye (Fig. 5), but despite splinting the grafts for 3 months with a plastic ring, contraction has been marked and it now seems necessary to carry out further grafting. When this is done it is also proposed to shorten the vertical length of the upper lid. COM~fENT T h e initial stage was technically not difficult. However, the final result depended for success upon a soft and mobile upper lid. Replacing the thick upper half of the flap with a relatively supple free graft was an improvement in this respect. T h e final stage of repair involved more than simple separation of the " l i d s " Movement of the upper " l i d ""is dependent upon its levator attachment (and in this instance there was very little of levator substance left at all) and upon the amount of conjunctiva in the fornices. Shortage of conjunctiva also tethers the globe and may prevent safe cover of the cornea in sleep because the eye cannot roll upwards in the normal way. When awake, head movements are necessary to compensate for this reduction in the range of ocular movements. For these reasons it was essential to provide additional tissue by mucous membrane grafts. T h e first grafts have produced a vast improvement in that the globe can now roll freely upwards ; further tissue will be provided at a later stage. Surprisingly there has been no epiphora. T h e stiff flap tissue remaining as the
364
BRITISH JOURNAL OF PLASTIC SURGERY
lower " l i d " is thick and well applied to the globe; it shows no tendency towards ectropion or entropion. It is not intended to provide eyelashes; there is nowhere straight hair in the African and curly hair would, if grafted, inevitably cause trichiasis. Cosmetically the n e w " l i d s " are far less than elegant and must be later improved ; however, binocular vision has been restored to a young man and he is very happy with the result as it stands. AD K N O W L E D G E M E N T S I am most grateful to Mrff. C. Mustardefor his exhaustive long-range advice on management. Dr S. G. Pandit provided excellent anaesthesia at each stage of reconstruction. REFERENCE MOSTAROE,J. C. (1966). " Repair and Reconstruction in the Orbital Region. " Edinburgh : Livingstone.