- Email: [email protected]
Management of cicatricial entropion of the upper lid using acellular human dermal allograft
Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, 610e614
Management of cicatricial entropion of the upper lid using acellular human dermal allograft J. Chen, Z. Wang, J. Gu* State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, PR China Received 29 May 2006; accepted 15 June 2007
KEYWORDS Cicartricial entropion; Lid margin; Acellular dermis
Summary Cicatricial entropion with trichiasis can be a challenging problem to manage. This condition is caused by scarring of the tarsus and the inward rotation or the defect of the lid margin. A variety of biological materials have been used to reconstruct the disfigured lid margin. Tarsal wedge resection and modified grey line splitting with acellular human dermal allograft insertion by 10/0 nylon sutures passing through the eyelid margin allow for correction of the cicatricial entropion while providing a reconstructed lid margin. This technique produces satisfying cosmetic and functional results when used to treat mild to moderate cicatricial entropion with lid margin distortion. ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Severe eye burns often cause upper and lower eyelid entropion with metaplasia of the tarsal conjunctiva, trichiasis, and the irregularity of the lid margin by the tarsal scars. Malposition of the eyelids with trichiasis induces persistent corneal epithelial defect, ulceration and vascularisation of the graft. The unhealthy environment frequently leads to failure of keratoplasty. We report the results of 17 patients with cicatricial entropion treated successfully with anterior tarsal wedge resection and acellular dermis insertion in the split lid margin. The surgical technique is described.
Patients and methods Since 2003, 21 eyelids of 17 patients have been operated on. This group included 12 males and five females, aged 12e46 years (mean 24 years). Eleven eyes had chemical burns. The series also included one case of firecracker injury and five cases of melting metal accident. All patients had a minimum follow-up of 6 months at the time of the analysis of the data (Table 1). Before surgery, written informed consent to the procedure was obtained from each patient. All surgical procedures were carried out by same senior surgeon (JC).
Surgical technique * Corresponding author. Address: 54 Xianlienan Road, Guangzhou 510060, PR China. Tel.: þ86 20 87331540; fax: þ86 20 87331550. E-mail address: [email protected] (J. Gu).
Local anaesthesia is provided by infiltration of 2 ml of 2% lidocaine into the neuromuscular plane of the upper eyelid. A No.15 BardeParker scalpel blade is used to make a horizontal
1748-6815/$ - see front matter ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.06.010
Management of cicatricial entropion of the upper lid using acellular human dermal allograft Table 1
611
Summary of patient data for 17 patients, (21 eyelids)
Patient No./ Age,y/Sex
Side
1/12/F 2/37/M 2/37/M 3/46/M 4/21/M 5/19/F 5/19/F 6/31/M 7/24/M 8/29/F 9/27/M 10/21/M 11/19/M 12/25/F 13/27/M 14/19/M 15/21/M 15/21/M
L L R R L L R L R R L L R L L L R L
16/17/M
Diagnosis
Duration, (months)
Pre-op. VA
Firecracker Chemical burns Chemical burns Thermal injury Chemical burns Thermal injury Thermal injury Thermal injury Chemical burns Chemical burns Chemical burns Thermal injury Chemical burns Chemical burns Thermal injury Chemical burns Chemical burns Chemical burns
7 11 11 14 6 13 13 5 12 6 5 4 10 8 9 10 4 4
R
Chemical burns
17/14/F
R
17/14/F
L
Location of entropion Nasal
Middle
Lateral
Follow-up, (months)
6/24 6/60 6/12 6/9 3/60 6/60 CF 6/12 3/60 6/24 6/9 6/36 6/12 6/24 CF 6/36 6/12 CF
þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ
þ þ þ þ þ þ þ þ þ þ þ þ þ
þ þ þ þ þ þ þ
9 12 12 19 14 18 18 6 6 21 29 11 8 7 6 12 7 7
3
6/24
þ
þ
12
Chemical burns
3
6/36
þ
þ
6
Chemical burns
3
CF
þ
þ
þ
6
Reason for failure d d d d d d d d d d d d d d d d d Entropion recurred in all zones Entropion recurred nasally Entropion recurred nasally Entropion recurred in all zones
VA, visual acuity.
incision paralleling the lid margin made anteriorly through the full thickness of skin 5 mm proximal to the lid margin. The incision should extend several millimeters medially and laterally beyond the area of entropion. Wescott scissors are used to make a sharp dissection to release any scarring between anterior and posterior lamellae and to allow exposure of the tarsus. Anterior tarsal wedge resection is created by making two horizontal tarsal incisions inclined towards each other using a surgical blade. Closure of the tarsal groove with interrupted 6/0 polypropylene sutures rotated the eyelid margin outward. The skin-muscle incision is closed with an interrupted suture of 5/0 black silk. The upper lid is split just posterior to the lashes or the keratinised epithelium. This is usually at the posterior edge
of the lid. The skin flap containing the lashes is reflected forward with a traction suture, and dissection is made anterior to the tarsus for about 3e4 mm. All of the follicles of the metaplastic lashes are removed using fine tip forceps. With the help of a No.15 blade, a strip of wedgeshaped acellular dermis (ReDerm, Jieya Company, PR China) is created with the basement membrane as its base. After rehydration for 10 min in a balanced salt solution, the graft with its base 1 mm wide facing downward and paralleling to lid margin is then fixed in the split lid with a running 10/0 nylon suture by passing both anterior and posterior marginal segment of the upper lid (Fig. 1). A suture elevating the lower lid is used for 24 h to hold the lower lid firmly against the upper lid margin, which also helps rotate the lashes outward. An eye patch is placed for 24 h, and the patient is treated with tobramycin ointment for 1 week after surgery.
Result
Figure 1 The technique in cross-section and frontal view. The acellular dermis implanted (black arrow).
Seventeen eyelids of 17 patients (80.9%) were successfully treated, with no signs of recurrence or residual symptoms. However, four eyelids did eventually require second surgery. Recurrence resulted from tissue proliferation and subsequent scarring in two eyelids. These eyelids in which entropion recurred nasally yielded successful results with repeat surgery. The cumulative success rate was determined to be 90.5%. Two other eyelids showed recurrence of
612
J. Chen et al. granuloma formation and infection. The patients felt little swelling of the operated eyelid. About 1 week after surgery, neovascularisation and epithelialisation could be seen on the surface of the acellular dermis (Fig. 2). The acellular dermis fitted the contour of the eyelid margin well and no graft sloughing was observed.
Case reports Case one
Figure 2 Neovascularisation and epithelialisation of the graft (black arrow) 1 week after surgery.
entropion due to progressive shrinkage of the tarsus. A mucous membrane graft was inserted to enlarge and stabilise the posterior lamella. No complications were reported in the treated areas, including lid deformity,
Figure 3 Case 1: (a) contact of the corneal graft and lashes in medial upper lid before surgery; (b) the irregularity of the lid margin in this area.
A 12-year-old girl was injured by a firecraker in the left eye, with manifestation of keratoleukoma and medial upper lid entropion. She underwent lamellar keratoplasty and tarsotomy for the keratoleukoma and upper lid entropion simultaneously. Four months after surgery, the girl was referred to us with recurrence of upper lid entropion and the impairment of the medial upper lid margin (Fig. 3a,b). The parents were concerned about the eye irritation and photophobia of their child. She was treated with anterior tarsal v-wedge resection and acellular dermis insertion in the upper lid margin medially. The medial upper lid margin restored after surgery, with no contact of lashes and the globe. The results remained stable 9 months after surgery (Fig. 4a,b).
Figure 4 Case 1: (a) the cicatricial entropion resolved 9 months after surgery; (b) formation of a new lid margin.
Management of cicatricial entropion of the upper lid using acellular human dermal allograft
Figure 5 Case 2: (a) the patient’s right eye 12 months after an alkali burn with cicatricial entropion; (b) the disfiguration of the inner upper lid margin.
Case two A 24-year-old man was seen in the clinic with a history of alkaline assault on his face. He had undergone lamellar keratoplasty of the right eye 8 months previously. However, the inflammation of the upper lid continued and the inner upper lid margin disfigured (Fig. 5a,b). Treatment consisted of surgery of the upper lid using the same technique and topical corticosteroids. The right eye had a smooth ocular surface 6 months after surgery, and the vision improved from 3/60 to 6/60. The patient was satisfied with the disappearance of persistent irritation and photophobia (Fig. 6a,b).
Case three A 27-year-old man was injured in an accident that involved melted aluminum in the left eye. He developed pterygium, trichiasis and upper lid margin defect (Fig. 7) after the thermal burns. A lid splitting with acelluar dermis insertion alone resolved the trichiasis (Fig. 8). The lid margin healing was uneventful. The next procedure was a lamellar keratoplasty with the excision of the pterygium to enhance visual acuity.
Figure 6
613
Case 2: (a and b) right eye 6 months after surgery.
Discussion Shortening of the posterior lamella may cause cicatricial entropion, which pulls the lashes against the eyeball. Patients with trichiasis often pluck the lashes, breaking many and leaving stubs that do more corneal damage and may result in corneal ulceration and scarring. Method of surgical repair includes posterior lamellar grafts, anterior rotation of the lid margin, or lid margin splitting procedures. In severe eye burns, subconjunctival tissue proliferation can last for several months. The tarsotomy applied in case one may exacerbate the inflammation and leads to the recurrence of the entropion. The advantage of anterior tarsal wedge resection is that the conjunctiva is not incised or sutured. However, the impairment of the lid rim could not be resolved by this procedure alone. To ensure adequate realignment in cicatricial disease, the grey line often needs to be split because the lid margin structures are tightly bound.1 We believe that remaining scars in the lid margin perpetuate chronic inflammation and spoil every attempt at corneal transplantation. It was suggested that eyelid-splitting procedures alone might carry the risk of postoperative deformity of the eyelid margin.2 Therefore, lid margin-splitting procedures involve placement of a spacer such as mucous membrane, tarsus,3 or collagen
614
J. Chen et al.
Figure 7 Case 3: 27-year-old man with an upper lid margin defect (black arrow) and misdirected eyelashes rubbing against the globe before surgery.
Figure 8 Case 3: 3 months after surgery, the patient had normal eyelashes and upper lid margin.
film.4 The concept of our procedure is to reconstruct a new lid margin by inserting a strip of acellular dermis. Acellular dermis has been reported for a variety of applications in ophthalmic facial plastic surgery.5 The acellular dermis (ReDerm, Jieya Company, PR China) we selected has been approved by State Food and Drug Administration of China. All cases showed diminished inflammatory reaction after surgery. The characteristic of diminished cells in acellular dermis played an important role in the relief of immunological and inflammtory reaction. Another reason may be the existence of the intact dermal collagen in the acellular dermis to inhibit the wound contraction as Brown et al.6 have shown. The basement membrane of the graft facilitates the epithelisation on the lid margin. If mucuous membrane is used, additional oral incision with increased discomfort to the patient is required. We also found that patients with an ongoing underlying cicatricial process, such as unsubdued inflammation or chronic use of glaucoma medications, had a lower success rate. In patients with severe eye burns, it is difficult to determine the best time for the operation. The degree of scarring is a function of the balance between the activity of the matrix metalloproteinases and their tissue inhibitors, which itself depends on the amount of extracellular matrix present at the injury site.7 In four eyes, entropion recurred because of subconjunctival tissue proliferation and progressive shrinkage of the tarsus. In these eyelids, surgery was carried out at an early stage of the burn. We would recommend lid surgery in later stages to allow inflammation to regress.
With the help of high magnification of the operating microscope, the precise fixation of the graft by 10/0 nylon suture leads to a regular lid margin, with satisfying cosmesis. The use of a surgical microscope is also essential for detecting and adequately removing all of the follicles of the metaplastic eyelashes. Although the small sample size limits the ability to make definitive interpretations, this procedure seems to be a promising method in treating cicatricial entropion with disorders of the lid margin.
References 1. Kemp EG, Collin JR. Surgical management of upper lid entropion. Br J Ophthalmol 1986;70:575e9. 2. Steinkogler FJ. Treatment of upper eyelid entropion. Lid split surgery and fibrin sealing of free skin transplants. Ophthal Plast Reconstr Surg 1986;2:183e7. 3. Amdur J. Surgical treatment of temporal entropion of the upper eyelid. Arch Ophthalmol 1963;70:387e8. 4. Dortzbach RK, Callahan A. Repair of cicatricial entropion of upper eyelid. Arch Ophthalmol 1971;85:82e9. 5. Rubin PA, Fay AM, Remulla HD, et al. Ophthalmic plastic applications of acellular dermal allografts. Ophthalmology 1999; 106:2091e7. 6. Brown D, Garner W, Young VL. Skin grafting: dermal components in inhibition of wound contraction. South Med J 1990;83: 789e95. 7. Hani G, Faraj, Hoang-Xuan Thanh. Chronic cicatrizing conjunctivitis. Current Opinion in Ophthalmology 2001;12:250e7.
Management of cicatricial entropion of the upper lid using acellular human dermal allograft J. Chen, Z. Wang, J. Gu* State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, PR China Received 29 May 2006; accepted 15 June 2007
KEYWORDS Cicartricial entropion; Lid margin; Acellular dermis
Summary Cicatricial entropion with trichiasis can be a challenging problem to manage. This condition is caused by scarring of the tarsus and the inward rotation or the defect of the lid margin. A variety of biological materials have been used to reconstruct the disfigured lid margin. Tarsal wedge resection and modified grey line splitting with acellular human dermal allograft insertion by 10/0 nylon sutures passing through the eyelid margin allow for correction of the cicatricial entropion while providing a reconstructed lid margin. This technique produces satisfying cosmetic and functional results when used to treat mild to moderate cicatricial entropion with lid margin distortion. ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Severe eye burns often cause upper and lower eyelid entropion with metaplasia of the tarsal conjunctiva, trichiasis, and the irregularity of the lid margin by the tarsal scars. Malposition of the eyelids with trichiasis induces persistent corneal epithelial defect, ulceration and vascularisation of the graft. The unhealthy environment frequently leads to failure of keratoplasty. We report the results of 17 patients with cicatricial entropion treated successfully with anterior tarsal wedge resection and acellular dermis insertion in the split lid margin. The surgical technique is described.
Patients and methods Since 2003, 21 eyelids of 17 patients have been operated on. This group included 12 males and five females, aged 12e46 years (mean 24 years). Eleven eyes had chemical burns. The series also included one case of firecracker injury and five cases of melting metal accident. All patients had a minimum follow-up of 6 months at the time of the analysis of the data (Table 1). Before surgery, written informed consent to the procedure was obtained from each patient. All surgical procedures were carried out by same senior surgeon (JC).
Surgical technique * Corresponding author. Address: 54 Xianlienan Road, Guangzhou 510060, PR China. Tel.: þ86 20 87331540; fax: þ86 20 87331550. E-mail address: [email protected] (J. Gu).
Local anaesthesia is provided by infiltration of 2 ml of 2% lidocaine into the neuromuscular plane of the upper eyelid. A No.15 BardeParker scalpel blade is used to make a horizontal
1748-6815/$ - see front matter ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.06.010
Management of cicatricial entropion of the upper lid using acellular human dermal allograft Table 1
611
Summary of patient data for 17 patients, (21 eyelids)
Patient No./ Age,y/Sex
Side
1/12/F 2/37/M 2/37/M 3/46/M 4/21/M 5/19/F 5/19/F 6/31/M 7/24/M 8/29/F 9/27/M 10/21/M 11/19/M 12/25/F 13/27/M 14/19/M 15/21/M 15/21/M
L L R R L L R L R R L L R L L L R L
16/17/M
Diagnosis
Duration, (months)
Pre-op. VA
Firecracker Chemical burns Chemical burns Thermal injury Chemical burns Thermal injury Thermal injury Thermal injury Chemical burns Chemical burns Chemical burns Thermal injury Chemical burns Chemical burns Thermal injury Chemical burns Chemical burns Chemical burns
7 11 11 14 6 13 13 5 12 6 5 4 10 8 9 10 4 4
R
Chemical burns
17/14/F
R
17/14/F
L
Location of entropion Nasal
Middle
Lateral
Follow-up, (months)
6/24 6/60 6/12 6/9 3/60 6/60 CF 6/12 3/60 6/24 6/9 6/36 6/12 6/24 CF 6/36 6/12 CF
þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ
þ þ þ þ þ þ þ þ þ þ þ þ þ
þ þ þ þ þ þ þ
9 12 12 19 14 18 18 6 6 21 29 11 8 7 6 12 7 7
3
6/24
þ
þ
12
Chemical burns
3
6/36
þ
þ
6
Chemical burns
3
CF
þ
þ
þ
6
Reason for failure d d d d d d d d d d d d d d d d d Entropion recurred in all zones Entropion recurred nasally Entropion recurred nasally Entropion recurred in all zones
VA, visual acuity.
incision paralleling the lid margin made anteriorly through the full thickness of skin 5 mm proximal to the lid margin. The incision should extend several millimeters medially and laterally beyond the area of entropion. Wescott scissors are used to make a sharp dissection to release any scarring between anterior and posterior lamellae and to allow exposure of the tarsus. Anterior tarsal wedge resection is created by making two horizontal tarsal incisions inclined towards each other using a surgical blade. Closure of the tarsal groove with interrupted 6/0 polypropylene sutures rotated the eyelid margin outward. The skin-muscle incision is closed with an interrupted suture of 5/0 black silk. The upper lid is split just posterior to the lashes or the keratinised epithelium. This is usually at the posterior edge
of the lid. The skin flap containing the lashes is reflected forward with a traction suture, and dissection is made anterior to the tarsus for about 3e4 mm. All of the follicles of the metaplastic lashes are removed using fine tip forceps. With the help of a No.15 blade, a strip of wedgeshaped acellular dermis (ReDerm, Jieya Company, PR China) is created with the basement membrane as its base. After rehydration for 10 min in a balanced salt solution, the graft with its base 1 mm wide facing downward and paralleling to lid margin is then fixed in the split lid with a running 10/0 nylon suture by passing both anterior and posterior marginal segment of the upper lid (Fig. 1). A suture elevating the lower lid is used for 24 h to hold the lower lid firmly against the upper lid margin, which also helps rotate the lashes outward. An eye patch is placed for 24 h, and the patient is treated with tobramycin ointment for 1 week after surgery.
Result
Figure 1 The technique in cross-section and frontal view. The acellular dermis implanted (black arrow).
Seventeen eyelids of 17 patients (80.9%) were successfully treated, with no signs of recurrence or residual symptoms. However, four eyelids did eventually require second surgery. Recurrence resulted from tissue proliferation and subsequent scarring in two eyelids. These eyelids in which entropion recurred nasally yielded successful results with repeat surgery. The cumulative success rate was determined to be 90.5%. Two other eyelids showed recurrence of
612
J. Chen et al. granuloma formation and infection. The patients felt little swelling of the operated eyelid. About 1 week after surgery, neovascularisation and epithelialisation could be seen on the surface of the acellular dermis (Fig. 2). The acellular dermis fitted the contour of the eyelid margin well and no graft sloughing was observed.
Case reports Case one
Figure 2 Neovascularisation and epithelialisation of the graft (black arrow) 1 week after surgery.
entropion due to progressive shrinkage of the tarsus. A mucous membrane graft was inserted to enlarge and stabilise the posterior lamella. No complications were reported in the treated areas, including lid deformity,
Figure 3 Case 1: (a) contact of the corneal graft and lashes in medial upper lid before surgery; (b) the irregularity of the lid margin in this area.
A 12-year-old girl was injured by a firecraker in the left eye, with manifestation of keratoleukoma and medial upper lid entropion. She underwent lamellar keratoplasty and tarsotomy for the keratoleukoma and upper lid entropion simultaneously. Four months after surgery, the girl was referred to us with recurrence of upper lid entropion and the impairment of the medial upper lid margin (Fig. 3a,b). The parents were concerned about the eye irritation and photophobia of their child. She was treated with anterior tarsal v-wedge resection and acellular dermis insertion in the upper lid margin medially. The medial upper lid margin restored after surgery, with no contact of lashes and the globe. The results remained stable 9 months after surgery (Fig. 4a,b).
Figure 4 Case 1: (a) the cicatricial entropion resolved 9 months after surgery; (b) formation of a new lid margin.
Management of cicatricial entropion of the upper lid using acellular human dermal allograft
Figure 5 Case 2: (a) the patient’s right eye 12 months after an alkali burn with cicatricial entropion; (b) the disfiguration of the inner upper lid margin.
Case two A 24-year-old man was seen in the clinic with a history of alkaline assault on his face. He had undergone lamellar keratoplasty of the right eye 8 months previously. However, the inflammation of the upper lid continued and the inner upper lid margin disfigured (Fig. 5a,b). Treatment consisted of surgery of the upper lid using the same technique and topical corticosteroids. The right eye had a smooth ocular surface 6 months after surgery, and the vision improved from 3/60 to 6/60. The patient was satisfied with the disappearance of persistent irritation and photophobia (Fig. 6a,b).
Case three A 27-year-old man was injured in an accident that involved melted aluminum in the left eye. He developed pterygium, trichiasis and upper lid margin defect (Fig. 7) after the thermal burns. A lid splitting with acelluar dermis insertion alone resolved the trichiasis (Fig. 8). The lid margin healing was uneventful. The next procedure was a lamellar keratoplasty with the excision of the pterygium to enhance visual acuity.
Figure 6
613
Case 2: (a and b) right eye 6 months after surgery.
Discussion Shortening of the posterior lamella may cause cicatricial entropion, which pulls the lashes against the eyeball. Patients with trichiasis often pluck the lashes, breaking many and leaving stubs that do more corneal damage and may result in corneal ulceration and scarring. Method of surgical repair includes posterior lamellar grafts, anterior rotation of the lid margin, or lid margin splitting procedures. In severe eye burns, subconjunctival tissue proliferation can last for several months. The tarsotomy applied in case one may exacerbate the inflammation and leads to the recurrence of the entropion. The advantage of anterior tarsal wedge resection is that the conjunctiva is not incised or sutured. However, the impairment of the lid rim could not be resolved by this procedure alone. To ensure adequate realignment in cicatricial disease, the grey line often needs to be split because the lid margin structures are tightly bound.1 We believe that remaining scars in the lid margin perpetuate chronic inflammation and spoil every attempt at corneal transplantation. It was suggested that eyelid-splitting procedures alone might carry the risk of postoperative deformity of the eyelid margin.2 Therefore, lid margin-splitting procedures involve placement of a spacer such as mucous membrane, tarsus,3 or collagen
614
J. Chen et al.
Figure 7 Case 3: 27-year-old man with an upper lid margin defect (black arrow) and misdirected eyelashes rubbing against the globe before surgery.
Figure 8 Case 3: 3 months after surgery, the patient had normal eyelashes and upper lid margin.
film.4 The concept of our procedure is to reconstruct a new lid margin by inserting a strip of acellular dermis. Acellular dermis has been reported for a variety of applications in ophthalmic facial plastic surgery.5 The acellular dermis (ReDerm, Jieya Company, PR China) we selected has been approved by State Food and Drug Administration of China. All cases showed diminished inflammatory reaction after surgery. The characteristic of diminished cells in acellular dermis played an important role in the relief of immunological and inflammtory reaction. Another reason may be the existence of the intact dermal collagen in the acellular dermis to inhibit the wound contraction as Brown et al.6 have shown. The basement membrane of the graft facilitates the epithelisation on the lid margin. If mucuous membrane is used, additional oral incision with increased discomfort to the patient is required. We also found that patients with an ongoing underlying cicatricial process, such as unsubdued inflammation or chronic use of glaucoma medications, had a lower success rate. In patients with severe eye burns, it is difficult to determine the best time for the operation. The degree of scarring is a function of the balance between the activity of the matrix metalloproteinases and their tissue inhibitors, which itself depends on the amount of extracellular matrix present at the injury site.7 In four eyes, entropion recurred because of subconjunctival tissue proliferation and progressive shrinkage of the tarsus. In these eyelids, surgery was carried out at an early stage of the burn. We would recommend lid surgery in later stages to allow inflammation to regress.
With the help of high magnification of the operating microscope, the precise fixation of the graft by 10/0 nylon suture leads to a regular lid margin, with satisfying cosmesis. The use of a surgical microscope is also essential for detecting and adequately removing all of the follicles of the metaplastic eyelashes. Although the small sample size limits the ability to make definitive interpretations, this procedure seems to be a promising method in treating cicatricial entropion with disorders of the lid margin.
References 1. Kemp EG, Collin JR. Surgical management of upper lid entropion. Br J Ophthalmol 1986;70:575e9. 2. Steinkogler FJ. Treatment of upper eyelid entropion. Lid split surgery and fibrin sealing of free skin transplants. Ophthal Plast Reconstr Surg 1986;2:183e7. 3. Amdur J. Surgical treatment of temporal entropion of the upper eyelid. Arch Ophthalmol 1963;70:387e8. 4. Dortzbach RK, Callahan A. Repair of cicatricial entropion of upper eyelid. Arch Ophthalmol 1971;85:82e9. 5. Rubin PA, Fay AM, Remulla HD, et al. Ophthalmic plastic applications of acellular dermal allografts. Ophthalmology 1999; 106:2091e7. 6. Brown D, Garner W, Young VL. Skin grafting: dermal components in inhibition of wound contraction. South Med J 1990;83: 789e95. 7. Hani G, Faraj, Hoang-Xuan Thanh. Chronic cicatrizing conjunctivitis. Current Opinion in Ophthalmology 2001;12:250e7.