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“Somersault” transfer of a complete upper eyelid: A new technique
"SOMERSAULT " T R A N S F E R A NEW
OF A COMPLETE TECHNIQUE
UPPER
EYELID :
By C. BALAKRISHNAN,F.R.C.S.
Professor of Plastic Surgery, Medical College, Nagpur, India FULL-THICKNESSlOSS of even a large portion of the lower eyelid may not produce exposure damage of the eye if the upper lid is normal. Protection is given by increased downward excursion of the upper lid, assisted by a rolling movement upwards of the eyeball. In loss of the upper lid, however, the eye has no protection, and may soon be lost from exposure damage of the cornea. It is essential to repair upper-lid loss promptly if the eye is to be saved. Full-thickness loss up to one-third of the lid area can be repaired by local adjustments. Larger losses offer tough problems in reconstruction, the main difficulty being the provision of a lining which is tolerated by the cornea. Skin moving over the cornea is unthinkable, and free grafts of mucous membrane have not been satisfactory in practice. Hughes (I947), reversing a procedure which he first described in 1937, split the lower eyelid and brought its lining, stiffened by part of the tarsal plate, as a sliding flap into an upper-lid defect. Skin was moved into the defect for cover, and the temporarily united lids separated later through the line of the required lid border. In such cases the donor lid and its conjunctival fornix are heavily depleted, and the extent to which lid lining can be so transferred is strictly limited. To quote Stallard (I958), " complete closure of the lids is not always possible, but the cornea is adequately protected in those patients whose eyes turn up and laterally during sleep." In short, there is no completely satisfactory method of making good a large full-thickness loss of the upper lid with preservation of all eye and lid functions except by borrowing the upper lid of the opposite eye, if it could be spared. In the case here reported, a good eye was saved after excision of its upper lid by transferring to it the complete upper lid of the opposite eye which happened t o be blind. So far as I know, this particular piece of surgical opportunism has not been reported before, though exchange grafting of the corne~c for salvaging vision is well known. CASE REPORT D. S. was a 5o-year-old farmer from a village in hilly jungle country, 7o miles north of Nagpur. He had a blind left eye from childhood. In I953 a nodule appeared on the skin of the right upper eyelid and grew slowly. By I957 it became so bulky that he could see only by lifting the lid up with a finger. Then the growth ulcerated and he was admitted to the ophthalmic unit of our hospital. As a problem case he was transferred to the plastic unit on I7th September x957 (Figs. I and 2). There was then a tumour measuring 4 by 3 by I'5 crn. occupying most of the right upper lid and just encroaching on the outer canthus. The central portion had ulcerated, forming a deep crater. One surviving bridge of skin across the middle of the crater suggested recent excavation. The main bulk of the tumour was superficial to the tarsal plate. Some nodules had appeared on the conjunctival aspect near the lid border, but this portion was jutting well forwards clear of the eyeball. The cornea was normal, and vision was good when the lid was lifted out of the way. The conjunctiva was inflamed. A small, firm, mobile, slightly tender right pre-auricular gland was present. The right lower lid was normal. There was no perception of light by the left eye. The globe was shrunken with a rough white and insensitive cornea. The eyelids were normal. 72
" SOMERSAULT ~
TRANSFER
OF
A
COMPLETE
UPPER
EYELID
73
It was considered possible to remove the tumour preserving the right eye with its useful vision. A plan was worked out for transferring the complete left upper eyelid on a pedicle to replace the excised right upper lid immediately after the excision. The transfer was to be effected by a full-circle somersault of the lid carried on a pedicle across the bridge of the nose based on the right angular vein and its companion artery. On i8th September 1957 the flap was delayed. It was 2 cm. in width. The upper incision starting on the right side of the bridge of the nose, passed just below the line of the left eyebrow and dropped to the outer canthus. The lower incision starting at a point 2 cm. lower on the right side of the nose, passed straight to the left inner canthus. The left upper lid was detached at the canthi and along the upper conjunctival fornix.
FIG. i
FIG. 2
Figs. i and 2 . - - L a r g e c a r c i n o m a of the r i g h t u p p e r eyelid. T h e r i g h t eye is still good. T h e left eye was b l i n d from childhood.
Watching the blood supply at the outer end of the lid, the pedicle was raised progressively till the proposed base was reached. The somersault turn by which the lid was to reach the right eye was tried out and found to work well. The lid and pedicle were then sutured back as a delay. A biopsy taken from the tumour was reported as adenocarcinoma, probably arising from the sweat glands. Secondary sepsis in the ulcerated tumour and conjunctival inflammation subsided in a week. The pre-auricular gland ceased to be palpable after this. On 3oth September 1957, twelve days after the delay, the tumour was excised en bloc with the outer seven-eighths of the upper lid, the outer canthus, and the adjoining one-eighth of the lower lid. Excision appeared to be radical enough. The eyeball now stood completely exposed with a raw area above it extending from the upper conjunctival fornix to the line of the eyebrow. The pedicle carrying the left upper lid was now lifted. A full-circle somersault brought the lid neatly into position over the excision defect, the original outer end of the lid now becoming the inner. The lining layer was sewn in first by an atraumatic continuous mattressing catgut suture. The covering layer was then sutured along the inner canthal and superior edges of the defect.
74
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
FI6S. 3 to 6 Figs. 3 and 4.--Upper lid of blind left eye transferred to good right eye after excision of carcinoma. The pedicle is 0edematous. Raw areas covered by temporary skin graft. Figs. 5 and 6.--Fourteen days after the pedicle was returned and the lid transfer completed. T h e outer canthal c o r n e r o f the defect could n o t be sutured w i t h o u t straining t h e pedicle. I t was dressed w i t h a sheet o f skin graft, w h i c h c o n t i n u e d on to cover t h e raw surface o f t h e pedicle and also t h e d o n o r area f r o m w h i c h the pedicle was lifted. ,w
'~ SOMERSAULT" TRANSFER OF A COMPLETE UPPER EYELID
75
The shifted lid united in position and the raw areas healed by the twelfth day. T h e pedicle became swollen with cedema for a time, but this cleared up gradually (Figs. 3 and 4). T h e excised tumour, when studied by serial sections, was found to arise from the skin of the lid, with the appearance o f a basi-squamous carcinoma in places and o f a sweat gland carcinoma in others. On 6th November I957, thirty-seven days after the attachment, the pedicle was divided and returned. Repair of the outer canthus and adjoining defect was completed.
FIGS. 7 and 8 Result eight months later. (Edema of the lid settled down quickly after this. The lid regained function, and could open and close normally. T h e reversal of the lid, outer end for inner, did not make any difference to the lie of the eyelashes (Figs. 5 and 6): Eight months after the repair there was no recurrence, and the result--both cosmetic and fianctional--was very good (Figs. 7 and 8). Vision without glasses was 6/36.
I thank Dr J. B. Shrivastav for the histological studies, and Mr B. K. ffoshi Rao for the photographs. REFERENCES HUGHES,W. L. (1937). Arch. Ophthal., XT, lOO8. - - ( 1 9 4 7 ) . Arner.ft. Ophthal., 3 x, 98o. STALLARI),H. B. (1958). " Eye Surgery," 3rd ed., p. 24I. Bristol : John Wright & Sons.
OF A COMPLETE TECHNIQUE
UPPER
EYELID :
By C. BALAKRISHNAN,F.R.C.S.
Professor of Plastic Surgery, Medical College, Nagpur, India FULL-THICKNESSlOSS of even a large portion of the lower eyelid may not produce exposure damage of the eye if the upper lid is normal. Protection is given by increased downward excursion of the upper lid, assisted by a rolling movement upwards of the eyeball. In loss of the upper lid, however, the eye has no protection, and may soon be lost from exposure damage of the cornea. It is essential to repair upper-lid loss promptly if the eye is to be saved. Full-thickness loss up to one-third of the lid area can be repaired by local adjustments. Larger losses offer tough problems in reconstruction, the main difficulty being the provision of a lining which is tolerated by the cornea. Skin moving over the cornea is unthinkable, and free grafts of mucous membrane have not been satisfactory in practice. Hughes (I947), reversing a procedure which he first described in 1937, split the lower eyelid and brought its lining, stiffened by part of the tarsal plate, as a sliding flap into an upper-lid defect. Skin was moved into the defect for cover, and the temporarily united lids separated later through the line of the required lid border. In such cases the donor lid and its conjunctival fornix are heavily depleted, and the extent to which lid lining can be so transferred is strictly limited. To quote Stallard (I958), " complete closure of the lids is not always possible, but the cornea is adequately protected in those patients whose eyes turn up and laterally during sleep." In short, there is no completely satisfactory method of making good a large full-thickness loss of the upper lid with preservation of all eye and lid functions except by borrowing the upper lid of the opposite eye, if it could be spared. In the case here reported, a good eye was saved after excision of its upper lid by transferring to it the complete upper lid of the opposite eye which happened t o be blind. So far as I know, this particular piece of surgical opportunism has not been reported before, though exchange grafting of the corne~c for salvaging vision is well known. CASE REPORT D. S. was a 5o-year-old farmer from a village in hilly jungle country, 7o miles north of Nagpur. He had a blind left eye from childhood. In I953 a nodule appeared on the skin of the right upper eyelid and grew slowly. By I957 it became so bulky that he could see only by lifting the lid up with a finger. Then the growth ulcerated and he was admitted to the ophthalmic unit of our hospital. As a problem case he was transferred to the plastic unit on I7th September x957 (Figs. I and 2). There was then a tumour measuring 4 by 3 by I'5 crn. occupying most of the right upper lid and just encroaching on the outer canthus. The central portion had ulcerated, forming a deep crater. One surviving bridge of skin across the middle of the crater suggested recent excavation. The main bulk of the tumour was superficial to the tarsal plate. Some nodules had appeared on the conjunctival aspect near the lid border, but this portion was jutting well forwards clear of the eyeball. The cornea was normal, and vision was good when the lid was lifted out of the way. The conjunctiva was inflamed. A small, firm, mobile, slightly tender right pre-auricular gland was present. The right lower lid was normal. There was no perception of light by the left eye. The globe was shrunken with a rough white and insensitive cornea. The eyelids were normal. 72
" SOMERSAULT ~
TRANSFER
OF
A
COMPLETE
UPPER
EYELID
73
It was considered possible to remove the tumour preserving the right eye with its useful vision. A plan was worked out for transferring the complete left upper eyelid on a pedicle to replace the excised right upper lid immediately after the excision. The transfer was to be effected by a full-circle somersault of the lid carried on a pedicle across the bridge of the nose based on the right angular vein and its companion artery. On i8th September 1957 the flap was delayed. It was 2 cm. in width. The upper incision starting on the right side of the bridge of the nose, passed just below the line of the left eyebrow and dropped to the outer canthus. The lower incision starting at a point 2 cm. lower on the right side of the nose, passed straight to the left inner canthus. The left upper lid was detached at the canthi and along the upper conjunctival fornix.
FIG. i
FIG. 2
Figs. i and 2 . - - L a r g e c a r c i n o m a of the r i g h t u p p e r eyelid. T h e r i g h t eye is still good. T h e left eye was b l i n d from childhood.
Watching the blood supply at the outer end of the lid, the pedicle was raised progressively till the proposed base was reached. The somersault turn by which the lid was to reach the right eye was tried out and found to work well. The lid and pedicle were then sutured back as a delay. A biopsy taken from the tumour was reported as adenocarcinoma, probably arising from the sweat glands. Secondary sepsis in the ulcerated tumour and conjunctival inflammation subsided in a week. The pre-auricular gland ceased to be palpable after this. On 3oth September 1957, twelve days after the delay, the tumour was excised en bloc with the outer seven-eighths of the upper lid, the outer canthus, and the adjoining one-eighth of the lower lid. Excision appeared to be radical enough. The eyeball now stood completely exposed with a raw area above it extending from the upper conjunctival fornix to the line of the eyebrow. The pedicle carrying the left upper lid was now lifted. A full-circle somersault brought the lid neatly into position over the excision defect, the original outer end of the lid now becoming the inner. The lining layer was sewn in first by an atraumatic continuous mattressing catgut suture. The covering layer was then sutured along the inner canthal and superior edges of the defect.
74
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
FI6S. 3 to 6 Figs. 3 and 4.--Upper lid of blind left eye transferred to good right eye after excision of carcinoma. The pedicle is 0edematous. Raw areas covered by temporary skin graft. Figs. 5 and 6.--Fourteen days after the pedicle was returned and the lid transfer completed. T h e outer canthal c o r n e r o f the defect could n o t be sutured w i t h o u t straining t h e pedicle. I t was dressed w i t h a sheet o f skin graft, w h i c h c o n t i n u e d on to cover t h e raw surface o f t h e pedicle and also t h e d o n o r area f r o m w h i c h the pedicle was lifted. ,w
'~ SOMERSAULT" TRANSFER OF A COMPLETE UPPER EYELID
75
The shifted lid united in position and the raw areas healed by the twelfth day. T h e pedicle became swollen with cedema for a time, but this cleared up gradually (Figs. 3 and 4). T h e excised tumour, when studied by serial sections, was found to arise from the skin of the lid, with the appearance o f a basi-squamous carcinoma in places and o f a sweat gland carcinoma in others. On 6th November I957, thirty-seven days after the attachment, the pedicle was divided and returned. Repair of the outer canthus and adjoining defect was completed.
FIGS. 7 and 8 Result eight months later. (Edema of the lid settled down quickly after this. The lid regained function, and could open and close normally. T h e reversal of the lid, outer end for inner, did not make any difference to the lie of the eyelashes (Figs. 5 and 6): Eight months after the repair there was no recurrence, and the result--both cosmetic and fianctional--was very good (Figs. 7 and 8). Vision without glasses was 6/36.
I thank Dr J. B. Shrivastav for the histological studies, and Mr B. K. ffoshi Rao for the photographs. REFERENCES HUGHES,W. L. (1937). Arch. Ophthal., XT, lOO8. - - ( 1 9 4 7 ) . Arner.ft. Ophthal., 3 x, 98o. STALLARI),H. B. (1958). " Eye Surgery," 3rd ed., p. 24I. Bristol : John Wright & Sons.