The Closure of Vertical Lid Lacerations*

490

GEORGE M. HAIK, GEORGE S. ELLIS AND JOEL B. POLLARD

ic ophthalmic surgery. Am. J. Ophth., 56:731, 1963. 22. Bellows, J. G. : Cryo-extraction of cata­ racts. Highlights Ophth., 7:114, 1964. 23. Sudarsky, R. D., and Hulquist, R. : Biophy­ sical aspects and instrumentation in ocular cryosurgery. In press. 24. Haik, G. M, Waugh, R. L., Jr., and Lyda, W. :

Sympathetic ophthalmia. Similarity to bilateral endophthalmitis phacoanaphylactica : New thera­ peutic methods. Arch. Ophth., 47:437, 1952. 25. Haik, G. M., Kalil, H. H., Ferry, J. F., and Childers, M. D. : Subluxations and luxations of the lens: With a special note on the Barraquer operation and on Marian's and Marchesani's syn­ dromes. South. M. J., 54:642, 1961.

T H E CLOSURE O F VERTICAL LID LACERATIONS* A N D T H E REPAIR OF VERTICAL LID CICATRICES E D M U N D B.

SPAETH,

M.D.

Philadelphia, Pennsylvania

cause of that a vertical laceration of the con­ junctiva is not complicated but a deep hori­ zontal one definitely is. One sees the same effect to a convincing degree in the ptosis of cervical-sympathetic paralysis. The levator tendon also has a significant effect upon a through-and-through lid lac­ eration. The levator tendon, if still function­ ing, widens a vertical laceration, in the upper lid, as the orbicularis fibers pull the two cut surfaces farther apart into an in­ verted V, the closer to the midline the lac­ eration the wider the gaping of the wound * From The Graduate Hospital of the Graduate (fig. 2). School of Medicine, University of Pennsylvania. The mechanics of defects from lacera­ This paper was presented before the Section of Ophthalmology, Philadelphia College of Physi­ tions of the lower lid are not too dissimilar. cians, March, 1965. The normal lid attachments to the fascial This paper is dedicated to a distinguished and beloved member of this Section, recently de­ sheath of the inferior rectus muscle and the ceased, Dr. Alfred Cowan, emeritus professor of connections of this to the lower lid and to ophthalmology, The Graduate School of Medicine the septum orbitale limit the gaping of a of the University of Pennsylvania. Some achieve greatness through the drive of great genius, laceration of the lower lid in the midline. others reach that through the fortune of an Eli- This anatomic anchor, however, combined jah-Elisha relationship,1 but Dr. Cowan attained with the downward pull of the facial mus­ the pinnacle because of his intellect, his impecca­ ble integrity and his consistently human aspect to cles of expression and the separating orbic­ all things professional and cultural. There is no ularis fibers, causes a gaping of a lower lid wonder that we who knew him loved him. Dr. laceration when the wound is in the outer Cowan was a clinician, as his books and many papers demonstrate, and he was happiest when in­ third or the inner third of the lower lid. vestigating disease and working with patients. It This is different from the tendency for is proper, therefore, that this paper, in memory of him, be clinical. The subject is chosen deliber­ upper lid midline lacerations to separate ately for he referred to me my first serious widely (figs. 3 and 4). ophthalmic plastic surgery problem in civilian life These are the conditions which modify for he knew that I had had these cases thrust upon me while I was in the military service. I the primary repair of injuries of the lids. am proud that I can pay Dr. Cowan homage this They apply also to the primary closure of evening. colobomas in the midline of the upper lid,

Before discussing the aspects of closure of vertical lid lacerations and repair of ver­ tical lid cicatrices, a brief review of the anatomy of the lids significant to the subject will help to explain why poor cosmetic re­ sults are not uncommon. The orbicularis muscle fibers form a sphincter, adherent through the canthal liga­ ments (fig. 1) to the lateral and medial edges of the orbit. The Müller muscle fibers in the superior cul-de-sac are adherent to the conjunctiva of the superior fornix. Be-

CLOSURE AND REPAIR OF LID LACERATIONS

which is the usual site, and to colobomas of the lower lid at the lateral and medial an­ gles, which is their usual position. These op­ erations will not be considered here except as an example of the essential surgical prin­ ciples. Figures 5 and 6 illustrate the end-re­ sult after immediate primary closure of an extensive laceration. In each instance the surgery was done in anatomic layers. The surgical technique for the closure of the conditions just detailed is simple but exact­ ing. The two statements are not contradic­ tory. With traumatic cases, if there is no soft tissue lost as a result of the trauma, the lac-

Fig. 1 (Spaeth). Schematic drawing to illustrate lines of tension and orbicularis attachments.

Fig. 2 (Spaeth). Schematic drawing of the upper lid to illustrate separation of a laceration.

491

Fig. 3 (Spaeth). Separation of laceration, lateral canthal angle (schematic drawing).

Fig. 4 (Spaeth) Separation of laceration, medial canthal angle (schematic drawing).

erations should be closed in anatomic layers as a primary procedure, otherwise deformi­ ties may occur. Among these deformities are : ptosis of a lateral or medial half of an upper lid (fig. 7), notching of a lid with folds of redundant tissue, cicatricial notch­ ing in a lid at a canthal angle (fig. 8 ) , lower-lid defects in the midline, one edge of the wound in entropion, the other edge in ectropion (fig. 22), and cicatricial lateral angle and medial angle contracting scars (figs. 9 and 14). These cases are frequently complicated by a scar-closed canaliculus. Theoretically all these complications could have been prevented if attention had been paid to the primary surgical requirement—

492

EDMUND B. SPAETH

The satisfactory closure of contracting vertical scars of the upper and lower lids is not simple. Theoretically, if one could resect all the scar present and then close the wound in layers as if it were a fresh wound, one might expect a wholly satisfactory re­ sult. Some of the cases are as simple as that (figs. 10 and 11). Most of them, however, are complicated by the scars of clumsy and

Fig. 5 (Spaeth). Immediate repair of extensive laceration, upper and lower lid, with immediate simultaneous enucleation of eyeball. (Spaeth, E. B. : Principles and Practice of Ophthalmic Sur­ gery. Philadelphia, Lea, 1948, ed. 4.) Fig. 7 (Spaeth). Vertical scar with normal at­ tachment of one angle and ptosis of the opposite angle. (Spaeth E. B. : Principles and Practice of Ophthalmic Surgery. Philadelphia, Lea, 1948, ed. 4.)

Fig. 6 (Spaeth). Immediate repair of laceration of lower lid with simultaneous repair of lower canaliculus. (Spaeth, E. B. : Principles and Prac­ tice of Ophthalmic Surgery. Philadelphia, Lea, 1948, ed. 4.)

closure of lid lacerations in layers. This means the repair of cut lateral or medial levator tendon horns ; closing horizontally su­ perior cul-de-sac conjunctival and Müller muscle lacerations; accurate tarsus and con­ junctiva approximation; orbicularis fibers repair ; re-establishing a normal lower cana­ liculus if that can be done; and, lastly, the accurate closure of the skin itself. Each su­ ture line must be offset from another. The second part of this paper is its prin­ cipal theme, for what has just been said is, in part, an introduction,

Fig. 8 (Spaeth). Cicatricial notching at a lateral eanthal angle,

CLOSURE AND REPAIR OF LID LACERATIONS

493

inept primary surgery, by the displacement of soft tissues, both muscle fibers and skin, by the loss of soft tissue through damage and necrosis and secondary infection, and by consequent contractures, with their con­ tracting pull in various directions, one against the other. These complications make this group of cases separate and special problems for the ophthalmologist. The basic principles of repair are three : The first is to study the case carefully and to decide where displaced tissues belong, normally, and to make preoperative sketches for the surgical replacement of these tissues after the excision of the scars (figs. 9 and Fig. 11 (Spaeth). The surgery necessary for the repair of the case shown in Figure 10. (Spaeth, E. B. : Principles and Practice of Ophthlamic Surgery. Philadelphia, Lea, 1948, ed. 4.)

Fig. 9 (Spaeth). Cicatricial contracture of ver­ tical scarring in lower lid, before and after sur­ gery. (Spaeth, E. B. : Principles and Practice of Ophthalmic Surgery. Philadelphia, Lea, 1948, ed. 4.)

Fig. 12 (Spaeth). Schematic sketch of scar over the elbow joint. The middle illustration shows the scar resection and incisions for the Zplasty. The lowest illustration shows the suture line to break up the pull of this contracting scar. (Ivy, R. : Personal communication.)

Fig. 10 (Spaeth). Dense adherent vertical scar, before and after surgery. (Spaeth, E. B. : Princi­ ples and Practice of Ophthalmic Surgery. Phila­ delphia, Lea, 1948, ed. 4.)

14). The necessary scar resections are planned and outlined on drawing paper. The second principle emphasizes the ne­ cessity for the thorough excision of all scar tissue.

494

EDMUND B. SPAETH

ing the elbow joint into the upper and lower arm, with marked and progressive limitation of movement at the elbow.2 A complete functional recovery followed this Z-plasty. The same principle is illustrated in Figure 13, wherein a cicatricial pull in the midline of a lid was satisfactorily corrected. There is no difference between these two cases except the location of the surgery. Figure 14 is the use of the same principle for a medial-angle cut from a windshield,

Fig. 13 (Spaeth). A contracting scar in the verti­ cal, resected with multiple Z-plasties.

Fig. 15 (Spaeth). Contracting scar, lateral central angle.

Fig. 14 (Spaeth). Scar contracture at the medi­ al canthal angle. Schematic illustration of scar. These sketches show the preoperative condition, the scar resection indicated, and the suture line.

The third, and perhaps the most impor­ tant, is to break up the pull of vertical scar lines by interposing flaps of some type across the line of the cicatrix. Plastic sur­ geons have illustrated this principle repeat­ edly, and beautifully, in their standardized procedure for contracting cicatrices over a joint, which limit motion. Figure 12 presents a classical example: a Z-plasty was done to a long cicatrix cross­

Fig. 16 (Spaeth). Suture line for repair in Figure 15 at end of the operation, all scar resected.

CLOSURE AND REPAIR OF LID LACERATIONS

with vertical contracture. In this case, soft tissue had been lost from necrosis and the patient had quite an ectropion. The princi­ ple, however, is the same. The lost tissue is replaced by a flap from above, the conjunctiva is thus inverted to its normal position and the vertical pull is broken up by the flaps. The basic principle of interposing tissues to break up a cicatrix is well illustrated in Figures 15 and 16. In this case an oblique vertical cicatrix was depressing the lateral angle of the lower lid. Figure 17 is the sche­ matic sketch of the surgery. The scar was resected, the orbicularis fibers rejoined and a simple flap from the lateral lip of the scar

495

Fig. 18. (Spaeth). A case similar to that shown in Figure 15, except that it is at the upper lid and at the medial canthal angle. ( Spaeth, E. B. : Principles and Practice of Ophthalmic Surgery. Philadelphia, Lea, 198, ed. 4.)

Fig. 19 (Spaeth). Sliding-flap technique for the correction of the defect in Figure 18.

Fig. 17 (Spaeth). Schematic sketch of the es­ sential surgery of case in Figure IS. The shaded portion is to be resected.

π-section wound was transplanted as a modification of a Z-plasty, to interpose tisMie. Figure 18 presents an even better ex­ ample. In this the upper lid defect is due to ;i cicatrix in the levator tendon, resulting from the failure to close accurately the canthai ligament and the cut tarsus edges. An illustration from the literature of the World War I shows one of Gillies'3 famous cases (fig. 20). Certainly there could be nothing more convincing than this group of illustrations, as they show the preoperative condition and the preoperative sketches, the immediate postoperative result and the later

496

EDMUND B. SPAETH

«Wf *******

Fig. 20 (Spaeth). A case of Gillies', dating from the First World War, illustrating the princi­ ples outlined in the text. (Gillies : Plastic Surgery of the Face. London, Oxford, 1920.)

Fig. 21 (Spaeth). Schematic sketch for the surgery in Figure 22. (Spaeth, E. B.: Principles and Practice of Ophthalmic Surgery. Philadel­ phia, Lea, 1948, ed. 4.) final result. Fortunately, most cases in civil­ ian life are not so extensive, though many are complicated. Two more cases are shown, comparing rather well with that of Gillies. The preoperative sketches of Figures 21 and 22 show the necessary scar resection, the suturing to demonstrate the principles for repair and the immediate postoperative and later result. Figure 23, is an outstanding example of the essentials just being discussed. The vertical

Fig. 22 (Spaeth). Illustration of scar resection and suturing, preoperative and postoperative. (Spaeth, E. B. : Principles and Practice of Ophthalmic Surgery. Philadelphia, Lea, 1948, ed. 4.)

CLOSURE AND REPAIR OF LID LACERATIONS

497

Fig. 23 (Spaeth). Vertical scar in the lower lid is adherent to the bone. Drawing to illustrate the scar resection necessary and the final suture line. (Spaeth, E. B. : Principles and Practice of Ophthal­ mic Surgery. Philadelphia, Lea, 1948, ed. 4.)

scar in the lower lid has one edge in entropion and the other in ectropion. The scar itself is adherent to the bony orbit, ex­ tending down across the nose toward the tip. The illustration shows the sketch neces­ sary for the scar resection. The vertical pull is eliminated, in part by orbicularis repair but, more important, by moving the triangu­ lar flap of skin into its repair position. CONCLUSIONS

Many defects of the lids secondary to trauma could be prevented if adequate ophthalmologic surgery had been done at the time of primary repair. For some reason, general surgeons and nonophthalmologic resi­ dents seem unwilling to postpone surgery

until a qualified ophthalmologist can be con­ tacted. Theoretically, and practically, all lid lacerations can be satisfactorily corrected at the time of primary surgery if the necessary principles are adhered to. Failing these, be­ cause of the complications mentioned, the later correction of the secondary results of the primary surgery has additional demands beyond those necessary for the primary sur­ gery. The principles indicated for these two groups, outlined in detail, are not dissimilar. 1930 Chestnut Street (19103). REFERENCES

1. The Scofield Bible (II Kings 2.) New York, Oxford. 2. Ivy, R. : Personal communication. 3. Gillies: Plastic Surgery of the Face. Lon­ don, Oxford, 1920.