Smith and Nesi’s Ophthalmic Plastic and Reconstructive Surgery

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Each layer of skin shouldbe approximated to the equivalent layer in the opposite woundedge to avoid creating a bump in the scar. If a raw edge issutured to an epidermal surface, an elliptic abnormality in thescar will result because the two will not properly seal. Dog EarsDog ears are created by redundant tissue at the terminationof an incision. Unequal incision lengths and incisions joinedat an angle that is too acute frequently cause dog ears.

Creating incisions of equal length and joining them atappropriate angles minimizes dog ears.

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FlapsThe oculoplastic surgeon must be able to adjust the surgicalplan as the intraoperative situation dictates. One of the most helpful techniques to facilitate wound clo-sure is undermining the edges. In most instances it is straight-forward to undermine the adjacent tissue in the subcutaneousplanes beginning at the wound margins. This is particularly true if the scar has repet-itive stretching forces on it, such as a scar in the upper eyelid.

This is par-ticularly helpful for square or rectangular defects Fig.

The eyelidsare a privileged sight with great vascularity; therefore it is rareto see tissue slough. Nevertheless, these priciples apply to theperiorbital regios as well as other sites. These buried sutures also decrease the ten-sion on the skin and distribute it more evenly. Once the direction of the mainvector is known, a V-shaped incision is made along themeridian of the main vector bisecting the V. The area lateralto the V is undermined.

This results in a release of the V inone direction, and the former base of the V lengthens.

Oculofacial Plastic Surgeon, Ophthalmologist: Julie Ann Woodward, MD

Thisarea is then closed by suturing the former base of the V in alinear fashion. The arms of the V are automatically convertedinto a Y Fig. It is also possible to make a Y into a Vby a reverse process. These techniques are most helpful inthe reconstruction of the medial and lateral canthi. A singlecut treats both edges simultaneously; folding the redundancy and cut-ting with one blade inside the fold treats each edge separatelyFig.

Those areas of puckered tissue can be excised as a triangleand closed with interrupted sutures. It isparticularly helpful for closing diamond-shaped incisions orelliptic incisions that have been converted to a rhomboid shape. The key to success is the ori-entation of the excision site. Before demarcating the lesion, thesurgeon should determine in which direction the skin is mostextensible.

This line becomes the lateral aspect of the channel. This approach ensures minimal wound tension at the conclu-sion of the procedure. The guideline cannot be perpendicularto the lid margins because this position may cause abnormaltension and result in malposition of the eyelid Fig. Theprocedure lends itself well to use in the orbital adnexal areas. Itis the same length as the corresponding side of the diamond. After it isrotated, near-far, far-near sutures are used to secure it.

Z-plastyZ-plasty is an important surgical option to release acontracted scar. It is also possible to com-pletely excise the scar or a mass within the central incision ofthe Z-plasty by enclosing it within a spindle-shaped exci-sion. The combination of a Z-plasty with a spindle-shapedexcision of a mass is called an O-Z plasty Fig.

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Thesebands must be excised completely because failure to releasethem may result in an inadequate surgical result. It may be appropriateto use buried sutures to minimize the effects of late scar con-tracture. Such problems may actually exacerbate the underly-ing condition rather than improve it. The use of the Z-plasty may range from apparently simpleapplications to extremely complex situations. It is useful forrelieving vertical contracture in the eyelids after trauma. It isalso helpful for long, complicated scars of the face.

To correct a vertical shortening of the upper eyelid fromscar contracture, the tension-relieving incision or excision ismade vertically through the cicatrized area of the lid.

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All of the underlying scar tissue is excised. Any scar tissue that remains will compromise the desiredsurgical result. It is frequently possible to increase the vertical dimen-sion of the eyelid by one-third of the length of the scar Fig. To enhance the early healing process, a tractionsuture should be placed through the upper eyelid margin andtaped to the cheek for approximately 1 week.

A double-armed 6—0 silk suture with cutting needles is placed through Gentle massageof the area can soften the subcutaneous scar.

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Z-plasty can also be used for more-complex types offacial scars. Multiple Z-plasties can be used for long scarsthat would not respond well to a single large Z-plasty. Theinitial, central incision is made through the center of the scar. Additional arms are created as necessary to completely treatthe scar Fig. Great care must be taken to ensure thatthese incisions parallel the original offset incisions. It is easyto become slightly disoriented, and each mistake will resultin successive mistakes in placement of the incision.

Thenumber of pairs of incisions depends on the length of the scarand adequate distribution of the wound tension. Each pair ofoffset incisions that forms a Z-plasty is treated as describedabove. Z-plasty is also helpful to rotate the eyelid or brow mar-gin. In this role it can be a useful alternative to skin grafting. When caring for burn patients, there is minimal skin avail-able for grafting, and avoiding a graft can be critical. Toenhance incision placement and accuracy, the surgeonplaces the eyelid on stretch before the incision.

This canbe accomplished with a 4—0 silk suture. The incision is madethrough the skin 2—3 mm outside of the ciliary margin. It may be necessary to A similar problem such as elevation of the lateral canthuscan be solved by adapting this technique. The level of the medial canthusis used as a guide to estimate the optimal placement of thelateral canthus. It is placed 3 mm below the cilia line. Parallelto the lid margin, it extends from the middle of the lowereyelid to the angle of the malpositioned lateral canthus, notthe future site of the new lateral canthus.

Then the incisionsweeps medially, superiorly, and obliquely toward the supra-tarsal crease of the upper lid. The inferior arm of the Z isbrought laterally and ends at the desired position of the newlateral canthus. This step is extremely important. The cicatrixcreating an abnormal canthal position is excised segmentallyuntil the lateral canthus freely drops into the desired position. Skin hooks or delicate atraumatic forceps are extremely helpfulduring these manipulations. The wound is then closed. An elevated brow can also be corrected by a Z-plasty.

Theincisions are marked out while keeping in mind that thefuture position of the elevated brow will be determined by itsplacement in the temporal and inferior arm of the Z Fig. The site is estimated by comparison both to thecontralateral brow and the medial aspect of the ipsilateralbrow. The absence of cilia in the elevated brow or aberrantgrowth should be noted. If they are found, placement of thebrow should be adjusted accordingly. The central portion ofthe Z is placed under and parallel to the arch of the affectedbrow. The superior arm is then offset to follow the curve ofthe superior orbital rim.

The inferior arm of the Z is placedparallel to the superior incision. It may be necessary to extendthe lateral aspect of the inferior incision slightly in order tolessen wound tension and accommodate the transposition. This frequently makes the Z resemble the number 2.

Transmarginal Repair of the EyelidAll incisions or lacerations of the eyelid margin requiresurgical repair to restore the structural integrity of the eyelid. This is true even if the involvement is only partial thickness. This type of surgical repair can be performed with a generalor local anesthetic as the situation dictates.

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Thetechnique of pentagonal wedge resection can be used to closea horizontal lid defect regardless of the underlying cause. Thisallows a more precise closure and removes debris from theincision. The eyelid margin is grasped with toothed forceps.

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While keeping the eyelid under tension, the blade is insertedthrough full-thickness eyelid. It is brought upward in onecontinuous motion to remove all of the irregular tissue whilecreating a smooth wound edge. The lateral wound edge istreated in a similar fashion. Attention is directed to closingthe wound edge without leaving a notch in the eyelid margin.

The center point of this effort is placing three 6—0 silk suturesthrough the eyelid margin. A double throw is placed in the suture and the eye-lid margin is evaluated. The eyelid margin should be wellapproximated with a solid mirror-image pass.