Chapter 57 - Adnexal surgery - sx tx Flashcards
What are the reconstruction blepharo plastic tx available?
- sliding skin flap
- conjuntival advancement flap
- full thickness eyelid graft
- rhomboid graft
- sliding z flap
What is a common cause of eyelid trauma in horses?
Exposure of the equine eye and hazards in confined environments.
Why is it essential to determine if an eyelid laceration is full or partial thickness?
To assess the extent of the injury and determine the proper treatment.
What is the benefit of using cold packs on an eyelid laceration?
Cold packs help reduce swelling if tolerated.
How should lacerations affecting the medial eyelid be managed?
By confirming nasolacrimal patency before closure.
What solution is recommended for flushing eyelid lacerations before closure?
A 1:50 dilution of 10% povidone-iodine solution followed by sterile saline.
Why is a two-layer closure preferred for eyelid lacerations?
To prevent abnormalities from proud flesh and scarring.
When can fresh eyelid lacerations be closed immediately?
If they are not long-standing or infected.
How are tissue-loss defects affecting less than one-third of the eyelid margin managed?
By direct apposition closure.
What is a common suture pattern used for palpebral conjunctiva closure?
Simple interrupted or simple continuous pattern.
What suture type is recommended for infected lacerations?
Nonabsorbable suture material, to be removed after 10-14 days.
What suture technique prevents corneal abrasion from suture tags?
A figure-of-eight suture pattern.
Figure 57-13. Repair of eyelid laceration. (A) Minimal débridement is performed. (B) Closure is performed in two layers, starting at the eyelid margin to ensure optimal alignment. (C) and (D) Skin closure is accomplished with simple interrupted sutures (4-0 or 5-0). A figure-of-eight suture pattern is useful for closure of the eyelid margin, as it allows suture placement on the eyelid margin, with placement of the knot away from the globe.
What is an aftercare recommendation to prevent postoperative rubbing?
Use of a protective eye mask with a hard cup.
When is reconstructive blepharoplasty indicated?
For lacerations or defects involving more than one-third of the eyelid margin.
Describe the sliding skin flap technique in blepharoplasty.
Vertical incisions are made, and small triangles (Burow triangles) are excised to close without dog ears.
describe the sliding technique
vertical incisions are made in the eyelid skin that extend in height approximately twice the width of the eyelid defect. Slightly diverging incisions will compensate for some expected wound contracture. Small triangular portions of skin (Burow triangles) are excised at the base of the vertical incisions (see Figure 57-16, A). These triangles allow closure without skin folds (dog ears) and help to distribute tension; they should approximate half of the full height of the vertical incision. The surrounding skin, skin flap, and conjunctiva are undermined using blunt dissection, and the skin flap is advanced to the eyelid margin (see Figure 57-16, B). Wound contracture should be anticipated, and a slight initial advancement and fixation of the flap past the eyelid margin may provide a better ultimate cosmetic result. The flap is sutured to the conjunctiva at the eyelid margin, and to the adjacent skin in a simple continuous pattern using 4-0 to 6-0 absorbable suture (polyglactin 910) (see Figure 57-16, C). A temporary tarsorrhaphy may provide additional support during healing.
Figure 57-16. Sliding skin flap to repair eyelid defects. (A) Proportions of incisions should be ab=b=cd=de. (B) Equilateral triangles of skin are excised, as is the affected portion of eyelid. The skin flap and adjacent skin are undermined with scissors. Adjacent conjunctiva is mobilized and closed with absorbable suture (polyglactin 910 [6-0 Vicryl]). (C) The skin flap is advanced, and the leading edge of the flap is sutured to the conjunctiva and skin.
What is the purpose of excising Burow triangles during sliding skin flap surgery?
To distribute tension and avoid skin folds.
How is wound contracture managed in sliding skin flaps?
By initially advancing and fixing the flap past the eyelid margin.
Figure 57-17. Tarsoconjunctival advancement flap. (A) A skin advancement flap is prepared as in Figure 57-16. (B) Conjunctiva of the upper eyelid opposite the defect is incised 3 to 4 mm from the eyelid margin and is undermined to create a flap. (C) The conjunctival flap is advanced and sutured into the defect.
(D) The skin flap is advanced and sutured in place. (E), A temporary tarsorrhaphy relieves tension on the flaps. The use of stents helps to distribute tension. (F) After 4 weeks, the tarsorrhaphy is removed and the conjunctival flap is severed at the level of the eyelid margin. The conjunctiva and skin are apposed with a continuous pattern of 6-0 or 7-0 absorbable suture.
What does a conjunctival advancement flap involve?
Advancing conjunctiva from the opposite eyelid to repair defects.
Why might a temporary tarsorrhaphy be necessary during conjunctival advancement flap healing?
To reduce tension on the conjunctiva.
When is a full-thickness eyelid graft required?
For extensive eyelid skin lesions where sliding skin flaps are insufficient.
Where is the graft tissue usually taken from in a full-thickness eyelid graft?
From the upper eyelid for a lower eyelid defect.
What suture material is recommended for skin closure in a full-thickness eyelid graft?
Nonabsorbable monofilament nylon.
describe the tarsoconjunctival advancement flap
In cases of neoplasia or trauma with extensive conjunctival involvement, a conjunctival advancement flap from the opposing eyelid may be required (Figure 57-17). A sliding skin flap is created as detailed previously (see Figure 57-17, A). Palpebral conjunctiva from the opposing eyelid is incised approximately 2 to 3 mm from the eyelid margin measuring the same width as the eyelid defect, and vertical incisions are made towards the conjunctival fornix (see Figure 57-17, B). The conjunctival flap is sutured to the remaining conjunctiva in the eyelid defect (see Figure 57-17, C). Closure of the sliding skin flap is as previously described. A temporary tarsorrhaphy is required to alleviate tension on the conjunctiva. A second procedure is performed to transect the base of the conjunctival flap and remove the tarsorrhaphy, approximately 1 month following the initial surgery (see Figure 57-17, F). This procedure can generally be performed on the standing, sedated horse using local anesthesia.
tarsoconjunctival advancement flap is used when?
In cases of neoplasia or trauma with extensive conjunctival involvement
what is the full thickness eyelid graft technique? describe
This technique is easier to perform on a lower eyelid defect using the more mobile and extensive upper eyelid as the donor tissue. A sliding skin flap of the lower eyelid can provide partial closure of the defect to be grafted. The width of the graft should be 1 to 2 mm larger than the width of the defect in the opposing eyelid margin. The donor eyelid is incised approximately 5 mm from the eyelid margin (to spare the meibomian glands) (see Figure 57-18, B). The flap should be split into skin/muscle and tarsoconjunctival portions to aid mobility of the tissue. The tarsoconjunctival portion of the graft is sutured to the conjunctival defect in the lower eyelid using a simple continuous suture of 6-0 polyglactin 910 (see Figure 57-18, C). The skin portion of the graft is sutured to the lower eyelid skin defect using 4-0 nonabsorbable suture (e.g., monofilament nylon) (see Figure 57-18, D). The bridge in the upper eyelid is sutured to the graft to prevent retraction and a temporary tarsorrhaphy is placed. In a second procedure, following 4 to 6 weeks of healing time, the flap is transected along the new eyelid margin (see Figure 57-18, E), and the lower eyelid conjunctiva and skin are sutured using 6-0 absorbable suture material (polyglactin 910) in a simple continuous pattern (see Figure 57-18, F). The donor flap is sutured back within the upper eyelid.
Figure 57-18. Full-thickness eyelid graft. (A) The area of affected lower eyelid is excised. (B) The upper eyelid is excised 5 mm above the eyelid margin opposite the defect. (C) The graft is split into skin and tarsoconjunctival layers. The graft is advanced under the eyelid margin and sutured in place. (D) The bridging eyelid margin is sutured to the graft. A temporary tarsorrhaphy alleviates tension on the graft. (E) After adequate healing has occurred, the graft is severed along the intended eyelid margin. (F) The conjunctiva and skin are apposed along the eyelid margin with a continuous suture pattern. The skin flap is sutured to the bridge to complete the closure.
rhomboid graft flaps are used in which situations?
Rhomboid and modified rhomboid flaps are used to treat large periocular skin
describe the surgical procedure of a large rhomboid graft flap
A large periocular or eyelid margin defect can be grafted by generating a rhombus—an equal-sided parallelogram, which can be rotated to cover the eyelid defect (Figure 57-19). The rhombus can be constructed as a square or with sides at approximately 60 and 120 degrees. Once the defect is created, two incisions are made in the distal eyelid skin to form two further sides of the rhombus (see Figure 57-19, B). The skin is undermined using blunt dissection and the rhombus is rotated 90 degrees to fill the defect (see Figure 57-19, C). Conjunctiva from the distal palpebral or bulbar surfaces should be advanced to the new eyelid margin. Simple interrupted or simple continuous sutures of 4-0 to 6-0 absorbable suture material are used to suture the conjunctiva to the new eyelid margin and to suture the graft in place (see Figure 57-19, D).
Figure 57-19. Rhomboid graft flap. (A) The rhomboid is aligned with one side along the position of the eyelid margin. Sides of the rhomboid are equal. The replacement flap is incised on a line (A1) continuous with the diagonal of the rhomboid, for a distance equal to the sides of the rhomboid. The second incision (A2) is also equal in length, and is placed parallel to the side of the rhomboid. (B) The lesion is excised and conjunctiva is mobilized to cover the replacement flap. (C) The flap is dissected free from underlying tissue and rotated into position. (D) The flap is sutured in position with the leading edge forming the new eyelid margin. (Angles 1 and 2 are indicated on B and D to aid in orientation.)
when do you use the sliding Z flap?
Mass excision or tissue loss at the lateral canthus
Figure 57-20. Sliding Z flap. (A) Growths of the lateral eyelid can be removed en bloc. The triangular areas of skin to be removed adjacent to the defect are marked. Excision of these flaps facilitates skin mobilization. (The bases of the triangles align with the diagonal of the defect.) (B) Adjacent skin is undermined. (C) Equivalent triangles of skin are excised. (Cut edges A, A′, B, and B′ are shown to aid in orientation for advancement of the flap.) (D) The flap is advanced and sutured in place.
describe in detail the surgical tx of sliding z flap
The lesion should be fully excised or débrided, and the surrounding skin and tarsoconjunctiva should be separated using blunt dissection (see Figure 57-20, B). Triangles of skin are excised superior and inferior to the defect (see Figure 57-20, C). The skin is advanced to cover the defect. The new portion of eyelid margin is created by suturing skin and conjunctiva together using 4-0 to 6-0 absorbable suture material (polyglactin 910). The remaining skin is sutured in a similar manner (see Figure 57-20, D).
How is a rhomboid graft flap constructed?
By creating a rhombus that can be rotated 90 degrees to cover the defect.
What is the benefit of a rhomboid graft flap?
It fills large periocular or eyelid margin defects effectively.
When is a sliding Z flap typically used?
For reconstructing defects at the lateral canthus.
