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The Versatile Lid Crease Approach to Upper Eyelid Margin Rotation.

Cruz AA, Akaishi PM, Al-Dufaileej M, Galindo-Ferreiro A - Middle East Afr J Ophthalmol (2015 Oct-Dec)

Bottom Line: We demonstrate that using a lid crease incision combines the basic mechanisms of the anterior and posterior approaches and in addition, addresses a variety of lid problems commonly found in the aged population with cicatricial entropion.Forty percent of the patients (24 lids) had more than 3 months of follow-up.Adequate margin rotation was achieved in all lids but one that showed a medial eyelash touching the cornea.

View Article: PubMed Central - PubMed

Affiliation: Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, School of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil ; Oculoplastic Division, King Khaled Eye Specialists Hospital, Riyadh, Saudi Arabia ; Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA.

ABSTRACT
Lid margin rotational procedures have been used to correct cicatricial trachomatous entropion since the 19(th) century. There are two basic types of surgeries used for lid margin rotation. The first type is based on through-and-through approach combining tarsotomy and the use of sutures on the anterior lamella. The second type of surgery was suggested by Trabut, who proposed a tarsal advancement by posterior approach. We demonstrate that using a lid crease incision combines the basic mechanisms of the anterior and posterior approaches and in addition, addresses a variety of lid problems commonly found in the aged population with cicatricial entropion. After tarsal plate exposure, a tarsotomy through conjunctiva is performed as described by Trabut. Then, instead of using external sutures secured by bolsters, internal absorbable sutures can be used to simultaneously advance the distal tarsal fragment and exert strong tension on the marginal orbicularis muscle. Sixty lids of 40 patients underwent surgery with a lid crease incision. The follow-up ranged from 1 to 12 months (mean 3.0 months ± 2.71). Forty percent of the patients (24 lids) had more than 3 months of follow-up. Adequate margin rotation was achieved in all lids but one that showed a medial eyelash touching the cornea.

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Related in: MedlinePlus

Main surgical steps of the lid crease approach to upper lid margin rotation: (a) Using a standard blepharoplasty incision a pretarsal skin-muscle flap is raised exposing the whole tarsal flap until the lash roots are visualized, (b) tarsotomy is performed with a conjunctival incision 3–4 mm from the lid margin, (c) a 6-0 Vycril suture is inserted first through the distal segment of the tarsus, (d) the suture is passed on the orbicularis muscle close to the lash roots, (e) as the suture is tied the distal tarsal fragments is slightly advanced over the marginal tarsus and traction is exerted on the orbicularis, (f) final aspect of the lid rotation
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Figure 1: Main surgical steps of the lid crease approach to upper lid margin rotation: (a) Using a standard blepharoplasty incision a pretarsal skin-muscle flap is raised exposing the whole tarsal flap until the lash roots are visualized, (b) tarsotomy is performed with a conjunctival incision 3–4 mm from the lid margin, (c) a 6-0 Vycril suture is inserted first through the distal segment of the tarsus, (d) the suture is passed on the orbicularis muscle close to the lash roots, (e) as the suture is tied the distal tarsal fragments is slightly advanced over the marginal tarsus and traction is exerted on the orbicularis, (f) final aspect of the lid rotation

Mentions: The main steps of the surgery are shown presented in Figure 1. The surgery is usually performed under local anesthesia. First, the lid crease is located and carefully marked. At this point, if desired, a standard blepharoplasty skin or skin + muscle resection can be outlined the lid is then infiltrated with a local anesthetic solution and a 4-0 silk traction suture is inserted through the tarsal edge of the lid margin. A pretarsal skin muscle flap is raised exposing the whole tarsal plate to the level of the lash roots [Figure 1a]. The lid is everted over a cotton-tipped applicator with care to place the applicator under and not over the skin-muscle flap. Using a number 15 Bard-Parker scalpel blade and Westcott scissors, a curved incision parallel to the lid margin is performed through the full thickness of the tarsus 3 mm posteriorly to the margin [Figure 1b]. The lid is returned to its natural position. Three double-armed 6-0 polyglactin (Vicryl) sutures are then passed through half thickness of the central, medial, and lateral aspects of the distal cut edge of tarsus [Figure 1c] and attached to the orbicularis near the lash line [Figure 1d]. The noncentral sutures should be placed in a radial fashion similar to corneal transplant stitches. As the sutures are tied, the distal portion of the tarsus is advanced over the marginal tarsus [Figure 1e], and the marginal orbicularis is pushed backward rotating outward both lamellae of the lid margin [Figure 1f]. The patient is seated, and the lid position is assessed. If necessary, the levator aponeurosis can be recessed or advanced to correct any retraction or ptosis. The sutures remain within the lid, and no bolsters are used. The lid crease incision is closed with a running 6.0 fast absorbable suture.


The Versatile Lid Crease Approach to Upper Eyelid Margin Rotation.

Cruz AA, Akaishi PM, Al-Dufaileej M, Galindo-Ferreiro A - Middle East Afr J Ophthalmol (2015 Oct-Dec)

Main surgical steps of the lid crease approach to upper lid margin rotation: (a) Using a standard blepharoplasty incision a pretarsal skin-muscle flap is raised exposing the whole tarsal flap until the lash roots are visualized, (b) tarsotomy is performed with a conjunctival incision 3–4 mm from the lid margin, (c) a 6-0 Vycril suture is inserted first through the distal segment of the tarsus, (d) the suture is passed on the orbicularis muscle close to the lash roots, (e) as the suture is tied the distal tarsal fragments is slightly advanced over the marginal tarsus and traction is exerted on the orbicularis, (f) final aspect of the lid rotation
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4660523&req=5

Figure 1: Main surgical steps of the lid crease approach to upper lid margin rotation: (a) Using a standard blepharoplasty incision a pretarsal skin-muscle flap is raised exposing the whole tarsal flap until the lash roots are visualized, (b) tarsotomy is performed with a conjunctival incision 3–4 mm from the lid margin, (c) a 6-0 Vycril suture is inserted first through the distal segment of the tarsus, (d) the suture is passed on the orbicularis muscle close to the lash roots, (e) as the suture is tied the distal tarsal fragments is slightly advanced over the marginal tarsus and traction is exerted on the orbicularis, (f) final aspect of the lid rotation
Mentions: The main steps of the surgery are shown presented in Figure 1. The surgery is usually performed under local anesthesia. First, the lid crease is located and carefully marked. At this point, if desired, a standard blepharoplasty skin or skin + muscle resection can be outlined the lid is then infiltrated with a local anesthetic solution and a 4-0 silk traction suture is inserted through the tarsal edge of the lid margin. A pretarsal skin muscle flap is raised exposing the whole tarsal plate to the level of the lash roots [Figure 1a]. The lid is everted over a cotton-tipped applicator with care to place the applicator under and not over the skin-muscle flap. Using a number 15 Bard-Parker scalpel blade and Westcott scissors, a curved incision parallel to the lid margin is performed through the full thickness of the tarsus 3 mm posteriorly to the margin [Figure 1b]. The lid is returned to its natural position. Three double-armed 6-0 polyglactin (Vicryl) sutures are then passed through half thickness of the central, medial, and lateral aspects of the distal cut edge of tarsus [Figure 1c] and attached to the orbicularis near the lash line [Figure 1d]. The noncentral sutures should be placed in a radial fashion similar to corneal transplant stitches. As the sutures are tied, the distal portion of the tarsus is advanced over the marginal tarsus [Figure 1e], and the marginal orbicularis is pushed backward rotating outward both lamellae of the lid margin [Figure 1f]. The patient is seated, and the lid position is assessed. If necessary, the levator aponeurosis can be recessed or advanced to correct any retraction or ptosis. The sutures remain within the lid, and no bolsters are used. The lid crease incision is closed with a running 6.0 fast absorbable suture.

Bottom Line: We demonstrate that using a lid crease incision combines the basic mechanisms of the anterior and posterior approaches and in addition, addresses a variety of lid problems commonly found in the aged population with cicatricial entropion.Forty percent of the patients (24 lids) had more than 3 months of follow-up.Adequate margin rotation was achieved in all lids but one that showed a medial eyelash touching the cornea.

View Article: PubMed Central - PubMed

Affiliation: Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, School of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil ; Oculoplastic Division, King Khaled Eye Specialists Hospital, Riyadh, Saudi Arabia ; Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA.

ABSTRACT
Lid margin rotational procedures have been used to correct cicatricial trachomatous entropion since the 19(th) century. There are two basic types of surgeries used for lid margin rotation. The first type is based on through-and-through approach combining tarsotomy and the use of sutures on the anterior lamella. The second type of surgery was suggested by Trabut, who proposed a tarsal advancement by posterior approach. We demonstrate that using a lid crease incision combines the basic mechanisms of the anterior and posterior approaches and in addition, addresses a variety of lid problems commonly found in the aged population with cicatricial entropion. After tarsal plate exposure, a tarsotomy through conjunctiva is performed as described by Trabut. Then, instead of using external sutures secured by bolsters, internal absorbable sutures can be used to simultaneously advance the distal tarsal fragment and exert strong tension on the marginal orbicularis muscle. Sixty lids of 40 patients underwent surgery with a lid crease incision. The follow-up ranged from 1 to 12 months (mean 3.0 months ± 2.71). Forty percent of the patients (24 lids) had more than 3 months of follow-up. Adequate margin rotation was achieved in all lids but one that showed a medial eyelash touching the cornea.

Show MeSH
Related in: MedlinePlus