Result of the Patient who Lost his Upper Eyelid in Car Accident.

This Indonesian man returned from Pontianak for his eyelid suture to be removed. I am pleased to seehis eyelid recovered much faster than expected, normally it would take 3 to 4 weeks for the eyelid to be fully open after a big repair but he was able to fully open his eye 11 day postoperative. I advised him to return in 4 weeks for another final check.

 

Before the reconstruction, loss of 3/4 of upper eyelid 

from windscreen injury.

 11 days after the repair. Eye can fully open and good shape.

Good lid closure.

Reconstruction of Traumatic Loss of Upper Eyelid

As mentioned earlier this patient lived across the border in Kalimantan, Indonesia, I decided to choose a technique that required no revision (2-stage reconstruction) in case he failed to return for follow-up. The technique I chose was reversed Tenzel's flap. 

Traumatic loss of the upper eyelid from road traffic accident.

The patient was referred from another medical centre.

Marking of the Tenzel's flap. Arrow shows loss of the skin

on the nasal stump of the eyelid.

The ends of the eyelid were pulled tight to determine the amount

of tissue needed to bridge the gap.

Creation of the flap.

The two ends were sutured tarsal plate to tarsal plate.

Arrows show area of skin loss that needs to be covered.

This was achieved by using advancement flap.

At the end of the operation.

Apperance of the eye the next day.

Side view of the face. The eye should open spontaenously

over the next two to three weeks.

He returned to Kalimantan the day after the operation. I shall report his progress in my next blog if he returned for follow-up.  

Ways of Repairing Lost Upper Eyelid

 The traumatic loss of upper eyelid in this patient can be repaired by a variety of methods. Some are more complicated than the others and some may need more than one stage to complete the repair. As this patient lives in Kalimantan, there is a chance that he may default from follow-up so it is important to choose the appropriate method.

I shall show the pictures in my next blog of the method I had chosen for him. Before then, here are some of the methods which may be used to repair the loss upper eyelid. The first two pictures show the one-stage methods in which the repairs are ompleted in one procedure. The last two pictures show the two-stage methods in which the patients need to return for another procedure to complete the repair.

 

One-stage procedure: Posterior lamellar graft with local myocutaneous flap.

One-stage procedure: Reverse Tenzel's flap

Two-stage procedure: Pedicle flap from lower lid.

Two-stage procedure: Cutler-Beard's technique.

Challenging Eyelid Cases: Contracture of the Upper Eyelid from Shingles

This unfortunate girl had a left upper eyelid contracture from shingles. She was unable to shut her eye at sleep and without treatment she would eventually lose the right vision. To correct the contracture, it was important to remove the contracture. This could be achieved in two ways: skin graft or skin flaps using z-plasty to lengthen the skin. Although skin graft is the easier technique, the result maynot be good as the graft may not match the colour of the eyelid and additionally prolonged patching would be required to avoid eyelid movement which can result in graft failure. Therefore, I decided to perform skin flaps using a combination of z-plasty and glabellar flap (skin from the forehead).

Left upper eyelid contracture with corneal scarring.

Markings done before performing the surgery.

The forehead skin was used to replace the skin shortage.

The upper eyelid was kept on traction to facilitate surgery.

The flaps were created along the marked lines.

The forehead skin was trimmed to make it thinner.

The skin flaps were openedand the subcutaneous tissues

that give rise to contracture (arrows) were excised.

Additional cuts were needed to completely release

the contracture.

The scar tissues should be excised as much as possible

to release the contracture.

The upper and lower eyelids were sutured together to immobilize

 the upper eyelid so that the flaps have a higher chance of success.

The forehead skin was rotated 90 degrees to replace the skin shortage.

Suturing of the skin flaps.

At the end of the operation.

4 days after the surgery, the contracture appear to be

corrected but it is important to keep the eyelids closed

to avoid early contracture of the flap.

I will report the patient's progress in future blog.

Two Challenging Eyelid Cases

When I returned to work on Monday after a long Chinese New Year holiday, I was referred these two interesting and challenging cases to test my oculoplastic skills. Both cases had been operated on Thursday and I shall relate the procedure for each case separately in my next blogs and report the progress.

The first case was a 6 year-old girl from upper Rajang River who developed shingle (herpes zoster) in August, 2010. As the family lived far from any medical facilities, the girl receives no medical treatment. Over the next three weeks, as she recovered, she developed scarring of the upper eyelid and pain in the eye. The parents noticed that she was unable to shut her left eye while asleep. It was not until February, 2011 that they could afford to come to Sibu for a consultation. Unfortunately, there was no surgeons there who could reconstruct the eyelid so she was referred to my private clinic. Because the parents could not afford the private medical fee, so I referred her to my government clinic in Sarawak General Hospital, Kuching.

The second case was a road traffic accident victim who lost 3/4 of his right upper eyelid. The doctor in the peripheral hospital could not manage the case so he was referred to my oculoplastic clinic in Kuching.

Squamous cell carcinoma of the eyelid

This elderly woman noticed loss of her left lower eyelid eyelashes and the formation of undulating skin lesion. She consulted a private eye surgeon who performed a tissue biopsy which showed it to be an aggressive form of squamous cell carcinoma of the eyelid. Without treatment, this tumour could spread rapidly and involve the eye and the orbit. If this were to occur, the entire eye and the orbital content would have to be removed in order to save the patient's life.

As the tumour was extensive and the private surgeon was not confident to reconstruct the eyelid, she was referred to our oculoplastic clinic. The tumour was excised with a 5mm clear margin and closed by using tissue from the lateral part of the eyelid using a technique called the Tenzel's flap.

At completion of the procedure.

10 days post-operative and the sutures removed.

At 10 days post-operative.





"You Can Now Meet the Visitors During the Chinese New Year."

I performed suture technique on this patient  one week ago who wanted to have double eyelids during the Chinese New Year but minimal down time. After spending the past 7 days hiding behind sunglasses, she returned for a check-up 3 days before the Chinese New Year. The double eyelids appear well-formed with minimal swelling and with a bit of make-up she looked presentable for the CNY.

The top picture was taken the next day after

 the procedure and the lower one week later.