Eyelid reconstruction function of the eyelids



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EYELID RECONSTRUCTION
FUNCTION OF THE EYELIDS

  1. Protect the globe

  2. Distribute tears



AETIOLOGY OF EYELID DEFECTS

  1. Congenital: coloboma

  2. Trauma, including burns

  3. Neoplasia, including treatment: RT.

  4. Infection

  1. Hordeolum/stye

    1. External – infection of glands of Zeiss or Moll

    2. Internal – infection of meibomian gland

  2. Chalazion - Painless chronic inflammation of secondary to blocked duct

    1. Superficial - blocked Zeiss pilosebaceous gland

    2. Deep – block meibomian gland



Eyelid tumours

  1. Benign (37%)

    1. seborrheic keratosis

    2. nevi (intradermal most common)

    3. dermoid cysts (lateral brow at line of embryonic closure)

    4. vascular malformations

    5. Neurofibromas

  2. Malignant

    1. BCC (12%)

      1. More common on lower eyelid and medial canthus

      2. BCC eyelids 30x more common than SCC

    2. SCC

      1. Erythematous raised lesion with destruction of lashes

      2. May occur on inner conjunctival surface

      3. Metastatic potential of <1%

  3. Sebaceous gland carcinoma

    1. Third most common eyelid malignancy

    2. Arise from meibomian gland or glands of Zeiss; 75% of all sebaceous carcarcinomas arise periocularly

    3. Usually in upper eyelid (2-3x more), 6th decade

    4. most common presentation is a firm, slowly enlarging nodule of the upper eyelid, often mistaken for a chalazion

    5. Rarely associated with Muir-Torre syndrome or rhinophyma

      1. autosomal dominant condition with variable penetrance characterized by skin manifestations, including benign and malignant sebaceous neoplasms, keratoacanthomas, and internal manifestations (eg, colonic polyps, low-grade visceral malignancies)

    6. aggressive clinical course, with a significant tendency for both local recurrence and distant metastasis.

    7. Often multifocal (intraepithelial pagetoid spread), frozen section or mapping biopsies recommended

    8. Treatment with >5mm margins, or Mohs

    9. Eye involvement require exenteration

    10. Recurrence rates in the 30%, usually within 5 years

    11. Radiotherapy not considered curative

    12. Metastasis occurs in 14-25% of cases, first to the draining lymph nodes and then to distant sites.

  4. Melanoma

    1. Assess involvement of conjuctival and eye ?exenteration

    2. Lesions involving the margin have a much worse prognosis – reason unclear unclear, but the presence of efferent blood vessels and lymphatics at the margin as well as the repeated minor trauma from blinking may be related.

    3. 100% mortality with DXT only as opposed to 14% with wide surgical excision




MANAGEMENT OF EYELID LOSS

  1. Eyelid loss may be complete or partial. It may involve one or more layers of the lid.

  1. 2 layers: lammelae 1) skin /obricularis(external )

  1. tarsus /conjunctiva (support and lining)

  1. With upper lid loss, there is the risk of corneal desiccation and a subsequent keratolytic response that can result in loss of vision. This is less so with lower lid loss.

  1. Ocular protection is therefore important: artificial tears, ointment, surgery ASAP.

  1. Other methods that have been used are sectioning the inferior rectus muscle to allow the globe to rotate up and moisture chambers.



Principles of Reconstruction

  1. Replacement of like with like.

  1. The use of similar available eyelid tissue to replace deficient tissue.

  1. 3 layers need to be provided: skin, support and lining.

  1. The margin must be stable and not turn inwards or outwards.

  1. FT defects can be reconstructed with a flap to one lamella and a graft to the other or with 2 flaps, but not with 2 grafts as vascularity will then be a problem. At least one lamella should have blood supply to support the other.

  1. The tarsal plate is not a solid plate of ct tissue, but rather consists largely of meibomian glands. The free margin is a thickened flange whereas the rest is thin and does not contribute to support.

  2. According to Mustarde, support is solely a function of the orbicularis muscle (ectropion can develop with paralysis of the orbicularis with an intact tarsus)

  1. He also stated that only 3/4 of the width of each lid requires reconstruction.



CLASSIFICATION

Zones of the eyelid and periorbital tissues. The eyelids and periorbital tissues can be divided into five surgical zones: zone I, on the upper eyelid; zone II, on the lower eyelid; zone III, on the medial canthal region; zone IV, the lateral canthal region; and zone V, outside but contiguous with zones I to IV. (From Spinelli, H. M., and Jelks, G. W. Periocular reconstruction: A systematic approach. Plast. Reconstr. Surg. 91: 1017, 1993)

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