Secondary repair of eyelid trauma usually requires treatment of cicatricial changes that resulted from either the initial trauma or the surgical repair (Fig 11-5). Scar revision may require a simple excision with primary closure or a more complex tissue rearrangement. The location of a scar in relation to the relaxed skin tension lines determines the best technique or combination of techniques to use. An elliptical scar excision is most useful for revising scars that follow the relaxed skin tension lines. Single or multiple Z-plasty flap techniques can be used to revise scars that do not conform to relaxed skin tension lines.
Figure 11-4 Repair of right lower eyelid laceration involving the canaliculus. A, Avulsion injury of the right lower eyelid. B, Lacrimal probe placed demonstrating the canalicular involvement. C, Lacrimal stent placement through the lacerated eyelid. D, Immediate postoperative result after reconstruction.
(Courtesy of Bobby S. Korn, MD, PhD.)
Figure 11-5 Anterior lamella cicatrix after trauma resulting in lagophthalmos.
(Courtesy of Cat N. Burkat, MD.)
Free skin grafts, performed alone or in combination with various flaps, are used when tissue has been lost or when lengthening of the anterior lamella is required. Although any non-hair-bearing skin can be used, the ideal donor site for eyelid reconstruction is full-thickness upper eyelid skin. Harvested skin should be similar in color and thickness to the skin it is replacing, and it should also be hairless and supple, with minimal actinic damage.
Tarsoconjunctival flaps are good substitutes for posterior lamella eyelid defects when both the tarsal plate and conjunctiva are deficient. Buccal mucosa may be used when only the conjunctiva is missing. Hard palate composite grafts can be used for posterior lamella tarsal defects in the lower eyelid; however, these grafts should be avoided in the upper eyelid due to the presence of keratinized epithelium, which can irritate the cornea.
Before treatment is considered for traumatic ptosis, the patient can be observed for 3–6 months to allow for spontaneous improvement. An exception to this rule may be amblyogenic ptosis in a young child.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.