Before repair of any laceration, explore the depths of the wound to ensure that deeper injury has not occurred. Any visible orbital fat means that the orbital septum has been violated (Figure 13-5). Make sure that you are not dealing with a potentially more serious injury involving damage to the orbital contents or brain (Figure 13-6). If the laceration occurs perpendicular to the orbicularis fibers and the wound is pulled open, placement of deep absorbable sutures in the muscle will help to approximate the wound edges without tension on the skin closure.

Figure 13-5 Any visible orbital fat means that the septum has been violated. Rule out injury to eye, orbit, or brain and the possibility of the presence of a foreign body.

Figure 13-6 Deep orbital penetration through a small skin wound at the inferior orbital rim. (A) The patient had a small laceration and ecchymosis after falling on a tree branch. (B) Total ophthalmoplegia and no light perception (NLP) vision were noted as a result of penetration of the branch through the orbit and into the brain.

Lacerations parallel to the orbicularis muscle do not require closure of the muscle layer. Placement of interrupted permanent skin sutures that bisect the wound in successive halves prevent the formation of a “dog-ear” (redundant tissue on one side of the wound noted at the completion of closure). A running suture can be used for longer straight lacerations, but this does not permit individual removal of sutures if any infection should occur. Suitable sutures for eyelid skin closure include 6-0 and 7-0 nylon using a reverse cutting needle. Lacerations of the brow in thicker skin can be closed with 4-0 or 5-0 nylon sutures. Blue 5-0 Prolene sutures are especially useful in the brow, where black sutures can easily be confused with eyebrow hairs. A layered closure can be used in the dermis or subcutaneous tissues to remove tension from the skin edges. Do not close the orbital septum. Lagophthalmos may result.

Complex laceration repair

Complex lacerations have many jagged edges and extend into deeper tissue layers. Repair of a complex laceration is like building a jigsaw puzzle. First, you start with pieces of the puzzle that you can identify, the edges and corners, and put them together. Then you fill in the missing areas in the center of the puzzle, looking for less obvious details to guide you.

The steps of complex laceration repair are:

1. Clean and inspect the wound (Figure 13-7, A–C)

A. Rule out deep injury.

B. Remove any foreign material.

C. Do not debride any tissue. You will be surprised how well this tissue survives.

2. Repair the deep layer

A. To begin the laceration repair, identify anatomic landmarks such as the eyebrow, the lid margin, and the canthus (Figure 13-7, D).

B. Place deep sutures to reposition the anatomic landmarks in proper alignment.

C. In some cases, temporary “tacking” sutures of large caliber (2-0, 3-0, or 4-0) can be placed full thickness through the skin to help with the orientation of tissues and take tension off the wound while deep layers are being closed. These temporary sutures are removed as the wound comes together.

D. Start with the deepest layers of closure first, including any posterior lamellar repair of conjunctiva, tarsus, canthal tendons, or levator aponeurosis (Figure 13-7, E).

E. Close the subcutaneous layer with buried absorbable long-lasting sutures such as 4-0 and 5-0 Vicryl or PDS sutures. In large lacerations extending on the scalp, 3-0 PDS sutures are appropriate. Use a reverse cutting needle for these closures. If you are unhappy with the position of a deep suture, replace it. The final skin closure cannot compensate for poor deep closure alignment.

F. Complete the deep closure before starting closure of the superficial layer.

3. Close the superficial layer

A. Approximate the edges of the skin with interrupted sutures (Figure 13-7, F).

B. Most commonly, 6-0 and 7-0 nylon sutures are used on the eyelids, and 4-0 and 5-0 nylon sutures are used in the thicker periocular skin.

C. You can use absorbable sutures such as 5-0 or 6-0 fast absorbing gut for the final skin closure (Figure 13-7, G).

D. Use a topical antibiotic ointment such as erythromycin, placed over the wound.

E. Dressings are not necessary.

Figure 13-7 Eyelid laceration resulting from an explosion of a bottle containing dry ice. Complex laceration repair series. (A) Upper eyelid and medial canthal lacerations. The eye is soft and filled with blood. (B) A large piece of glass penetrated the cornea. (C) Primary enucleation was performed. (D) A canalicular laceration was identified and repaired (small arrow points to punctum; large arrows point to cut ends of canaliculus). (E) The posterior lamella and eyelid were repaired. (F) The anterior lamella was repaired last. (G) Nine months after repair with ocular prosthesis in place.

Suture removal should be done between 5 and 10 days after surgery. If you are removing sutures early, you may want to remove every other suture initially and have the patient return a few days later for removal of the remaining sutures. Superficial wound healing occurs within the first week or two. Scar maturation does not occur until 6–12 months after surgery. You need to be supportive during this period. Avoid revisions until all healing is complete and scars are flat and nonerythematous (Box 13-3).

Box 13-3 Complex Laceration Repair

Preparation

• Use general anesthesia, if the laceration is large

• Clean the wound and remove any foreign material

• Inspect the wound

• Determine the depth of the wound

• Rule out injury to deep tissues

• Do not debride any tissue

• Inject the wound with local anesthetic containing epinephrine (inject before cleaning the wound if using local anesthesia)

Repair deep tissue injuries first

• Levator aponeurosis

• Tarsus

• Medial or lateral canthal tendon

Align identifiable surface anatomic landmarks

• Eyebrow, eyelid margin, corners of the wound

• Deep suture placement, 4-0 or 5-0 PDS sutures

• Larger temporary full-thickness “tacking” sutures, 3-0 PDS or 4-0 silk

Complete the deep interrupted closure

• Anatomic alignment of the layers of the subcutaneous tissue or dermis

Close the skin

• Eyelid skin

• Interrupted 6-0 or 7-0 nylon sutures

• Consider 5-0 or 6-0 fast absorbing gut sutures

• Periocular skin

• Interrupted 4-0 or 5-0 nylon sutures

Use topical and oral antibiotics

You will see lid margin lacerations as isolated minor injuries or in the context of large facial wounds (Figure 13-7, Box 13-4). The technique for repair is the same in either situation. Repair begins with identifying the appropriate anatomic landmarks of the eyelid, especially the landmarks of the lid margin. The strength of the closure is in sutures placed in the tarsal plate. Eyelid margin eversion is necessary to prevent lid notching.

Box 13-4 Eyelid Margin Repair

Inject local anesthetic with epinephrine

Align the lid margin

• 7-0 Vicryl vertical mattress suture through the meibomian gland orifices

Suture the tarsus

• 5-0 Vicryl lamellar pass, two or three sutures

Suture the lid margin

• An additional 7-0 Vicryl vertical mattress suture placed anteriorly in the lid margin

• An additional simple interrupted suture to align the eyelashes as needed

Close the skin

• 5-0 or 6-0 fast absorbing gut interrupted sutures

• Consider 5-0 Vicryl sutures in muscle, if under tension

Eyelid margin repair includes:

• Injecting local anesthetic

• Aligning the lid margin

• Suturing the tarsal plate

• Suturing the lid margin

• Closing the skin

The steps of eyelid margin repair are:

1. Inject local anesthetic

A. Repair can be done with local or general anesthesia.

B. Instill topical anesthetic drops and inject local anesthetic with epinephrine into the wound.

2. Align the lid margin: Use a 7-0 Vicryl vertical mattress suture passed through meibomian gland orifices to align the lid margin. Keep this suture long for traction (Figure 13-8, A).

3. Suture the tarsal plate: Use two or three interrupted 5-0 Vicryl sutures passed in a lamellar fashion to align the tarsal plate. Traction on the initial lid margin suture will help with the positioning of your tarsal sutures (Figure 13-8, B).

4. Suture the lid margin

A. Go back to the lid margin and place an additional 7-0 Vicryl vertical mattress suture anterior to the gray line. The vertical mattress sutures should provide eversion of the lid margin wound (Figure 13-8, C).

B. If you are unhappy with the alignment of the lid margin, replace the sutures.

C. An additional anterior suture may be used to help the alignment of the eyelashes (Figure 13-8, D).

D. I prefer to use 7-0 Vicryl sutures for the eyelid margin. Traditional teaching suggests the use of 6-0 or 8-0 silk sutures, which should be left long and require removal later. The 7-0 Vicryl sutures can be cut on the knot and allowed to absorb.

E. Don’t tie the margin sutures very tightly because the tissue may die, resulting in a lid margin notch.

5. Close the skin

A. The skin can be closed with an interrupted simple or vertical suture using permanent or absorbable sutures (Figure 13-8, D).

B. If the wound seems to be under tension, you may want to place 5-0 Vicryl sutures through the orbicularis muscle before closing the skin.

Figure 13-8 Lid margin repair. (A) Align the lid margin using a vertical mattress suture passed through the meibomian gland orifices. (B) Suture the tarsal plate using two or three interrupted sutures passed in a lamellar fashion. (C) Suture the lid margin using an additional vertical mattress suture anterior to the gray line. (D) Close the skin.

Postoperative care is routine. Occasionally, the sutures will rub against the cornea and require removal.

Canalicular reconstruction

Diagnosis of canalicular laceration

Assume that the canaliculus has been cut if there is any injury extending close to the lid margin medial to the puncta of the eyelids (Figure 13-9). If there is any question, confirm the presence of a laceration by passing a probe through the canaliculus. Canalicular lacerations may occur because of a laceration from direct trauma to the canaliculus or, as stated above, as a result of an avulsion from lateral tension on the eyelid. Direct laceration of the canaliculus is easier to fix than an avulsion type injury. Direct lacerations involve the middle portion of the canaliculus, making it easier to find and repair the ends of the lacerated canaliculus. Avulsion type injuries generally tear the canaliculus close to the sac, making visualization of the proximal cut end of the canaliculus difficult. For these injuries, the operating microscope is helpful.