The use of tarsorrhaphies in the acute management of eyelid burns and their subsequent reconstruction is controversial. ^{, ,} Although we do not use this procedure routinely in the acute management of eyelid burns, there are two clinical situations where a tarsorrhaphy may be a valuable tool in patient management. Appropriate patient selection, attention to surgical technique, and close monitoring can prevent complications from tarsorrhaphies.

A tarsorrhaphy may be helpful if the eyelid wound closure is delayed. The eyelid burn may be treated conservatively and heal on its own. If this takes longer than 2 or 3 weeks, there is a greater chance that scar contracture will occur with retraction of the eyelids, increasing the risk of corneal exposure. This is often seen in patients with extensive burn injuries because the limited skin graft donor sites are used elsewhere as a life-saving measure. In addition, an initially diagnosed partial-thickness burn of the eyelids may take much longer to heal because of the overall wound-healing slowdown observed in these severely burned patients. Nevertheless, if lid retraction occurs with the risk of corneal exposure and injury, then a temporary tarsorrhaphy can be performed to achieve lid closure and counteract the contracting forces present in either lid. The tarsorrhaphy is left in place until the scar is mature and the risk of recurrence is resolved, or the tarsorrhaphies are deemed ineffective, and a more aggressive surgical approach with release and skin grafting is required.

The second instance requiring tarsorrhaphies is with skin grafting of the eyelids. This maintains the lid in an optimal, “fully expanded” position and minimizes eyelid movement, optimizing skin-graft resurfacing and take.

The technique ( Fig. 57.3 ) is similar for both indications. An intermarginal tarsorrhaphy technique is the least invasive and the author’s chosen method. Two points of contact are created on each eyelid margin. These are located over the sclera, just outside the medial and lateral edges of the iris. With two closure sites, better immobilization of the entire eyelid is achieved. At the same time, a small, central opening is available for the patient to see through and permits inspection of the cornea. The operation is performed under general anesthesia with infiltration of the area with 1% lidocaine with 1:100,000 epinephrine. It can occasionally be performed at the bedside in critically ill patients who are otherwise unconscious or sedated to avoid transport to the operating theater.

(A and B) Intermarginal tarsorrhaphy technique. (C) Patient with intermarginal tarsorrhaphy and grafted upper and lower eyelid releases, the lower with a bolster in place.

A small stab incision is first placed in the gray line of the lid margin between the eyelashes and the tarsal edge. The stab incisions measure approximately 5 mm and are placed in both the upper and lower lid margins directly opposite. A 5-0 Prolene suture secures the lids together in a crisscrossing pattern. All of the entrance and exit sites for the suture are placed along a vertical line perpendicular to the (ends of the) original lid margin incision. The suture first enters the upper lid approximately 5 mm directly above one end of the ciliary margin incision. It passes through the lid obliquely (45 degrees). It exits the upper lid about 2.5 mm from the ciliary margin at a site immediately superior to the opposite end of the lid margin stab incision. The suture is then reinserted close to its exit point and travels obliquely toward and exits through the other end of the marginal stab incision. The suture is then inserted into the stab incision of the opposite lid margin on the same end that it exited. As it enters the opposite lid, it again runs obliquely to exit 2.5 mm from the ciliary margin at a site immediately inferior to the opposite end of the lid margin stab incision. A second oblique bite of the lower lid is taken, and at this point a small rubber protective shod is placed over the suture. The author generally uses a No. 8 red rubber pediatric urinary catheter. This small rubber tube protects the underlying skin. It dissipates some pressure exerted when the suture is tied and prevents the suture from cutting through the skin like a cheese knife. The rubber tube must be approximately 5 mm long, corresponding with the length of the lid margin stab incision and the amount of suture exposed at this site. The suture is then reinserted into the lower lid at approximately 5 mm from the lid margin directly inferior to the opposite end of the stab incision. It is inserted obliquely, and the tarsorrhaphy is completed in a crisscross fashion, similar to the previous description. Once it exits in the upper lid, a second rubber protective shod is placed over the suture. Once tightened, the lids are brought into contact with the stab incisions of the upper and lower lid margins directly across from one another. Healing can occur across the gap, producing a “synechia,”which provides a longer-lasting effect. This can be easily divided in the office under local anesthetic and does not significantly alter lid margin appearance or function. Occasionally, if the tarsorrhaphy is only necessary for a very short period, the stab incision along the lid margin can be eliminated. A more invasive tongue-in-groove technique has been described, but this should be avoided because it is more likely to result in a problematic lid margin deformity.

Once adequate lid adhesion has been achieved, the suture can be removed. Postoperatively, the areas are cleansed and irrigated with saline, and an antibiotic ointment is applied. With eyelid closure in this fashion, the need for repetitive corneal lubrication and irrigation is significantly reduced.

Variations of the tarsorrhaphy technique exist, and often, the choice depends on the surgeon’s experience and the patient’s specific needs. In severe injuries where the anterior lamella is unavailable, a posterior lamellar tarsorrhaphy has been described to protect the cornea.

Potential complications from tarsorrhaphy include direct corneal abrasions, corneal irritation from epithelialization of the conjunctiva, severe lid margin damage, and failure with separation of the eyelids. Disuse amblyopia is a possibility in children.

A full-thickness or deep partial-thickness burn of the eyelid may need skin grafting. Because the eyelid’s surface is relatively small, spotty areas of full-thickness or deep injury will generally reepithelialize from adjacent areas of partial-thickness injury or undamaged skin.

Therefore skin grafting of the eyelids is generally required only when the entire lid and adjacent face sustain a full-thickness injury. An entire aesthetic unit graft will be necessary ( Fig. 57.4 ). Unlike a surgical release for contracture, split-thickness skin grafts are usually sufficient for resurfacing both the upper and lower eyelids. If possible, they should be harvested from the head and neck area, and often, the posterior or lateral neck or scalp are available. Lille et al. and others have advocated using full-thickness skin grafts in the acute setting to avoid additional surgeries and reconstruction. ^, They report the need for subsequent ectropion release to be over 50% less with full-thickness skin grafts. The concern with this approach is that revascularization of a full-thickness skin graft on traumatized tissue may not be as dependable as with a split-thickness graft. The only graft losses were observed in the full-thickness skin graft group.

Aesthetic facial units.

As in many areas of burn wound management, more aggressive surgical closure has been advocated for the eyelids. Historically, debridement and skin grafting were indicated if the eyelid burn had not spontaneously reepithelialized within an acceptable length (2–3 weeks) and lagophthalmos was absent. Early surgical management (within 7 days) is recommended as it has been shown to diminish corneal injury from exposure keratitis, even though it will not reduce the need for subsequent eyelid releases. ^{, ,}

Meticulous preparation of the wound is imperative. Careful removal of all nonviable tissue (Weck dermatome, tenotomy scissors, Versajet) and precise hemostasis are necessary to achieve optimal, and hopefully complete, graft take. Small areas of skin graft loss can lead to secondary healing, subsequent contraction, and postburn deformities and contracture. A two-stage procedure is preferred if an entire face is to be grafted. The wound is first excised, hemostasis is achieved, and an allograft is applied. The damage is reinspected the next day, any further minor debridement is performed, and sheet autografts are applied. This way, even minor graft loss can be avoided, optimizing the final aesthetic result.

Before skin graft application, a temporary tarsorrhaphy may be performed. This maintains the grafted area in an “expanded” state and limits movement that can be detrimental to the take of the skin graft. A thick (0.0015–0.0020 inch) sheet, split-thickness skin graft is tailored to the aesthetic unit and secured in place with interrupted 6-0 chromic sutures around its periphery after a fibrin sealant has been applied to the wound bed (Artiss). A piece of Xeroform gauze is cut in the exact shape of the graft and placed upon it, followed by a mineral oil-soaked cotton bolster. One end of the 6-0 chromic sutures is left long and tied over the cotton. The bolster is left in place for 5 days. After removal, the skin is managed in the usual manner. The tarsorrhaphy is released once the skin graft is vascularized and eyelid exercises are initiated.

In severe burn injuries, the eyelid margins and a significant amount of the upper and lower eyelids may be destroyed. With the exception of chemical injuries, tissue loss, and destruction are usually limited to the anterior lamella, sparing the tarsal conjunctiva. However, as a result of the overlying wound and scar contraction, the conjunctiva is in an abnormal, retracted, and folded position and does not afford any protection to the corneal surface. This is generally a late postburn or reconstructive problem and can be managed by conjunctival approximation and skin grafting (Masquerade procedure), described later in the chapter.

Ectropion is the eversion, or “turning out,” of the lid margin. It is the most common periorbital burn scar deformity encountered by the reconstructive burn surgeon. ^{, , , ,} In addition to the deformation and disfigurement from asymmetry and malalignment of the eyelid axis, it presents functional problems such as epiphora. More importantly, it can result in corneal and conjunctival exposure, drying, and irritation, leading to injury, infection, and, ultimately, ulceration and visual loss.

Scar contraction can easily overcome the forces and tissue characteristics that interact to maintain normal eyelid movement and position. Bowers has described the factors present in both the upper and lower eyelids ( Fig. 57.5 ). When this balance is disrupted by the scar in burn patients, lid retraction, lagophthalmos, and ectropion will occur. The forces producing wound retraction of the lower eyelid are generally more substantial, and therefore the incidence of lower-lid ectropion is much greater than upper-lid involvement.

Eyelid forces.

Patients with burned eyelids often have some degree of compromised corneal lubrication secondary to injury to the glandular structures. With the loss of meibomian gland function, there is a decrease in the lipid content of the tears, resulting in more rapid evaporation. Lid retraction and ectropion compound this problem. Lid retraction reduces the normal moisturizing effect of the conjunctiva as it passes over the cornea, and the ectropion interferes with the normal drainage of tears through the canalicular system. Exposure of the delicate conjunctiva can also lead to further irritation and increase the risk of infection.

In most instances of burn scar contracture, the most effective prevention method is establishing early wound closure. This is not necessarily true for the burned eyelid, as the need for lid release is still substantial after skin grafting, perhaps consistent with it being a more severe injury. ^{, , ,} Even so, timely closure may mitigate the severity of the ectropion, allowing nonoperative modalities to be more effective or reducing the scope of future releases. Nevertheless, regular reassessment and vigilance are important until the wound fully matures.

Nonoperative management is primarily preventative with a regular program of aggressive, repetitive, and consistent massaging exercises to assist with stretching the scar tissue and maintaining length. Regular “squinting” or “blinking” exercises are also helpful. Although used at some facilities, the use of custom-made conformers and splints is generally not effective for the prevention of ectropion. These devices have to be placed under a face mask and usually become dislodged; can irritate the fragile, healing tissue; and are often quite uncomfortable to wear. For these reasons, compliance with their use is generally very poor. Taping the eyelid closed at night may be useful in reducing eye irritation during sleep, but it is generally not useful in preventing ectropion. Artificial tears, ophthalmic ointment, and eye patching are used with the previously mentioned measures to prevent corneal desiccation.

Mild degrees of ectropion with minimal eye irritation can be observed during scar maturation. This is particularly true when no ectropion exists at rest but is only evident with facial animation, such as mouth opening or at night during sleep. Minimally invasive techniques such as fractional laser resurfacing, hyaluronic acid injection, and fat grafting have all been described for treating mild to moderate cicatricial ectropion. However, evidence-based data are lacking.

If a conservative approach fails, operative management should be considered, mainly if chronic conjunctivitis or the lack of an adequate protective Bell’s phenomenon increases the risk of corneal injury. Even if the problem is identified early before significant retraction has occurred, a temporary tarsorrhaphy is unlikely to maintain lid height against the strong contractile forces in the scar, and surgical release will be necessary. In most instances, the reconstructive burn surgeon prefers the scar tissue to fully mature before embarking on a surgical release. This approach optimizes their ability to perform an effective, long-term release, reducing the recurrence risk. However, the eyelid exhibiting retraction/ectropion is one of the instances where early release may be necessary to prevent functional problems, specifically corneal damage. In the late acute phase of burn treatment, this usually becomes necessary between 21 and 50 days after burn. ^,

Before embarking on the surgical release of the ectropion, it is important to eliminate any extrinsic forces on the eyelid contributing to the deformity. Contracture bands and tissue loss in the forehead, cheek, and neck may affect the eyelids and require attention before or concomitant with addressing the eyelid contracture. ^{, ,}

A few general comments can be made concerning the surgical management of upper and lower burn ectropion. Release and resurfacing with flap tissue is the ideal solution for burn contractures, as recurrence rates are substantially reduced. Unfortunately, when the eyelids are burned, adjacent areas of the face are usually involved and are not an available flap source.

Release and skin grafting are, therefore, the mainstay of ectropion management. ^, Regardless of the eyelid being treated, the contracture must be fully released and overcorrected in both the vertical and horizontal dimensions to achieve the desired long-term results. The release should extend beyond the medial and canthal regions to achieve this overcorrection. The extent of this release can be best achieved if the upper and lower eyelids are managed in separate surgical procedures. It is recommended that the most severe ectropion be addressed first, with the second eyelid released after 4–6 weeks.

The release should be delayed until the scar is mature if the cornea is not at risk. Recurrence of deformity is not uncommon and has been reported to be up to 30%, which demands close follow-up until the scar is mature. This is particularly problematic if the surgery is performed early before the scar matures. ^{, ,}

Maintaining the surgical release while the skin graft revascularizes is often necessary. For this purpose, a Frost stitch ( Fig. 57.6 ) or, in severe cases, a temporary tarsorrhaphy may be incorporated into the surgical plan.

Frost stitch.

Lower eyelid.

A subsidiary, horizontal releasing incision is used to correct lower-lid ectropion ( Fig. 57.7 ). It is 2 to 3 mm inferior to the lid margin to provide room for sutures. It is extended slightly beyond the medial and lateral canthal areas to provide a full release. Sloan et al. recommended a 15-degree inclination above the horizontal at the medial and lateral ends, whereas others extended the incision laterally in a natural “crow’s foot” location. Some surgeons recommend creating a “fishtail” release at the end using a forked incision at this location. This will expand the lateral release and avoid a straight suture line. Sloan also recommended extending this 15 mm beyond the canthus; however, the author has found that 5 to 10 mm is usually adequate laterally and 3 to 5 mm medially. In instances where the contracture is particularly severe and significant, distortion is present in the region of the medial canthus; it is recommended that the lower lacrimal canaliculus be cannulated to prevent injury.

Lower-eyelid ectropion release and full-thickness skin graft.

The incision extends through the entire thickness of scar tissue down to the orbicularis muscle. A sufficient rim of tissue must be preserved superiorly to permit the placement of sutures. Using blunt scissor dissection, the incision is opened to achieve release of the contracture. Often, upward traction on the lid margin using skin hooks or temporary silk sutures can facilitate obtaining the release. Although it is preferable to preserve orbicularis muscle at the base of release, this may not be practical or possible because it often adheres firmly to the undersurface of the eyelid scar. Every effort should be made to maximize the release and overcorrect the eyelid height, so orbicularis release may be necessary. Meticulous hemostasis is mandatory to maximize the take of the sheet graft to be placed in the defect. Full-thickness skin grafts are the method of choice for lower-lid release. The preferred donor sites include the postauricular or supraclavicular areas or the opposite upper eyelid to optimize aesthetics with a better texture and color match. However, other locations might have to be used in extensively burned patients. When determining the appropriate size of the skin graft, the defect is maximized by upward traction on the lid margin to accomplish overcorrection. The skin graft is tailored to the defect and draped over the wound edges, avoiding any tenting. A fibrin sealant (Artiss) is applied to the wound bed, and the graft is secured in place with interrupted 5-0 chromic or silk sutures. Each suture is left long for a tie-over technique over a cotton bolster.

After the skin graft is sutured, a nonadherent gauze is placed directly over the graft, and a contoured, dampened cotton bolster is applied to maximize graft apposition to the concave defect. The bolster is removed at 5 days, followed by standard skin-graft care with cleansing and application of an antibiotic ointment. A temporary tarsorrhaphy or Frost stitch can be removed or left in place for 5 to 7 days while skin graft revascularization matures.

If the burn injury to the lower eyelid is isolated and adjacent, normal tissue is available; the surgeon might consider resurfacing the lower-eyelid release with a local flap. Nasolabial (nasojugal) flaps can be helpful, especially for a medial ectropion ( Fig. 57.8 ). In the classic description of this flap, the vascular supply is retrograde flow in the angular artery. However, it is most commonly raised as a randomly patterned flap for the current application. Its base must be designed at the most medial extent of the horizontal ectropion release incision. If the flap design is incorrect or mobilization is inadequate, an inferior pull on the eyelid may be created and the ectropion correction compromised. The donor site is closed primarily with the scar along the nasolabial crease. Even in optimal conditions using a flap, the reoperation rate can still approach 10%.

Lower-eyelid ectropion release and nasolabial flap.

An inferiorly based temporal flap may be useful for an ectropion localized to the lateral end of the lower eyelid. Because the flap’s donor site is superior to the horizontal releasing incision, an upward pull on the lower lid will occur, improving eyelid support and correction of the deformity. If the entire lower eyelid is to be released, it may be wise to delay the flap. Care must be exercised in the dissection to avoid injury to the frontal branch of the facial nerve and frontalis muscle. The donor defect is directly closed.

Particularly in older individuals with upper-eyelid skin redundancy, an orbicularis oculi myocutaneous flap has been used for the management of lower-lid ectropion ( Fig. 57.9 ). By incorporating the orbicularis oculi muscle, the blood flow to the transferred skin is optimized. The flap has been described with a medial or lateral base and a modified Tripier, bipedicled design. The author’s preference is a laterally based flap. The mobility of the bipedicled flap is often a problem, and a medially based flap can result in distortion of the medial canthus and risks injury to the lacrimal drainage system.

Lower-eyelid ectropion release and upper eyelid myocutaneous flap.

The tissue of the upper-eyelid myocutaneous flap is very similar to that excised in a standard blepharoplasty technique. The amount of tissue available is determined by pinching the upper-lid skin with forceps with the lids closed. This technique results in a very acceptable and well-healed supratarsal fold scar. By basing the flap laterally, suspension and added support are provided to the lower lid. The upward pull of the laterally based flap assists in maintaining the lower-lid release in the desired position and reduces the risk of recurrence.

Correction of ectropion has been described using local, small tissue expanders. However, this is probably limited to mild degrees of ectropion or very localized scar bands and applies only to burns in unusual circumstances.

A more aggressive, multimodality approach is recommended with more severe forms of ectropion, mainly if it is recurrent or has an extrinsic force component. This can include locoregional flaps, augmentation of lid support, canthoplasties, and midface suspension techniques.

Locoregional flaps may be available for lower-lid ectropion management, often including hair-bearing tissue for eyebrow reconstruction. These can provide thin flaps with a good color match to the eyelid skin. Bozkurt et al. have described a three- “finger” superficial temporal artery fascial flap, the Medusa flap, with a large fan-shaped fascial component. This is split to provide the upper and lower eyelids a fascial base to place a full-thickness skin graft and a hair-bearing island for the eyebrow. Elbanoby et al. describe a bifurcated superficial temporal artery flap that contains a hair-bearing island on the parietal branch for the eyebrow and a skin island on the frontal branch, which can be used for upper- or lower-eyelid ectropion resurfacing. Paramedian forehead flaps can be split to manage severe burn scar ectropion or even total loss of both upper and lower eyelids. Retrograde postauricular island flaps based on communications between the superficial temporal and postauricular arteries may also be available for this application.

It may be helpful to increase lid support to counteract contractile forces. Acellular dermal allograft, hard palate, and conchal cartilage grafts augment tarsal support. Fascial slings of temporalis fascia or tensor fascia lata placed between the orbicularis and tarsal plate and fixated to the medial and lateral canthal ligament insertions have been recommended to reduce ectropion recurrence. ^,

A canthopexy/canthoplasty may be indicated to provide additional support in severe or recurrent cases of ectropion, significantly if the burn compromises the function of the lateral canthal ligament. The choice of technique will depend on the severity of the lateral canthal deformity and surgeon preference. Inferior retinacular suspension, dermal orbicular pendant canthoplasty, and lateral tarsal strip techniques have been described with fixation to the lateral orbital rim periosteum. Zucal et al. recommend a lateral transosseous canthopexy with the suspension of the canthal tendon employing a nonabsorbable suture through drill holes in the orbital rim. This provides a more permanent result and is likely the optimal approach for significant burn scar ectropion. Lengthening of the lid margin may occur with long-standing ectropion or a preexisting lower-lid laxity in an older patient. To correct this, a wedge resection of the lateral, posterior lamella should be combined with a canthopexy.

Extrinsic forces from cheek and neck scars can contribute to lower-eyelid ectropion. Nonoperative techniques such as scar massage, compression garments, silastic sheeting, Uvex masks, facial exercises, and a Therabyte device have all been used to stretch, soften, and mature the facial scar tissue. In limited degrees of contracture, local tissue rearrangement, perhaps in conjunction with fractional laser and lateral tarsorrhaphies, can be helpful. ^, Larger local flaps, such as the cervicofacial rotation/advancement flap, have been used; however, long term, they tend to experience a downward pull because of gravity and facial animation, compromising the improvement. Scar release and skin grafting, even augmented with dermal substitutes, results in poor aesthetic results as it looks like a “patch.” As a result, midface suspension, often combined with a canthoplasty, has been proposed for more severe forms of lower-lid ectropion, especially if extrinsic forces are present. This is similar to the techniques of aesthetic midface lifting with the suspension of the suborbicularis oculi fat and malar fat pads to the orbital periosteum. ^, Vana and others ^, recommend bone fixation using nonabsorbable sutures through drill holes in either the inferior orbital rim or anterior skull to provide a more permanent result. Supraperiosteal and subperiosteal approaches have been described through open, transconjunctival, or endoscopic access.

Egeland et al. advocate a particularly aggressive, multimodality approach in pediatric patients, which includes complete intrinsic and extrinsic scar release, including orbicularis, reinforcement of the tarsal support with a conchal cartilage graft, medial and lateral canthoplasties, midface suspension, and closure of the lower lid defect with a full-thickness skin graft.

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