Reconstruction of Burned Eyelids
David A. Billmire
Kim A. Bjorklund
The majority of ocular sequelae following facial burns occur as a result of secondary eyelid deformities.1
Burn scar contracture can lead to cicatricial ectropion and lagophthalmos, which may in turn produce exposure keratopathy and in severe cases result in corneal scarring.
The eyelids are complex structures providing protection and lubrication for the surface of the globe.
They contain an anterior and posterior lamella, which are separated by the orbital septum.
In children, the levator muscle is rarely involved.
Eyelid skin is naturally thin and may result in a deeper burn than a similar heat exposure elsewhere in the body.
Contractures most often affect the lower lids.
Reduction of motion and coverage may be the result of direct scar contracture to the lid itself (intrinsic) or burn scar contracture in sites remote to the lids such as the cheeks, mouth, neck, and forehead.
Burn scar contracture affects the motion and excursion of the lids and consequently the coverage of the cornea.
With deeper burns, lagophthalmos of the lids develops and places the eye at risk.
Bell phenomenon reflex helps prevent corneal epithelial defects and may be problematic if absent such as in heavily sedated or paralyzed patients.1
NATURAL HISTORY AND PHYSICAL FINDINGS
Patients frequently present with an inability to fully close their eyes and may complain of irritation and discomfort.
The eyes should be carefully examined to determine the etiology of the dysfunction, noting if the anterior or posterior lamellae are affected and whether there are additional extrinsic burn scars contributing to the contracture.
These symptoms tend to be better tolerated in children than adults.
The depth and extent of the eyelid burns should be noted, as well as presence of eyebrows and eyelashes.1
The eyelids tend to demonstrate stiffness and fail to completely cover the eyes, which may be most noticeable when the patient is asleep. Parents should be queried about the status of the lids when the child sleeps. It is also easily noticed when the child is under anesthesia.
The conjunctiva of the lower lids may be everted and pulled down onto the cheeks.
The upper lids may demonstrate “clotheslining” where a band of scar runs from the lateral canthus to medial canthus and functions as a fixed point holding the lid up and preventing closure.
Reconstructive planning should include examination of both upper and lower eyelids, extent of surrounding scar, including cheek and forehead, and donor sites for potential FTSG.
In mild to moderate cases, eye drops and lubricants and taping can be used temporarily until definitive release is performed.
In the acute burn phase, corneal exposure may be managed by a temporary tarsorrhaphy, which is replaced as soon as the patient is stable with a formal eyelid release-resurfacing.
The eyelids are delicate structures and tarsorrhaphies routinely pull out and fail and should not be relied upon for an extended period of time.
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