RU2611940C1 - Method of blepharoplasty of vast full-thickness defects of eyelids by means of autotransplant with complex composition - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to ophthalmology, and is intended for reconstructive surgery of vast full-thickness defects of eyelids. First autotransplants are prepared: free mucoperiosteal flap from hard palate, free skin flap on posterior surface of pinna and muscular-fascial flap from temple on wide feeding base not less than 10 mm. Internal layer of eyelid is formed by fixation of mucoperiosteal flap to remnants of ligament apparatus and/or periosteum of orbital rim and to edge of fornix conjunctiva, after that, to form medium layer muscular-fascial flap from temple with wide feeding base is rotated and laid into defect zone and sewn to remnants of circular muscle, then external layer of eyelid is formed by free skin flap from posterior surface of pinna with its sewing to edges of recipient zone, after which 1-2 temporary immobilising U-shaped sutures , which are removed together with sutures from skin transplant on 10-12 day, are applied on formed and healthy eyelid.

EFFECT: method makes it possible to achieve correct eyelid position, reconstruction of its normal shape and good functional activity, increase of cosmetic efficiency of operation.

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Description

The invention relates to medicine, namely to ophthalmology, and is intended for reconstructive surgery of extensive full-layer defects of the eyelids.

Extensive full-layer defects of the eyelids are defects affecting 50% of the area of the eyelid or more with the depth of damage to all three layers of the eyelid: skin, muscle and mucous-cartilaginous. The most common cause of such eyelid defects are injuries and severe burns, which are accompanied by deep destruction and tissue necrosis. Another equally important reason for full-layer defects of the eyelids is the surgical removal of tumors that capture the entire thickness of the eyelid. For reconstruction of the eyelids in such cases, it is necessary to restore all layers of the eyelid, the front and back surfaces.

Clinical practice shows that the replacement of full-layer extensive defects of the eyelids by moving adjacent tissues from the face is not always possible due to concomitant periorbital cicatricial changes due to both trauma and oncological surgery, as well as previously unsuccessfully performed plastic reconstructions (Egorova E.V., Gushchina M.B., Tereshchenko A.V., Molotkova I.A., 2005, Kataev M.G., 2013)

In reconstructive blepharoplasty, the most widely used methods of replacing eyelid defects with free skin, mucous and mucous-cartilage grafts (Grusha Y.O., Ismaylova D.S., Rizopulu E.F., 2013, Lantukh V.V., Lantukh E.V., 2001, Filatova I.A., 2007). The places of borrowing the skin in these methods are the forehead, temple, cheeks, nasolabial triangle, the inner surface of the shoulders, the mucous membranes of the mouth and nose.

The disadvantage of such techniques is that when choosing a donor area in the face area, new skin scars appear in cosmetic and aesthetic areas that reduce the quality of the psychological life of patients. In addition, transplantation of free transplants carries a high risk of vascular-trophic disorders, necrosis, rejection, contractions, secondary cicatricial deformities of the eyelids (inversion, eversion, lagophthalmos, retraction of the eyelids), which require, according to ophthalmic literature, 20-60% of repeated cases reconstructive operations (Malakhovskaya V.I., 1997).

At present, with extensive full-layer defects of the eyelids, preference has been given to combined methods of reconstructive surgery aimed at the anatomical restoration of the normal three-layer structure of the eyelids.

There is a blepharoplasty method described by F. Burian, which consists in replacing the anterior surface of the eyelid with a flap of skin on a leg cut from the temporal region and forming the posterior surface of the eyelid due to the preserved conjunctiva (Burian F. Atlas of Plastic Surgery // State Publishing House of Med. Lit., Prague, Medicine. - Moscow, 1967. - Т 2. - P. 339-340).

The disadvantages of the method:

- lack of a skeleton of the eyelid, which leads to sagging of the formed eyelid, impaired shape, position and functional activity and creates a risk of repeated deformations requiring surgical correction;

- difficulties in obtaining the necessary volumes of the conjunctiva with complex deformations of the eyelids of large areas due to its gross changes;

- the impossibility of the simultaneous formation of both eyelids;

- insufficient depth of the lower arch for the installation of an ocular prosthesis;

A known blepharoplasty method for complex eyelid defects, proposed by Cutler Bird and Hughes, the essence of which is to close the defect with a flap on a feeding base cut from the opposite eyelid and close the donor area with a free skin autograft (Bobby S. Korn, Don O. Kikkawa Atlas of oculofascial plastic and reconstructive surgery 2011, p. 105-108).

The disadvantages of this method are:

- the condition for the successful application of the method is an intact opposite eyelid;

- the method is suitable only for plastic reconstruction of defects of the eyelids of small sizes;

- the method cannot be applied with extensive cicatricial changes in both eyelids.

There is a method for full-layer restoration of the lower eyelid, by cutting out a skin flap on a wide feeding base in the cheek area, by laterally displacing the cheek skin flap to the lower eyelid region and transplanting a free mucous-cartilaginous nasal septum flap onto the posterior surface of the displaced flap (Wesley RE, Klippenstein LA, Gallo SA, Biesman BS. Full-thickness eyelid reconstruction. Ch7. In: Oculoplastic syrgery. The essentials. Ed. By WP Chen. Thieme, New York, Stutgart. 2001. 250 p.).

The disadvantages of this method are:

- the formation of additional scars in the cosmetic and aesthetic area of the face;

- difficulties in obtaining a mucocartilaginous flap due to copious nosebleeds;

- difficulty in nasal breathing in the postoperative period due to iatrogenic wound surface;

- the operation is applicable only for plastic reconstruction of the lower eyelid and is technically not feasible for complex defects of the upper eyelid.

There is a way through plastic lower eyelid. First, a wide flap forms a skin flap below an existing lower eyelid defect. This flap is replaced with a defect of the lower eyelid. The remaining conjunctiva of the lower vault and the eyeball is separated from the eyeball and moved, tamping the displaced skin flap from the inside. A skin defect resulting from wide separation is replaced by a flap on a leg from the temporal region (Lazarenko V.I., Polezhaeva N.S., Sychev A.G. Method of through plastic surgery of the lower eyelid. RF patent No. 2214174. Publish. 20.10.2003 )

The disadvantages of this method are:

- the formation of additional scars in the central cosmetic and aesthetic areas of the face;

- the risk of cicatricial retraction of the lower eyelid in the area of suturing flaps;

- a decrease in the functional activity of the restored eyelid due to the lack of anatomical and morphological correspondence between donor material and tissues of the recipient zone.

- shortening of the conjunctival arch, with the risk of forming symblepharon.

- the risk of anomalous anatomical position of the eyelids (inversion, eversion) due to the unrestored full three-layer structure of the eyelid.

The closest analogue prototype is a method of layer-by-layer reconstruction of the eyelids with anophthalmos. A circular incision is made along the border of the preserved skin of the periorbital region and the mucous membrane. Tissues are dissected through this incision in the sagittal direction with the formation of flaps on the leg of the tissues adjacent to the wall of the orbit, and with the base at the orbital edge. These flaps rotate in the frontal plane, free full-layer autologous grafts of the lip mucosa are cut out. Then, free transplants of the mucosa are transplanted onto the posterior surfaces of the flaps and fixed to the edge of their own conjunctiva. An ocular prosthesis is placed in the formed cavity, the free edges of the mucosal autografts and then the flaps on the leg are sutured together, after which the wound surface is covered with a free full-layer skin flap. After 3-4 months, eyelashes are transplanted using rags with an eyebrow and, after engraftment of the last, an eye slit is formed (Kataev MG, Method for layer-by-layer eyelid reconstruction with anophthalmus. RF patent No. 2454210. Publ. 27.06.2012).

The disadvantages of the prototype are:

- the use of intraorbital tissues as a nourishing base carries a high risk of developing vascular trophic disorders in autografts due to the absence of an axial type of blood supply;

- a high risk of extreme inflection of blood vessels and the cessation of blood flow during rotation of intraorbital tissues, since it is impossible to form a wide feeding base;

- Inadequate blood supply to rotated flaps worsens the quality of autograft engraftment;

- the use of intraorbital tissues with severe scarring due to anophthalmos carries a high risk of secondary deformation and the need for repeated reconstructive operations;

- in the anophthalmic orbit often there is not a sufficient number of full intraorbital tissues for the formation of the feeding base with extensive defects;

- this technique does not allow to form a good skeleton of the eyelids due to the lack of fascial and cartilaginous elements in it, which creates a high risk of anomalous anatomical position of the eyelid (inversion, inversion), even during eyelash transplantation;

- The restoration of the eyelids in this way can only be done with anophthalmia.

The objective of the invention is the surgical reconstruction of the eyelids with extensive full-layer defects using a complex three-layer autograft.

The technical result of the invention is the ability to achieve the correct position of the eyelid, restore its normal shape and good functional activity, increase the cosmetic effectiveness of the operation and the quality of life of the patient, while multiple stages of blepharoplasty are excluded, there is no development of secondary cicatricial deformities and the period of surgical rehabilitation is shortened.

The invention is illustrated by drawings:

FIG. 1 - general view of the defect.

FIG. 2 - the formation of the inner layer of the eyelids using mucoperiostal flap.

FIG. 3 - rotation of the formed muscle-fascial flap from the temple on a wide feeding base.

FIG. 4 - the formation of the middle layer of the eyelids with a muscle-fascial flap from the temple with its fixation to the remains of the circular muscle.

FIG. 5 - formation of the outer layer of the eyelid with fixation of a free skin flap in the recipient area.

1. The remains of the ligamentous apparatus.

2. The periosteum of the orbital region.

3. The edge of the conjunctiva of the arch.

4. The remains of the circular muscle.

5. Mucoperiostal flap with a firm palate.

6, 12. U-shaped absorbable sutures.

7, 14. Continuous seams.

8. Muscle-fascial flap from the temple.

9. The wide nourishing base of the muscle-fascial flap.

10. The ends of the threads of the purse string suture.

11. A purse string suture.

13. Loose skin flap from the back of the auricle.

15. Immobilization U-shaped seams.

The technical result is achieved as follows.

After processing the surgical field, the defect of the damaged eyelid is corrected by dissecting and excising scars, and separating the wound edges of the recipient zone. For hemostasis, a plate of a sterile collagen hemostatic sponge is placed on the wound surface. Next, they prepare the complex three-layer autograft and model the tissue flaps that make it up, corresponding in shape and area to the defect.

First, a free mucoperiostal flap is prepared from the hard palate, which, until the eyelid defect is replaced to prevent infection of the wound surface of the recipient area with the microbial flora of the oral cavity, is placed in a sterile cloth soaked in 0.3% tobromycin solution.

A free skin flap is then formed on the posterior surface of the auricle, which is also placed in a sterile tissue soaked in a 0.3% tobromycin solution.

The last is to cut the muscle-fascial flap from the temple on a wide nourishing base, through a skin incision made in the preauricular zone behind the hair growth. In a dull way, the superficial temporal fascia is separated from the subcutaneous fat. 2 mm away from the line of attachment of the temporal muscle to the temporal bone, in order to prevent bleeding, a purse string suture 11 is applied to the temporal-parietal fascia and the superficial muscle portion (Fig. 3), while to create a retaining ligature, the ends of the threads 10 are 3 cm long, which knotted on 2-3 knots. The superficial temporal fascia and muscle are cut off from the attachment point in front of the purse string suture and separated with a single complex from the deep temporal fascia and the deep portion of the muscle towards the upper edge of the zygomatic arch, reaching the edge of the zygomatic arch (the site of the formation of the middle temporal artery from the superficial temporal artery and posterior temporal artery arteries from the maxillary artery, which play a major role in the blood supply to the separated tissues). In this case, the feeding base is left at least 10 mm wide in order to prevent the inflection of the vascular bundle during rotation of the muscular-fascial flap from the temple to the recipient area.

Then proceed directly to the elimination of an extensive full-layer defect of the eyelid (Fig. 1) with the help of prepared flaps. Remove the hemostatic sponge. Initially, the inner layer of the eyelid is formed (Fig. 2) by fixing the mucoperiostal flap 5 in the recipient area to the remnants of the ligamentous apparatus 1 and / or periosteum of the orbital edge 2 with U-shaped absorbable sutures 6 with a 4-0 polyglycolide thread and to the edge of the conjunctiva of the arch 3 with a continuous absorbable suture 7 strand 7-0 polyglycolide.

Then rotate (Fig. 3) the muscle-fascial flap from the temple 8 on a wide feeding base 9 into the defect zone and form the middle layer of the eyelid (Fig. 4). The ends of the threads 10 of the purse string suture 11 forming the ligature are cut off, the muscular-fascial flap 8 is placed over the mucoperiostal flap and fixed to the remnants of the circular muscle by 4 U-shaped absorbable sutures 12 with a 4-0 polyglycolide thread.

Then, the outer layer of the eyelid is formed (Fig. 5) with a free skin flap from the posterior surface of the auricle 13 with fixation by a continuous suture 14 to the edges of the recipient zone with a 5-0 polyglycolide thread. Next, 1-2 temporary immobilization U-shaped suture 15 is applied to the formed and healthy eyelid (Fig. 5).

Sutures from the skin graft and immobilization sutures of temporary blepharography are removed on 10-12 days.

The advantages of the proposed method are:

1. The method allows for one operation to carry out the replacement of an extensive defect of the eyelid with a lesion area of 50% or more.

2. The method fully provides in one operation the possibility of restoring the three-layer structure of the eyelid, which leads to its correct anatomical shape and position, correct functional activity.

3. There is no risk of transplant rejection, necrolysis, wrinkling, secondary scarring due to good vascular-trophic conditions of engraftment due to the use of our own biomaterial that does not have antigenic properties.

4. There is no risk of extreme kinking of blood vessels and cessation of blood flow during rotation of the muscular-fascial flap from the temple to the recipient area due to the wide feeding base - 10 mm or more.

5. There is no need for multi-stage plastic reconstruction for eyelid extensions.

6. Provides uncomplicated engraftment of a complex autograft to the patient's avascular tissues.

7. The duration of the period of surgical rehabilitation is reduced.

8. The conditions for the operation are improved, hematoma prophylaxis is achieved due to a decrease in the bleeding of the vessels of the feeding base of the muscular-fascial flap by applying a purse string suture to its top.

9. The presence in the complex complex of the restored eyelid of a mucoperiostal flap that imitates the density of the cartilaginous plate, and the presence of fascia in the temporal muscle make it possible to form a dense skeleton of the eyelids and avoid the risk of an anomalous anatomical position of the eyelids (inversion, inversion).

10. Improving the quality of the patient’s psychological life, eliminating the negative consequences of the patient’s moral and aesthetic injury, since the necessary volumes of transplant biomaterial are obtained outside the central cosmetic and aesthetic zones of the face.

11. Reconstruction of the eyelids is possible both in the presence of an eyeball, and with anophthalmos.

The proposed method for plastic and reconstructive surgery of full-layer eyelid defects using a complex tissue complex was applied in 15 patients (15 eyes) aged 30 to 62 years (average age 48.9 ± 14 years), of which 9 were men and 6 were women.

The immediate cause of cicatricial deformity of the eyelids was: mechanical (road) injury - 7 people, gunshot and explosive injury - 2 people, tumor surgery - 4 people, animal bites - 2 people. In 10 patients, complex cicatricial defects occurred in the upper eyelid, in 5 - in the lower. Each of the patients included in the observation group had previously undergone from 2 to 4 reconstructive plastic surgeries.

The area of cicatricial deformation of the eyelids, subject to plastic reconstruction, was measured with a millimeter grid and varied from 69 mm ² to 105 mm ² (average 87.5 ± 9.0 mm ² ).

Patients of the above group were operated according to the proposed method using a complex autograft to close the zone of a full-layer eyelid defect. The postoperative follow-up period ranged from 1 to 2 years, the average follow-up was 16 months. During this period, additional stages of surgical correction were not required. As a result of the operation, a positive result was achieved in all cases: the correct position of the eyelids, complete closure of the palpebral fissure, their good adaptation to the eyeball, and normal size of the fissure. In no case was the formation of secondary cicatricial deformity recorded.

Example No. 1

Patient K., 25 years old, was admitted with a diagnosis of post-traumatic cicatricial full-layer defect of the lower eyelid of the right eye.

From the anamnesis: 2 years ago received an injury (dog bite). He underwent 3 operations, after which a full-layer defect of the lower eyelid with an area of 69 cm ² remained unclosed. A reconstructive surgery was performed to restore the lower eyelid of the claimed method.

After processing the surgical field, a correction of the eyelid defect was performed by dissection and excision of scars, subseparation of the wound edge of the recipient zone, hemostasis using a collagen hemostatic sponge. The preparation of a complex transplant was made by cutting out the tissue flaps of its constituent, corresponding in shape and area: a free mucoperiostal flap from the hard palate, a free skin flap from the posterior surface of the auricle; muscle-fascial flap from the temple on a feeding base 12 mm in size through an incision in the preauricular zone behind hair growth. The operation to replace the scar defect consistently included: the formation of the inner surface of the eyelid by fixing the mucoperiostal flap with a U-shaped suture to the remnants of the ligamentous apparatus and a continuous suture to the edge of the conjunctiva of the lower arch; rotation of the muscle-fascial flap from the temple to the area of the defect and its fixation to the remnants of the circular muscle with U-shaped seams; the formation of the outer surface of the eyelid using a skin flap, fixing it with a continuous suture to the edges of the recipient zone; Then, 2 immobilization U-shaped sutures were placed on the formed and healthy eyelid.

The sutures from the skin graft and the immobilization sutures of temporary blepharography were removed on the 11th day after the operation. In the early postoperative period (up to 10 days), moderate postoperative tissue edema was observed in the area of the operation, there were no signs of transplant necrosis, and there were no inflammatory reactions.

Late postoperative period (on day 28): position and shape of the eyelids correct, complete closure of the palpebral fissure. The cosmetic effect of the operation is quite high, the width of the palpebral fissure - 11 mm - corresponds to the healthy side, the color of the skin in the transplant area does not differ from the color of the surrounding healthy skin.

On examination after 2 years: a positive result was achieved - plastic reconstruction remains stable, there is no tendency to the formation of secondary cicatricial deformity of the lower eyelid.

Example No. 2

Patient S., 56 years old, was admitted with a diagnosis of cicatricial full-layer defect of the upper eyelid of the right eye. The defect area was 72 cm ² .

From the anamnesis: operated on for basal cell carcinoma T3N0M0, and then - 2 times to replace the resulting defect, which remained unclosed. The operation for blepharoplasty of the upper eyelid by the claimed method.

After processing the surgical field, a correction of the eyelid defect was performed by dissection and excision of scars, subseparation of the wound edge of the recipient zone, hemostasis using a collagen hemostatic sponge. A complex autograft was prepared by cutting out the tissue flaps that made it up, corresponding to the defect in shape and area: a free mucoperiostal flap from the hard palate, a free skin flap from the posterior surface of the auricle; muscle-fascial flap from the temple on a feeding base 15 mm in size through an incision in the preauricular zone behind the hair growth zone. The operation to replace a scar defect consistently included: the formation of the inner surface of the eyelids by fixing the mucoperiostal flap with a U-shaped suture to the remnants of the ligamentous apparatus and a continuous suture to the edge of the conjunctiva of the superior fornix; rotation of the muscle-fascial flap from the temple to the area of the defect and its fixation to the remnants of the circular muscle with U-shaped seams; the formation of the outer surface of the eyelid with a skin flap and its fixation with a continuous suture to the edges of the recipient zone; Then, 2 immobilization U-shaped sutures were placed on the formed and healthy eyelid.

The sutures from the skin graft and the immobilization sutures of temporary blepharography were removed on the 10th day after the operation. In the early postoperative period (up to 10 days), moderate postoperative tissue edema was observed in the area of the operation, there were no signs of transplant necrosis, and there were no inflammatory reactions.

Late postoperative period (30 days): the position and shape of the eyelids are correct, complete closure of the palpebral fissure. The cosmetic effect of the operation is high, the width of the palpebral fissure of the operated eye is 10 mm, the healthy side is 11 mm, the color of the skin in the transplant area does not differ from the color of the surrounding healthy skin.

Claims (1)

A method for blepharoplasty of extensive full-layer defects of the eyelids using a complex autograft, which consists in restoring the eyelid by moving tissue grafts, characterized in that autografts are first prepared: a free mucoperiostal flap from the hard palate, a free skin flap on the posterior surface of the auricle and a muscular-fascial flap with on a wide feeding base of at least 10 mm, then the inner layer of the eyelid is formed by fixing the mucoperiostal flap to the remains with of the lingual apparatus and / or periosteum of the orbital margin and to the edge of the conjunctiva of the arch, then, to form the middle layer of the eyelid, the muscle-fascial flap from the temple is rotated and laid on the wide feeding base and stitched to the remains of the circular muscle to form the outer layer of the eyelid with a free with a skin flap from the posterior surface of the auricle with its hemming to the edges of the recipient zone, then 1-2 temporary immobilization U-shaped sutures are applied to the formed and healthy eyelid, which are removed together with the sutures c skin graft on days 10-12.

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