RU2750746C2 - Method for reconstruction of lower eyelid after wide excision of tumor - Google Patents

Abstract

FIELD: plastic surgery, ophthalmology.

SUBSTANCE: invention relates to reconstructive plastic surgery, ophthalmology and oncology. A skin-fascial paramedian frontal flap is formed on the feeding pedicle from the supra-block vessels. The formed flap is moved to the area of the resected eyelid and the anterior wall of the lower eyelid is formed. The flap is fixed at the edges of the wound, and nodal sutures are additionally applied between the flap and the periosteum of the lower wall of the orbit. A skin bridge flap is formed from the upper eyelid and rotated into the area of the resected inner wall of the orbit, the skin pad of the flap is set in the position of the mucosa and fixed at the edges of the remnants of the conjunctiva of the eye. Next, the upper edges of the flaps are sewn together with separate nodal sutures and a bridge-like flap restores the integrity of the mucosa of the resected eyelid. After that, the donor wounds are sutured in layers with a cosmetic suture and temporary stitches are applied between the formed lower eyelid and the upper eyelid, the feeding leg of the flap is crossed after 2 months.

EFFECT: method makes it possible to form the anterior and posterior layers of the resected eyelid, which have a stable frame, as well as to improve the functional and cosmetic result and the quality of life of the patient.

1 cl, 4 dwg, 1 ex

Description

The invention relates to reconstructive plastic surgery in oncology, namely to plastic ophthalmic surgery, and relates to methods for restoring the eyelids during their resections for oncological operations.

Extensive full-thickness eyelid defects are considered defects involving 50% of the area of the eyelid or more with the depth of the lesion of all three layers of the eyelid: cutaneous, muscular and muco-cartilaginous. The most common causes of such eyelid defects are surgical resections for cancer, trauma and severe burns. After resections for large tumor formations, complete or partial absence of the eyelid may occur, and lesions may also involve both eyelids. In this connection, the use of adjacent surface tissues does not provide the necessary reconstructive and cosmetic effect. For the full rehabilitation of patients in such cases, it is necessary to restore all layers of the eyelid, the front and back surfaces.

Clinical practice shows that replacement of full-thickness extensive eyelid defects by moving adjacent tissues from the face is not always possible due to concomitant periorbital cicatricial changes caused by both the trauma itself and the oncological operation, and 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-cartilaginous grafts (Grusha Ya.O., Ismaylova D.S., Rizopulu E.F., 2013, Lantukh V.V., Lantukh E.V., 2001, Filatova I.A., 2007).

Skin donors for skin collection can be areas of skin with less pronounced hair: the biting area, the inner surface of the shoulders, the frontal, temporal region. The mucous membranes of the mouth and nose can serve as donors of mucous flaps. Cartilage from the curl of the auricle, nasal septum.

There are various methods for full-layer eyelid reconstruction.

The known method of Hughes and Cutler-Byrd, including the formation of one layer of the eyelid due to the flap on the supply base, cut out from the opposite eyelid, and the transplantation of a free graft that covers the wound surface of the first flap and performs the second layer of the eyelid (Long JA. Oculoplastic surgery. Saunders, Elsevier . 2009, pp. 119-125).

However, the known method has several disadvantages: an intact opposing eyelid is required; the method is suitable only for the reconstruction of small defects of the eyelids, and with extensive cicatricial changes in both eyelids, this method cannot be used.

There is a known method for restoring the lower eyelid (Bastrikov N.I. Method for restoring missing eyelids. "Bulletin of Ophthalmology", No. 2, 2004, page 36), including dissection of skin scars and subcutaneous tissues below the missing lower eyelid, stitching the eyelids and grafting a free skin flap on the wound surface in the area of the lower eyelid. The main purpose of this method is to protect the cornea from xerosis.

However, the known method is ineffective for gross cicatricial changes in the soft tissues of the intraorbital region.

The known method of blepharoplasty, including the replacement of the front surface of the eyelid with a flap of skin on the leg, cut out from the temporal region and the formation of the posterior surface of the eyelid due to the preserved conjunctiva (Burian F. Atlas of plastic surgery // State Publishing House Med. Lit., Prague, Medicine. - Moscow, 1967. - T 2. - S. 339-340).

However, the known method has several disadvantages:

- there is no frame basis of the eyelid, which leads to sagging of the formed eyelid, the risk of deformities that may require repeated surgical correction;

- lack of volume of the conjunctiva with complex deformities of the eyelids of large areas.

There is a known method of through plastic surgery of the lower eyelid, where at first a skin flap is formed below the existing defect of the lower eyelid with a wide separation, the defect of the lower eyelid is replaced with this flap, and the remaining conjunctiva of the lower fornix and the eyeball is separated from the eyeball and moved, knocking the displaced skin flap from the inside, the defect The skin formed as a result of wide separation is replaced with a pedicle flap 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. Publ. 20.10.2003) ...

The disadvantages of this method are:

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

- shortening of the conjunctival fornix, with the risk of the formation of simblepharon;

- the risk of an abnormal anatomical position of the eyelids (volvulus, eversion) due to an unrecovered full three-layer eyelid structure.

For the prototype, Mustard's method was adopted, including full-layer restoration of the lower eyelid by cutting out a skin-fat buccal flap on a wide base, the buccal flap is displaced to the area of the resected lower eyelid and a free muco-cartilaginous nasal septum flap is transplanted onto the posterior surface of the displaced flap (Wesley RE, Klippenstein LA , Gallo SA, Biesman BS. Full-thickness eyelid reconstruction. Ch 7. In: Oculoplastic surgery. The essentials. Ed. By WP Chen. Thieme, New York, Stutgart. 2001, p. 250).

However, in the known method there is no sufficient amount of tissues in case of cicatricial changes in the surrounding tissues, because it is necessary to widely mobilize the skin-fat buccal flap, which leads to a high risk of damage to the buccal and zygomatic branches of the facial nerve with the development of paresis or paralysis of these branches of the facial nerve, as well as traumatization of the nasal septum during the collection of the cartilaginous portion of the flap, which may further lead to disruption nasal breathing.

The objective of the present invention is to develop an improved method for the reconstruction of the eyelids with extensive full-thickness resections of the lower eyelids.

The technical result of the proposed invention is the formation of the anterior and posterior layers of the resected eyelid, having a stable frame, as well as a functional and cosmetic result and an improvement in the patient's quality of life.

The indicated and technical therapeutic results are achieved due to the fact that, as in the known method, the lower eyelid is fully restored by cutting out a skin-fatty buccal flap on a broad base and the cervical flap is displaced to the area of the resected lower eyelid and a free muco-cartilaginous flap of the nasal septum is transplanted onto the posterior surface of the displaced flap.

The peculiarity of the proposed method lies in the fact that the skin-fascial paramedian frontal flap is formed on the feeding leg from the supra-block vessels, the formed flap is moved to the area of the resected eyelid and the anterior wall of the lower eyelid is formed, the flap is fixed along the edges of the wound, and interrupted sutures are additionally applied between the flap and the periosteum the lower wall of the orbit, a skin bridge-like flap is formed from the upper eyelid and rotated into the area of the resected inner wall of the orbit, the skin area of the flap is set in the position of the mucous membrane and fixed along the edges of the remnants of the conjunctiva of the eye, then the upper edges of the flaps are sutured together with separate interrupted sutures and the bridge-shaped flap is restored the integrity of the mucous membrane of the resected eyelid, after which the donor wounds are sutured layer by layer with a cosmetic suture and temporary sutures are applied between the formed lower eyelid and the upper eyelid, the feeding leg of the flap is cut after 2 months.

The invention is illustrated by a detailed description, a clinical example and illustrations, which depict:

FIG. 1 - operation scheme: 1 - postoperative defect of the lower eyelid; 2 - bilobar fascial flap from the forehead; 3 - bridge skin flap from the upper eyelid; 4 - bridging skin flap from the forehead, rotated 180 °.

FIG. 2 - photo illustration of patient T., before surgery.

FIG. 3 - photo illustration of patient T., reconstruction stage.

FIG. 4 - photographic illustration of patient T., through the final view after surgery.

The method is carried out as follows.

At the first stage, an oncological operation is performed in volume with a full-layer resection of the lower eyelid. Next, a paramedian skin-fascial frontal flap is formed on the feeding pedicle from the supra-block vessels. The formed flap is moved to the area of the resected eyelid, thus forming the anterior wall of the lower eyelid and fixed along the edges of the wound. Additionally, interrupted sutures between the flap and the periosteum of the inferior wall of the orbit are applied holding the flap in this position. A skin bridge-like flap is formed from the upper eyelid, the formed flap is rotated into the area of the resected inner wall of the orbit, the skin area of the flap is set in the position of the mucous membrane and fixed along the edges of the remnants of the conjunctiva of the eye. The upper edges of the flaps are sutured together with separate interrupted sutures. Thus, with a bridge flap, the integrity of the mucous membrane of the resected eyelid is restored (Fig. 1).

Donor wounds are sutured in layers with a cosmetic suture on the skin. Temporary sutures are applied between the formed lower eyelid and the upper eyelid, which are removed after 10-14 days. After 2 months, the next stage of reconstruction is performed - the feeding leg of the flap is crossed.

Clinical example of the method.

Patient T., 70 years old. Diagnosis: Basal cell carcinoma of the skin of the lower eyelid on the left, IIst cT2N0M0. Condition after surgical treatment with laser ablation and PDT from 31.08.2012. Relapse of rT3N0M0 tumor (Fig. 2).

An oncological operation was performed with a full layer resection of the lower eyelid. A fascial paramedian cutaneous frontal flap was formed on the feeding pedicle from the supra-block vessels. The formed flap was moved to the area of the resected eyelid, and the anterior wall of the lower eyelid was formed, fixing it along the edges of the wound. Additionally, a retaining flap was applied in this position, interrupted sutures between the flap and the periosteum of the inferior wall of the orbit. A skin bridge-like flap was formed from the upper eyelid and rotated into the area of the resected inner wall of the orbit, the skin area of the flap was placed in the position of the mucous membrane and fixed along the edges of the remnants of the conjunctiva of the eye. The upper edge of the flaps was sutured together with separate interrupted sutures and the integrity of the mucous membrane of the resected eyelid was restored. Donor wounds were sutured in layers with a cosmetic suture on the skin (Fig. 3).

Temporary sutures were placed between the formed lower eyelid and the upper eyelid, which were removed after 10 days. After 2 months, the feeding pedicle of the flap was transected (Fig. 4).

The proposed method makes it possible to create, using a paramedian flap, the outer wall of the lower eyelid and the frame structure of the lower eyelid with its extensive and subtotal defects; using a skin bridge flap, the inner wall of the lower eyelid is restored. This method leads to the achievement of the best functional and cosmetic results of the reconstruction.

Claims (1)

A method for reconstruction of the lower eyelid after a wide excision of the tumor, including full-thickness restoration of the lower eyelid by cutting out a flap, displacement of the flap to the area of the resected lower eyelid, characterized in that a skin-fascial paramedian frontal flap is formed on the feeding pedicle from the supra-block vessels, the formed flap is moved to the area of the resected eyelids and form the anterior wall of the lower eyelid, the flap is fixed along the edges of the wound, additionally interrupted sutures are applied between the flap and the periosteum of the lower wall of the orbit, a skin bridge-like flap is formed from the upper eyelid and rotated into the area of the resected inner wall of the orbit, the skin area of the flap is set in the position of the mucosa and fixed along the edges of the remnants of the conjunctiva of the eye, then the upper edges of the flaps are sutured together with separate interrupted sutures and a bridge-like flap; the integrity of the mucous membrane of the resected eyelid is restored, after which the donor wounds are sutured in layers cosmetically kim suture and temporary sutures are applied between the formed lower eyelid and the upper eyelid, the feeding leg of the flap is crossed after 2 months.

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