Chapter 94 – Eyelid Trauma and Reconstruction Techniques
JEFFREY P. GREEN
GEORGE C. CHARONIS
ROBERT ALAN GOLDBERG
• Injuries varying from simple skin abrasions to more complex cases with extensive tissue loss and underlying fractures of the facial skeleton.
• Caused by blunt or penetrating facial trauma.
• Partial-thickness eyelid injury.
• Eyelid margin lacerations.
• Eyelid injuries with tissue loss.
• Full-thickness eyelid injury.
Injuries that involve the eyelids and periorbital area are common after blunt or penetrating facial trauma. Such injuries can vary from simple skin abrasions to more complex cases that have extensive tissue loss and underlying fractures of the facial skeleton. A complete assessment of the trauma patient is critical to determine the extent of the underlying systemic damage, but stabilization of vital systems should be the first priority in the management of these patients. After successful stabilization of the patient’s systemic condition has been achieved, attention can be directed toward the specific ocular adnexal injuries. Restoration of structure and function along with adherence to basic esthetic principles should be the primary concern of the reconstructive surgeon involved in the management of such injuries.
In this chapter, general principles for the evaluation and management of eyelid trauma are discussed. The most common types of adnexal injuries are presented in a systematic approach. Ocular adnexal trauma can be very challenging and often tests the ingenuity of the reconstructive surgeon. Several management principles and surgical techniques that can minimize postoperative complications and improve esthetic results and function are explained. This can often have a dramatic impact on the patient’s life, as secondary defects can be very difficult or even impossible to correct in later surgery.
PREOPERATIVE EVALUATION AND DIAGNOSTIC APPROACH
The evaluation of periorbital injuries begins after the traumatized patient has been stabilized and life-threatening injuries addressed. The role of the ophthalmologist in the evaluation and management is very important—good communication must exist between the trauma team and the ophthalmologist. The presence of subjective symptoms related to the visual system or physical evidence of periorbital injuries demands the immediate attention of the ophthalmologist. The incidence of ocular injuries in craniofacial trauma is high, ranging between 15 and 60% in various studies.
A complete history is obtained to determine the time course and circumstances of the injury. For children, consideration must be given to the possibility of child abuse as the cause of ocular and periorbital injury. A history consistent with injuries from high-speed projectile particles may require the appropriate imaging studies to determine the presence of intraocular or intraorbital foreign bodies. Animal and human bites deserve particular attention and are managed accordingly with the administration of appropriate antibiotics. The site of injury is inspected carefully for any missing tissue, and any amputated tissue found at the site of injury is preserved and placed on ice as soon as possible. In most cases this tissue can be sutured back to the proper anatomic location.
Assessment of visual acuity is mandatory and made prior to any reconstructive efforts. The pupils are checked and, if a relative afferent pupillary defect is found, the potential of poor visual outcome is discussed with the patient prior to surgical repair. The extraocular muscles are evaluated and any diplopia documented prior to surgery. The external examination includes a complete bone assessment of the facial skeleton, with particular emphasis on the periorbital region. A palpable step-off, crepitus, or unstable bone requires radiological evaluation. The baseline measurement of globe projection is documented with Hertel exophthalmometry because enophthalmos is a common late sequela of orbital trauma. Eyelid position, orbicularis muscle function, and any evidence of lagophthalmos are documented thoroughly. Measurement of the intercanthal distance and evaluation of the integrity of the canthal tendons are also performed because traumatic tendon dehiscence and telecanthus are frequently associated with periorbital injuries. The integrity of the lacrimal system is checked, with a high index of suspicion for canalicular lacerations (see Chapter 98 ).
All injuries are documented precisely and completely. This can be done with detailed drawings on the patient’s charts or, even better, with photographic documentation. Bullets and other projectiles must be retained and marked so that no break occurs in the chain of evidence. The medicolegal implications can be significant, so every effort must be made to complete the preoperative documentation of every injury.
TABLE 94-1 — GUIDELINES FOR TETANUS PROPHYLAXIS IN WOUND TREATMENT
Clean, Minor Wound
Other Type of Wound
Tetanus and diphtheria toxoids*
Tetanus and diphtheria toxoids + tetanus immune globulin
None or one previous dose
Tetanus and diphtheria toxoids**
Tetanus and diphtheria toxoids + tetanus immune globulin
Two previous doses
Tetanus and diphtheria toxoids**
Tetanus and diphtheria toxoids†
More than three previous doses
None unless the last dose is more than 10 years previously
None unless the last dose is more than 10 years previously
Adapted from Mustarde JC. Eyelid reconstruction. Orbit. 1983;1:33–43.
* Adult type; for children less than 7 years of age, DTP (diphtheria, tetanus, pertusis).
† For wounds more than 24 hours old, add tetanus immune globulin.
Laboratory and Radiographic Evaluation
Usually, an appropriate laboratory evaluation is performed by the emergency room team. A complete blood count and serum chemistry analysis are often needed for anesthetic purposes. Coagulative studies may be helpful in selected cases, and blood chemistry studies for alcohol and other toxic substances are necessary in others. When the clinical suspicion of orbital fractures is high, appropriate orbital imaging studies, mainly computed tomography, should be ordered (see Chapter 84 ). Ultrasonic examination of the globe contents, extraocular muscles, optic nerve, and orbit sometimes can be an important adjunctive study.
Prevention of infection is a primary concern. A complete tetanus immunization history is obtained and the appropriate management followed if the patient is not up to date with immunizations (see Table 94-1 ). If an animal bite is known or suspected, all information about the site of injury, the owner of the animal, and any abnormal animal behavior must be obtained and the local animal care department notified. The standard rabies protocol is followed. A section on dog bites is presented later and contains more detailed information on the evaluation and management of such injuries.
Cat bites, and even wounds caused by cat claws, carry a high risk for infection, mainly with Pasteurella multocida (see the later section on dog bites ). Appropriate prophylaxis includes penicillin VK (phenoxymethylpenicillin) 500?mg a day for 5–7 days. In allergic patients tetracycline may be given.
Human bite injuries require the administration of appropriate antibiotics, such as penicillin, Augmentin (amoxicillin and clavulanic acid), erythromycin, or dicloxacillin, as the potential exists to inoculate a large number of bacteria.  Additional consideration should be given to human immunodeficiency virus and hepatitis and the appropriate testing administered.
Following any type of bite injury, copious irrigation of all injured tissues and removal of superficial foreign bodies lodged in the conjunctival fornices are performed. Vigorous irrigation and removal of foreign bodies are generally sufficient to prevent wound infection in most bites.
Timing of Repair
The timing of the repair is governed by several factors. Every effort must be made to reconstruct the injured tissues as soon as possible after the patient has been thoroughly evaluated and appropriate ancillary studies have been obtained. However, waiting for 24–48 hours to assemble the most efficient and experienced reconstructive team is a viable alternative unless amputated tissue needs to be replaced. It must be emphasized here that the best chances for restoration of structure and function and for successful cosmesis exist in the initial surgery. To try to address complications or a poor outcome in secondary procedures can be difficult. Should a slight delay in treatment be deemed necessary, the wound should be kept moist with continuous application of soaked saline gauze pads to prevent wound drying and desiccation. Adequate eye protection with copious lubrication must be given or even a temporary tarsorrhaphy performed if a significant threat of exposure keratopathy exists.
The choice of anesthetic for the repair of adnexal injuries depends on several factors. Obviously, the patient’s age is critical because almost all children require general anesthetic for the best reconstructive results to be achieved. Large injuries with extensive soft tissue and osseous involvement are best managed in a similar setting. However, even with general anesthetic, local infiltration of epinephrine (adrenaline) is essential for hemostasis. The majority of adult injuries can be repaired with local infiltrative or regional anesthetic of 1–2% lidocaine (lignocaine) with 1:100,000 epinephrine. Infiltrative anesthetic can cause significant tissue distortion; this can be minimized with the use of hyaluronic acid (hyaluronidase), which facilitates spreading of the anesthetic solution. Regional anesthesia of the infraorbital, supraorbital, infratrochlear, and supratrochlear nerves can be a very effective adjunct and causes no associated tissue distortion.
The techniques of eyelid and orbital reconstruction after trauma are numerous and varied; which is used largely depends upon the extent of the injury and the specific adnexal structures involved. The general approach is to address each anatomic structure independently and to respect appropriate priorities—eye protection first, then function, and finally cosmesis. In many cases, a number of reconstructive techniques are combined to achieve an acceptable result.
Partial-Thickness Eyelid Injuries
Small, superficial eyelid lacerations that do not involve the lid margin and that are parallel to the relaxed skin tension lines can be stabilized with skin tape. Larger lacerations and those that are perpendicular to the relaxed skin tension lines require careful approximation and eversion of the skin edge. This can be accomplished with simple interrupted 6-0 or 7-0 absorbable or nonabsorbable sutures. If the full thickness of the orbicularis muscle is involved, it should be repaired separately. Penetration of the orbital septum (see Chapter 82 ) with resultant levator aponeurosis injury must be ruled out in upper eyelid injuries; if present, such injuries must be repaired.
Eyelid Margin Lacerations
This type of adnexal trauma requires the most meticulous eyelid approximation, which must be precise to avoid eyelid notching and margin malposition. A good esthetic result depends heavily upon wound preparation. All tarsal irregularities at the wound
edges are trimmed to allow good tarsal-to-tarsal approximation of the repaired edges. This is done along the entire vertical height of the tarsus to prevent tarsal buckling, even though the primary laceration may involve only the marginal tarsus. The repair begins with the placement of a 6-0 suture in the plane of the meibomian glands at the lid margin, approximately 2?mm from the wound edges and 2?mm deep ( Fig. 94-1, A ). Historically, the margin sutures used are nonabsorbable. However, the authors have routinely used absorbable sutures (such as 6-0 Dexon that comes with a convenient half-circle D1 needle; Davis & Geck) and have not experienced complications from premature suture absorption. This option is particularly useful in children.
The traction suture is pulled to determine whether a satisfactory approximation of the margin edges has occurred. A good margin eversion should be the goal. This suture is left long and untied, and traction is applied to facilitate repair of the remaining lid segments. The tarsus is next closed with fine, interrupted, partial-thickness sutures, such as 6-0 or 7-0 Dexon, polyglactin (Vicryl), or 7-0 silk. The knots are tied on the anterior tarsal surface to avoid corneal irritation ( Fig. 94-1, B ). Additional margin sutures are then placed, usually in the eyelash line and in the gray line. These sutures are tied and left long. The anterior lamella of the eyelid is closed next, with fine interrupted sutures. The long margin sutures are tied through these skin sutures to prevent the suture ends from abrading the cornea ( Fig. 94-1, C ). When nonabsorbable sutures are used, they are removed after approximately 2 weeks.
Eyelid Injuries with Tissue Loss
Injuries of the eyelid that result in tissue loss provide a difficult reconstructive challenge. It is incumbent on the surgeon, when the patient with eyelid trauma is evaluated, to define not only whether and how much of the eyelid is missing but also which layers of the eyelid are absent. In the evaluation of these patients, it is very useful to consider the eyelid as a structure that has anterior and posterior lamellae, the skin and orbicularis being the anterior lamella and the tarsus and conjunctiva the posterior lamella (see Chapter 82 ). If a full-thickness loss of eyelid tissue leads to lagophthalmos and corneal exposure, aggressive lubrication with antibiotic ointments is instituted or a temporary tarsorrhaphy placed until definitive repair can be accomplished.
Tissue loss that involves only the anterior lamella may be repaired, if the tissue loss is small and the defect lies anterior to the septum, by allowing the defect to granulate. This method may obviate the need for skin grafts and myocutaneous flaps;
Figure 94-1 Direct closure of a marginal eyelid laceration. A, The suture is placed precisely in the plane of the meibomian glands at the eyelid margin, approximately 2?mm from the wound edges and 2?mm deep. This placement should provide adequate margin eversion. B, Partial-thickness lamellar sutures are placed across the tarsus and tied anteriorly. C, The anterior skin and muscle lamella is closed with fine sutures, and these are tied over the long marginal sutures to prevent corneal touch.
however, the wound must be monitored carefully for infection and late contracture. The result of allowing the eyelid to granulate spontaneously can be equal to, or even surpass, the outcome of primary repair.
If the loss of anterior lamella is more extensive, with exposure of the underlying fat and posterior lamellar tissue, local advancement flaps and skin grafts are required. Acute skin grafting may produce an excellent cosmetic result; also, it may reduce the possibility of a shrinkage phase, which can result in lagophthalmos, lid retraction, and the corneal exposure that is likely to occur if the eyelid is left to granulate spontaneously. Caution must be observed in the employment of grafts and large flaps, as their use in the acute setting is associated with an increased incidence of infection and failure. Whether the surgeon chooses to employ acute skin grafting or other means of repair, it must be recognized that immediate repair is directed at protection of the integrity of the globe, with the recognition that further reconstructive surgery may be necessary to achieve the maximal functional and cosmetic result.
Full-Thickness Eyelid Lacerations
Full-thickness lacerations that do not involve the eyelid margin may be associated with significant internal disarrangement of lid structures and perforation of the globe. These injuries require adequate layer-by-layer inspection of the wound to assess the integrity of the orbital septum, levator muscle and levator aponeurosis, conjunctiva, rectus muscles, and the globe. Meticulous layered closure is required, with the septum left unsutured.
If the posterior lamella of the eyelid is involved in a full-thickness eyelid injury but can be reapproximated without undue tension, it is repaired directly. Tarsal alignment is achieved best through interrupted buried sutures. The authors prefer to use 6-0 or 7-0 polyglactin (Vicryl) sutures; however, Dexon, silk, and chromic sutures are all adequate for tarsal closure. In the upper eyelid these sutures must be passed through the tarsus but remain subconjunctival because full-thickness sutures may result in corneal contact and irritation.
When an injury is severe enough to result in full-thickness tissue loss that involves both the anterior and posterior lamellae of the eyelid, the technique of repair depends on the amount and location of tissue loss. Many of the repair techniques for such injuries are used in lid reconstructions implemented after eyelid skin cancer resections.
The amount of tissue loss usually can be ascertained only after careful reapproximation of the wound. Fortunately, tissue
loss is usually less significant than the initial presentation may suggest, as retraction of the tissue gives the appearance of greater tissue loss than actually has occurred. Every effort is made to preserve all tissue. The generous adnexal vascular supply usually preserves even narrow pedicles, and even largely avulsed tissue can be reattached with significant survival rates. If large defects persist, standard methods of eyelid reconstruction are employed to complete the anatomic repair.
Upper and Lower Full-Thickness Eyelid Injuries
TISSUE LOSS OF 0–25%.
If either the upper or lower eyelid has sustained a full-thickness injury that results in less than 25% loss of tissue (including the eyelid margin), the repair can generally be closed primarily. However, it is often necessary to “freshen up” the eyelid margins prior to reconstruction. This not only removes any necrotic, nonviable tissue but also allows the surgeon to create two perpendicular, tarsal-to-tarsal wound edges to prevent any postoperative abnormalities of the lid contour. Other than this minimal débridement required to square off the tarsal edges, no other eyelid tissue should be discarded. Closure of the resultant defect can be accomplished with the same technique as used for full-thickness marginal lid lacerations. In older patients, because of increased eyelid laxity, primary closure of both the upper and lower eyelid may be accomplished for injuries that have up to 40% tissue loss. Injuries with greater than 25% full-thickness tissue loss (40% in the elderly) require borrowing or advancing adjacent tissue for closure.
Figure 94-2 Repair of a lower eyelid defect with the Tenzel myocutaneous flap.
Figure 94-3 A periosteal flap can be rotated to supplement the lateral posterior lamella in eyelid reconstruction. (Courtesy of Regents of the University of California, 1997, reprinted with permission.)
TISSUE LOSS OF 25–60%.
Primary closure of upper or lower eyelid injuries with full-thickness tissue loss that includes the margin can be accomplished by release and advancement of lateral tissues. Some injuries that are at the upper limit of primary closure may have their closure facilitated by a lateral canthotomy, followed by cantholysis of the lateral canthal tendon of the involved upper or lower eyelid.
If more tissue is required to reconstruct an upper or lower eyelid defect, the lateral canthotomy can be made in a semicircular fashion. The entire semicircular skin-muscle flap can be rotated into the lid defect area as described by Tenzel and Stewart (see Fig. 94-2 ). A periosteal flap can be used to supplement the lateral posterior lamella when either the upper or lower eyelid is reconstructed (see Fig. 94-3 ). Also, the lateral posterior lamella can be supplemented with hard palate or ear cartilage grafts.  Initially, the eyelid may appear tense, but it gradually relaxes over time.
Another technique for upper lid defects with tissue loss between 25 and 60% is the Mustarde lid-switch technique. This technique is useful in patients who have broad, shallow defects of the upper eyelid. It is a two-stage procedure in which the first stage involves the transfer of a pedicle flap from the lower eyelid to the upper eyelid ( Fig. 94-4, A ). An advantage of this flap is that lashes are transferred to the upper eyelid. The amount of tissue that can be transferred without the need to reconstruct the lower eyelid with an advancement flap is 6?mm. The width of the flap is 7–8?mm, and it contains the marginal artery. As the middle portion of the lower eyelid has the longest eyelashes and is away from the canthal regions, it is often the best donor site. The second stage, in which the pedicle flap is separated, should be performed 2–3 weeks after the first stage ( Fig. 94-4,B ).
Figure 94-4 The Mustarde eyelid switch is a very helpful technique in patients who have broad, shallow defects of the upper eyelid. A, A pedicle flap of marginal eyelid is cut from the central lower lid and rotated into the upper eyelid defect. B, After 2–3 weeks the flap is separated and repaired to restore satisfactory upper and lower eyelid contours, with preservation of lashes. (Courtesy of Regents of the University of California, 1997, reprinted with permission.)
Full-Thickness Eyelid Injuries with Greater Than 60% Tissue Loss
The repair of large tissue defects of the lower lid requires supplemental tissue from adjacent regions. The Hughes tarsoconjunctival flap is a two-stage procedure best suited to large, centrally located, lower eyelid full-thickness defects that spare the eyelid margins medially and laterally ( Fig. 94-5 ).
Shallow, full-thickness, lateral lower eyelid defects may be addressed with the transposition tarsoconjunctival flap described by Hewes et al. This is a one-stage procedure in which the superolateral portion of the upper lid tarsus is used as a flap based at the lateral canthus. The flap is rotated down and sutured to the tarsus and conjunctiva in the lower lid, with the tarsal margin in the downmost position. This transposed tarsoconjunctival flap is then covered with a full-thickness skin graft from a suitable donor site.
The Mustarde flap is a large, rotational, skin-muscle cheek flap that, if necessary can, be relied on to cover virtually any lower lid defect ( Fig. 94-6 ). It may be considered a progression in size from the smaller Tenzel semicircular rotational flap. This flap is most useful for vertical, deep, medial, full-thickness lower lid defects. The advantage of this procedure is that it is a one-stage, complete lower lid reconstruction. The disadvantages of this procedure are the excessively long scar on the face and the adynamic nature of the reconstructed lower lid. A graft of either hard palate or ear cartilage is needed for posterior lamellar support.
The authors have used an advancement of suborbital ocularis oculi fascia in lower lid defects that cannot be closed primarily. This myocutaneous advancement flap allows reconstruction of the lower lid posterior and anterior lamellar structures in a vertical direction, by directing cheek tissue superiorly. In conjunction with lifted suborbital ocularis oculi fascia, posterior lamellar
Figure 94-5 The Hughes tarsoconjunctival flap procedure. A, The lower eyelid defect is examined to estimate the width of the flap. B, The flap is dissected from the posterior lamella of the upper eyelid. At least 4?mm of tarsus must remain along the upper eyelid margin to enable stabilization. C, A skin graft can provide adequate anterior lamella of the lower eyelid. D, After 4–6 weeks the flap is divided to restore the eyelid margins. (Courtesy of Regents of the University of California, 1997, reprinted with permission.)
Figure 94-6 Repair of large, full-thickness lower eyelid defects with the Mustarde myocutaneous flap.
and anterior lamellar grafts can be used as needed to complete the lower eyelid reconstruction.
When large, upper eyelid defects are reconstructed, the surgeon must appreciate the effects of both horizontal and vertical tension on the final result. Excessive horizontal tension on the upper lid causes tether ptosis, and excessive vertical tension causes lagophthalmos. Care must be taken to avoid these postoperative complications. Multiple surgical modalities exist to address full-thickness tissue loss greater than 60%, all of which share the principles of replacement of both posterior and anterior lamellar structures.
A large, horizontal advancement of an upper eyelid tarsoconjunctival flap is useful for full-thickness defects of up to two
thirds the length of the upper lid margin. The anterior lamella can be replaced with a full-thickness skin graft.
A Cutler-Beard bridge flap reconstruction is useful for upper eyelid defects covering up to 100% of the eyelid margin ( Fig. 94-7 ). This technique, a two-stage procedure, takes tissue from the lower eyelid to reconstruct the upper eyelid. First, skin, muscle, and conjunctiva are advanced from the lower eyelid to replace the defect in the upper eyelid; the second stage can usually be performed 3–4 weeks after the initial reconstruction. This procedure does not replace lost eyelashes of the upper eyelid and is also fraught with the need for secondary corrective procedures.
For the first 2 days after any reconstructive surgery on the eye, the patient should be instructed to use ice compresses on the wound and to keep the head of the bed elevated. These steps help to reduce postoperative edema. If there is concern that the patient may rub the wound, a Fox shield can be applied. The authors prefer not to bandage the patient’s eye unless skin grafts have been used. Antibiotic ointment placed on the wound two to three times a day not only helps to prevent infection but also assists in lubrication of the wound. This helps to débride the wound and prevent the sutures from becoming crusted. The antibiotic ointment also helps to hasten re-epithelialization of portions of the wound that may be left to granulate spontaneously. The authors generally remove skin sutures at 5–7 days and lid margin sutures at 10–14 days.
Patients are instructed to stay out of direct sunlight and to use sun block on the maturing scar for at least 6 months postoperatively. This helps to avoid abnormal pigmentation of the scar. When the cicatricial phase of wound healing commences, at 3–4 weeks, the patient is instructed to massage the wound. It is hoped that this lessens late contracture of the wound, and it prevents cicatricial changes such as ectropion, entropion, or lagophthalmos and the resultant exposure keratopathy.
Late Repair of Eyelid Injuries
It is not uncommon for the patient who has undergone extensive traumatic eyelid repair to require secondary surgery. Skin grafts on the upper eyelid for lagophthalmos and on the lower eyelid for lower eyelid cicatricial ectropion are often necessary in the late postoperative period ( Fig. 94-8 ). To improve the postoperative esthetic result, donor sites for skin grafts should be matched to the area of skin loss. The contralateral upper eyelid,
Figure 94-7 The Cutler-Beard bridge flap. A full-thickness flap of lower eyelid tissue is advanced beneath a marginal bridge into the upper eyelid defect. After 3–4 weeks the flap is cut at the appropriate level and the lower lid is repaired. (Courtesy of Regents of the University of California, 1997, reprinted with permission.)
pre- or postauricular areas, and supraclavicular areas have been used with excellent results for skin grafts on eyelids and the periocular region. When skin grafts are used in either the acute setting of trauma or the late postoperative period, the involved upper or lower eyelid should be kept on stretch using a traction suture (Frost or reverse Frost suture). Alternatively, a vertical scar in the lower eyelid that causes vertical shortening can be corrected with Z-plasty techniques. If the patient has shortening of the posterior lamella in the late postoperative period, hard palate or mucous membrane grafts can be implemented to treat cicatricial entropion.
Of the 44,000 facial dog bites that present to emergency rooms in the United States each year, orbital and periorbital injuries occur in 4–8% of cases.  In a recent series in the ophthalmic literature, over half of these bites occurred in children younger than 5 years and two thirds in children younger than 10 years.
It is essential to ascertain information about the dog’s health and rabies vaccination status. Immunocompromised patients, those who have undergone prior splenectomy, patients who suffer from chronic obstructive pulmonary disease or alcoholism, and even healthy infants are at particular risk for the development of fulminant septicemia 24–48 hours after the bite. Pasteurella multocida is identified in up to 50% of dog bite injury infections  ; Pa. multocida infections commonly occur within 48 hours of inoculation and are characterized by prominent wound inflammation and drainage. The organism is a small gram-negative coccobacillus that grows in both aerobic and anaerobic environments.
Figure 94-8 A patient had an obvious cicatricial left medial canthal dystopia as a result of trauma. A, Primary repair did not address the reconstruction of the critical deep portion of the medial canthal tendon. B, The same patient as in A after left medial canthoplasty and anterior lamella reconstruction with a skin graft. It is imperative to reconstruct all elements of the medial canthal complex to achieve satisfactory eyelid apposition to the globe. (Courtesy of Regents of the University of California, 1997, reprinted with permission.)
Septicemia, meningitis, and, in rare cases, death have been reported as a result of infection by a gram-negative, non–spore-forming rod, Capnocytophaga canimorsus. The organism was previously referred to as CDC group DF-2 (Centers for Disease Control and Prevention group Dysgonic Fermenter-2) and can be cultured from the mouths of healthy dogs.       
Gonnering, in a study of periorbital dog bites, found no penetration injuries of the globe and no tissue loss. Disruption of the lacrimal system was present in 14 of the 16 cases. All dog bite wounds are presumed to be contaminated and, therefore, must be decontaminated prior to surgical repair to limit infection. Forceful irrigation with at least 200?ml of normal saline using a 35?ml syringe and 18-gauge irrigating cannula is recommended, while the cornea is protected with a scleral contact lens.
Surgical repair is carried out as for any other eyelid reconstruction, with restoration of normal anatomic structure and function. Care should be taken to evaluate and repair medial canthal tendon avulsions as well as lacrimal system injuries.
Adjunct medical therapy includes tetanus prophylaxis and rabies prophylaxis if the rabies status of the dog is unknown or positive. The need for prophylactic antibiotics in dog bites is controversial. Adequate wound decontamination is probably the single most important modality that prevents infection. Various studies have isolated many different pathogens as the cause of infections after dog bites. No single antimicrobial agent is optimal against these various pathogens, which may include Staphylococcus aureus, S. epidermidis, Pseudomonas aeruginosa, and anaerobes in addition to Pa. multocida and C. canimorsus. Recommended choices of antibiotic prophylaxis include penicillin, Augmentin (amoxicillin and clavulanic acid), cefuroxime, and cephalexin. Alternatives for the penicillin-allergic patient include erythromycin and tetracycline. Decisions about tetanus prophylaxis depend on the patient’s immunization history and the character of the wound (see Table 94-1 ).
If rabies is suspected, health department officials should be notified. The health department can assist in quarantine of the animal as well as offer advice about current recommendations for rabies prophylaxis. The incubation period for rabies averages 30–50 days. Prophylactic treatment must be administered before the onset of clinical disease. The treatment consists of inactive rabies virus human diploid cell vaccine, which offers active immunity, and rabies immune globulin, which offers passive immunity.
Severe burn injuries frequently involve the face, with the incidence of eyelid involvement being 20–30%. Fortunately, Bell’s phenomenon, the blink reflex, rapid reflex head movements, and shielding of the eyes with arms and hands often prevent conjunctival and corneal injury.
The initial evaluation of an eyelid burn includes an assessment of the depth of the burn wound. First- and second-degree burns are partial-thickness skin injuries, and third-degree burns are full-thickness injuries. The mild swelling, erythema, and pain of first-degree burns (which involve only the epidermis) generally resolve within 5–10 days with no compromise of eyelid function and structure, as the damage is quite superficial.
Second-degree burns, characterized by erythema, bulla formation, considerable edema, and pain, often heal uneventfully within 7–14 days without sequelae. A deep second-degree burn can result in cicatricial eyelid deformities, especially if superinfection occurs.
Third-degree burns represent the most severe burn injuries. The burned lids may have a dark, leathery appearance or appear translucent or waxy white. These burns are not very painful because the terminal nerve endings have been destroyed. A thick black eschar forms and then separates within 2–3 weeks. Granulation tissue then forms and the myofibroblasts produce contracture, with ensuing eyelid retraction, cicatricial ectropion, and lagophthalmos.
Acute treatment of all eyelid burns requires frequent lubrication with artificial tear drops and lubricating ointment at bedtime. If associated corneal and conjunctival injuries exist, appropriate topical antibiotic ointment is used as well. The topical antibiotic is continued until the cornea has re-epithelialized. Topical burn medications are placed on the periorbital skin in coordination with the burn-team care.
In the intermediate phase (1–4 weeks) of eyelid burn healing, first-degree burns generally do not undergo significant cicatricial changes and often heal without sequelae. Second- and third- degree burns are accompanied by cicatrization and shortage of skin surface area. This results in lagophthalmos secondary to lower eyelid ectropion and upper eyelid retraction. Corneal exposure may lead to epithelial compromise, and it may be followed by sterile or infectious corneal ulcers. In this intermediate period, prior to full cicatrization before the wounds are ready for skin grafts, it is best to perform temporizing measures. If heavy ocular lubrication is not sufficient, surgical scar release using Frost suture eyelid closure or non–margin-injuring tarsorrhaphy can be performed.
When burn wounds are healed completely and the cicatricial phase of healing is over, definitive eyelid reconstruction may be undertaken. Usually, full-thickness skin grafts are used for eyelid reconstruction. Optimal donor sites for a full-thickness graft are the non–hair-bearing retroauricular, contralateral eyelid, and supraclavicular skin. In a severely burned patient, any available donor site may be used for full-thickness tissue, and split-thickness skin grafts may be used if necessary.
The technique used for skin grafts in the burn patient is similar for both the upper and lower eyelid. The only exception is that the lower eyelid may require a horizontal eyelid-shortening procedure in addition to the skin graft. The eyelid that is to receive the graft is placed on stretch. In the upper lid, the scar tissue is released with a lid crease incision, and a subciliary incision is employed to release scar tissue in the lower eyelid. After all the scar tissue has been released, the eyelid remains on stretch, and the skin graft is harvested and placed in the recipient bed. The graft is sutured into position with numerous interrupted 6-0 sutures, with one arm of each suture left long. A stent or bolster is placed over the graft, and the sutures are tied over this graft so that they press the graft down onto the host site. A pressure dressing is applied over the bolster with mild pressure, and after 5–6 days the dressing and bolster are removed.
The late phase of eyelid-burn healing may also lead to scar formation (webbing) of the lateral and medial canthi. Skin grafts and Z-plasty techniques can be employed to address this canthal webbing.
In the treatment of the eyelid-burn patient, emphasis is placed on protection of the cornea and conjunctiva. Skin deformities can often be repaired in the late postoperative period, after temporizing measures to protect the cornea have been implemented.
The expected goals of reconstructive surgery on the eyelids are:
• Preservation of vision
• Restoration of eyelid structure and function to as near normal as possible
• Achievement of adequate cosmesis
Although all three objectives are important, esthetic concerns should not override functional considerations. In most cases, patients can expect good to excellent results for all three goals. In some cases, multiple repeated operations may be necessary to achieve these results.
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