Chapter 97 – Enucleation, Evisceration, and Exenteration
• Enucleation: surgical removal of the entire globe
• Evisceration: surgical removal of the entire contents of the globe leaving a scleral shell
• Exenteration: removal of the entire orbit including the globe, eyelid, and orbital contents—usually performed for malignant tumors
Enucleation, evisceration, and exenteration surgery all involve the permanent removal of the patient’s eye. In this chapter the important aspects of each procedure are emphasized, including:
• Indications for surgery
• Preoperative patient counseling
• Surgical techniques
• Postoperative management
• Complications of surgery
PREOPERATIVE EVALUATION AND DIAGNOSTIC APPROACH
Indications for Surgery
Enucleation or evisceration surgery may be indicated for a blind painful eye, endophthalmitis, or cosmetic improvement of a deformed eye. In cases of intraocular neoplasms or the treatment of severe ocular trauma with a ruptured globe, where sympathetic ophthalmia is a concern, enucleation is appropriate and evisceration is contraindicated. Other indications for enucleation may include progressive phthisis bulbi and severe microphthalmia.
In the vast majority of situations, the indication for exenteration surgery is to eradicate life-threatening malignancy or life-threatening orbital infection. The extent of the procedure should be explained to the patient, especially which tissues are to be removed (this includes the eyeball, orbital soft tissues, and part or all of the eyelid structures). The surgeon should avoid lengthy discussions regarding the “mutilating” nature of the procedure but rather should help support the patient to remain focused on the treatment of this potentially life-threatening problem through the life-saving nature of the exenteration surgery.
A summary of the indications for surgery is given in Box 97-1 .
Faced with the permanent loss of an eye, a patient requires the physician’s reassurance, caring explanations, and psychological support, both before and after the surgery. The patient (and family) should understand that evisceration and enucleation surgery involve the complete, permanent removal of the diseased or deformed eye. The general nature of the anophthalmic socket should be explained to the patient, who must be informed that an ocular prosthesis will be fitted secondarily approximately 6 weeks following the surgery. The indication for surgery, whether it is pain, poor visual prognosis, the risk of sympathetic ophthalmia, or the presence of an intraocular neoplasm, should be clearly explained. The patient should be informed of the choices between enucleation and evisceration surgery and of the availability of a variety of orbital implants, including common alloplastic implants  (e.g., polymethyl methacrylate sphere), newer implants designed to maximize ultimate ocular prosthesis motility     (e.g., hydroxyapatite implants), or autologous tissue orbital implants     (e.g., dermis-fat grafts).
The patient should understand the risks and benefits of wrapping orbital implants with either autologous tissues or preserved donor tissue and that donor tissues may carry the risks of communicable diseases, such as syphilis, hepatitis, and human immunodeficiency virus. It should be explained to the patient that if a hydroxyapatite implant is used in primary enucleation or evisceration surgery, a delayed second-stage procedure (i.e., second-stage drilling of the hydroxyapatite implant with placement of the motility peg) may be needed in order to maximize the ocular prosthesis motility. A thorough explanation allows the patient and family to make a well-informed decision regarding surgery. Although the specific decision for surgery is to be made by the patient and family, it is reasonable for the surgeon to make a best-judgment recommendation to help with the myriad of choices available (e.g., enucleation versus evisceration and the variety of types of orbital implants).
Following enucleation or evisceration, most patients undergo a grief reaction to varying degrees. The patient, therefore, requires psychological support from the physician. The exenteration candidate must also be informed of the nature of the surgery and the more radical amount of tissue to be resected. Although the patient must be given a full and truthful explanation regarding exenteration surgery, the surgeon should avoid overly gruesome details so as not to deter inadvertently the patient from receiving necessary treatment, such as for a potentially life-threatening neoplasm.
Removal of the Wrong Eye
Removal of the wrong eye presents one of the greatest disasters that can occur to the ophthalmic surgeon and patient. Every ophthalmologist and surgeon must be aware of this possibility, no matter how remote. Preoperatively, the surgeon may mark the forehead or trim the lashes on the appropriate side. These methods, however, are not foolproof. In the operating room, the surgeon should thoroughly review the chart, including the operative permit and the examination notes. It is important, then, that the surgeon him- or herself prepares and drapes the patient. Traquair suggested the use of local anesthesia to prevent removal of the wrong eye, although not even this method is fail-safe. It must never, never happen that a surgeon hurries into the
Indications for Surgery
• Blind painful eye
• Intraocular tumor
• Severe trauma with risk of sympathetic ophthalmia
• Phthisis bulbi
• Cosmetic deformity
• As for enucleation, except for intraocular tumors or risk of sympathetic ophthalmia
• Cutaneous tumors with orbital invasion
• Lacrimal gland malignancies
• Extensive conjunctival malignancies
• Other orbital malignancies
• Chronic orbital pain
• Orbital deformities
operating room where the patient is already under general anesthesia and begins the operation without an appropriate review of the situation.
Once a sterile operative field is set up, the surgeon must again verify that the correct eye is about to undergo enucleation. Following severe trauma, the correct eye is often externally deformed. In cases where the external appearance of both eyes is normal, the surgeon must compulsively reexamine the fundus to verify the pathology.
The finality of the enucleation procedure cannot be overstressed. No degree of thoroughness is excessive in order to avoid removal of the wrong eye.
Enucleation surgery usually is performed using local anesthesia. For psychological reasons, and occasionally for medical reasons, general anesthesia may be employed. Under any circumstance, agents should be used that maximize intraoperative hemostasis, suppress the oculocardiac reflex, and minimize postoperative pain. The author’s choice is to instill 10% phenylephrine eye-drops into the conjunctival cul-de-sac to achieve intense vasoconstriction, and to infiltrate extensive retrobulbar and peribulbar bupivacaine 0.5% with epinephrine (adrenaline) 1:100,000 and hyaluronidase. After adequate time, an excellent anesthetic and vasoconstrictive effect is achieved.
Most evisceration surgeries are also performed under local anesthesia with intravenous sedation. A mixture of lidocaine (lignocaine) 2% with epinephrine 1:100,000, bupivacaine 0.5% with 1:100,000 epinephrine, and hyaluronidase is injected in retrobulbar fashion into the muscle cone. The use of intravenous anesthetic sedatives prevents either the local anesthetic injection or the surgical procedure itself from being unpleasant or producing anxiety. Exenteration surgery is usually performed under general anesthesia, which may be combined with bupivacaine and epinephrine infiltration to aid hemostasis and provide postoperative analgesia.
The indications for enucleation surgery and important aspects of preoperative counseling have already been discussed. Here two surgical techniques are described:
• Enucleation with placement of a simple sphere implant
• Enucleation with placement of a sclera-wrapped hydroxyapatite implant for improved motility
Figure 97-1 Enucleation procedure. Following a 360° conjunctival peritomy, a small pair of tenotomy scissors is used to dissect bluntly Tenon’s fascia in all four quadrants.
Before describing the specifics of enucleation surgery, a few aspects in regard to Tenon’s fascia must be mentioned. Tenon’s capsule is the fibroelastic tissue that surrounds the eye and extraocular muscles in the anterior orbit (see Chapter 83 ). Anteriorly, Tenon’s fascia fuses with the conjunctiva near the corneal limbus. At its posterior extent, Tenon’s fascia encircles and fuses with the dura over the optic nerve. The four recti muscles originate from the annulus of Zinn and extend anteriorly to the eyeball. Posterior to the equator of the globe, the rectus muscles penetrate through Tenon’s capsule before inserting into the sclera. That part of Tenon’s fascia anterior to the rectus muscles is anterior Tenon’s, and that part of Tenon’s fascia posterior to the site of the rectus muscle penetrations is posterior Tenon’s. It is critically important to understand this anatomical concept in order to achieve the proper, desirable orbital implant placement during enucleation surgery.
ENUCLEATION WITH SIMPLE SPHERE IMPLANT.
A self-retaining lid speculum is placed to expose the entire epibulbar surface. A 360° conjunctival peritomy is performed ( Fig. 97-1 ). Tenon’s fascia is bluntly dissected away from the sclera in all four quadrants. Each of the four rectus muscles is sequentially gathered on a muscle hook, secured with double-armed 6-0 Vicryl suture, and detached from the globe. The superior oblique tendon is severed and detached from the globe. The inferior oblique muscle should be hooked and secured with a 6-0 Vicryl suture, detached, and saved for later attachment to the inferior border of the lateral rectus muscle. This use of the inferior oblique muscle is perhaps more important as an eventual “hammock” for the orbital implant than to enhance meaningfully anophthalmic socket motility.
After the extraocular muscles are detached, the surgeon is ready to sever the optic nerve. Anterior traction on the globe is useful when cutting the optic nerve and can be achieved with a curved hemostat applied to the medial rectus tendon or with a double-armed 4-0 silk suture sewn through the medial and lateral tendon insertions. In most cases it is the author’s preference to clamp the optic nerve with a curved hemostat inserted behind the globe in the superonasal direction ( Fig. 97-2 ). With the hemostat in place, a slender curved Metzenbaum scissors is used to
Figure 97-2 Each of the four rectus muscles is tagged with a double-armed 6-0 Vicryl suture and detached from the globe. Some 4-0 silk sutures may be placed through the medial and lateral recti muscle stumps to provide anterior traction on the globe, as a slender curved hemostat is used to clamp the optic nerve.
Figure 97-3 The globe has been removed and cautery is applied to the optic nerve stump to maintain meticulous hemostasis.
transect the optic nerve, and the entire eyeball is removed. The surgeon should inspect the entire globe for intactness and/or unusual findings before submitting the specimen for histopathological examination. Malleable retractors are placed so as to visualize directly the still clamped cut edge of the optic nerve, and the central retinal vessels are cauterized to obtain meticulous hemostasis before removing the clamp ( Fig. 97-3 ). If the optic nerve is not clamped, such as for intraocular tumors, orbital packing with direct pressure for 5–10 minutes can be applied to achieve adequate hemostasis. In select enucleations, as with tumors in contact with the optic disc, it may be necessary to obtain a long segment of optic nerve. 
For the average-sized adult orbit a 20?mm polymethyl methacrylate orbital implant is usually adequate. The implant
Figure 97-4 An orbital implant has been placed behind posterior Tenon’s fascia. This layer is then closed with multiple, interrupted 6-0 Vicryl sutures. The four rectus muscle stumps remain free with the 6-0 Vicryl sutures attached.
type and size can, of course, vary, and it may also be wrapped in either autologous fascia or donor sclera. The orbital implant is inserted behind posterior Tenon’s fascia, through the central rent left by cutting the optic nerve. Multiple interrupted 6-0 Vicryl sutures securely close posterior Tenon’s fascia that overlies the orbital implant.
Each of the four rectus muscles is sutured to the adjacent fornix by passing the previously placed double-armed Vicryl sutures full-thickness through Tenon’s fascia and conjunctiva (see Fig. 97-4 ). This will provide motility to the ocular prosthesis. Care should be taken to avoid advancing the superior rectus suture too close to the midline to avoid inadvertent tension or traction on the superior rectus muscle, which could induce an upper lid ptosis. After anterior Tenon’s fascia is closed in the midline with 6-0 Vicryl sutures ( Fig. 97-5 ), the conjunctival edges are loosely reapproximated with a 6-0 plain gut running suture.
At the end of the procedure an additional deep orbital injection with bupivacaine 0.5%, epinephrine, and hyaluronidase is given. A broad-spectrum ophthalmic antibiotic ointment is applied to the conjunctiva. A medium-sized clear acrylic lid conformer is placed and a firm pressure bandage applied over the socket.
The pressure bandage remains intact for 3–4 days postoperatively and, upon removal, the patient uses topical cool compresses with crushed ice. Pain medication is prescribed as appropriate. This perioperative and postoperative management regimen allows the large majority of enucleation procedures to be performed as outpatient procedures, with adequate control of postoperative pain.
ENUCLEATION WITH HYDROXYAPATITE IMPLANT.
The purpose of the hydroxyapatite implant is to allow the potential for maximum motility of the ocular prosthesis. Coralline hydroxyapatite contains 500?m diameter pores that are similar to the structure of the haversian systems of cancellous bone. The microstructure of this implant allows fibrovascular ingrowth of the host tissues in the anophthalmic socket.  Once the hydroxyapatite implant is well vascularized, it can be secondarily drilled and fitted with a motility peg implant. This motility peg is then coupled to the ocular prosthesis to enhance maximally prosthesis motility.
A standard enucleation technique is performed, as already described. The socket may be “sized” using sterile trial spheres, but
Figure 97-5 Enucleation surgery—final closure. The 6-0 Vicryl rectus sutures are sewn onto their respective fornices by passing the sutures through Tenon’s fascia and conjunctiva. The anterior Tenon’s is closed with 6-0 Vicryl and the conjunctiva with a running 6-0 plain suture.
in most cases an 18?mm or a 20?mm hydroxyapatite implant is appropriate. Keep in mind that wrapping the implant with sclera or fascia adds approximately 1–1.5?mm to the overall diameter of the implant.
In most situations, the hydroxyapatite implant is wrapped in donor sclera. The scleral shell should be cut to the appropriate size and shape to enclose the implant securely. Multiple interrupted 6-0 Vicryl sutures are suitable for securely closing the sclera. The hexagonal rosettes of the hydroxyapatite exoskeleton should be aligned in the anterior-posterior direction and an open scleral window should be present at the posterior apex of the hydroxyapatite implant, corresponding to the site of the corneal button removal. Rectangular windows, approximately 2–4?mm, are cut through the sclera located within 8–10?mm from the anteriormost apex of the implant. To promote further fibrovascular ingrowth into the implant, a handheld 20-gauge needle is used to create drill holes in the hydroxyapatite at the site of each window and at the site of the posterior round corneal window.
The wrapped hydroxyapatite implant is placed into the anophthalmic orbit and the four rectus muscles are secured to the anterior lip of the corresponding rectangular scleral window. Anterior Tenon’s fascia is sutured with multiple interrupted 6-0 Vicryl sutures. The conjunctiva can be closed with a loosely running 6-0 plain suture, which is tied and cut on each end. Some authors report a higher exposure rate with hydroxyapatite     compared with alloplastic sphere implants,  thus emphasizing the need for meticulous closure. As is the case with any enucleation procedure, a polymethyl methacrylate lid conformer is placed in the conjunctival cul-de-sac with broad-spectrum antibiotic ointment and a pressure bandage applied.
The unique properties of a hydroxyapatite implant allow fibrovascular ingrowth and integration of the implant with the ocular prosthesis. Without placement of the motility peg, no demonstrable motility difference exists between a sclera-wrapped hydroxyapatite implant and a similarly wrapped polymethyl methacrylate implant. Thus hydroxyapatite implantation is most appropriate for patients who express a strong interest in eventual second-stage drilling of the implant to maximize prosthesis motility. These titanium motility pegs are surgically inserted after adequate fibrovascular ingrowth into the hydroxyapatite implant has occurred.   
Evisceration is the surgical technique that removes the entire intraocular contents of the eye while leaving the scleral shell and extraocular muscle attachments intact. Evisceration surgery is a simpler procedure than enucleation surgery and offers better preservation of the orbital anatomy and natural motility of the anophthalmic socket tissues.
In cases of documented or suspected intraocular malignant tumors, evisceration is contraindicated. Similarly, evisceration may be contraindicated if precise histopathology of the specimen is needed. Evisceration surgery may be more difficult in eyes with severe phthisis or scleral contracture or that are severely deformed. Finally, the issue of potential sympathetic ophthalmia should be considered.     Evisceration surgery in a previously injured eye carries a definite small risk of sympathetic ophthalmia in the apposing eye because some uveal tissue is always left behind in scleral canals.
Figure 97-6 Evisceration procedure. A 360° conjunctival peritomy is made, followed by complete excision of the corneal button.
Although some surgeons perform evisceration with preservation of the cornea, this author prefers removal of the cornea. The procedure begins with a 360° conjunctival peritomy ( Fig. 97-6 ). Tenon’s fascia is bluntly separated from the underlying sclera in all four quadrants. A full-thickness incision around the corneal limbus is made with a sharp scalpel blade and the entire corneal button removed. The sclera is grasped with a forceps, and a cyclodialysis spatula is used to separate the iris root and ciliary body from the sclera. The remainder of the uveal tissue is dissected away from the scleral wall back to the attachment around the optic nerve with an evisceration spoon ( Fig. 97-7 ). The intraocular contents are lifted from the scleral shell and submitted for histopathologic examination. All remaining uveal tissue is carefully removed from the scleral shell with a small curette or the sharp end of a caudal periosteal elevator. Cotton-tip applicators saturated with 70% ethanol may be used to cleanse the interior of the scleral shell and denature any remaining uveal pigmented tissue. Cautery is applied if needed to control the oozing of blood.
A polymethyl methacrylate or hydroxyapatite spherical implant is placed in the evisceration scleral shell ( Fig. 97-8 ). When the cornea is removed, it is unusual to place an implant larger than 14–16?mm. The scleral edges are closed with multiple interrupted 6-0 Vicryl sutures, with the medial and lateral scleral edges cut to reduce any dog ears ( Fig. 97-9 ). The conjunctiva is gently closed with a running 6-0 plain gut suture. If a larger implant is desired, it is necessary to perform radial relaxing sclerotomy incisions posteriorly between the rectus muscles ( Fig. 97-10 ). If a hydroxyapatite implant is used, such sclerotomy openings are necessary to enhance vascular ingrowth.
Dressing and postoperative care are as for enucleation.
Exenteration surgery involves complete removal of the eyeball, the retrobulbar orbital soft tissues, and most or all of the eyelids. The most common indication for exenteration surgery is for the treatment of epithelial malignancy with orbital invasion. 
When exenteration is performed for orbital malignancies, periorbita is usually excised to remove completely all potentially involved tissues. The bare orbital bone can slowly heal by secondary
Figure 97-7 An evisceration spoon is used to detach the ciliary body and bluntly elevate the choroid from the scleral wall.
intent, but in most situations the exenterated orbit is covered with a split-thickness skin graft at the time of the procedure. As there is potential for recurrent tumor, reconstruction with thick, bulky tissue grafts, which could obscure recurrence, is avoided. In very select situations, however, a variety of ancillary reconstructive techniques may be of use, such as those involving ipsilateral temporalis muscle flaps,  free dermis-fat grafts, latissimus dorsi myocutaneous free flaps, osseointegrated implant techniques, and other procedures.    
The area of the proposed exenteration incision is marked with adequate wide margins where necessary for tumors, yet with preservation of as much normal periocular soft tissue as possible ( Fig. 97-11 ). If necessary, adjacent areas of the medial canthus, temple, or forehead are included in the excision site. When surgery is necessary for a conjunctival or deep orbital tumor, a subciliary incision around the eyelid margins and wrapping around the inner canthus preserve the eyelid skin and orbicularis muscle, which can be used for reconstruction.
The skin is incised along the mark and any orbicularis muscle to be spared dissected in a suborbicular plane. The dissection is carried down through periorbita to expose the orbital rim. A periosteal elevator is used to elevate periosteum over the orbital rim and periorbita from the orbital walls ( Fig. 97-12 ). Firm attachments to bone are encountered at the lateral orbital tubercle, the superior oblique trochlea, the medial canthal tendon, the distal lacrimal sac as it enters the bony nasolacrimal canal, the inferior oblique origin near the posterior lacrimal crest, and the superior and inferior orbital fissure attachments ( Fig. 97-13 ; see Chapter 83 ). Except for these sites of resistance, the periorbita can be elevated quite easily. Medially, the surgeon should use particular care when elevating periorbita so as to avoid inadvertent penetration of the lamina papyracea into the ethmoid sinus air cells, which could result in a chronic sino-orbital fistula.
Superiorly, the superior orbital bone may be quite attenuated in elderly patients and atrophic bony defects may be present. Monopolar cautery to the orbital roof should be avoided, as this may cause inadvertent cerebrospinal fluid leakage. It is generally safe to use bipolar cautery along the orbital roof and deep orbital tissues without the risk of cerebrospinal fluid leakage.
The periorbital lining is mobilized along all orbital walls toward the orbital apex. The dissection and mobilization of soft tissues must extend posteriorly beyond the extent of tumor invasion. A thin curved hemostat can be used to clamp the apical
Figure 97-8 A sphere introducer is used to place the orbital implant into the evisceration scleral shelf.
tissues while a slender pair of Metzenbaum scissors are used to excise the exenteration specimen anterior to the clamp ( Fig. 97-14 ). An enucleation snare may also be used to incise the apical stump to complete the severing of the exenteration specimen. When necessary, frozen section pathology analysis of the apical stump tissues should be used to verify that the margins of resection are free and clear of neoplasm. The orbital bone should be carefully inspected for subtle bone pitting or other signs of bone erosion or destruction.
In patients who have very bulky or massive orbital neoplasms, exenteration may be difficult, with little space in which to separate periorbita from orbital bone. It may be helpful here first to enucleate the eyeball to make enough room for access to the deeper apical soft tissues under good visualization.
In most patients the orbit will be lined with a split-thickness skin graft harvested from the anterior surface of the thigh. It is
Figure 97-9 The scleral opening is closed with multiple, interrupted 6-0 Vicryl sutures. Conjunctiva is subsequently closed over the scleral wound using running 6-0 plain gut sutures.
Figure 97-10 A unipolar cautery is used to incise relaxing sclerotomy slits to expand the scleral shell. This sclerotomy technique to enlarge the scleral shell volume is “optional” with polymethyl methacrylate sphere implants. Sclerotomy slits are “mandatory” when using hydroxyapatite spheres in order to facilitate vascular ingrowth.
usually preferable to expand the skin graft in a mesher. Multiple interrupted 6-0 Vicryl sutures secure all residual host skin edges to the meshed skin graft. The graft is tamponaded within the orbit with a Telfa dressing and Xeroform gauze packing under pressure.
If the upper lid and lower eyelid skin and muscle are preserved, it may be possible in elderly patients with a lot of loose
Figure 97-11 Cross-sectional view of surgical planes of dissection for exenteration surgical techniques: total exenteration, subtotal exenteration with sparing of myocutaneous eyelid tissue, and enucleation with partial socket ablation.
Figure 97-12 Exenteration procedure. A 360° skin incision is made down to the periosteum of the orbital rim. A periosteal elevator is used to begin reflecting the superior periorbita downward.
eyelid skin simply to suture the skin edges together and then place a pressure dressing to tamponade the myocutaneous edges against the bare bone.
The orbital pack and pressure dressing should remain in place for approximately 5–7 days. Following removal of the dressing, the patient can use gentle
hydrogen peroxide rinses to cleanse the socket. Generally, these orbits heal best when left open to the air, so the patients should wear a patch only when going out in public. The surgeon should remain vigilant to the possibility of infection of the skin graft, especially by Pseudomonas, Staphylococcus, or Streptococcus. Systemic antibiotics may be necessary if these infections arise. In some patients, the exenterated orbit retains chronic, moist, ulcerated areas intermixed with areas of healthy keratinizing epidermis. The use of a gentle handheld hair dryer can help “cure” these slower healing areas.
A combined eyelid-ocular prosthesis can be made by an anaplastologist. Many exenteration patients prefer simply to wear a black patch.
Figure 97-13 Bony orbit demonstrating the normal sites of increased resistance to dissection during orbital exenteration.
Figure 97-14 Periorbita has been elevated for 360°. Forward traction is applied to the orbital contents as a hemostat is used to clamp the apical orbital tissues.
Postoperative infection is always of concern when evisceration surgery is performed in the setting of endophthalmitis or panophthalmitis. The use of broad-spectrum systemic antibiotics usually minimizes this risk, and the surgeon can generally use a primary orbital implant. Postoperative extrusion of the orbital implant is a complication of evisceration surgery that may be related to postoperative scleral shell shrinkage, to poor wound healing of the scleral edges, or to improper selection of the orbital implant size. Postoperative pain is more common when the cornea is retained.
Orbital implant extrusion is also a complication of enucleation surgery. Meticulous attention to careful Tenon’s fascia wound closure and the proper selection of implant size are important principles in avoiding this outcome. Risk of implant extrusion is increased with prior irradiation treatment of the eye and orbit, severe traumatic injuries to the eye and orbit, and severe eye and orbital infections. Long-term complications of the anophthalmic socket are numerous, including generalized volume deficiency of the anophthalmic socket, lower eyelid laxity with poor prosthesis support, orbital implant migration, upper eyelid ptosis, and chronic conjunctivitis and mucoid discharge.
Exenteration surgery carries the risk of severe blood loss. It is important preoperatively to discontinue aspirin and all other medicines that could adversely affect blood clotting. Other complications unique to exenteration surgery include cerebrospinal fluid leakage via orbital roof transgression of the dura and chronic sino-orbital fistulas through the region of the lamina papyracea and ethmoid sinus air cells. During the first few weeks of healing, free skin grafts are susceptible to infection. Patients may require treatment with broad-spectrum systemic antibiotics for coverage of Staphylococcus, Streptococcus, Pseudomonas, and
other bacteria. The administration of systemic antibiotics is combined with maintenance of vigorous topical hygiene of the split-thickness skin graft using hydrogen peroxide rinses. Long term, the surgeon should always remain vigilant for the possible recurrence of tumor.
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