4 Eyelid Margin Laceration Repair
A margin-involving eyelid laceration requires special attention to prevent postrepair complications such as eyelid notching and trichiasis. In this chapter, we will review the important techniques to successfully repair margin-involving eyelid lacerations.
Become comfortable with the basics of repairing an eyelid margin laceration.
Understand the possible complications of eyelid laceration repair and how to prevent them.
A thoughtful and well-planned approach will provide the patient with the most optimal functional and aesthetic outcome.
Learn the steps to reapproximate the eyelid margin.
Learn how to avoid postoperative complications.
4.4 Key Principles
The most important initial step in any eyelid injury is to ensure that any other head and systemic injuries have been addressed. Next, ensure the integrity of the globe, and address any open globe repair before eyelid repair. Under most circumstances, primary eyelid laceration repair is preferable to delayed repair.
Missing tissue is rare after eyelid margin laceration. As a result, tissue rearrangement and skin grafting are typically not needed for most eyelid margin laceration repairs, and these techniques will not be discussed in this chapter.
Full-thickness upper or lower eyelid margin lacerations.
Eyelid laceration with tissue missing/excessive tension.
4.7 Preoperative Preparation
Preoperatively, several factors should be taken into consideration in order to achieve an optimal outcome. This includes the size and orientation of the eyelid margin laceration, surrounding vascular supply, age of the patient, prior eyelid repair surgery, age of the wound, and any history of radiation therapy, all of which may affect healing.
When eyelid margin defects are associated with trauma, the first priority is to assess for and stabilize any concomitant life-threatening injuries. Once stabilized, a complete history, with special attention to the mechanism of injury should be taken. Any history of projectile objects, gunshots, and penetrating foreign bodies such as a pencil or tree branch should raise suspicion for a retained foreign body. In cases of severe head trauma, it is also essential to obtain imaging, typically a computed tomography (CT) scan of the head and orbits to assess for intracranial hemorrhage and craniofacial bony fractures.
These evaluations should be followed by a complete eye exam to evaluate for globe perforation, and retinal and optic nerve injuries. Fat prolapse from the wound suggests a deep laceration, and in the upper eyelid, damage to the levator aponeurosis or muscle should be suspected. All wounds should be thoroughly explored and irrigated to evaluate their extent and to ensure no retained foreign body, especially vegetative debris. The edges of traumatic eyelid lacerations are often jagged and irregular, but usually tissue is not missing. Efforts should be made to preserve all eyelid tissue, but if necrosis is present, then cautious debridement is important before reconstruction can begin. Primary repair undertaken within the first 24 hours of injury can usually prevent necrosis and tissue loss.
If a medial upper or lower eyelid laceration is present, the surgeon must rule out canalicular involvement (see section on canalicular repair).
Prophylactic antibiotic use is controversial; however, most surgeons agree that they should be given perioperatively in heavily contaminated wounds, especially in cases of a human or animal bite. First-generation cephalosporins will typically cover against skin originating methicillin-sensitive Staphylococcus aureus and other gram-positive species. For animal/human bites, amoxicillin-clavulanate is the first-line antibiotic and for immunosuppressed patient, broader spectrum agents may also be considered. 1
Tetanus prophylaxis is required if not given in the last 5 years or if it is unknown when last given. It is also important to note time of last meal, as this may affect the timing of surgical repair, especially in a patient who requires general anesthesia (children and uncooperative patients)—for which, usually no oral intake for the prior 8 hours is required. Animal bites should be reported according to local protocol. 2
Timing of eyelid laceration repair is very important to achieve the best cosmetic outcome. Though there exists some variability among surgeons on the absolute latest an eyelid laceration can be repaired, in general these should be closed as quickly as possible, ideally within 24 hours of injury. Given that many of these lacerations will present in the setting of trauma, management of life-threatening emergencies will always take precedence. In these situations, every attempt should be made to repair the eyelid laceration within 48 to 72 hours. Maintaining the integrity of the tissue with antibiotic ointment and wet dressing is important if there will be a delay in surgical repair.
4.8 Operative Technique
Apply a drop of topical anesthetic (e.g., tetracaine or proparacaine) in both eyes. Inject local anesthetic with epinephrine subcutaneously and into the wound. Regional nerve blocks may also be employed, as these may minimize the need for local anesthetics that can distort the eyelid structures.