40.1 Patient History Leading to the Specific Problem

The patient is a 48-year-old woman who underwent carbon dioxide laser resurfacing of the bilateral lower lids and perioral area (wavelength of 10,600 nm, pulse energy of 0.5 J, and output power of 100 W). She returned 2 weeks following treatment complaining of delayed wound healing, persistent erythema, and fibrinous discharge (Fig. 40-1). The patient denied vision changes and dry eye, and was otherwise healthy. Cultures (viral and bacterial) were obtained to rule out infection, and a trial of oral antibiotics was attempted with no improvement of symptoms. Area was determined to be a full-thickness burn injury to the subtarsal lower lid with surrounding partial-thickness burn to the pretarsal and malar skin in addition to perioral skin. Prior to our initial evaluation, patient developed bilateral ectropion and underwent bilateral tarsal sling and steroid injections in the burn scars in another state.

40.2 Anatomic Description of the Patient’s Current Status

The patient presented to Paces Plastic Surgery, to Doctors Hester and McCord, 6 months following the laser resurfacing and two previous attempts to correct lid retraction. She had worsening lid retraction resulting in significant scleral show. The patient had developed hypertrophic scarring involving her pretarsal, subtarsal, and malar skin, resulting in lid malposition. Additionally, the patient has developed hypertrophic scarring of the perioral skin, particularly affecting the oral commissure.

The evaluation of the patient’s problem begins with assessment of burn depth and affected structures. The area must initially be allowed to demarcate prior to any procedures to correct the aesthetic deformity, which will allow recovery of adjacent areas with partial-thickness injury and proper assessment of the necessity to replace them. Additionally, incompletely healed burn will continue to contract, thereby adversely affecting an already completed reconstruction.

Lid position is often assessed by evaluation of the lid margin’s position relative to the limbus. A youthful eye is synonymous with a 0.5-mm overlap of these structures with no scleral show at rest. Assessment of the eye must include evaluation of upper lid excursion for complete eye closure and presence of Bell’s phenomenon. Bell’s phenomenon, which is present in 75% of the population, is an upward and outward movement of the eye upon closure. Incomplete eye closure, particularly in the absence of Bell’s phenomenon, increases the risk of exposure keratopathy and damage to the cornea. Lid retraction is a result of shortening of both anterior and posterior lamella combined with tarsoligamentous laxity. This is of particular importance when attempting to correct the deformity as in the patient with a full-thickness injury, as both lamellae must be addressed.

Assessment of the lower lid laxity should always involve a “snap back” test or a more objective skin distraction test. The skin distraction test involves measuring the distance from the globe to the lid margin while traction is applied away from the globe. A distance of 2 mm or greater indicates lid laxity, which can be addressed with tightening of the tarsoligamentous sling, while a distance of 6 mm or greater requires skin resection in the horizontal plane. The “snap back” aspect of the examination refers to a firm return of the lower lid margin to the globe when released after distraction (Fig. 40-2). A delayed return would also indicate a requirement of tarsoligamentous sling tightening.

The approach to the anatomy of this region can be daunting, especially when the goal is resection of a significant surface area of skin to address a poorly aesthetic scar. Scar resection must be balanced with lid position as they are competing forces. This patient presents with a lid distraction test greater than 2 mm with delayed “snap back” indicating tarsoligamentous laxity. Additionally, the patient has scleral show, indicating there is a shortening of both the anterior lamellar skin/orbicularis and the posterior lamella tarsus/conjunctiva. She had persistently irritated eyes secondary to incomplete lid closure, which was addressed in the short term with eye drops.