Fig. 4.1
Suture needles used in ophthalmic plastic surgery. (a) Structural zones of a surgical needle. (b) Various types of needle points. (c) Schematic cross section of each needle point. (d) Schematic cross section of tissue tracks created by each needle design shown above. (e) Examples of curvatures commonly used for surgical needles (Adapted from Cahill and Carroll [1])
The taper point is used when tissue resistance is low and tissue cutting by the point is to be minimized. Taper-point needles are recommended for superior rectus bridle sutures, microvascular anastomoses, and closure of conjunctival flaps in glaucoma filtration surgery. Because the tapered point stretches the tissue around it as it passes, rather than cutting the tissue, the hole created by the pass is as compact and watertight as possible. Tapered points are at a disadvantage in thicker skin and soft tissue, as it may take significantly more force to push the needle through the pass compared to a cutting needle.
The cutting and reverse cutting needles pass through tissue much more easily because they cut a larger track. On each of these needles, the point is shaped like the prow of a boat and acts as a tiny blade to slice through the tissue as the leading edge of the needle contacts it. For a classic cutting needle, the cutting surface is oriented toward the interior curve of the needle. On a reverse cutting needle, the cutting surface is oriented toward the outer curvature, making it less likely to inadvertently cut back through the tissue (“cheese wire”) if the needle is pulled toward the surgeon. Reverse cutting needles are the most frequently used needles in ophthalmic plastic surgery.
Spatulated needle points also pass with minimal resistance. They have a cutting surface at the lateral sides of the needle head, but are smooth along the inner and outer curvature of the needle. As such, they cut a horizontal tract and are utilized when a suture is to be passed through a thin, flat tissue. For example, spatulated needles are invaluable for scleral sutures in strabismus surgery, securing a mucous membrane graft over the cornea, partial-thickness tarsal sutures in ptosis surgery, and securing cartilage or hard palate grafts in eyelid reconstruction surgery.
The shaft of the needle typically has a partly flattened profile to permit secure fixation in the jaws of a needle holder. The surgeon should take care to grasp the needle at its flat shaft rather than near its head (which dulls the point) or its rounded base (which allows the needle to roll and rotate within the needle driver).
The eye of the needle is now typically replaced by a “swedged-on suture” in which the suture material has been attached by the manufacturer by means of crimping it into the back end of the needle rather than threading the material through an opening or the eye in the needle.
The needles used in ophthalmic plastic surgery are most often curved, commonly with an arc that is 3/8 of a circle (135°). Some spatulated needles used for making straight passes through the tarsus or sclera have an arc that is 1/4 of a circle (90°). Sutures that must be passed in extremely tight spaces or with a deep-yet-short course, such as those used in canalicular laceration repairs, may be provided with a stiff needle that is 1/2 of a circle (180°).
Although the curvature of a needle assists the surgeon in making different shapes of suture tracts, the path through which the needle point is directed is the ultimate determinant of the shape of the suture tract. This can be influenced by tissue traction and by the torsional force applied to the needle holder. Regardless of the curvature of the needle, the length of the needle should always be greater than the desired course of the suture, so that the needle shaft can be grasped by the needle holder during both insertion and removal. Attempting long passes with short needles can result in burial of the entire needle beneath the soft tissue, making it difficult to retrieve.
Suture Materials
Suture materials commonly used in ophthalmic plastic surgery are gut, polyglactin (Vicryl, Dexon), silk, nylon, and polypropylene (Prolene).
Gut can be obtained in plain, fast-absorbing, or chromic forms. Plain gut has relatively low tensile strength and dissolves over time. Standard plain gut can take several weeks to fully absorb and frequently leaves suture tract scars on the skin. A fast-absorbing plain gut has been developed for skin sutures that do not have to be removed (Ethicon 1916G). It absorbs within a week so that an epithelialized suture tract is unlikely to form. Chromic gut is chemically treated to resist breakdown, so it absorbs even more slowly than plain gut. It provides tensile strength for approximately 2 weeks and can be used for buried sutures to close tarsal plate, orbicularis muscle, and the subcuticular tissue plane. 5-0 chromic gut can provide a good material for temporary tarsorrhaphy sutures after enucleation surgery if it is placed from gray line to gray line (i.e., suture is externalized through the lid margin and tied, rather than through the skin of the anterior lamella), holding the lid closed for ~2 weeks without the need for suture removal thereafter.
Polyglactin is a synthetic, absorbable, braided multifilament suture material. It has high tensile strength for approximately 3 weeks. The tensile strength is then gradually lost over the next month. It is used for sutures in the tarsal plate, for orbicularis muscle closure, buried deep sutures to take tension off of wound closure, and in repairs of the canthal tendons that are not under excessive tension. Because of its slow breakdown time, it should not be left in place as a skin closure, as this will lead to visible scarred suture tracts.
Silk is a multifilament suture material with high tensile strength. It is an easy suture to use because it is fairly pliable and ties easily, but it does not absorb. It is not used often for buried sutures because it occasionally causes a suture granuloma or becomes a site of infection. 6-0 black silk can be used for eyelid skin sutures, which are typically removed after 5 days. When used for lid margin repairs, 6-0 black silk can be left for 8–12 days without creating suture scars.
Nylon and polypropylene are nonabsorbable synthetic monofilament suture materials with high tensile strength. Nylon degrades over several years, while polypropylene is virtually permanent. Polypropylene is used for canthal tendon surgery if a permanent suture is needed. Either of these materials can be used for skin sutures where a “slick,” easily removed suture is desired. Because nylon and polypropylene are monofilament materials, they can be placed in running fashion with less resistance to passage through tissue during removal than a multifilament suture material. Polypropylene has less tissue resistance than nylon and is the most “wiry” suture material, which makes it more difficult to handle. Because of their slick and wiry properties, polypropylene and nylon sutures are more likely to unravel if knots are not tied secure and square with multiple throws and long tails.
Intraoperative Techniques: Incision, Dissection, and Traction
Incision Location
Faulty placement or execution of an incision may result in a functional success but cosmetic disaster [2]. Incisions in adults are usually planned preoperatively to follow the normal skin creases and folds, often enabling planned incisions to be hidden or camouflaged (Fig. 4.2). These folds occur along relaxed skin tension lines (RSTL) , which correspond to the directional pull existing in relaxed skin. In children the surgeon may have to imagine where these lines will be in later life, as they have not yet formed. However, some lines are formed by deeper skin attachment to facial muscles so that a crease or dimple may be seen with smiling or other forms of expression. Polaroid or digital pictures can help to remind the surgeon of the location of such lines and the possible use of these for surgical incision.
Fig. 4.2
Relaxed Skin Tension Lines (RSTL) in children represent future wrinkle lines
Marking
Incision lines should be marked prior to injecting local anesthesia to avoid blurring anatomic landmarks and misplacing the incision. If the marks are to be drawn prior to skin preparation, the skin should first be gently wiped with an alcohol swab and dried. This permits the ink to penetrate the skin so that the scrub will not remove it.
Protecting the Eye
Prior to creating incisions near the eye, a plastic protective shell lubricated with ointment may be placed on the globe both for protection from blades, needles, and instruments. The shell also keeps the operating room light from bothering the patient under local anesthesia.
Creating the Incision
It is helpful to begin cutting at the lowest gravity-dependent part of the incision to keep blood from obscuring the advancing incision line. With rare exceptions (i.e., incisions within the eyebrow), incisions should be made perpendicular to the skin’s surface, keeping the skin taut to avoid beveling the incision and subsequent poor wound closure secondary to overlapping wound edges. The skin incision should be made through the epidermis and dermis, which is the thinnest in the eyelid and the thickest immediately above the brow. The depth of the incision can be judged by looking at the cut edges. They will begin to spread once the full thickness of the dermis is cut in taut skin.
To minimize tissue trauma, either skin hooks or fine-toothed forceps should be used to handle the wound edges. If forceps are used, the finest instrument that will accomplish the task is usually chosen. This applies mostly to the final skin closure. When working with larger or heavier flaps, a larger, toothed forceps is useful to avoid tearing the tissue from the weight or tension created by pulling or supporting such flaps. Brow tissue, for example, may require heavier forceps (e.g., Adson or Adson-Brown), whereas fine 0.5 mm Castroviejo forceps may be more appropriate for delicate eyelid skin.
Dissection
A variety of scissors are useful in ophthalmic plastic surgery. Spring action scissors such as Westcott, and direct action scissors such as Iris or Kaye, should be kept immediately available on the instrument tray. In general, gently curved, sharp-pointed scissors are most satisfactory in completing a curved incision. The curve of the instrument should correspond to the directional curve of the incision. Blunt-tipped, curved scissors (e.g., Stevens Tenotomy) are of particular value in undermining. The blunt tip allows the surgeon to push into the tissue plane and spread the blades with minimal risk of “buttonholing” the overlying eyelid skin. Delicate, sharply pointed, fine-tipped scissors are especially useful in surgery near the lacrimal apparatus.
Traction and Countertraction
Placing skin and soft tissue on stretch enables finer incision lines, better view of dissection planes, optimized access for cautery without injury to surrounding tissue, and improved exposure within deep incisions or in the orbit. Depending upon the situation, traction can be achieved with the assistance of cotton-tipped applicators, atraumatic smooth retractors (e.g., Desmarres or Ragnell for the eyelid, or malleable ribbons within the orbit), toothed retractors such as skin hooks or rakes to firmly engage the elevated tissue, or specialized eyelid forceps (e.g., Von Graefe) which provide ridges for traction but a broad platform to distribute the force less traumatically.
Traction sutures may also be placed through the upper or lower eyelid margin and then held in place by an assistant or a hemostat affixed to the drape. For eyelid margin traction sutures, the plane of the gray line is utilized. A 4-0 black silk suture with a reverse cutting needle is introduced into the gray line in a vertical direction, while the lid is kept on stretch horizontally. After the needle penetrates 2 mm, it is turned so that the curvature of the needle is followed parallel to the plane of the lid until the point of the needle emerges in the gray line. This suture can be left in place and used postoperatively as a Frost suture, if indicated.
Intraoperative Techniques: Hemostasis
The benefits of meticulous hemostasis are apparent during surgery, but carry forward into the postoperative period as well. Hemostasis aids visualization, which permits accurate tissue identification, dissection, and wound closure. At the conclusion of the case, it eliminates the need for elaborate dressings. Postoperatively, it promotes optimum wound healing, as blood clots trapped in a wound can retard healing, increase scarring, and serve as a nidus for microorganism growth.
The use of a local anesthetic containing epinephrine (1:100,000–1:200,000), even when the patient is under general anesthesia, is a worthwhile first step in achieving good hemostasis. The anesthesiologist should be consulted prior to local epinephrine use so that cardiac and blood pressure changes can be anticipated.
Manual pressure with cotton-tipped applicators or a gauze sponge is frequently sufficient to obtain hemostasis from pinpoint bleeding sources during eyelid surgery. Most bleeding in the eyelids is adequately handled with a disposable thermal cautery unit or monopolar or bipolar electrocoagulation. The Colorado needle (Colorado Biomedical, Evergreen, CO 80439) is particularly useful. It is a very fine, reusable, monopolar cautery tip that can be used in modes for cutting and cautery.
When working deep within a cavity, such as when performing a dacryocystorhinostomy, the ophthalmic surgeon should consider using the combined suction-electrocautery unit popular with neurosurgeons. Pharmaceutical adjuncts such as cotton pledgets soaked in 1:100,000 epinephrine solution or a 1:1 mixture of 4% cocaine and oxymetazoline (Afrin), an absorbable gelatin sponge soaked in thrombin, or microfibrillar collagen hemostat powder (Avitene) are occasionally useful for orbital and lacrimal surgeries, or within the oral cavity after graft harvest.
Patients, families, and the general pediatricians managing their systemic care should be asked about anticoagulant usage, with specific attention to warfarin, heparin, clopidogrel, aspirin, and other NSAIDs, but also non-prescription supplements such as fish oil and gingko [3]. If at all medically possible, anticoagulants should be stopped for an appropriate time interval before surgery in order to minimize the risk of bleeding. Optimal coagulation is especially important in children, both to decrease blood loss during surgery and to reduce the risk of postoperative hemorrhage. Lower circulating volume means that intraoperative blood loss has a higher relative hemodynamic impact on smaller patients. Furthermore, it is often difficult to maintain activity restrictions postoperatively in young children, which raises the risk of hemorrhage after surgery due to prematurely straining, bending, or rubbing the wound.
Intraoperative Techniques: Wound Closure
If a wound is contaminated, cleansing should be the first step in management. This is usually done by thoroughly irrigating the wound with sterile saline or antibiotic solutions. In addition, the wound must be carefully searched for foreign bodies that could interfere with wound healing and give rise to a draining fistula tract. Foreign bodies or dirt trapped in the subcutaneous tissue or skin may leave tattoo marks that are most difficult to manage satisfactorily once healing has occurred.
While extensive debridement in the eyelids should be avoided, frankly necrotic tissue should be carefully trimmed prior to suturing. Any trimming of the wound edges, however, should be done with extreme care, especially if the wound crosses the relaxed skin tension lines. A straight scar from a wound that has been carelessly trimmed may ultimately be more disfiguring than the scar from a carefully closed jagged, irregular laceration.
Closing Deep Tissue
“Dead space,” which is an open cavity in the internal recesses of the incision, can serve as a reservoir for hematoma and microorganisms, prevent accurate wound closure, and impair wound healing. Properly placed deep sutures should not only eliminate dead space in the depths of the wound but also relieve tension from the cutaneous suture line, thereby minimizing postoperative widening of the wound.
For deep closure, absorbable sutures are popular (e.g., 4-0 or 5-0 chromic gut or polygalactin on a spatulated needle or reverse cutting needle). The knots of the subcutaneous sutures are usually buried to avoid interference with skin closure and decrease the risk of postoperative erosion of the knot through the wound surface (Fig. 4.3). To ensure that the knot does in fact assume the desired buried position in the depths of the wound, the surgeon must be sure that both ends of the suture are on the same side of the loop before tying the suture and must then pull the ends of the suture in a direction along the length of the incision while tightening the knot. Tarsal sutures are a specific exception to burying the knot of a subcutaneous suture, as erosion through the conjunctiva may cause corneal ulceration. Instead, the knot for deep tarsal sutures should be oriented toward the anterior (orbicularis) surface rather than the posterior (conjunctival) surface.
Fig. 4.3
Technique of buried suture placement. The knots of subcutaneous sutures should lie in the base of the incision (Adapted from Cahill and Carroll [1])
Closing Skin
There is room for personal preference regarding the suture material (silk, nylon, fast-absorbing gut, etc.) and the method of suturing (interrupted, running, subcuticular, etc.). However, there are baseline principles to be followed every time in order to minimize the final scar:
Choose a needle holder that is appropriate to the size of the needle, allowing a controlled movement which follows the curve of the needle as it passes through the tissue.
Use the smallest caliber suture that will accomplish the specific task. Size 6-0 or 7-0 sutures on atraumatic cutting or reverse cutting needles are commonly used for closure of thin skin on the eyelids. Size 5-0 or 6-0 sutures may be used above the brow or beyond the nasojugal fold.
Skin tension should be minimized in order to prevent widening of the scar as the incision heals. This is accomplished by orienting incisions appropriately and by using appropriate supportive deep sutures. Some types of wounds require special tension-relieving sutures for skin closure, such as the vertical and horizontal mattress suture or the near/far-far/near suture (Fig. 4.4). The vertical mattress suture lies perpendicular to the wound edges and is most useful in the heavier tissues of the eyebrow, cheek, and temple or when closing the donor site for a dermis-fat graft taken from the buttock. This suture can be used to reduce the number of buried subcutaneous sutures and therefore help minimize “suture reaction.” To eliminate inturning of the wound edges, the vertical mattress suture should not be used to bring the skin edges completely together; rather, an interrupted or running suture should be used for this purpose after the vertical mattress sutures have been placed. The horizontal mattress suture finds specific application in closing the tips of triangular flaps and in closing unequal wound edges. The near/far-far/near suture is occasionally useful in relieving tension on snug eyelid margin closures.
Wound edges must be aligned without overlap or rolling under of the skin edge. The edge opposite the surgeon should be grasped with either fine-toothed forceps (e.g., Bishop-Harmon, Manhattan, Castroviejo) or a skin hook directly in line with the suture needle. This helps maintain a pass perpendicular to the wound edge. In thin eyelid skin with a tendency to roll under at the incision edge, the tooth of the forceps can be used to unscroll the edge and then maintain it in everted position during the suture pass.
Everting the wound edges is essential in preventing late depression of the resulting scar. This is especially important in the thicker skin of the brow and cheek. In cross section, the sutures should assume a trapezoid configuration where slightly more deep tissue is included in the suture, thereby forcing the wound edges outward when the knot is tied.
Suture knots must be tied with appropriate tension. Faulty suture tension can give rise to necrosis of the wound edges if the sutures are tied too tightly; an unsightly wide scar may result if they are tied too loosely. In tying sutures, the surgeon can obtain the desired tension with an initial “double throw,” or two wraps, of the suture material. Additional single-wrap throws are then placed as square knots to secure this tension. Usually two additional throws are sufficient with monofilament sutures, particularly if there is any weight or tension. Occasionally, an initial triple throw is useful to avoid slippage when the closure is under tension. The surgeon should resist the common tendency to increase suture tension with the second throw, as this can result in distortion of the wound edges and subsequent unnecessary scarring. To prevent a bothersome loop of suture in the attempt to tie a knot, it is helpful to pull the suture far enough through the wound so that the end of the suture can be grasped with the needle holder or tying forceps. This also saves suture material. Another valuable point is to work with an appropriate length of suture. Although one wishes not to waste material, 18 inches of suture only gets in the way of efficiency. One should trim the excess as needed.
The sutures should be removed or absorbed as soon as incisional healing allows. Sutures which remain in place too long can lead to local reactions, scars, or epithelialized suture tracts. To minimize scarring, skin sutures that have little or no tension on them should be removed in 3–5 days. If necessary, the wound edges can then be reinforced with 1/8-inch or 1/4-inch Steristrips (3 M Medical-Surgical Division, St. Paul, MN) for an additional 3–5 days. If vertical mattress sutures have been used in closing the wound, they are removed in 7 days. Lid margin sutures are usually removed in 8–12 days.
Fig. 4.4
Tension-relieving sutures . (a) The vertical mattress suture, (b) the horizontal mattress suture, and (c) the near/far-far/near suture (Adapted from Cahill and Carroll [1])
Traction Sutures and Tarsorrhaphy Sutures
Traction sutures placed through the gray line of the lids may be useful to ensure corneal protection and/or to keep lid tissues on stretch. A Frost suture can be used to stretch one lid (Fig. 4.5a). An intermarginal suture brings both lids together, but may limit visualization of the ocular surface depending on placement (Fig. 4.5b, c). The serpentine intermarginal suture brings both lids together and can be loosened to permit inspection of the ocular surface (Fig. 4.5d).
Fig. 4.5
Gray line sutures. (a) A Frost gray line suture can be taped to the skin for tension and loosened to inspect the globe. (b) An intermarginal gray line suture keeps the ocular surface protected but does limit visualization of the globe unless tied with a slipknot. (c) The intermarginal suture technique can be done in any combination of central, lateral, and/or medial as dictated by the clinical situation. The sutures can be secured with or without a bolster. (d) An intermarginal serpentine gray line suture can also provide a reversible lid method of closure. The ends may be taped in place and loosened for visualization as needed. The serpentine suture can remain in place for 2–3 weeks
As an added consideration in children, postoperative suture removal can be traumatic, at times even requiring a return to the operating room for removal under anesthesia if the child will not permit safe removal in the clinic. Thus, although nonabsorbable materials are often used for skin closure in adults, using absorbable sutures in children eliminates the need for suture removal.
A rapidly dissolving 6-0 fast gut suture is available for suturing skin (e.g., Ethicon 1916G). This rarely causes epithelialized suture tracts or skin inflammation, which can result from the use of regular gut sutures. It allows more flexibility in the timing of postoperative visits. Because the rapidly dissolving gut suture has less tensile strength than other sutures of the same caliber, it must be used only for skin alignment and not for closing wounds under tension. Additional throws may be placed on the knots since the decreased tensile strength may prevent the knot from being cinched as tightly as stronger sutures. For supporting wounds under tension, beige-colored Vicryl or Dexon (Davis & Geek, Inc., Manati, Puerto Rico) can be effective. The 7-0 Dexon can be used as an interrupted stitch for skin closure to supplement a running fast-absorbing gut. It is also very useful for small flaps and Z-plasties as in epicanthal fold repairs.
Postoperative Dressings and Wound Care
Bandages can be avoided after many ophthalmic plastic procedures, particularly in the pediatric patient. In children, dressings tend to become an annoyance that leads to more picking and wound manipulation. Meticulous intraoperative attention to hemostasis and wound closure results in sutured incisions that do not need postoperative dressings. However, there are times when a dressing should be utilized: After surgery of anophthalmic sockets and some orbital cases, a dressing may be necessary in order to protect the site, apply pressure, or decrease the risk of postoperative hemorrhage. Bolster dressings may be needed after lid reconstructive cases with skin grafts in order to improve graft adherence and survival. Tegaderm dressings are particularly useful for fat graft harvest wounds on the buttock, providing protection in children wearing diapers. If there is concern of disrupting the eyelid wound during sleep, the patient may be asked to wear a protective metal or plastic shield to bed.
When such bandages are required, the use of elbow restraints is often very useful in young or developmentally delayed pediatric patients. These allow the child to play, but not be able to reach hands to face. Masking of signs and symptoms, injury to delicate eyelid tissue, and blindness have been reported following the use of “pressure” patches, so their use should be monitored appropriately.
For postoperative swelling and ecchymosis, cold packs or preferably several gauze pads soaked in ice water can be used intermittently for a total of 15 min out of each waking hour on the day of surgery for their vasoconstrictive effect in minimizing postoperative edema. Warm packs for 10 min every 3 h may be started 24 h after surgery to promote vasodilation and absorption of the edema that has occurred. The use of these may, however, be difficult in the pediatric age group. Excessive straining, which may cause venous congestion, increased swelling, and bleeding, should be avoided as much as possible.
The family should be specifically instructed on how to keep the area clean (e.g., gentle, twice-daily wiping with a clean, moist cloth or cotton ball, followed by the application of a small amount of ophthalmic antibiotic ointment). Some patients have difficulty attending to this wound hygiene because of their fear of “hurting something.” Instructions regarding baths or showers must be individualized. Prolonged soaking of the wound disrupts the healing process.
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