Eyelid Laceration Repair
The first concern when dealing with a lacerated eyelid is to perform a complete eye examination to rule out associated intraocular trauma. Attention should also be paid to the levator function, especially for a transverse laceration of the upper lid. In lacerations of the medial canthal area, the puncta and canaliculi should be inspected for evidence of involvement (see later discussion). Inquiry must be made into the status of the patient’s tetanus immunity, and appropriate tetanus prophylaxis should be given if necessary.
Because of the excellent blood supply of the eyelid and periocular tissues, the usual rules for handling wounds do not always apply. Lacerations may be closed well beyond the usual 6-hour “golden period” without risk of infection. Even apparently devitalized tissue need not be debrided, as it will usually survive if attempts are made to reapproximate it.
ANESTHESIA
Lid laceration repair may be carried out with general anesthesia (for small children), and nerve block or subcutaneous infiltration with local anesthetics. The laceration should be irrigated copiously before infiltration anesthesia if there is concern about bacterial contamination (e.g., dog bites). Following infiltration with anesthesia, wounds should be prepared with povidone-iodine (Betadine) solution.
FULL-THICKNESS EYELID LACERATION
Tissue debridement is discouraged in eyelid lacerations because of the excellent blood supply that will usually allow preservation of apparently devitalized tissue. Lacerations of the tarsal plate itself are usually fairly linear, but, if extremely irregular, may be trimmed in a pentagonal fashion to allow closure with eversion of the lid margin. Up to one third of the posterior lamella may be lost and primary closure will still be possible.
The key to satisfactory repair of a full-thickness lid laceration is precise reapproximation along the eyelid margin. Apposition of the tarsal plate is undertaken first. A Westcott scissors is used to separate a plane between the anterior lamella and the posterior lamella. The orbicularis is freed from the underlying tarsus for about 3 mm on either side of the laceration.
Figure 3-1. The key to satisfactory repair is precise reapproximation of the tarsal plate.This is accomplished by using the visible meibomian gland orifices as landmarks to ensure exact reapposition. A 6–0 silk suture is initially passed as a vertical mattress suture in and out of the meibomian gland orifices of tarsus on both sides of the wound. This is perhaps the most important suture to place in preventing postoperative lid notching. The tarsal plate is now apposed with three to four interrupted 5–0 Vicryl sutures on a spatula needle. These sutures are placed at the distal lid margin, the proximal tarsal border, and midway between these two points. The 5–0 Vicryl suture is passed as a lamellar bite of the tarsal plate, taking care to enter on the anterior surface, but not to pass full-thickness through the posterior surface. The anterior lamella is retracted with fine skin hooks to expose the tarsal plate, and the needle enters on the anterior surface approximately 2 to 3 mm from the laceration edge. The needle is passed through the laceration edge, taking care to stay at middepth in the tarsal plate. It is drawn out of the wound and then repassed through the lacerated edge of the opposite side at an identical lamellar depth and again exits the anterior surface of the tarsal plate 2 to 3 mm from the laceration edge.
Figure 3-2. After preplacing three to four lamellar tarsal sutures, the sutures are then clamped with a hemostat. These sutures need not be tied at this point. Placement of the lid margin suture is performed next. This is perhaps the most important suture to place in preventing postoperative lid notching.
Figure 3-3. A 6–0 silk suture is passed in a vertical mattress fashion through the tarsal plate. The needle point is passed through a meibomian gland orifice, approximately 2 mm from the laceration edge, and exits from the cut edge of the tarsal plate, 3 to 4 mm from the margin. The needle is then inserted at a similar point 3 to 4 mm from the margin on the opposing lacerated tarsal edge, emerging through a meibomian gland orifice 2 mm from the cut edge. The needle is then passed back through the lid margin in a “near-to-near” fashion, taking care to again enter through the meibomian gland orifice, but now passing about 1 mm from the lacerated edge. The needle should again exit the lid margin and enter the opposing lid margin at similar levels (see Figure 3-2). This suture is not tied but left long until the previously placed Vicryl sutures on the tarsal plate are tied. The lamellar tarsal sutures are then tied, drawing the tarsal edges into firm apposition. The suture ends are cut on the knots. The 6–0 vertical mattress silk suture is tied at the lid margin. These sutures are left long. A second 6–0 silk suture is passed in an interrupted fashion through the lash follicles, entering and exiting 2 mm from the lacerated edge. The long ends of the lid margin suture are then draped over and tied into the lash follicle suture. Once the long ends of the suture have been tied within the lash follicle stitch, the ends of the lash follicle stitch may be cut short.
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