Eleven consecutive patients with tumours involving the lower eyelid margin were treated with margin-including full-thickness excision of the eyelid and suturing of bleeding vessels as the sole primary surgical procedure, needing less than 10 minutes The resulting defects of 2/5 to 7/8 of the horizontal extent of the eyelid and varying in height from 4 to 7 mm were allowed to heal spontaneously In all the 11 patients the wounds healed, without ocular or palpebral complications in about 6 weeks and underwent further cosmetic improvement for the ensuing 6--8 weeks Cosmetic results were excellent in 8 patients with excisions of 2/5 to 1/2 of the eyelid All procedures including the secondary reconstructions were carried out on day-case basis under local anaesthesia Histology confirmed complete tumour clearance in all the patients Apart from being the first report of a planned study of spontaneous repair of full-thickness surgical wounds of the lower eyelid this study shows that the conventional method of dressing such wounds can be replaced by the less expensive and convenient 'dressing' of a cartella shield with an improvised central hole

https://bjo.bmj.com/content/bjophthalmol/72/11/856.full.pdf

Spontaneous reformation of upper eyelid.

An appraisal of a personal series of 115 unselected and surgically treated cutaneous cancers of palpebral region is presented. Histological confirmation of the diagnosis and adequacy of excision was obtained for all lesions. Seven of the 8 patients with doubtful clearance were successfully treated with further surgery very soon. Complications were few, the incidence of reoperations low, and cosmetic as well as functional results were mostly satisfactory. Tumour recurred in 1 case (0.87%). Two patients had a poor cosmetic result. Seventy-nine cases (69%) were treated as day cases under local anaesthesia even for major repairs like full-thickness reconstruction of two-thirds of the lower eyelid and repairs with large full-thickness skin grafts of up to 20 x 55 mm by a new simple technique of graft fixation. The use of longer-acting local anaesthetics in oculoplastic surgery is described. Attention is drawn to the dangers of using direct wound closure for repair.

/pdf/surgical-management-of-carcinoma-of-eyelids-and-periorbital-55hgkl2c0e.pdf

Surgical management of carcinoma of eyelids and periorbital skin.

A technique of free full thickness skin graft fixation utilising central and paracentral sutures between the graft and the depths of the recipient bed is described. The intrinsic fixation provided by these sutures allow larger free grafts, thus eliminating the need to use local flaps. These sutures also allow double free grafts-mucosal and dermal-for full thickness lower eyelid reconstructions. Patients do not need hospital admission and can resume normal activity immediately after the operation. One hundred and nine skin grafts secured by this technique have yielded very satisfactory results.

https://bjo.bmj.com/content/bjophthalmol/63/2/125.full.pdf

A new method of full thickness skin graft fixation.

The progress of surgery has been utterly dependent on continuing innovations by surgeon innovators, largely because surgeons work in an environment that is very conducive to innovating. Of all clinicians surgeons excel at improvisations and innovations. The aim of this review is to outline some of my innovations, the circumstances leading to their origin, and to explain some of the fundamental concepts behind those innovations, with a view to inviting and encouraging younger surgeons to consider breaking away - sensibly - from convention at times, and embark on a journey towards innovation. The context and the qualities required of a would-be innovator are explained and the process of innovation itself is analysed. Rigid adherence to prevailing assumptions and practices stifles originality, while adopting a questioning attitude with a smidgen of irreverence facilitates innovation. That an innovation has resulted purely by a chance observation or occurrence - serendipity - may render it less glamorous but never less useful. Innovations in surgical techniques necessitate adoption of a novel pragmatic surgical philosophy. Confined as they are to Oculoplasty, the concepts of innovations cited and illustrated in this review, are equally valid for Plastic surgery and indeed for Surgery in general. Working in a small hospital or an isolated Institution need not be a hindrance to a would-be innovator.

https://www.jprasurg.com/article/S1748-6815(08)01107-8/pdf

On innovations in plastic surgery.

Fifteen patients with suspected malignant lesions of the lower eyelids or inner canthal region, needing large excisions, were managed as day cases with spontaneous repair and simultaneous subtotal primary surgical reconstruction under local anaesthesia. For lesions confined to the lower eyelid, only those patients requiring full-thickness margin-inclusive (FTMI) excisions of more than half the horizontal extent of the eyelid are included in this study-the largest excision being 21 x 6 mm. For malignant lesions of the inner canthus, only those patients needing moderate to large excision of inner canthal skin and orbicularis with simultaneous FTMI excision of the medial one-third (8 x 5 mm) of the upper as well as the lower eyelid are included. The 16th patient had traumatic loss of inner canthal tissue. The final cosmetic and functional results in all 16 patients were satisfactory and comparable with the results of competent and in-toto primary surgical reconstructions. For large excisions at the inner canthus spontaneous with partial primary surgical repair allows the use of a less extensive and less elaborate surgical procedure that is within the capabilities of most ophthalmic surgeons.

https://bjo.bmj.com/content/bjophthalmol/73/7/488.full.pdf

Simultaneous spontaneous and primary surgical repair of eyelids

A review of 473 patients operated upon as day cases indicates that such surgery is safe, effective, and practicable. The surgical procedures included strabismus and ptosis correction in 265 children; major oculoplastic surgery for subtotal full-thickness eyelid reconstruction; and intraocular surgery in adults for trabeculectomy, cataract extractions with or without simultaneous intraocular implant introduction, and cataract extractions combined with trabeculectomy. No modification in surgical technique was required for strabismus and ptosis surgery. Slight modification was necessary for cataract surgery, and certain innovations were made in oculoplastic surgery.

H K Mehta

Papers

Assessment of major intraocular and extraocular surgery performed as day cases.