The first edition of this slim paperback appeared in 1983. Although the author states that the main change in the second edition is the addition of a chapter on lacrimal surgery by R. A. N. Welham, in fact, most chapters have been modified, and the discussion of trauma and cosmetic surgery has been expanded substantially. The first edition consisted of 134 pages with eight chapters and 92 illustrations. The second edition has 166 pages with 10 chapters and 119 illustrations. After an introductory review of pertinent anatomy, subsequent chapters deal with major topics, such as entropion and trichiasis, ectropion, ptosis, and socket surgery. Collin's approach to each problem is based on his extensive experience as director of the Lid Clinics at Moorfields Eye Hospital in London, England. Most chapters contain one or more flow charts summarizing Collin's "system" for a particular problem. The flow charts lead the reader through a

A manual of systematic eyelid surgery

Plastic surgery of the face

Reconstruction of the lower lid often is a greater task than originally anticipated in preoperative evaluations. The Mustardé and Hughes methods are commonly used for extensive lower lid reconstruction. Certain difficulties encountered in these methods may be minimized by variations in the basic techniques. Structural support for a Mustardé flap may be provided by a free tarsal conjunctival graft rather than a nasal septal cartilage mucosa graft. Late complications following the Hughes procedure include upper lid retraction and entropion. These may be minimized by removing Mueller's muscle from the flap at the time of the original dissection. The Hughes flap may be lysed in 3 to 4 weeks. Lid margin abnormalities, which occur occasionally, are corrected with minor modifications.

Orbit and Lids: Modification of the Mustardé and Hughes methods of reconstructing the lower lid

Summary Background We evaluated the use of laser speckle contrast imaging (LSCI) in the perioperative planning in reconstructive flap surgery. The aim of the study was to investigate whether LSCI can predict regions with a high risk of developing postoperative necrosis. Our hypothesis was that, perioperatively, such regions have perfusion values below a threshold value and show a negative perfusion trend. Methods A porcine flap model based on the cranial gluteal artery perforator was used. Images were acquired before surgery, immediately after surgery ( t  = 0), after 30 min ( t  = 30 min), and after 72 h ( t  = 72 h). Regions of interest (ROIs) were chosen along the central axis of the flap. Clinical evaluation of the flap was made during each time point. Results At t  = 72 h, a demarcation line could be seen at a distance of 15.8 ± 0.4 cm away from the proximal border of the flaps. At t  = 0, perfusion decreased gradually from the proximal to the distal ROI. At t  = 30 min, perfusion was significantly lower in the ROI distal to the final demarcation line than that at t  = 0, and in all flaps, these ROIs had a perfusion t  = 72 h, perfusion in the ROI proximal to this line returned to baseline levels, whereas perfusion in the distal ROI remained low. Conclusions In our model, a decrease in perfusion during the first 30 min after surgery and a perfusion t  = 30 min was a predictor for tissue morbidity 72 h after surgery, which indicates that LSCI is a promising technique for perioperative monitoring in reconstructive flap surgery.

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The use of laser speckle contrast imaging to predict flap necrosis: An experimental study in a porcine flap model.

PURPOSE: Large upper eyelid defects can be repaired by rotational full-thickness lower eyelid flaps. The aim was to measure the blood perfusion in such flaps, and how it is affected by the length of the flaps, and the degree of rotation and stretching.METHODS: Nine patients underwent the Quickert procedure for entropion repair in which a full-thickness eyelid flap of approximate width 0.5 cm and length 2 cm was dissected in the lower eyelid. This generates a full-thickness eyelid flap similar to that used to repair large upper eyelid defects. Perfusion was measured using laser speckle contrast imaging, before and after the flap was rotated 90° and 120°, and stretched using forces of 0.5, 1, and 2 N.RESULTS: Blood perfusion decreased gradually from the base to the tip of the flap; being 75% of the reference value 0.5 cm from the base, 63% at 1.0 cm, 55% at 1.5, 23% at 1.75 cm, and 4% at 2.0 cm. Rotating the flaps by 90° or 120° had little effect on the perfusion. Stretching reduced the perfusion from 63% to 32% at 2 N, when measured at 1 cm. The combination of stretching and rotation did not lead to any further decrease.CONCLUSIONS: Blood perfusion in lower eyelid rotational flaps seems to be more sensitive to stretching than to rotation. Provided the flap is no longer than 1.5 cm, the perfusion will be greater than 20%, even when rotated, which should be sufficient for adequate survival and healing. (Less)

Blood Perfusion in Rotational Full-Thickness Lower Eyelid Flaps Measured by Laser Speckle Contrast Imaging.

OBJECTIVE: The time taken to reach maximal haemostatic effect following local anaesthesia with epinephrine is generally believed to be <10 min. This is based on clinical experience and indirect measurements of perfusion using methods such as laser Doppler flowmetry and oxygen spectroscopy. However, the only study in which bleeding has been measured quantitatively in an intra-operative setting in humans showed that the full haemostatic effect was not achieved until 30 min after anaesthesia. The aim of this study was to determine the time taken to reach maximum haemostatic effect when using epinephrine for local anaesthesia in oculoplastic surgery.METHODS: Intra-operative bleeding following infiltration anaesthesia with either lidocaine 20 mg/ml (2%) or lidocaine + epinephrine 12.5 μg/ml (1:80 000) was measured after 7, 15 and 30 min in the eyelids of 16 patients undergoing upper eyelid blepharoplasty.RESULTS: Bleeding was decreased by 74.6% (with 95% CI, 6.16-87.6%) 7 min after the injection of lidocaine + epinephrine (p = 0.0048) compared with lidocaine without epinephrine. There was no further decrease in bleeding after 15 or 30 min (p = n.s.).CONCLUSION: The optimal time for skin incision in eyelid surgery is within 7 min of injection of lidocaine with epinephrine. Waiting longer does not lead to a further decrease in bleeding. (Less)

A waiting time of 7 min is sufficient to reduce bleeding in oculoplastic surgery following the administration of epinephrine together with local anaesthesia.

PURPOSE: It is well known that blood perfusion is important for the survival of skin flaps. As no study has been conducted to investigate how the blood perfusion in human eyelid skin flaps is affected by the flap length and diathermy, the present study was carried out to investigate these in patients.METHODS: Fifteen upper eyelids were dissected as part of a blepharoplastic procedure, releasing a 30-mm long piece of skin, while allowing the 5 mm wide distal part of the skin to remain attached, to mimic a skin flap (hereafter called a "skin flap"). Blood perfusion was measured before and after repeated diathermy, using laser speckle contrast imaging.RESULTS: Blood perfusion decreased from the base to the tip of the flap: 5 mm from the base, the perfusion was 69%, at 10 mm it was 40%, at 15 mm it was 20%, and at 20 mm it was only 13% of baseline values. Diathermy further decreased blood perfusion (measured 15 mm from the base) to 13% after applying diathermy for the first time, to 6% after the second and to 4% after the third applications of diathermy.CONCLUSIONS: Blood perfusion falls rapidly with distance from the base of skin flaps on the human eyelid, and diathermy reduces blood perfusion even further. Clinically, it may be advised that flaps with a width of 5 mm be no longer than 15 mm (i.e., a width:length ratio of 1:3), and that the use of diathermy should be carefully considered. (Less)

Blood Perfusion in Human Eyelid Skin Flaps Examined by Laser Speckle Contrast Imaging-Importance of Flap Length and the Use of Diathermy.

BACKGROUND: A previous study in pigs has shown that the pedicle of the tarsoconjunctival flap does not appear to have adequate blood perfusion. The aim of this study was to monitor perfusion in tarsoconjunctival flaps in patients with large lower eyelid defects resulting from tumor surgery.METHODS: The modified Hughes procedure was performed in 13 patients. Blood perfusion was monitored using laser Doppler velocimetry and laser speckle-contrast imaging.RESULTS: Blood flow decreased gradually from the pedicle base to the end of the flap and was 19% at the flap base, 11% in the middle of the flap, and 4% in the distal end of the flap. The flaps survived, and there was no tissue necrosis.CONCLUSIONS: Tarsoconjunctival tissue survival does not seem to be dependent on a conjunctival flap. Free tarsoconjunctival grafts or composite grafts might be considered as viable alternatives in reconstruction of major eyelid defects.

Perfusion Monitoring Shows Minimal Blood Flow From the Flap Pedicle to the Tarsoconjunctival Flap.

PURPOSE: It is generally believed that large eyelid defects must be repaired using a vascularized flap for 1 lamella, while the other can be a free graft. Recent studies indicate that the pedicle of a tarsoconjunctival flap does not contribute to blood perfusion. The purpose of this study was to explore whether large eyelid defects can be repaired using a free bilamellar eyelid autograft alone.METHODS: Ten large upper and lower eyelid defects resulting from tumor excision were reconstructed using bilamellar grafts harvested from the contralateral or opposing eyelid. Revascularization of the flap was monitored during healing using laser speckle contrast imaging, and the surgical outcome was assessed.RESULTS: The functional and cosmetic results were excellent. All grafts survived and there was no tissue necrosis. Only 1 patient underwent revision after 4 days as the sutures came loose. Two patients developed minimal ectropion but needed no reoperation. All patients were satisfied with the surgical results. Perfusion monitoring showed that the grafts were gradually revascularized, exhibiting 50% perfusion after 4 weeks and 90% perfusion after 8 weeks.CONCLUSIONS: A free bilamellar eyelid graft appears to be an excellent alternative to the tarsoconjunctival flap procedure in the reconstruction of both upper and lower eyelid defects, especially in patients who cannot tolerate visual axis occlusion or the 2-stage procedure of the conventional staged flap procedure. (Less)

Reply Re: "Successful Free Bilamellar Eyelid Grafts for the Repair of Upper and Lower Eyelid Defects in Patients and Laser Speckle Contrast Imaging of Revascularization".

Kajsa Tenland

Papers

A waiting time of 7 min is sufficient to reduce bleeding in oculoplastic surgery following the administration of epinephrine together with local anaesthesia.

Blood Perfusion in Human Eyelid Skin Flaps Examined by Laser Speckle Contrast Imaging-Importance of Flap Length and the Use of Diathermy.

Perfusion Monitoring Shows Minimal Blood Flow From the Flap Pedicle to the Tarsoconjunctival Flap.

Blood Perfusion in Rotational Full-Thickness Lower Eyelid Flaps Measured by Laser Speckle Contrast Imaging.

Reply Re: "Successful Free Bilamellar Eyelid Grafts for the Repair of Upper and Lower Eyelid Defects in Patients and Laser Speckle Contrast Imaging of Revascularization".