skin graft – Tropical Ophthalmology

Cicatricial upper eyelid ectropion (thermal burns), case #2 – Part II

Part I was here. It was the case of a young boy, who dropped himself into fire during epilepsy attack and got extensive left upper face burn with eventual upper and lower eyelids cicatricial ectropion. In Part I I described the first 74 days after he got burns, together with the repair of the ectropion of upper lid (performed in August 2017).

Here I will display the photos of outcome, which were taken precisely 2 months after the skin grafting for upper lid.

Cicatricial ectropion upper lid after skin-grafting

Cicatricial ectropion upper lid 2 months after skin-grafting (137 days after burn)

Lower lid cicatricial ectropion was progressing and required a surgery later. But it was definitely not that dangerous for the cornea, and the timing allowed to postpone the surgery until burn scarring process completion. I felt therefore my duty to prevent the unnecessary blindness in this kid was fully accomplished. (Lower lid surgery was performed by general plastic surgeon upon my departure from Zambia).

Случай августа 2017 года. Хотел поделиться случаем рубцового выворота с коррекцией кожным трансплантатом (с внутренней стороны плеча) у мальчика лет 8, который пострадал в результате падения на огонь во время приступа эпилепсии. В первой части я показал прогрессирование рубцевания за первые 70 дней, что в верхнем веке было настолько выражено, что привело даже к экспозиции слёзной железы (и, естественно, роговицы). Что было неотложным показанием к операции, в других условиях проводящейся в гораздо более поздние сроки из-за прогрессирующего послеожогового рубцевания. На втором коллаже представлены фотографии 2 месяца спустя после операции рубцового выворота. Рубцовый выворот нижнего века также прогрессировал, но срочности не представлял.

Ах два. Интересный факт. Тарзорафию это рубцевание рвало дважды (фотография 1, слева сверху под свежим ожогом), варианта оттянуть экспозицию роговицы практически не оставалось.

18.08.2019 Add Comment

Cicatricial upper eyelid ectropion (thermal burns), case #2 – Part I

With this new case of cicatricial upper eyelid ectropion I was guided by Dr. Roy W. Pelton (“Dr. Pelton” in rest of the post), through a wonderful tele-consultation system of Orbis (Cybersight Consult). Dr. Roy Pelton is a consultant oculoplastic surgeon from Colorado, USA, and thus he helped me a lot with quite a few cases.

So I feel it will be interesting to see the story how it was, in a chronological order, through our communication.

Fresh thermal burn, cicatricial upper eyelid ectropion, lagophthalmos

(more…)

26.08.2017 Add Comment

Cicatricial upper lid ectropion (Part II)

This is an extension of the previous case, where a skin graft was used to correct cicatrix of the upper lid. Luckily, my first skin graft survived and healed very well. Unfortunately though, there was a relapse of lagophthalmos and some amount of graft contraction.

Despite all my attempts to prevent future contraction, the graft has contracted. I did a small root cause analysis through a consultation with Dr. Goran Jovic (consultant plastic surgeon) and my favourite “Ophthalmic Plastic Surgery” textbook by Sidney Fox. That helped much.

I think, best will be to provide quotes from Fox’s textbook, which I have consulted before surgery as well:

One of the main elements in successful skin grafting is infinite attention to detail. Full understanding of these details is perhaps better obtained by the trial and error of experience than by formal exposition, However, broad essential principles can be outlined. Some are obvious. Others are learned only through failure. All are important.

…

… in preparation of the graft bed… First and foremost is the removal of scar tissue. This cannot be overemphasized. The extent to which a graft can shrink almost to nothing as the surgeon stands by helplessly in horrified amazement is something hard to describe. After one such experience, however, one will never again fail to resect all scar tissue from the recipient bed.

…

If lid skin is used, the graft is cut just a trifle larger than the recipient bed. Grafts from other areas should be taken at least one-quarter and preferably one-third larger.

Those words in bold are all possible causes of my surgery failure. So:

Despite that I had removed a lot of scarred orbicularis, I had probably not removed enough.
I had taken the skin graft of a same size as a graft bed from retroauricular sulcus. Apparently, it should have been larger by quarter or third.
I had to do this mistake once to learn it forever.

Finally, I don’t think my release of tarsorrhaphy was too early. Ten days is enough according to many textbooks. Key reasons are probably listed above.

Skin graft contraction – 21st postop day

17.06.2017 Add Comment

Cicatricial upper lid ectropion (Part I)

This is a young 21 y.o. lady, who had thermal a thermal burn to the face during an epileptic seizure. She had upper eyelid cicatricial ectropion as a result, with vertical deficiency of anterior lamella as a result. Exposure keratitis developed subsequently with decrease of vision in the same eye. The lady presented 5 months after the incident. The cicatrix was released and the resultant skin defect managed with retroauricular skin autograft with bolster for graft to “take” for 7 days and tarsorrhaphy for 10 days.

Photos are showing her pre-operative status (mix #1), intraoperative resultant skin defect and graft source (mix #2) and postoperative day 10 after tarsorraphy release. Lid contour, height and skin color are all expected to improve in a mid and long-term. Lagophthalmos and ectropion are fully releaved, and her pre-existing exposure keratitis well healed during 10 days of tarsorrhaphy.

Upper lid cicatricial ectropion after thermal burn, preoperative status

Upper lid cicatricial ectropion after thermal burn, intraoperative skin defect and graft source.

Upper lid cicatricial ectropion after thermal burn, postoperative status

P.S. I am grateful for the valuable consultations provided by Dr. Christine Nelson and Dr. Tristan Reuser to polish the operative management of the case.

This story has an extension: See Cicatricial upper lid ectropion (Part II).

28.05.2017 Add Comment