RU2711142C1 - Method of minimally invasive surgical elimination of paralytic lagophthalmos by "reinforcement" of the lower eyelid - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to ophthalmology and plastic surgery. For elimination of paralytic lagophthalmos of lower eyelid starting from middle one-third of lower eyelid by microsurgical blade making six microsections of eyelid skin, and one skin incision in area of medial adhesion of eyelids, two incisions – in the middle between the upper and lower eyelid edges, four incisions – parallel to the border of the upper and lower eyelid edges, one incision – within the medial adhesion of the eyelids, 1.5–2.0 mm long each. First, two micro cuts are made in the middle between the upper and lower cartilage edges of the lower eyelid, the first microincision is made on the border of the outer and middle one-third of the eyelid, the second microincision is made on the border of the inner and middle one-third of the eyelid. Further, microincisions are made at the border of the upper and lower cartilage of the eyelid in pairs in opposition to each other, wherein the third incision is made in the middle third of the eyelid at the upper edge of the cartilage, the fourth incision opposite it at the lower edge of the cartilage of the eyelid, the fifth one – in the inner one-third of the century near the upper boundary of the cartilage, the sixth incision – opposite the fifth one at the lower edge of the cartilage of the eyelid, and the last seventh microsurgical incision is performed in the area of medial adhesion of lids. Then through the obtained microsurgical incisions, prolene suture 5.0 is performed on two needles through all layers of the eyelid, grasping the cartilage with crossing the suture in the wound. Further, the suture ends are tightened to the correct position of the lower eyelid and tied with a submerged unit; the sutures are not applied on the microsurgical incisions of the lower eyelid.EFFECT: method is minimally invasive, provides a fast rehabilitation period with good cosmetic effect, reliable protection against damaging factors and improves drainage of lachrymal fluid by increasing turgor of lower eyelid tissues and good adhesion of eyelids to the eyeball.1 cl, 6 dwg, 2 ex

Description

The invention relates to medicine, namely to ophthalmology and plastic surgery, and can be used to eliminate paralytic lagophthalmos.

A known method of eliminating lagophthalmus by incisions and excisions of triangular skin-conjunctival-cartilaginous plates with subsequent matching of the edges of the defect and their suturing. [Krasnov M.L. Guide to eye surgery. M: Medicine, 1988, p. 47]. The disadvantages of this method include high trauma to all layers of the lower eyelid, frequent relapses and prolonged atony of the lower eyelid.

Also known is a method of treating lagophthalmus by strengthening the lower eyelid with a dura mater transplant, first the graft is stitched along the upper edge with straight stitches, and before the graft is strengthened, incisions are made over both adhesions of the eyelids, beyond which the ends of the thread are inserted, after which the placed graft is pulled to the end of the thread and stitched they lower edge of the graft towards the center where they are connected [RF patent No. 2036625, 1991, A61F 9/00]. The disadvantage of this method is its high invasiveness, the performance of large incisions and the unsatisfactory cosmetic effect of the operation.

A known method of correcting eversion according to the method of Kunt-Shimanovsky (A. Kalahan "Surgery of eye diseases" Medghiz 1963, pp. 70-72). Splitting of the lower eyelid into the musculocutaneous and tarsal conjunctival plate along the length of the entire eyelid is performed. A sector-shaped section of a triangular shape is excised from the back plate (its dimensions are determined individually), then the edges of the defect are sutured with nodal or mattress sutures (catgut or vicryl). A muscular-dermal flap of a triangular shape is excised from the anterior plate in the region of the cheekbone 3-5 mm more than the flap of the posterior plate. The edge of the eyelid with eyelashes located laterally to the corner is removed. The edges of the skin incisions are sutured with interrupted sutures and removed after 10 days. This method is very time-consuming to perform, it is carried out in stages, is time-consuming, in some cases it is a factor in the negative psychoemotional reactions of the patient, since postoperative scars remain and the eyelid does not always occupy the correct position.

There is also known a way to eliminate paralytic eversion "according to Fuchs" (Rumyantseva AF "Eye Surgery" II edition, State Medical Publishing House of the Ukrainian SSR, Kiev 1959, p. 64). The method includes several steps. Along the intermarginal margin of the lower eyelid from the external commissure, an incision is made 1/3 of the length of the lower eyelid, after which we split the eyelid into the musculocutaneous and tarsal conjunctival plates and the same section of the upper eyelid, but with excision of the ciliary edge. Then the upper and lower eyelids are sutured, cartilages with refreshed edges are pulled together. The skin flap of the lower eyelid fits on the prepared skin defect on the upper eyelid, where it is strengthened with sutures. The known method is quite time-consuming to perform, the upper eyelid is affected, the area of skin with eyelashes is removed, the width of the palpebral fissure is noticeably reduced.

There is also known a way to eliminate paralytic eversion "according to Gref" (Rumyantseva AF "Eye Surgery" II edition, State Medical Publishing House of the Ukrainian SSR, Kiev 1959, p. 64). A pointed scalpel on the upper and lower eyelids is an intermarginal incision 2 mm deep, 4-8 mm from the external commissure of the eyelids. Parallel to the intermarginal edge, a skin incision is made of the same length 2-3 mm from the free edge of the eyelids.

The ends of the skin incisions are connected by two perpendicular incisions, and the strip of skin with eyelashes is removed, three sutures are applied to the skin wound. The disadvantage of this method is that the skin is gradually stretched and the effect of the operation is reduced. In addition, the outer corner of the palpebral fissure lacks eyelashes.

A known method of correcting lagophthalmus by the method of lateral displacement of tissues along the Irma. (Zaykova MV "Plastic ophthalmic surgery", M., Medicine, 1980, pp. 70-71), which includes several stages. The skin incision is carried out at the level of the lower inner edge of the eyelid, the second is done in front of the lacrimal opening. The cut flap on a wide leg is displaced towards the nose due to the excision of a triangular flap according to Burov from the medial edge of the wound. Impose interrupted sutures. The known method is quite time-consuming to perform, additional areas of facial tissues are affected, leaves behind scars.

There is a method of correcting lagophthalmus with eversion of the lower eyelid in case of chronic facial paralysis by resection of the tendon in the superior tarsal muscle, an external cantotomy and cantolysis followed by fixation of the lower eyelid tarsal plate to the periosteum of the lateral edge of the orbit or bone of the same region through the formed openings, by circular conducting from the inner corner in the tunnels of the upper and lower eyelids and tying the ends under the periosteum in the outer corner of the eye [patent No. 2342106, A61F 9/007, 2007]. The disadvantages of this method are the development of ptosis of the upper eyelid with intervention on the upper tarsal muscle, rigid fixation and trauma to the bones of the orbit during fixation of the tarsal plate, exposure or teething, and narrowing of the palpebral fissure due to circular threading.

There is a method of eliminating lagophthalmus by performing an incision along the fold of the upper eyelid, flapping the flap, fixing the simulated ear autograft to the tarsal plate of the upper eyelid (RF patent No. 2610218 IPC A61F 9/007, publ. 08.02.2017), characterized in that the skin-subcutaneously exfoliate - a fat flap, forming a receptive bed by separating the surface of the levator tendon from the upper tarsal plate, a simulated ear autograft is placed between the upper edge of the tarsal plate of the upper eyelid and the surface of the levator tendon, then it is fixed, starting from the medial angle of the eye from above to the surface of the levator tendon, and from below to the upper part of the tarsal plate of the upper eyelid, then at the lateral angle of the eye, a tunnel is formed through which the thread is passed to the lower eyelid, then the thread is carried out in the middle of the tarsal plate of the lower eyelid by successive injections and punctures, with each subsequent injection coinciding with the previous puncture, the ends of the thread at the medial corner of the eye are tied and fixed to the periosteum. The main disadvantage of this method is multi-stage, affecting other areas of the face, a large amount of surgical intervention and, as a result, a longer rehabilitation period.

A known method of eliminating paralytic lagophthalmus, including strengthening the lower eyelid, (RF patent No. 2635082, IPC A61F 9/00, A61F 9/007, A61F 2/02, A61F 2/14 publ. 02/08/2017), characterized in that the strengthening of the lower eyelids are carried out using an implant made of polytetrafluoroethylene, fix it to the front surface of the tarsal plate and periosteum in the projection of the ligaments of the eyelids, an additional recession of the upper eyelid levator is carried out using an polytetrafluoroethylene implant, while the levator aponeurosis is cut from the tarsal plate and the implant is hemmed t to the tarsal plate at one end and to the aponeurosis on the other end. The disadvantage of this method is the large volume of the operation, affecting the upper eyelid and cutting off the levator aponeurosis.

Closest to the proposed method is the elimination of lagophthalmus (RF patent No. 2614889, IPC A61F 9/007, publ. March 30, 2017) by circularly conducting the thread at the level of the tarsal plates of the upper and lower eyelids, characterized in that the upper eyelid is carried out by sequential injections and punctures from the medial corner of the eye in the middle of the tarsal plate, with each subsequent injection coinciding with the previous puncture, then an injection is made at the lateral edge of the tarsal plate of the upper eyelid, and a puncture is made at the lateral edge of the tarsal plate izhnego century, where in the same way as on the upper eyelid, the thread is carried to the medial corner of the eye in the middle of the lower eyelid tarsal plate and then tying the ends of the threads in the medial corner of the eye and the fixation to the medial canthal ligament.

The disadvantage of this method is that the upper eyelid is affected, it performs a supporting function and its mobility is limited.

The objective of the invention is the development of a method for eliminating paralytic lagophthalmus in a simple, affordable and minimally invasive way with minimal cost, without the need for resection of parts of the lower eyelid, without displacement of a musculocutaneous flap and lateral cantotomy followed by cantorography.

The task is achieved in that, starting from the middle third of the lower eyelid, six skin incisions are made with a microsurgical blade parallel to the edge of the eyelid and one skin incision in the area of the medial adhesion of the eyelids 1.5-2.0 mm long each. First, two micro incisions are made in the middle between the upper and lower edges of the cartilage of the lower eyelid, the first incision is made at the border of the outer and middle third of the century, and the second incision is at the border of the inner and middle third of the century. After that, four micro incisions are made at the very edge of the upper and lower border of the cartilage of the eyelid in pairs opposite each other, the third section is performed in the middle third of the century at the upper edge of the cartilage, the fourth section opposite it at the lower edge of the cartilage of the eyelid, the fifth in the inner third of the century at the upper border of the cartilage , sixth incision - opposite the fifth at the lower edge of the cartilage of the eyelid and the last seventh microsurgical incision is performed in the area of the medial adhesion of the eyelids. Through the obtained microsurgical incisions conduct prolene thread 5.0 on two needles "u" and "z". The first injection is performed into the incision at the border of the outer and middle third of the century so that the thread passes through all layers of the eyelid, capturing cartilage and intersecting each other in soft tissues. The needle “u” is punctured into the incision corresponding to the lower border of the cartilage of the eyelid, and the needle “z” is punctured into the incision corresponding to the upper border of the cartilage of the eyelid, then the needle “y” and “z” are punctured into the same pairwise located incisions from which they emerged , passing in soft tissues with capture of the cartilage of the eyelid, the needles are punctured into the incision located on the border of the inner and middle third of the lower eyelid, tying the thread on one knot, which is immersed in the skin incision. After that, the “y” and “z” needles are injected into the same incision from where they came from, passing in the layers of the circular muscle with stitching of the cartilage, the thread is crossed and then the “y” needle is punctured into the incision corresponding to the lower border of the eyelid cartilage, and the needle “ z ”is punctured into the incision corresponding to the upper border of the cartilage of the eyelid, then each needle is punctured into the same incision from which it emerged, and, passing in the layers of the circular muscle, stitching the periosteum and medial adhesion of the eyelids, the needles are punctured into the incision located in the medial region adhesions of the eyelids. Pull the ends of the thread to the correct position of the lower eyelid, and tie a submersible node, while the seams on the microsurgical incisions of the lower eyelid are not imposed.

The technical result of the proposed method is giving the lower eyelid the correct position, a good adaptation of the eyelids to the eyeball and a pronounced cosmetic effect.

The inventive method is illustrated in the drawing and photographs, where in FIG. 1 schematically shows the stages of surgical intervention:

A - microsurgical incisions of the skin of the eyelid, in the amount of six pieces (No. 1-6);

B - holding prolene 5.0 yarn with needles “y” and “z” at two ends;

B - cross-thread in soft tissues;

G - one microsurgical skin incision (No. 7) in the area of medial adhesion of the eyelids. Flashing of the periosteum and medial adhesion of the eyelids with the subsequent withdrawal of both needles with thread through a skin incision is shown;

D - tying the thread on the immersion unit;

пунктиром показано прохождение нити в мягких тканях.

the dotted line shows the passage of the thread in the soft tissues.

on a photo 1 - patient S. is presented - paralytic lagophthalmus of the right eye, initial state;

on a photo 2 - the patient S. is presented right after the end of operation;

on a photo 3 - patient S. is presented in 2 weeks after operation, an eyelid occupies the correct position, there is no lagophthalmos;

on a photo 4 - patient A. is presented - a paralytic lagophthalmus of the right eye, an initial state;

on photo 5 - patient A. is presented 1 month after the operation, the eyelid is in the correct position, there is no lagophthalmos.

The method is as follows. Starting from the middle third of the lower eyelid, six skin micro-incisions are made with a microsurgical blade parallel to the edge of the eyelid and one skin incision in the area of the medial adhesion of the eyelids, each 1.5-2.0 mm long (see Fig. 1). Sections No. 1 and No. 2 are made along the midline between the upper and lower edge of the eyelid.

Section No. 1 at the border of the outer and middle third of the century, section No. 2 at the border of the inner and middle third of the century. Four incisions - No. 3, No. 4, No. 5, No. 6 are located at the very edge of the upper and lower boundaries of the cartilage in pairs opposite each other. Section No. 3 in the middle third of the century at the upper border of the cartilage, section No. 4 opposite it at the lower edge of the cartilage. Section No. 5 in the inner third of the century at the upper edge of the cartilage, section No. 6 opposite it at the lower edge of the cartilage. Section 7 is made in the area of medial adhesion of the eyelids. Then, through the obtained cuts, a prolene 5.0 thread is carried out on two needles “y” and “z”.

The needle “y” and the needle “z” are injected into incision No. 1, crossing the thread between each other, the thread passes through all layers of the circular muscle with capture of the cartilage of the eyelid, and the needles are punctured out: needle “u” through section No. 4, needle “z "Through section No. 3. Then the needle “u” is injected back into the incision No. 4, and the needle “z” is injected back into the incision No. 3, both needles pass in the layer of the circular muscle, passing the thread behind them, they are punctured into the incision No. 2, at the exit of the incision the thread is tied on one submersible unit. Next, the needles “y” and “z” are injected back into the incision No. 2, passing in the layers of the circular muscle, the thread crosses and the needles are punctured: the needle “y” through the incision No. 6, the needle “z” through the incision No. 5. Then each needle is injected into the same incision from which it came out (needle “y” into incision No. 6, needle “z” into incision No. 5) and, passing through the layers of the circular muscle, having sutured the periosteum and medial adhesion of the eyelids, the needles are punctured into the incision Number 7. The thread is pulled to the correct position of the lower eyelid and tied to a submersible knot. Sutures on microsurgical incisions do not impose.

According to the claimed method performed three surgical interventions with quite good results. The example of two patients shows the technique and the final result of plastic surgery of the claimed method.

Example 1. Patient C is presented who underwent surgery in 2001 for an auditory nerve neuroma on the right. During the operation, the facial nerve was injured, after which right-sided paralysis of the entire facial muscles and paralytic lagophthalmus of the right eye developed. In March 2017, the patient underwent surgery according to the claimed method under local infiltration anesthesia: lidocaine 2% 2.0 ml + mesatone 1% 0.3 ml. Starting from the middle third of the lower eyelid, a microsurgical blade made six skin incisions parallel to the edge of the eyelid and one incision in the area of the medial adhesion of the eyelids 1.5-2.0 mm long, the distance between the incisions 4.5-5.0 mm. Two micro incisions were made in the middle between the upper and lower edges of the lower eyelid. Four incisions were made at the very edge of the upper and lower border of the cartilage of the eyelid opposite each other and one microsurgical incision in the area of the medial adhesion of the eyelids. Then, through the obtained microsurgical incisions, a 5.0 prolene thread was made with needles at both ends by successive injections and punctures, and each subsequent injection coincided with the previous puncture in each skin incision. The thread was held so that it passed through all layers of the eyelid, capturing the cartilage, with the crossing of the thread in the wound (see Fig. 1, B) with a single knot tied in section No. 2 and No. 7 (see Fig. 1 D). When passing the last incision, we stitched the periosteum and the medial adhesion of the eyelids, brought both ends of the thread into the skin incision above the medial adhesion of the eyelids (see Fig. 1, D) and pulled the thread with such force that the lower eyelid pressed against the eyeball and occupied the correct anatomical position. After that, the thread was tied to a knot, which was immersed in a skin incision. The edges of all seven microsurgical skin incisions matched independently without suturing. When examining the patient after surgical removal of lagophthalmus, the palpebral fissure on the right is symmetrical to the fissure on the left. When closing the eyelids on the right - complete closure. The eyelids are adjacent to the eyeball on the right. Tearing is not noted.

Example 2. Patient A. is presented, who suffered an acute cerebrovascular accident in 2009 (ischemic stroke of the brain) as a result of the above acute vascular pathology, there was facial paralysis on the right and paralytic lagophthalmus of the right eye. In August 2017, the patient underwent surgery according to the claimed method under local infiltration anesthesia: lidocaine 2% 2.0 ml + mesatone 1% 0.3 ml. Starting from the middle third of the lower eyelid, a microsurgical blade made six skin incisions parallel to the edge of the eyelid and one incision in the area of the medial adhesion of the eyelids 1.5-2.0 mm long, the distance between the incisions 4.5-5.0 mm. Two micro incisions were made in the middle between the upper and lower edges of the lower eyelid. Four incisions were made at the very edge of the upper and lower border of the cartilage of the eyelid opposite each other and one microsurgical incision in the area of the medial adhesion of the eyelids. Then, through the obtained microsurgical incisions, a 5.0 prolene thread was made with needles at both ends by successive injections and punctures, and each subsequent injection coincided with the previous puncture in each skin incision. The thread was held so that it passed through all layers of the eyelid, grasping the cartilage, with the crossing of the thread in the wound (see Fig. 1, B) with tying on a single knot in section No. 2 and No. 7 (see Fig. 1 D). When passing the last incision, we stitched the periosteum and the medial adhesion of the eyelids, brought both ends of the thread into the skin incision above the medial adhesion of the eyelids (see Fig. 1, D) and pulled the thread with such force that the lower eyelid pressed against the eyeball and occupied the correct anatomical position. After that, the thread was tied to a knot, which was immersed in a skin incision. The edges of all seven microsurgical skin incisions matched independently without suturing. When examining the patient after surgical removal of lagophthalmus, the palpebral fissure on the right is symmetrical to the fissure on the left. When closing the eyelids on the right - complete closure. The eyelids are adjacent to the eyeball on the right. Tearing is not noted.

The advantage of this method is low invasiveness, short operation time (15 min.) And a quick rehabilitation period with a good cosmetic result, as well as an increase in turgor of lower eyelid tissues and a good fit of the eyelids to the eyeball, which provides more reliable protection against damaging factors and improves drainage of the tear fluid.

Claims (1)

A method for minimally invasive surgical removal of paralytic lagophthalmos by “reinforcing” the lower eyelid, characterized in that, starting from the middle third of the lower eyelid, six microsections of the skin of the eyelids and one skin incision are made in the region of the medial adhesion of the eyelids, two cuts in the middle between the upper and lower the edges of the eyelid, four cuts - parallel to the border of the upper and lower edges of the eyelid, one cut - in the area of the medial adhesion of the eyelids, each 1.5-2.0 mm long, with two micro cuts being made in the middle first between the upper and lower edges of the cartilage of the lower eyelid, the first micro section is made at the border of the outer and middle third of the century, the second micro section is at the border of the inner and middle third of the century, then the micro section is made at the edge of the upper and lower borders of the cartilage of the century in pairs opposite each other, and the third section performed in the middle third of the century at the upper edge of the cartilage, the fourth incision opposite it at the lower edge of the cartilage of the eyelid, the fifth - in the inner third of the century at the upper border of the cartilage, the sixth section - opposite the fifth at the lower edge of the cartilage of the century and the last gray My microsurgical incision is performed in the area of the medial adhesion of the eyelids, then through the obtained microsurgical incisions conduct prolene 5.0 with two needles, the injection of which is performed into the incision at the border of the external and middle third of the century so that the thread passes through the skin incision, with all layers of the eyelid sutured and capturing the cartilage, it crossed in soft tissues, then one needle is punctured into the incision corresponding to the lower border of the eyelid cartilage, and the second needle is punctured into the incision corresponding to the upper border of the eyelid cartilage, then both needles are injected into the same pairwise cuts from which they emerged, the thread is carried out in soft tissues with the capture of cartilage, the needles are punctured into a cut located on the border of the inner and middle third of the lower eyelid, tying the thread onto one knot, which is immersed in the skin incision , then both needles are injected into the same incision from where they came out, passing in the layers of the circular muscle with the cartilage being inserted, the thread is crossed and then one needle is punctured into the incision corresponding to the lower border of the eyelid cartilage, and the other needle is punctured into the incision corresponding to the upper border of the cartilage of the eyelid, then each needle is pierced into the same incision from which it emerged, and, passing in the layers of the circular muscle, having stitched the periosteum and the medial adhesion of the eyelids, the needles are punctured into the incision located in the area of the medial adhesion of the eyelids, pulling the ends of the thread to the correct position of the lower eyelid, and tie a submersible knot, while the seams on the microsurgical incisions of the lower eyelid are not imposed.

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