Eyelid involvement is common in facial burns.1 Although direct thermal injuries rarely result in blindness, the subsequent scar contracture following eyelid burn can cause eyelid ectropion, leading to several potentially serious ocular complications, including exposure keratitis, conjunctivitis, corneal ulcer, perforation, and even blindness.2,3 The eye has a complex anatomical structure, and the skin covering it is the thinnest in the body.4 Eyelid reconstruction, which usually requires both functional and aesthetic considerations, aims to restore eyelid structure and function, achieve a cosmetically acceptable appearance with the least amount of surgery, and, most importantly, ensure that the ocular surface remains stable to prevent damage to vision.5,6

Many surgeons use adjacent flap transposition or the anterior and posterior lamella as composite flaps to treat lower eyelid ectropion, among which the lateral advancement flap is usually the first choice to repair moderate lower eyelid defects.7,8 After reconstructive surgery, cicatricial ectropion may occur due to hypertrophic scarring and skin shortage.4 While the lower eyelid benefits from inherent structural support, facilitating the effective use of adjacent flaps for treating simple lower eyelid defects, clinical strategies for patients with upper eyelid defects or combined upper and lower eyelid defects are often different.

Owing to its highly specialized function, reconstruction of the upper eyelid is more challenging than that of the lower eyelid.9 The upper eyelid is a thin structure that opens and closes to lubricate and protect the ocular surface while allowing an unobstructed visual axis. Using a skin flap requires dexterity; the upper eyelid is easily bloated when using a skin flap, which affects the opening of the eyes, making it prone to ptosis. Any disruption of the upper eyelid tissue can cause loss of eyelid mobility by scarring and tethering of the lid margin.9 However, half of the patients with eyelid ectropion require a secondary operation or even multiple operations because of postoperative complications such as lagophthalmos, exposure keratopathy, upper eyelid entropion, and ptosis.10

Simple lower eyelid ectropion is most appropriately treated using an advancement flap. However, in patients with severe burns around the eyelid or even full-face burns, there is no suitable flap donor site due to extensive scar contracture. In 1959, Converse reported on a technique using the tarsoconjunctival flap in severe burn surgery.11 This technique involves making an incision along the eyelid margin, grafting the skin of the upper and lower eyelids after release, and separating the flap in the second stage of the operation.11 Although full-thickness skin transplantation with less contracture is used, skin contracture and deformity recurrence can easily occur due to the release of the skin graft.

In 1961, Fox described a new tarsorrhaphy suture, which could temporarily adhere to the upper and lower eyelid margins.12 While this method can be applied in practice to prevent secondary scar retraction after skin grafting in cases of ectropion following eyelid burns, it has several limitations. For example, maintaining adhesion using sutures is unreliable and has proven to have a low success rate in the clinic. In our previous clinical experience, when faced with severe cicatricial contracture affecting whether part of the entirety of the eyelid after burn, we used traditional interventions, employing sutures to promote eyelid adhesion. However, during the later stages of cicatricial or skin flap contracture, the sutures would often torn off too early due to the considerable tension exerted by the contracture. Moreover, its ability to resist skin contracture of the upper and lower eyelids is poor. Subsequent improvement strategies implemented to address these issues include several techniques, such as pressure dressing,13 bolsters,14,15 bolsterless intratarsal,16,17 drawstring,18 and loop lock.19 However, while these approaches aim to improve outcomes and reduce the risk of complications associated with eyelid surgery and skin grafting procedures, they have not exhibited significant improvements in adhesion strength. Therefore, we aimed to describe a simple and safe eyelid adhesion method designed to prevent the recurrence of skin contracture and ectropion after eyelid skin grafting.

METHODS Study Design and Population

This retrospective analysis included patients who underwent surgery using the tunnel orbicularis oculi muscle flap technique to form eyelid adhesion combined with skin grafting to repair burned ectropion between January 2006 and March 2022. The inclusion criteria were as follows: 1) patients with postburn eyelid ectropion caused by scar contracture and intended to undergo surgical treatment; and 2) patients who could be followed up for at least 6 months.

Ethics Statements

The clinical research portion of this project was approved by the ethics committee at Hangzhou First People’s Hospital and was performed according to its clinical research rules and regulations. The experiment was performed in accordance with the Declaration of Helsinki as amended in 2013, and written informed consent was obtained from all patients.

Therapeutic Regimen

After anesthesia, an incision was made 2–3 mm away from the eyelid margin, and the scar adhesion was released to maintain the integrity of the orbicularis muscle of the basal eye as much as possible and reset the upper and lower eyelids. The most obvious and severe area of ectropion in the upper and lower eyelids or the mid-point of the eye fissure was considered as the eyelid adhesion point. A horizontal incision of 5–6 mm in length was made between the gray and white lines in the middle of the eye fissure, from the surface of the tarsal plate and parallel to the tarsal plate using a sharp knife, to form a tunnel at the eyelid margin. An orbicularis oculi muscle flap of 3–5 mm in width and 15 mm in length was created at the pretarsal orbicularis oculi muscle near the eyelid margin and at the base of the upper and lower eyelid contracture release incision, the pedicle of which was located at the vertical line of the tunnel. After the conjunctival sac was rinsed, the upper and lower eyelids were closed. The upper eyelid muscle flap was then passed through the tunnel and fixed to the basal muscle of the lower eyelid incision with 5–0 absorbable sutures. The lower eyelid muscle flap was sutured in a similar fashion (Fig. 1). Full-thickness skin grafts of the released incision and the upper and lower eyelid grafting areas were covered with a tie-over dressing of wet cotton balls, which were removed after 7 days. One year later, once the facial and periorbital scars had softened and stabilized, the orbicularis flap was cut under local anesthesia. If the patient had a full-face scar or if there was still significant tension in the upper and lower eyelids after 1 year, the incision could be delayed or even not.

FIG. 1.:

(Top panel) The orbicularis oculi muscle flap is passed through the horizontal incision of the eyelid margin and sutured and fixed at the contralateral basal muscle. (Bottom panel) The orbicularis oculi muscle flap of the upper and lower eyelids was prepared. After the horizontal incision of the eyelid margin is made, a rubber strip is used to cross the formed tunnel.

RESULTS

Our study comprised 26 patients (6 women and 20 men), with a total of 46 burned eyelids. The average age of the patients was 37.65 years (range: 20–57 years). The average time from burn to treatment at our facility was 17.50 months (range: 6–36 months). The percentage of burn areas on the head, face, and neck was 5.69% (range: 1–9%). The burn types included flame (n = 17), hydrothermal (n = 3), chemical (n = 2), explosive injury (n = 2), molten iron (n = 1), and steam (n = 1) burns. Among the patients, 6 (9 eyes) had not previously undergone skin grafting or other treatments for eyelid adhesion, while the remaining 20 (37 eyes) had undergone tarsorrhaphy and/or skin grafting after which ectropion recurrence occurred.

Before treatment, when the eyes were open, the average distance between the upper and lower eyelids was 13.89 mm (7–26 mm). When the eyes were closed, the average distance was 7.72 mm (2–26 mm). During the treatment, none of the patients reported intraocular foreign body sensation. One patient had excessive conjunctival sac secretion which, however, did not affect the form and follow-up effect of the adhesion. There were no cases of adhesion failures, and the skin graft survival rate was above 98% in the 46 eyes, with no significant graft shrinkage. After the orbicularis oculi muscle flap was cut, the average distance between the upper and lower eyelids was 8.75 mm (8–11 mm) in 44 eyes. The orbicularis oculi muscle flap was not cut in 2 eyes, and the distance between the upper and lower eyelids was 5 mm in 1 eye and 6 mm in the other. The average distance between the upper and lower eyelids was 0.22 mm (0–2 mm) in 46 eyes when the eyes were closed at the last follow-up.

The adhesions in all patients were not accidentally disconnected, with an average adhesion time of 21.87 ± 10.08 (12–60) months in the 46 eyes. One of the patients had bilateral adhesions that were not cut, and the last follow-up time was 5 years. The average follow-up time was 24.72 ± 13.44 (12–60) months, with a median of 24 months. Throughout the eyelid adhesion period, no disruptions to the patients’ day-to-day life and work were reported, and no instances of trichiasis were observed (Table).

- Patient characteristics Value (%) Sex  Male 20 (77)  Female 6 (23) Age at the time of treatment (years) Median 37  IQR 31–43.5 Burn areas on the head, face, and neck Median 6  IQR 3–7.25 Skin grafting performed or eyelid adhesion  Yes 20 (77)  No 6 (23) Distance between the upper and lower eyelids (pretreatment, open eyes) Median 14  IQR 12.75–15 Distance between the upper and lower eyelids (pretreatment, closed eyes) Median 7  IQR 5–10 Distance between the upper and lower eyelids (last follow-up, open eyes) Median 9  IQR 8–9 Distance between the upper and lower eyelids (last follow-up, closed eyes) Median 0  IQR 0–0 Adhesion time (months) Median 24  IQR 13–24 Follow-up time (months) Median 24  IQR 14.5–24.75

IQR, interquartile range.

DISCUSSION

The tarsal adhesion method, as described by Fox, is limited by suturing, which easily damages the eyelid tissue with frequent blinking and may prevent the formation of effective scar adhesion.12 The tunnel orbicularis oculi muscle flap can be used to form a stable and effective adhesion, which is not easy to detach as in the case of sutures. Moreover, because of the elasticity of the orbicularis oculi muscle flap, the upper and lower eyelids can be closed when the eyes are shut, and the eyelid adhesion tissue can be elongated when the eyes are opened. This prevents complete closure of the upper and lower eyelids, maintaining visual spaces on both sides of the muscle flap, which helps the patient live independently. Despite the visual field being partially blocked by columns during treatment, patients who had adhesions in OU still maintained the visual ability necessary to lead a normal life. Notably, some patients had OU adhered for up to 5 years (Fig. 2).

FIG. 2.:

A, A 39-year-old man suffered a deep burn to the whole head. After skin grafting, severe ectropion appeared in his eyes. B, There was difficulty in closing OU, and the eyelid conjunctiva was seriously exposed, accompanied by serious discomfort. C, After treatment, the double eyelids were completely closed, and the skin graft survived well without necrosis. D, Five years after the operation, the orbicularis oculi muscle flap was not cut, and the upper and lower eyelids remained adhered. Moreover, this procedure did not affect the patient’s normal life. E, Five years after adhesion, there was a gap of 1–2 mm when the eyes were closed; however, the patient experienced no discomfort such as tears or corneal dryness.

The orbicularis oculi muscle, fascia, and possible scar tissues are regarded as the components of eyelid adhesion. The elasticity, activity, and toughness of these tissues collectively contribute to the elastic fixation of the upper and lower eyelids, which remain stable under subsequent tension conditions. After the operation, the muscle flap formed scar adhesion with the surrounding tissues, including muscle and skin. Compared with previous surgical methods in which adhesion is maintained for several months,20 the tunnel orbicularis oculi muscle flap is a better option because it has good tension resistance. It can provide short-term intraoperative tension using absorbable sutures and tie-over dressings, and muscle flap gradually produces adhesion with surrounding tissues within the first 7–10 days. After 1 week, the tie-over dressing was opened, and the absorbable suture subsequently fell off. From that point onward, the tension is provided by the muscle flap and the adhesion formed, which can be easily maintained for several years under the strong tension of scar contracture. The blood supply follows the fibers of the orbicularis muscle,21 providing adequate blood supply, and therefore, reducing the risk of necrosis. Moreover, the technique exhibits strong anti-infection properties, with minor infections in the conjunctival sac having little impact on muscle flap survival and tension. This technique also maintains a stable closing tension for more than 1 year, including the period in which the formation of scar contracture peaks. In addition, compared with gauze, wet cotton balls, which were used as the skin graft tie-overdressing, offer greater plasticity, and prevent friction between the grafted skin and eyeball (Fig. 3).

FIG. 3.:

A, A 32-year-old man with conjunctiva after suffering a flame burn. His eyelid margin showed a defect. B, Conjunctival exposure is aggravated when the eyes are closed. C, Tie-over dressing with a wet cotton ball after the operation. D, After removing the tie-over, the skin graft survived well without necrosis. E, After 30 months, the adhesion remained intact. F, When the eyes are closed tightly, no obvious scar contracture is found on the upper and lower eyelids. G, Three months after the adhesion was opened, the size of the eye fissure was normal. H, There is a slight gap in the closure; however, the patient experienced no discomfort.

One year postoperation, as the contracture period of the eyelid skin graft area passed, the muscle flap maintaining eyelid adhesion was cut, retracting into the upper and lower eyelids due to tension. This cut did not leave any residue in the eyelid margin or affect subsequent eye opening and closing. The traditional technique of resecting the tissue from the eyelid margin may lead to eyelid margin structural loss. When the adhesion is reopened using the traditional technique described, many adverse reactions can occur in the eyelids, including trichiasis, eyelid margin irregularity, pyogenic granuloma, and keloid formation.14,22 However, the lid margins were not removed during our operation. Therefore, inherent structural changes, scarring, and distortion of the eyelid margin are not expected to occur in the future (Fig. 4).

FIG. 4.:

A, A 32-year-old woman, after being burned by sulfuric acid, had an eversion of both eyelids. She had been treated with tarsorrhaphy twice before, both of which failed. B, After general anesthesia, OU have incomplete closure. C, Two years after the adhesion of the orbicularis oculi muscle flap, the visual ability is normal. D, The eyes could be closed without any defects. E, After the adhesion was cut, the eye fissure returned to normal when the eyes were opened. F, After 3 years of the adhesions were opened, there was no scar or deformity on the eyelid margin.

The principle of plastic surgery is to maintain the integrity of the existing structure to the greatest extent and minimize tissue damage.23 For patients with extensive burns all over the body, the commonly used strategy of transposition of adjacent flaps often does not work owing to severe scar contracture and the lack of suitable flap sources. The orbicularis oculi muscle flap surgical technique presented in this study does not require the use of a skin flap to restore upper and lower eyelid closing; instead, it only requires full-thickness skin grafting, which complements the insufficient skin area in patients with systemic burns. Moreover, this surgical method that uses an orbicularis oculi muscle flap for upper and lower eyelid adhesion is simpler than various flap propulsion methods, which prevents the postoperative eyelid from becoming cumbrous.

In conclusion, our method for eyelid adhesion using the tunnel orbicularis oculi muscle flap technique with skin grafting can provide long-term stable adhesion without causing structural disorder of the eyelid margin, with little influence on the surrounding tissues, few postoperative complications, and effective resistance against contracture. It is also of great value for repairing eyelid tissue defects and warrants further investigation.

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