Videos of Surgical Procedures in Dermatology
Intraoperative Care During Eyelid Surgery
Cuidados intraoperatorios en cirugía palpebral
M.E. Iglesias-Zamora, S. Oscoz-Jaime
, A. Larumbe-Irurzun, B. Bonaut-Iriarte
Corresponding author
Servicio de Dermatología, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain
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Iglesias-Zamora, S. Oscoz-Jaime, A. Larumbe-Irurzun, B. Bonaut-Iriarte" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M.E." "apellidos" => "Iglesias-Zamora" ] 1 => array:4 [ "nombre" => "S." "apellidos" => "Oscoz-Jaime" "email" => array:1 [ 0 => "saioaoscoz@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Larumbe-Irurzun" ] 3 => array:2 [ "nombre" => "B." "apellidos" => "Bonaut-Iriarte" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cuidados intraoperatorios en cirugía palpebral" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 800 "Ancho" => 773 "Tamanyo" => 82894 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Basal cell carcinoma at the medial canthus.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Reconstruction of defects of the eyelids after oncologic surgery can be complex. The techniques required at this site can be some of the most difficult in dermatologic surgery. After appropriate oncologic surgery to the eyelids, reconstruction must be extremely precise in order to preserve palpebral function.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> Optimal cosmetic and functional results can be achieved if, additionally, care is taken with a series of intraoperative factors.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Description of the Technique</span><p id="par0010" class="elsevierStylePara elsevierViewall">We present the surgical excision of a basal cell carcinoma affecting the free margin of the lower eyelid at the medial canthus, with reconstruction of the resulting defect, and we describe aspects of intraoperative care (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). Prior to the intervention, we applied 4% lidocaine eyedrops and a protective hydroxypropylmethylcellulose gel. After infiltration of the skin, tarsus, and conjunctiva with 2% mepivacaine, an eye guard was inserted as a mechanical protector and a 3/0 silk suture was placed in the mid zone of the tarsus for traction and to facilitate mobilization of the lower eyelid during the operation. A dilator was used to visualize the 2 lacrimal ducts and we then proceeded to the full-thickness surgical excision of the lesion, with a wide surgical margin that included the inferior lacrimal duct.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> The incision was performed with a no. 15 scalpel, dissection with Stevens scissors, and meticulous hemostasis was performed with bipolar electrocautery (the patient had a pacemaker).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The resulting defect affected more than a quarter and less than a third of the length of the eyelid, making it necessary to perform a tension-releasing incision horizontally from the lateral canthus toward the lateral margin of the orbit (canthotomy). The deep part of the orbicularis oculi muscle was divided, positioning the scissors along the bisector of the angle of the lateral canthus.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> This allowed tension-free transposition and final closure of the defect. The tarsus was sutured to the medial canthal tendon with a 6/0 absorbable suture and the skin with 5/0 silk, taking care to align the gray line and fixing the free ends of the suture with Steri-Strips to prevent them damaging the cornea. The canthotomy was then closed by suturing the skin to the superior tarsus with 5/0 silk. The superior lacrimal duct was dilated to prevent epiphora, and finally we administered dexamethasone and tobramycin eyedrops.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Histology confirmed the diagnosis of basal cell carcinoma and the borders were free of tumor. The cosmetic and functional results 5 days and a month after the intervention were very good (<a class="elsevierStyleCrossRefs" href="#fig0010">Figures 2 and 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Indications</span><p id="par0025" class="elsevierStylePara elsevierViewall">This technique is suitable for patients with tumors that affect the free margin of the lower eyelid and whose surgical excision leaves a defect of between a quarter and a third of the length of the lower eyelid.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Advantages and Drawbacks</span><p id="par0030" class="elsevierStylePara elsevierViewall">Canthotomy allows defects of up to a third of the lower eyelid to be closed without tension.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The main drawback is that canthotomy is sometimes insufficient, and cantholysis must also be performed to release the lower eyelid from the orbital ring and achieve additional relaxation of the lower eyelid.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In our patient, although the defect was slightly less than a third of the lower eyelid, canthotomy was performed in order to avoid tension that could provoke symptoms. Furthermore, as it was necessary to fix the tarsus to the medial canthal ligament, we considered it advisable to reduce tension as much as possible. This is a simple technique that does not carry major risks for the patient and that preserves eyelid function.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Complications</span><p id="par0045" class="elsevierStylePara elsevierViewall">The palpebral reconstruction we present is very safe, and complications are rare. One issue to avoid is leaving a notch at the palpebral margin; this can be prevented by careful suturing. In our patient, as the tumor affected the entire medial canthus, we had to fix the tarsus to the medial canthal ligament using an absorbable suture. Excessive tension in the lateral segment of the eyelid can provoke lateral ectropion.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Regarding intraoperative care, we would like to draw attention to the importance of protecting the surface of the eye both with lubricant gels and with mechanical guards to avoid possible complications from ocular damage. Apart from the metallic guard we present in the video, corneal shields are used throughout surgery to avoid injury to the cornea; these are more comfortable for patients operated under local anesthesia.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Considerations Regarding the Technique</span><p id="par0055" class="elsevierStylePara elsevierViewall">For the excision of lesions on the free border of the eyelid using the V technique, it is helpful to design a pentagonal V in the skin and a smaller V at the conjunctival border to facilitate closure of the defect.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusions</span><p id="par0060" class="elsevierStylePara elsevierViewall">We have focused on the peculiarities of oncologic surgery of the eyelids. In addition to appropriate surgical excision and reconstruction, eyelid function must be preserved to avoid adverse effects that could damage the anterior pole of the eye and affect visual acuity. It is important to use the correct instruments for intraoperative care.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Description of the Technique" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Indications" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Advantages and Drawbacks" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Complications" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Considerations Regarding the Technique" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusions" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 8 => array:2 [ "identificador" => "xack253812" "titulo" => "Acknowledgments" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Iglesias-Zamora ME, Oscoz-Jaime S, Larumbe-Irurzun A, Bonaut-Iriarte B. Cuidados intraoperatorios en cirugía palpebral. Actas Dermosifiliogr. 2016;107:855–857.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The video received 2nd prize in the first “Best Video in Dermatologic Surgery” competition organized by the Spanish Academy of Dermatology and Venereology (AEDV), and was screened at the XXVIII Meeting of AEDV's Dermatologic Surgery, Cutaneous Oncology and Laser Therapy Group held in Valencia on 27 and 28 November, 2015.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0080" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Additional Material" "identificador" => "sec0050" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 800 "Ancho" => 773 "Tamanyo" => 82894 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Basal cell carcinoma at the medial canthus.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 708 "Ancho" => 800 "Tamanyo" => 81622 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Result 5 days after the operation.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 577 "Ancho" => 800 "Tamanyo" => 60400 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Result 1 month after the operation.</p>" ] ] 3 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 206530658 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "F.J. 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Spinelli" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:5 [ "fecha" => "2004" "paginaInicial" => "1" "paginaFinal" => "27" "editorial" => "WB Saunders" "editorialLocalizacion" => "Philadelphia" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0035" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reconstrucción del párpado y región cantal. Colgajos locales en la reconstrucción de cabeza y cuello" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "I.T. Jackson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:5 [ "fecha" => "1990" "paginaInicial" => "273" "paginaFinal" => "323" "editorial" => "Salvat" "editorialLocalizacion" => "España" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0040" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cirugía oncológica del párpado y la región orbitaria" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.E. Iglesias" 1 => "R. Santesteban" 2 => "A. Larumbe" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ad.2014.11.011" "Revista" => array:6 [ "tituloSerie" => "Actas Dermosifiliogr" "fecha" => "2015" "volumen" => "106" "paginaInicial" => "365" "paginaFinal" => "375" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25701895" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack253812" "titulo" => "Acknowledgments" "texto" => "<p id="par0070" class="elsevierStylePara elsevierViewall">We would like to thank Xabier Belzunegui of the Communication and Design Unit of Navarra Biomed for recording and editing the video.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010700000010/v1_201611260103/S1578219016302347/v1_201611260103/en/main.assets" "Apartado" => array:4 [ "identificador" => "6209" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Videos of Surgical Procedures in Dermatology" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010700000010/v1_201611260103/S1578219016302347/v1_201611260103/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016302347?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 14 | 23 |
| 2024 October | 87 | 43 | 130 |
| 2024 September | 86 | 24 | 110 |
| 2024 August | 109 | 44 | 153 |
| 2024 July | 101 | 26 | 127 |
| 2024 June | 85 | 24 | 109 |
| 2024 May | 91 | 32 | 123 |
| 2024 April | 67 | 16 | 83 |
| 2024 March | 86 | 29 | 115 |
| 2024 February | 68 | 28 | 96 |
| 2024 January | 79 | 29 | 108 |
| 2023 December | 59 | 13 | 72 |
| 2023 November | 77 | 23 | 100 |
| 2023 October | 71 | 13 | 84 |
| 2023 September | 59 | 25 | 84 |
| 2023 August | 68 | 27 | 95 |
| 2023 July | 54 | 24 | 78 |
| 2023 June | 61 | 20 | 81 |
| 2023 May | 59 | 23 | 82 |
| 2023 April | 47 | 19 | 66 |
| 2023 March | 55 | 30 | 85 |
| 2023 February | 42 | 25 | 67 |
| 2023 January | 39 | 34 | 73 |
| 2022 December | 49 | 46 | 95 |
| 2022 November | 28 | 21 | 49 |
| 2022 October | 26 | 23 | 49 |
| 2022 September | 23 | 40 | 63 |
| 2022 August | 25 | 27 | 52 |
| 2022 July | 35 | 35 | 70 |
| 2022 June | 13 | 24 | 37 |
| 2022 May | 34 | 29 | 63 |
| 2022 April | 39 | 37 | 76 |
| 2022 March | 35 | 38 | 73 |
| 2022 February | 37 | 25 | 62 |
| 2022 January | 36 | 33 | 69 |
| 2021 December | 34 | 42 | 76 |
| 2021 November | 43 | 40 | 83 |
| 2021 October | 41 | 52 | 93 |
| 2021 September | 26 | 37 | 63 |
| 2021 August | 20 | 27 | 47 |
| 2021 July | 19 | 24 | 43 |
| 2021 June | 25 | 21 | 46 |
| 2021 May | 28 | 36 | 64 |
| 2021 April | 34 | 43 | 77 |
| 2021 March | 31 | 24 | 55 |
| 2021 February | 29 | 21 | 50 |
| 2021 January | 20 | 11 | 31 |
| 2020 December | 20 | 9 | 29 |
| 2020 November | 22 | 23 | 45 |
| 2020 October | 15 | 9 | 24 |
| 2020 September | 22 | 13 | 35 |
| 2020 August | 24 | 17 | 41 |
| 2020 July | 15 | 12 | 27 |
| 2020 June | 28 | 33 | 61 |
| 2020 May | 21 | 11 | 32 |
| 2020 April | 22 | 13 | 35 |
| 2020 March | 25 | 15 | 40 |
| 2020 February | 3 | 0 | 3 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 4 | 0 | 4 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 4 | 0 | 4 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 4 | 2 | 6 |
| 2019 April | 2 | 4 | 6 |
| 2019 February | 2 | 0 | 2 |
| 2019 January | 3 | 0 | 3 |
| 2018 December | 3 | 0 | 3 |
| 2018 November | 24 | 0 | 24 |
| 2018 October | 1 | 0 | 1 |
| 2018 September | 4 | 0 | 4 |
| 2018 February | 21 | 0 | 21 |
| 2018 January | 34 | 13 | 47 |
| 2017 December | 34 | 8 | 42 |
| 2017 November | 22 | 4 | 26 |
| 2017 October | 26 | 7 | 33 |
| 2017 September | 21 | 15 | 36 |
| 2017 August | 23 | 7 | 30 |
| 2017 July | 30 | 8 | 38 |
| 2017 June | 37 | 14 | 51 |
| 2017 May | 20 | 5 | 25 |
| 2017 April | 37 | 12 | 49 |
| 2017 March | 25 | 23 | 48 |
| 2017 February | 23 | 4 | 27 |
| 2017 January | 25 | 8 | 33 |
| 2016 December | 80 | 33 | 113 |
| 2016 November | 23 | 25 | 48 |
| 2016 October | 2 | 5 | 7 |
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