HARLAN: Restoration of the Lower Eyelid.
-1 81
nerve, and there were the remains of extensive hemorrhages in the retina. In this case the iron finger probably either pene-t trated to the orbit or splintered the orbital walls, leading to extensive post-ocular hemorrhage, or possibly direct injury to the optic nerve.
A MODIFICATION OF DIEFFENBACH'S OPERATION FOR RESTORATION OF THE LOWER EYELID. By GEORGE C. HARLAN, M.D., PHILADELPHIA.
For the removal of cicatrices or small growths from the lower eyelid, or for the cure of ectropion, less extensive operative procedures may often be preferable, but when it is necessary to remove the whole lid its place can bc better supplied by the sliding flap recommended by Dieffenbach than in any other way. The broad base of the flap reduces the danger of sloughing to a minimum, while the abundant new material supplied affords a good margin for subsequent contraction. The transplanting, however, of so large a piece of skin necessitates the leaving of a considerable bare space to be filled by granulation, and the cicatrization of this space, in its usual position, tends to stretch the flap horizontally and at the same time to produce deformity by drawing the external canthus downwards. This is well shown in the photograph of a patient in whom the operation was done for extensive epitheliomatous disease, and in whose case the result was otherwise entirely satisfactory. It was taken nine months after the operation. In the case of another patient, also the subject of an epitheliomatous growth which involved the whole lid and measured an inch in its horizontal and three-fourths of an inch in its vertical diameter, I modified the operation by filling the space from which the flap was taken by another flap formed from the skin of the temple; and the result, as will be seen by her photograph, taken more than three years after the
I82
HARLAN: Restoration of the Lower Eyelid.
operation, is unusually good. The deformity is really very slight and, at a distance of a few feet, is scarcely noticeable. Dr. Norris recently operated in the same way upon an extremely discouraging subject. The patient was very old, badly nourished, and unmanageable, and his ctise seemed almost desperate, but the present condition is excellent, and if any subsequent contraction takes place it is not likely to draw down the canthus, as the granulating surface was above it. His photograph, taken two months after the operation, shows that while there is some depression of the margin of the lid; resulting from considerable sloughing of the flap, the external canthus is very nearly in its normal position. The triangular spaces left by removal of the flaps can be much diminished by freely undermining the skin at their margins and stretching it.This operation involves a rather formidable dissection of the skin of the face, but the region is so vascular and the bases of the flaps are so broad that, if the operation and the after-treatment are conducted with strict antiseptic precautions, there is usually not much danger of sloughing. It is, however, recommended only when the disease is so extensive as to necessitate a considerable operation, and the new lid is less likely to slough if both of its edges are stitched to sound skin than if one is left to form the margin of a rather extensive granulating surface. Figure I represents the lines of the incisions; Fig. 2, the position of the uncovered space in Dieffenbach's operation, and Fig. 3, its position in the modified operation.
.4
FIG. 2.
FIG. I.
i _ ,
fi
z% 2~~ FIG 3
-1 81
nerve, and there were the remains of extensive hemorrhages in the retina. In this case the iron finger probably either pene-t trated to the orbit or splintered the orbital walls, leading to extensive post-ocular hemorrhage, or possibly direct injury to the optic nerve.
A MODIFICATION OF DIEFFENBACH'S OPERATION FOR RESTORATION OF THE LOWER EYELID. By GEORGE C. HARLAN, M.D., PHILADELPHIA.
For the removal of cicatrices or small growths from the lower eyelid, or for the cure of ectropion, less extensive operative procedures may often be preferable, but when it is necessary to remove the whole lid its place can bc better supplied by the sliding flap recommended by Dieffenbach than in any other way. The broad base of the flap reduces the danger of sloughing to a minimum, while the abundant new material supplied affords a good margin for subsequent contraction. The transplanting, however, of so large a piece of skin necessitates the leaving of a considerable bare space to be filled by granulation, and the cicatrization of this space, in its usual position, tends to stretch the flap horizontally and at the same time to produce deformity by drawing the external canthus downwards. This is well shown in the photograph of a patient in whom the operation was done for extensive epitheliomatous disease, and in whose case the result was otherwise entirely satisfactory. It was taken nine months after the operation. In the case of another patient, also the subject of an epitheliomatous growth which involved the whole lid and measured an inch in its horizontal and three-fourths of an inch in its vertical diameter, I modified the operation by filling the space from which the flap was taken by another flap formed from the skin of the temple; and the result, as will be seen by her photograph, taken more than three years after the
I82
HARLAN: Restoration of the Lower Eyelid.
operation, is unusually good. The deformity is really very slight and, at a distance of a few feet, is scarcely noticeable. Dr. Norris recently operated in the same way upon an extremely discouraging subject. The patient was very old, badly nourished, and unmanageable, and his ctise seemed almost desperate, but the present condition is excellent, and if any subsequent contraction takes place it is not likely to draw down the canthus, as the granulating surface was above it. His photograph, taken two months after the operation, shows that while there is some depression of the margin of the lid; resulting from considerable sloughing of the flap, the external canthus is very nearly in its normal position. The triangular spaces left by removal of the flaps can be much diminished by freely undermining the skin at their margins and stretching it.This operation involves a rather formidable dissection of the skin of the face, but the region is so vascular and the bases of the flaps are so broad that, if the operation and the after-treatment are conducted with strict antiseptic precautions, there is usually not much danger of sloughing. It is, however, recommended only when the disease is so extensive as to necessitate a considerable operation, and the new lid is less likely to slough if both of its edges are stitched to sound skin than if one is left to form the margin of a rather extensive granulating surface. Figure I represents the lines of the incisions; Fig. 2, the position of the uncovered space in Dieffenbach's operation, and Fig. 3, its position in the modified operation.
.4
FIG. 2.
FIG. I.
i _ ,
fi
z% 2~~ FIG 3
