_Second step._ Both flaps are dissected up, and, when all bleeding has ceased, the apices of the triangles are transposed and sutured in position, the incision thus forming a _Z_-like figure (Fig. 157). A canthorrhaphy is generally required.

=Fricke's operation.= This has for its object the transplantation of flaps from the side of the forehead or face into the lid to remedy a loss of tissue resulting from operation or cicatricial contraction.

=Indications.= The operation is usually performed for cicatrices about the upper lid, the flap being turned down from the side of the forehead.

A flap may be turned in from the inner side in addition if necessary.

The operation may also be applied to ectropion of the lower lid.

=Operation.= When planning the flaps the following points must be taken into account:--

(i) The flap must be cut so that its base contains the main blood-supply of the part made use of.

(ii) It should be at least one-third larger than the area to be covered.

This is estimated by cutting a piece of protective the size of the area to be covered and laying it on the skin before the flap is cut.

[Ill.u.s.tration: FIG. 158. FRICKE'S OPERATION. To replace the loss of portions of the skin of the upper lid.]

(iii) The base of the flap should consist of a considerable amount of subcutaneous tissue as well as skin, but the apex may be little more than the skin itself.

(iv) The direction of the subsequent contraction should be taken into account so as to a.s.sist the final result.

_First step._ The lid is first freed by dividing all the cicatricial bands, or, if only a small cicatrix be present, by excising that. The lid is then pulled down into position and put fully on the stretch. This is best performed by st.i.tching the margin of the lid to the cheek.

_Second step._ The flap is marked out at least one-third larger than the size required to cover the raw area. The base of the flap should be placed a little below the raw area to be covered, so that the rotation of the flap into position is easily performed without danger of constriction to the base (Fig. 158).

_Third step._ The flap having been raised and all bleeding stopped, it is rotated and sutured in its new position, the wound made by the removal of the flap being brought together by sutures or, if it be too large for this, covered by skin grafts (see Vol. I, p. 670).

BY THIERSCH'S SKIN-GRAFTING METHOD

=Indications.= As has already been pointed out, this method is not so satisfactory as the method by flaps described above, but it is frequently the only one available when the surrounding skin has been destroyed, as after extensive lupus of the face.

=Instruments.= Scalpel, forceps, skin-grafting razor, probes.

=Operations.= _First step._ As for the previous operation.

_Second step._ Grafts are cut from a situation free from hairs, such as the inner side of the upper arm (see Vol. I, p. 671).

_Third step._ After all bleeding has been stopped, the grafts are applied, straightened with probes, and pressed firmly down on to the raw surface. The edges of each graft should slightly overlap the one next to it. Great care should be taken in applying the dressings not to disturb the grafts (see Vol. I, p. 673).

If the whole thickness of the skin be used (Wolff's method), care should be taken to see that the under surface is free from fat.

THE REPAIR OF LARGE LOSSES OF SUBSTANCE FROM THE EYELIDS

Losses of portions of the lid margins usually result from operations for malignant growths. When the loss is in the _upper lid_, some modified form of Fricke's operation is the best method of remedying the deformity. When a large area is to be covered, transplantation of a flap from the arm by the Tagliacotian method has to be performed (see Vol. I, p. 679).

Fricke's operation is also applicable to the outer portion of the lower lid. When the inner end of the _lower lid_ is affected, De Vincentiis'

operation yields satisfactory results. When the whole lower lid has been lost, a modified Dieffenbach's method with the use of the ear cartilage is indicated.

=De Vincentiis' operation.= The operation aims at shifting the remains of the lid bodily inwards to cover the gap left by the removal of the growth.

=Instruments.= Scalpel, dissecting forceps, artery forceps, scissors, sutures.

=Operation.= _First step._ The portion of the whole thickness of the lid together with the growth is excised by a V-shaped incision (Fig. 159).

_Second step._ The outer canthus and orbito-tarsal ligament are divided with the scissors. The incision is then carried outwards and upwards with a scalpel, in a line with the lower margin of the lid, the incision being long enough to free the lower lid sufficiently to slide it inwards and to enable the edges of the V-shaped wound to be united (Fig. 160).

=Dieffenbach's operation= (modified with the use of ear cartilage). This operation consists in shifting inwards a flap of skin and subcutaneous tissue derived from the outer side of the face to take the place of the eyelid which has been removed, the conjunctiva and tarsal plate being represented by a piece of skin and cartilage taken from the posterior surface of the ear and st.i.tched to the inner surface of the flap.

[Ill.u.s.tration: FIG. 159. DE VINCENTIIS' OPERATION TO REPLACE THE LOSS OF THE INNER PORTION OF THE LOWER LID. Showing the inner portion of the lid removed by a V-shaped incision and the relief incision made outwards from the external canthus.]

[Ill.u.s.tration: FIG. 160. DE VINCENTIIS' OPERATION COMPLETED. The lower lid has been pulled inwards and united to the opposite side of the gap left by the V-shaped incision. The incision outwards from the outer canthus, now much diminished in length, is also sutured.]

=Operation.= _First step._ The growth, together with the eyelid, is first removed by a V-shaped incision, the base of the V being formed by the margin of the lower lid.

_Second step._ An incision is carried directly outwards from the external canthus. The length of this incision should be 1-1/4 times the length of the lid margin. An incision is then carried downwards from its outer end parallel to the outer limb of the V by which the lower lid has been excised. This flap is then raised freely (Fig. 161).

_Third step._ The ear is turned forward and a semilunar portion of the skin is marked out and deepened down to the cartilage. The base of this semilunar portion should be equal in length to the upper margin of the flap that is to form the new lid (Fig. 162). The skin is then dissected up for about 3 millimetres from the crescentic part of the incision back towards the straight one forming the base of the semilune. When this part of the skin has been raised the cartilage is divided, first by a curved incision, 3 millimetres behind that through the skin, and then along the straight incision joining the ends of the curved one. It is separated from the skin on the anterior surface of the ear, and the semilunar piece of skin and cartilage is thus removed. The portion of cartilage removed with the skin is smaller than the latter; the two portions coincide in length along their straight margins, but the depth of the crescent of cartilage is considerably less than that of the skin (Fig. 162). The cartilage is usually too thick to form the new tarsus and must be pared down until the right thickness is obtained. It is then applied to the inner surface of the flap to form the new lid, the skin surface being directed inwards to help to form the lower conjunctival sac. It is fixed firmly by sutures at its margin, which are pa.s.sed through the whole substance of both flaps, and tied on the outer surface of the new lid.

[Ill.u.s.tration: FIG. 161. MODIFIED DIEFFENBACH'S OPERATION TO REPLACE THE LOSS OF THE WHOLE LOWER LID. _First step._ The whole lower lid, together with the growth, is removed by the V-shaped incision and the flap to form the new lid is dissected up from the outer canthus. The diagram shows the incision marking out the flap.]

[Ill.u.s.tration: FIG. 162. MODIFIED DIEFFENBACH'S OPERATION. _Third step._ Showing the flap turned down, to the free border of which is attached the flap of skin and ear cartilage. The inset shows the proportion of skin and cartilage (light area) to be removed from the back of the ear.]

_Fourth step._ The flap forming the new lower lid is sutured in position. The surface from which the flap is taken is closed as far as possible with sutures after undermining the edges, any raw area being covered by skin grafts taken from the arm.

CHAPTER X

OPERATIONS UPON THE LACHRYMAL APPARATUS

Operations upon the lachrymal apparatus are divided into--

I. Operations upon the lachrymal ca.n.a.ls.

II. Operations upon the lachrymal gland.

The majority of operations are undertaken for the relief of obstruction to some portion of the ca.n.a.l which leads from the conjunctival sac to the nose, obstruction to which causes an overflow of tears (epiphora)--a condition which must be distinguished from hypersecretion (lachrymation).

The obstruction may occur in any part of the ca.n.a.l, that is to say, in the puncta, ca.n.a.liculi, lachrymal sac or duct; and it is most important to determine the cause and position of the obstruction in every case before undertaking an operation for its relief. Hence it need hardly be said that the nose should be carefully examined in every case unless the cause is obvious. The operations are divided into two cla.s.ses:--

1. Those which are undertaken for the relief of the obstruction.

2. Those which are undertaken for the obliteration of the ca.n.a.ls.

Except under exceptional circ.u.mstances, the latter operations are only undertaken when a cure cannot be brought about by the former.

The presence of a septic focus, such as a distended lachrymal sac, apart from the irritation and increased lachrymal secretion caused thereby, is a source of grave danger to the eye if not relieved, as it is a frequent cause of serpiginous corneal ulceration.