DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Phimosis, right eye.
2. Lymphoma, right orbit.
3. Orbital deformity, right eye.
4. Failed graft site, right lower lid.
5. Symblepharon, right eye.
6. Lid retraction, right eye.
7. Orbital granuloma, right eye.
OPERATION PERFORMED:
1. Lateral orbitotomy with biopsy.
2. Superolateral rim revision.
3. Myofasciocutaneous flap.
4. Orbital prosthesis.
5. Amniotic graft.
6. Lateral orbitotomy with biopsy, lateral tarsal strip.
7. Orbital implant removal.
8. Lateral canthoplasty.
9. Tarsorrhaphy of the right eye.
SURGEON: John Doe, MD
ANESTHESIA: General.
COMPLICATIONS: No complications.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position. General anesthesia was induced without any complications. The patient was then prepped and draped in the usual sterile fashion. Attention was directed to the right eye. We inspected the eye first because his eye was so painful and it was very difficult to even examine him to figure out what was going on. He had a swelling over the superior orbital rim laterally and a swelling over the lateral orbital rim. He also had some swelling inferiorly. We cut through the previous incision with a 15 blade and removed the deep sutures and were able to see the graft. The part of the graft over the lateral orbital rim, where the periosteum had been removed, looked like it was dissolving and the tissue next to it also was red and inflamed.
We removed the tissue next to it and sent it off to pathology along with the graft tissue. The ENDURAGen strip that had been made to replace the lateral canthal tendon had partially dehisced and seemed to be partially thinned out or necrosed. We cut that off and sent that off to pathology as well. Once we had done that, we were able to release the lower eyelid and then looked at the ENDURAGen graft that had been placed inferiorly superiorly to the tarsal border. The graft looked like it was taking and to remove the graft would have left the patient with a seriously retracted lower lid. He did have some inflammation in the inferior cul-de-sac next to the inferior border of the ENDURAGen graft and it seemed to be forming a small mass there and a symblepharon.
What we did is we removed the sutures and then gingerly cut open underneath where the graft had been placed. We also severed this symblepharon in 3 separate places in the cul-de-sac and sutured them close on the bulbar part of the conjunctiva with a 6-0 chromic and then sutured them close on the palpebral part of the conjunctiva with a 6-0 chromic suture as well. We then saw that the patient had more inflammation and it may have been part of the hard palate graft left still inferiorly. We removed that as well. He seemed to have sort of a rock-hard mass there. We opened up the myofasciocutaneous flap that had been there and removed the 3-0 Monocryl and inspected underneath the graft. He seemed to have some granulation tissue there, but we decided to dissect further down to lift his cheek even further as he was going to have that part of the ENDURAGen graft removed inferiorly and we wanted to get him to try to address his lower lid retraction by doing an even higher myofasciocutaneous flap.
We dissected down with Q-tips and opened the flap medially more as well as somewhat laterally and then put in 5 separate 3-0 Monocryl buried sutures to the periosteum to give him more lift through the subconjunctival incision we had made, thus completing an anterior orbitotomy and raising the flap up off the lower lid. He had some more granulomatous tissue, and it seemed like it might have granulated to the prior hard palate graft that had been placed there. That was also sent to pathology as specimen. Once we had elevated the lid, we were back to inspect the inferior conjunctiva. We trimmed the little of the inferior border of the ENDURAGen graft because superiorly it seemed like it was beginning to vascularize and then resutured it inferiorly using a 6-0 chromic in a running and then a few interrupted inferiorly and then we put a few more quilting stitches in to bolster the graft to the underlying orbicularis bed. Once that was done, we were able to pull on the lid. It was not as retracted, and with that, we were able to inspect more of the lateral angle as the lid then was not so retracted down.
Laterally, the patient had almost no periosteum left, and superiorly, where the eyebrow was, he has had a graft placed there, but it was from the ENDURAGen graft and there was still a little residual that was embedded in the tissue underneath the eyebrow. We removed that and then removed part of the ENDURAGen graft and revised the superolateral orbital rim. We just removed little more periosteum in trying to keep as much healthy periosteum as possible as needed to have something to cover over the bone, so that the patient could have some healing of the lateral canthal angle and laterally.
As stated, on the superior limb, he had necrosis of the canthus there and part of the lid. We removed that tissue and sent it off to pathology. We then undermined laterally where we did lateral orbitotomy to inspect to see if he had any orbital granulomas or bumps that were between the canthal angle and the eye. He did have one there and that was also sent off to pathology.
As noted, the granulation tissue had formed actually on the conjunctiva as well forming a painful bump almost directly over the lateral rectus. We reflected back the conjunctiva making a small cut with Westcott and removed part of the conjunctival granuloma that was there, being careful also to identify the lateral rectus by hooking it with a muscle hook to make sure that we had no way cut the lateral rectus. Once we had identified it, we then put in a few interrupted 6-0 Vicryl to reclose the conjunctiva, but making sure that the closure and the knot was not over the lateral rectus since the patient already was having scaring on the conjunctiva and on the angle laterally. It was very difficult to suture or develop the angle at all; the patient had just too much inflammation. Amniotic graft was placed over where the conjunctival granuloma had been laterally as we wanted to make sure the patient did not form any symblepharon there and that healed quickly, and also amniotic graft was also placed in the bulbar conjunctiva as well inferiorly, so as to avoid more symblepharon. The orbital implant superiorly in the lateral orbital rim was removed almost in entirety and then the temporalis flap was removed laterally over the lateral orbital rim to create space for that.
At this time, it still had to go in close the angle. We did a lateral tarsal strip superiorly and secured that to the periosteum that was remaining off the lateral orbital rim and then created another lateral tarsal strip by removing a small amount of the skin, conjunctiva, and creating inferior tarsus and then using a 4-0 Prolene, connected that to the limb of the inferior lateral orbital tendon. They were secured together to the periosteum having to make it somewhat high, as the patient did not have healthy periosteum inferiorly to lower the angle, and also, at this point in time, even the patient wanted to try for a lower angle, there just is not any healthy periosteum there to secure it to, and that is probably likely because the patient had lymphoma inferiorly and laterally and that was exactly where the radiation was and that probably explains why there was very little healthy tissue there.
Even we tried to cover it with the ENDURAGen graft, it just may be that the tissue adjacent to it does not have enough good vascularization to then have the graft take in that lateral angle. However, it does seem to be taking in the inferior lower lid, fitting in. Most of the ENDURAGen graft was left there. After this had been done and we had finished, we probed the temporalis flap forward laterally and then a myofasciocutaneous flap inferiorly to close the two together with interrupted 3-0 Monocryl just as we had done before because the prior surgery was so recent, basically just had to remove the sutures that were already there because a few of them had broken and I had to inspect the flaps to make sure that they do not have any inflammatory tissue there, as the patient had extreme tenderness over the area and resutured the flaps close after removing a little bit of inflammatory tissue as well. After that was done, the dermis was closed with 5-0 Vicryl and the skin was closed with interrupted 6-0 Prolene. Because we were worried about the stability of the angle, as basically we were not sure whether the lateral canthal angle that was being recreated with 4-0 Prolene stitch to the periosteum, even though it was somewhat high to hold.
We then did a partial closure of the two lids together using a 5-0 Vicryl through the more anterior part of the tarsal strip and the more anterior part of the inferior tarsal strip, and closing that, there was a knot to be removed later, which caused then more closure of the lateral canthal angle. Orbital prosthesis was put in to keep the lateral and inferior, especially the inferior cul-de-sac deep as it had formed symblepharon from the failure of graft and that was done with a plastic ring that we created by using the ring from the ProKera and then also put around thrombin-soaked Gelfoam inferiorly into the cul-de-sac to keep this deep. A lateral tarsorrhaphy stitch, bilateral canthoplasty was done with a 6-0 Vicryl through the inferior gray line of the lower lid laterally and then through the superior gray line of the lower lid laterally and then was closed. We also put in another tarsorrhaphy stitch medially to keep the lid closed in the same fashion. We cleaned up the eye and put bacitracin ointment on the eye and then put up the composite patch on. We then wanted to make sure that the patient was not able to open the eye and cause any kind of traction on the lateral angle as we were very, very worried about this patient having further necrosis and further symblepharon formation and thus trying to open the eye and pull out the stitches as it seems is what happened before. The patient was then awoken from anesthesia and sent to the recovery room in good condition. The patient was also given 500 mg of Levaquin during the procedure.
