A modified surgical technique in the management of eyelid burns: a case series

Acute Management of Deep Periorbital Burns: A 10-Year Review of Experience

Deep periorbital burns are an important issue mainly due to the presence of the eyes in the region, and the crucial importance of preservation of vision. There is no consensus regarding their treatment. A retrospective analysis of the treatment and outcome of 446 patients with deep burns of the periorbital region admitted to the Department of Burns and Plastic Surgery of St George's University Hospital in Plovdiv, Bulgaria over 10 years was conducted. The study covers 446 patients, 162 female (36.5%) and 284 male (63.5%) aged from 5 months to 92 years. Deep periorbital burns accounted for 74.8% of hospitalized deep facial burns. Most frequent burn agents were hot liquids and flames. The mean total body surface area affected was 19.6% (min 0.5%, max 80.0%). Concomitant ocular pathology was diagnosed in 14% (n=63) of the patients. An early, staged and precise surgical approach was preferred, aimed at fast wound closure without sacrificing survived tissues. Follow up time ranged from 3 months to 5 years, median 37 months. Late ocular sequelae occurred in 7.4% (n=33) of the patients. There was no incidence of secondary corneal perforation or definitive loss of vision. Timely and adequate treatment during the acute period can minimize initial damage and late sequelae. Favor is given to the early, balanced surgical approach aimed at rapid wound closure between day 2 and 10 post burn. Preservation of vision is a determining factor for the significance of trauma and the effectiveness of treatment.

Reconstruction of Bilateral Upper and Lower Eyelid Ectropion Caused by a Liquid Unblocker Chemical Burn

Liquid drain unblockers, although meant to be used by professionals with protective equipment, are sometimes used in the household without any precautions. This could lead to severe chemical burns, as in the case we present with severe eyelid ectropion. This study aims to stress the need for preventive measures regarding the use of chemicals and for close observation and timely surgical intervention in chemical burn patients to prevent and limit disfigurement. A 45-year-old woman was injured while using an unblocker (90% sulfuric acid) at home. Accidentally, a quantity of the liquid was spilled on her face. She was initially examined in ophthalmology emergencies because of the obvious ocular involvement, and the cutaneous component was underestimated. On the third post-burn day, she was referred as an outpatient to our clinic, and because of the soft consistency and patchy pattern of the burn, she was asked to revisit in a week. Unfortunately, she reappeared two months post-burn with severe ectropion of all four eyelids and a high risk of corneal abrasion, desiccation, and further damage to the already injured left eye as well as the right eye. She underwent three operations in six months and a fourth 15 months after the accident, with the release of the scarred eyelids with full-thickness skin grafts, Z-plasties, and V-Y plasties. After four operations and sessions of triamcinolone acetonide intralesional injection, the patient has a satisfactory eyelid position and function with adequate closure and scar maturation. Domestic use of strong industrial chemicals is dangerous, and public education for prevention is urgently needed. On the other hand, it is mandatory to follow up very closely with chemical burn patients to prevent severe sequelae, especially in the delicate and contraction-prone periocular and perioral areas. Reconstruction, in these cases, is a complex task. Often, several surgeries are needed to restore acceptable function and appearance. Burn disfigurement and self-stigma will follow the patients to some extent throughout their lives.

The successful treatment of Lamellar Ichthyosis-a plastic surgeons perspective

Congenital Ichthyosis represents a very rare group of congenital skin disorders characterized by some degree of scaling and thickening of the stratum corneum with skin inflammation. Severe forms such as Harlequin and Lamellar forms may present with limb and organ compromise, respectively. Patients with Lamellar subtype presents with severe ectropion which may lead to corneal ulceration, rupture and blindness. Treatment includes a multidisciplinary approach allowing for early intervention and treatment, which optimize the outcomes. The timing for intervention is not clearly defined in the literature. This is most likely due to a paucity in data due to the relative infrequency in these conditions. However, using principles similar to early treatment of ectropion in burnt patients may be employed. A case of Lamellar Ichthyosis that presented to our outpatient clinic which was successfully managed with early ectropion release and full thickness skin graft is discussed.

Burn Scar Ectropion Correction: Surgical Technique for Functional Outcomes

BACKGROUND

Eyelid scarring after severe burn injury of the face is a significant complication endangering vision in addition to the burn scar sequelae. Scar contraction leads to asymmetry and malposition of the eyelid axis, resulting in corneal exposure, eyelid retraction, and incomplete eyelid closure. In consequence, dryness and irritation of the cornea can lead to keratitis, corneal opacity, and vision impairment. In this study, we present our surgical technique for lateral canthopexy in combination with full-thickness skin grafting (FTSGing) in patients with eyelid axis distortion after scar contraction of the periorbital region after severe burn injuries of the face.

METHODS

In this retrospective, single-center case study, we present 5 consecutive patients who experienced severe burn injuries to the face between 2014 and 2019. Patients were suffering from ectropion and malposition of the eyelid axis. In all cases, we performed lateral transosseous canthopexy and FTSGing.

RESULTS

Improved symmetry and complete eyelid closure were restored in all 5 patients. The following ophthalmological examinations showed resolved corneal erosions, as well as reduction of chemosis and epiphora. Further vision impairment was successfully prohibited. Surgical revision with FTSGing was required in 2 patients because of recurrence of unilateral lower eyelid retraction.

CONCLUSIONS

Lateral transosseous canthopexy represents a suitable surgical method to durably correct eyelid malposition, ectropion, and incomplete lid closure in patients with severe scarring of the periorbital region after burns of the face. Early detection of patients at risk and timing of surgical intervention are of great importance.

Eyelid Chemical Burns: A Multidisciplinary And Challenging Approach

During second- and third-degree eyelid sulfuric acid burns, many surgeons prefer to wait until primary wound separation occurs before grafting. However, this approach may miss the chance to recover the eyelids and can cause ectropion, resulting in delayed eyeball healing with exposure keratitis. We propose that early eyelid release and grafting makes a significant difference in long-term outcomes and improves eyeball healing. Here, we present the case of a woman who presented second- and third-degree burns of the eyelids secondary to physical domestic assault with acid, who had an early surgical management with a full-thickness skin graft. Ten days after surgery, we found that the graft had survived totally, and the donor site of the right arm had already healed. Eyelids were successfully grafted and the functions of both eyelids were well recovered, allowing complete cover of the eyeball. Two months after surgery, functional and cosmetic results were satisfying, with no postoperative lagophthalmos or difficulties with exposure-related problems. Case reports of eyelid chemical burns are very few. No specific and codified management of eyelid chemical burns was found in the literature search. This case report demonstrated that a multidisciplinary approach led by both ophthalmologists and plastic surgeons must be decided early (<6h) in order to achieve synergistic and coordinated management between the eye and the eyelid. There is a significant improvement in ocular healing with early excision and grafting of eyelids after sulfuric acid burn.

Antegrade Foreheadplasty: A Novel Surgical Approach for Upper Eyelid Contracture Deformities in Pediatric Patients

The intricate and delicate structure of the periorbital region, particularly in pediatric patients, presents challenges to eyelid reconstruction. Much like the more common lower eyelid ectropion, upper eyelid ectropion can result from lack of tissue, scar contracture, or over-resection as in blepharoplasty. In burns and trauma, the cause of cicatricial ectropion is typically direct scar contracture from injuries to the eyelid. However, in some cases, extrinsic wounds involving contracture to the forehead or eyebrow can result in upper eyelid cicatricial ectropion. Direct reconstruction and skin grafting of the eyelid present complex challenges, especially in the acute inflammatory phase of traumatic injury and burn care. Furthermore, in many of these cases the periorbital and lamellae anatomy is preserved, but rather severely displaced due to scar contracture forces. The authors discuss our experience with treatment of extrinsic upper eyelid cicatricial ectropion in a series of 4 pediatric patients with burns or trauma to the forehead and periorbital regions. In all 4 cases, the antegrade foreheadplasty procedure helped to provide globe coverage, while avoiding skin matching difficulties and the intrinsic risks of operating on the eyelid during the acute phase of recovery. There is currently very limited data for the use of this technique to correct such defects. With this study, the authors hope to establish the antegrade foreheadplasty as a reconstructive option for a select patient population.

Current and Emerging Topical Scar Mitigation Therapies for Craniofacial Burn Wound Healing

Burn injury in the craniofacial region causes significant health and psychosocial consequences and presents unique reconstructive challenges. Healing of severely burned skin and underlying soft tissue is a dynamic process involving many pathophysiological factors, often leading to devastating outcomes such as the formation of hypertrophic scars and debilitating contractures. There are limited treatment options currently used for post-burn scar mitigation but recent advances in our knowledge of the cellular and molecular wound and scar pathophysiology have allowed for development of new treatment concepts. Clinical effectiveness of these experimental therapies is currently being evaluated. In this review, we discuss current topical therapies for craniofacial burn injuries and emerging new therapeutic concepts that are highly translational.

Case report of Wolfe grafting for the management of bilateral cicatricial eyelid ectropion following severe burn injuries

Introduction

Eye lid reconstruction followed by severe, extensive body and facial burns represents a surgical challenge due to difficulties to obtain proper, healthy skin graft, tissue ischemia and necrosis.

Presentation of case

We present a reconstructive lid surgery of cicatricial bilateral lower eyelid ectropion in a case of 31-year-old man who sustained thermal injuries, affecting more than 60% of total body surface area, causing severe, deep dermal burns. Reconstruction was made using the technique of skin cantus-to-cantus incision, contracture release, orbicularis liberation and lid elevation; and oversizing free full-thickness skin graft (FTSG) (Wolfe technique) from the left inguinal region, as the only healthy skin on the entire body surface. Residual lower left lid laxity was addressed by pentagonal wedge resection, not interrupting marginal arcade vessels, thus minimizing ischemia.

Discussion

Method of choice of the graft type has been much debated question; however, significantly less reoccurrence rate of ectropion was observed using FTSG. Time of grafting should be balanced to avoid excess granulation and, thus scaring caused by delayed grafting time, or poor graft adherence caused by premature grafting. An interruption of the marginal arcade vessels should not be performed due to already severe ischemic process and increased risk for lid necrosis.

Conclusion

Major issues when addressing cicatricial ectropion followed by severe burns are: right donor site selection, appropriate graft thickness with the least possible disturbance of the affected place vascularisation, followed by immediate grafting after debridement of scaring and unhealthy tissue, with generous preservation of the orbicularis muscle.

Chemical, Electrical, and Radiation Injuries

This article reviews the unique challenges presented by chemical, electrical, and radiation injuries. The authors discuss pathophysiology and diagnosis of these injuries and provide recommendations for management.

Lysyl oxidase-like 4 involvement in retinoic acid epithelial wound healing

Vitamin A and its active forms (retinoic acids/RAs) are known to have pro-healing properties, but their mechanisms of action are still poorly understood. This work aimed to identify the cellular and molecular processes by which atRA (all-trans RA) improves wound healing, using an in vivo model of mouse corneal alkali burns and an in vitro cellular human corneal epithelial injury model. Regulation by atRA has been studied on most of the cellular events that occur in wound healing. We investigated the direct influence of atRA on a specific target gene known to be involved in the extracellular matrix (ECM) dynamics, one of the pathways contributing to epithelial repair. Our results demonstrate that atRA promotes corneal epithelial wound healing by acting preferentially on migration. The induction of lysyl oxidase-like 4 (LOXL4) expression by atRA in the corneal epithelium environment was established as essential in the mechanism of atRA-dependent wound healing. Our study describes for the first time a direct link between a retinoic-induced gene and protein, LOXL4, and its general clinical pro-healing properties in ECM dynamics.

The devastating effects a fire burn in a child

Burn injuries are a serious global public health concern with significant worldwide mortality and morbidity rates. Burns are among the most devastating of all injuries, with outcomes ranging from physical impairment and disability to emotional and mental consequences. Paediatric burns requiring treatment often incur significant health and opportunity costs, and frequently result in death or long-term disability. A recent systemic review showed that almost 50% of patients hospitalised with severe burns in Europe were younger than 16 years of age, and nearly 60% were male. This report discusses the case of a 2-year-old boy with second and third-degree skin burns over almost 45% of his body, including his head and arms, who presented to the eye clinic at the State Hospital in Hakkari 1 month after a fire burn accident. Both eyes had been burnt and the bilateral anterior chambers had been injured so badly that the patient was left blind.