Part 47 (1/2)
_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.