BLEPH A ROPLAST Y; 
L(i(i$ to tl)e after the 
ferqoval of a Keloid (growth which 
involved both lid0. 
BY 
JULIAN J. CHISOLM, M. D. 
Professor of Eye and Ear Diseases in University of Mary- 
land ; and Surgeon in Charge of Baltimore Eye and 
Ear Institute. 
Extra copies from the published Transactions of the Maryland State Medical 
Society. MAKING OF BOTH LIDS TO THE LEFT EYE 
FROM CONTIGUOUS SKIN. 
A keloid growth, of twenty-seven years. involving the entire 
lower lid and two-thirds of the upper lid, including the 
skin of the left side of the nose. Growth removed and 
deformity corrected by a Plepharo-plastic operation, 
manufacturing the two lids from contiguous skin surfaces. 
Reported by Julian J. Chisolm, M. D., Professor of 
Eye and Ear Diseases in the University of Maryland, 
and Surgeon to the Patimore Eye and Ear Institute. 
John Rhineraan, aged 60, a sailor, in good health, twenty- 
seven years since, while in the navy, perceived a small lump, 
wart-like form, under the lower lid of the left eye. It gave 
him no pain, and the only discomfort was from its presence. 
Its growth was exceedingly slow. For fourteen years no 
treatment was instituted for it. In the meantime it had 
involved a considerable portion of the surface of the under lid,— 
and as a broad, elevated, w7arty tumor had commenced to be con- 
spicuous. At this period he submitted to an operation for its 
removal, which was only partially successful. The entire 
mass for some reason was not cut away. 
He came for the first time under my observation in 1869, 
at which period he was much disfigured by an immense wattle 
or nodular growth surrounding three-fourths of the edges of the 
left eye lids. The skin growth with sharply defined, precipi- 
tous margins was about one-half inch wide, and elevated fully 
one-eighth of an inch above the surrounding healthy skin. It 
involved the inner two-thirds of the lower left lid, and the 
inner one-half of the upper lid, being continuous around the 
inner canthus, at which point it had encroached upon the con- 
junctiva to the extent of involving the caruncula in a thick 
shelf of new growth. Under this fleshy skin the cornea would 
be rolled when the eye was inverted. In forcible evertion a 
healthy rim of conjunctiva could still be exposed, which indi- 2 
MAKING LIDS OF LEFT EYE 
cated that although the inner edge and even a portion of the 
ocular surface of the lids with thecaruncula had been converted 
into a nodular growth, the ocular conjunctiva still retained its 
integrity, allowing free movements to the eye ball. The 
puncta lachrymalia having been destroyed, epiphora was an 
annoying accompaniment. Although the tumor now repre- 
sented twenty-two years growth, it had never caused pain, nor 
had it taken on ulceration. 
I recognized in the disease an old acquaintance, a keloid 
growth, so common among the. blacks of the Southern States 
and Carribean islands; although I had seen that disease but 
seldom among the whites. In early years an accident to the 
right eye, apparently the good one, had so materially impaired 
vigor in it that the left eye, with keloid surroundings, was his 
only useful visual organ. The treatment suggested at this time 
was to cut off the caruncula which as a protruding shell 
interfered materially with vision. 
In 1870 he again presented himself for treatment. He 
expressed a desire to be rid of the growth if possible, as he 
wished to go to sea again, but could not ship on account of 
his prominent defect. On this occasion I cut away the 
larger portion of the mass from the inner canthus. The 
hemorrhage was very free, but was controlled after some delay 
by pressure. The wound in time cicatrized with decided 
improvement. 
In 1872 he again presented himself with an urgent appeal 
for relief. The growth had now involved the entire length of 
the lower lid and two-thirds of the upper one, leaving only the 
external one-third, with its border fringed with eye lashes. It 
had also spread to such an extent inward as to encroach over 
the median line of the bridge of the nose. Points of ulceration 
were also present over the elevated surface. His general 
health was excellent. 
After careful study, I determined to remove the disease and 
cover the large raw surfaces by a blepharo-plastic operation. 
I divided the procedure into two stages; in one I made the 
upper lid, and in the second, performed six weeks later, I 
manufactured the lower lid. FROM CONTIGUOUS SKIN. 
3 
In the first, operation I removed three-fourths of the growth, 
in the following way : I commenced by making in the healthy 
skin, at the edge of the growth, a vertical incision on the bridge 
of the nose, sufficiently extensive to cover the vertical diameter 
of the tumor. From this wound extended outward a horizontal 
incision running directly under the left eye-brow, to the extent 
of three-fourths of the upper lid, turning then at right angles 
downwards through the free border of the upper lid. From the 
lower extremity of the vertical nasal incision a secon i hori- 
zontal incision passed out wards.through the healthy skin under 
the growth upon the lower lid until it reached a level of the 
inner canthus, when it was made to pass upward through the 
surface of the tumor and end at the caruncula. All the 
keloid growth included within these five incisions was dis- 
sected away, leaving clean surfaces, as is usual in excising 
keloid tumors. The hemorrhage was very free, especially from 
the angular vessel, which would not hold a ligature after re- 
peated trials. 
When, after continued pressure, the surface was finally made 
dry, the plastic operation was commenced. The vertical inci- 
sion made in the median line of the nose was extended upwards 
for one and a half inches, until it reached a deep natural corruga- 
tion extending transversely across the forehead. A second ver- 
tical incision, parallel with the first, extended from the nasal 
termination of the right superciliary ridge upward, to reach the 
transverse groove already referred to. These two incisions 
inclosed a tongue of skin three-fourths of an inch wide and one 
and a half inches long. A bold incision three inches long was now 
made across the forehead in the transverse groove, extending 
equally on either side of the flap of skin. This defined the flap 
and allowed it to be dissected up to the full extent of the vertical 
incisions, leaving it attached, however, to the right side of the 
face by a foot-stalk as broad as the space between the bridge 
of the nose and the inner canthus of the right eye. The 
right angular vessel ramified in this flap and ensured its 
thorough nutrition. The loose flap was now twisted upon its 
pedicle and brought over to the left side, when it was found to 
cover nearly the entire raw surface from which the tumor had 
been removed. In adjusting the flap by twisting it, its upper MAKING OF LIDS OF LEFT EYE 
4 
edge became the lower edge when in position, and was united 
to the infra orbital margin of the wound. The extension of 
the incision in the direction of the median line of the nose 
being bent so as to be juxtaposed to the nasal incision. The 
right border of the when in its twisted position looked to 
the left and was free. To this free border the remnant of the 
upper lid was to be attached, but between the two there was 
still a considerable gap to be filled up. This deficiency was 
met by making an incision three-fourths of an inch long 
directly outwards from the external canthus, from the end of 
which temporal incision a second one passed upwards half an 
inch in length. The remnant of the upper eye-lid, with the 
flap of skin included within these two incisions, when dissected 
upwards, permitted the lid to glide across the orbital surface 
and to be sutured without tension to the free border of the frontal 
flap. In liberating the lid I had incised only the mucous 
membrane, so that the elevator muscle remained in tact. 
To fill up the large opening in the forehead from which the 
nasal flap had been taken, it was only necessary to dissect up 
the skin over each eye as far out as the temporal margin, and 
up to the transverse incision which had previously been made 
across the forehead. By traction the two flaps were made to 
meet in the median line, and thereby closed the entire exca- 
vation. Thread silk sutures were freely used to adjust the 
lines for union by the first intention. The wound was left 
without dressing, so that the little moisture from the wounds 
could dessicate, and form a protective scab or crust under which 
the healing would go on. The patient was given, $ Opii, gr. 
f, ext. bellad., gr. i, in pill, three times day, for the purpose 
of quieting irritation. This treatment was kept up for a week, 
at the end of which time a purgative pill was administered, as 
the patient had had no action on his bowels from the day of 
operation. The various lines of incision about the eye healed 
by the first intention, except a portion of the inferior margin, 
which was touching the keloid surface on the lower lid. In 
the forehead, where there had been such extreme traction as to 
polish the surface, some liitle suppuration showed itself in the 
median line of union. This discharge was also allowed to FROM CONTIGUOUS SKIN. 
5 
harden upon the surface as a thick crust, under which healing 
was perfected in two weeks. 
Immediately after the operation, when the severe pain of 
head somewhat subsided, the patient complained of a loss of 
feeling, dead sensation over the front and upper part of the 
head. This was easily explained, the transverse incision 
across the forehead having necessarily divided the supra orbital 
nerve on each side. 
By the third day after the operation the nasal flap had be- 
come quite thick, having at least doubled in bulk and making 
a very prominent swelling on the left side of the nose. When 
the new relations became thoroughly established, the swelling 
all subsided. A cicatricial line was also established where the 
inferior edge of the flap was brought in contact with the keloid 
edge of the lower lid. 
After six weeks the improvement in the appearance of 'the 
eye became so marked, the upper lid having acquired a good 
deal of elevation power that the patient became urgent to have 
the diseased lower lid replaced equally by healthy tissue. 
There was a belt of elevated keloid growth, half-inch wide, 
involving the entire length of the lower lid, including the 
ciliary edge, from which all lashes had disappeared. By making 
a vertical incision downwards from each canthus and joining these 
by a transverse cut in the healthy skin below the lower margin 
of the growth the entire disease was removed, leaving a very 
extended excavation. To fill this large raw space the vertical 
incision made at the external canthus was extended obliquely 
downwards for the distance of nearly two inches. Towards the 
temple a second vertical incision was made including between 
the two lines a tongue of skin three-fourths of an inch wide, 
and two inches long. The two vertical incisions were joined by 
a transverse one on a line a little above the angle of the mouth 
and the flap dissected up with its broad foot stalk continuous 
with the temple. This flap was turned at right angles to its 
former position, and was found to fill up perfectly the raw ex- 
cavation from which the growth had been removed. Several 
points of silk suture secured it in accurate juxtaposition. When 
the skin of the cheek was loosened on each side of the vertical 
incisions, the two cut edges were easily brought together with- 6 
MAKING LIDS OF LEFT EYE 
out tension, and when adjusted by sutures the space from 
which the lower lid had been manufactured was quite effaced. 
No dressing was used upon the wound, the surface being left 
to dry, with dessicated blood scabbing the various lines of 
section. 
For the first thirty-six hours the case progressed well. Then 
the newly cut surface took on erysipelatous inflammation which 
rapidly involved the side of the face and threatened the de- 
struction of the flap. Resort was at once had to the internal 
remedy which is found so valuable in the experience of the 
surgeons at the Infirmary, viz : the tinct. ferri muriatis in one 
drachm doses, every four hours, and without the use of local 
applications. Within twenty-four hours a marked subsidence 
of the inflammation had occurred, and after a few days the 
flap had united by the first intention, with suppuration only 
at the innermost point towards the nose where it joined the 
flap of the previous operation. 
The condition of the patient, now eight months after the 
operation, is most satisfactory. The temporarily thicked 
prominence of the flaps is all gone, as is also the red color of the 
scars, so that he can bear a rigid inspection without exposing 
the fact that two operations had been performed to remove a 
most disfiguring disease. The remnant of the upper lid with 
lashes attached, from constant stretching, seems to have ex- 
panded so as to cover well the eye ; also to have regained its 
natural movements, as in winking. The lower lid is, of course, 
without lashes and resembles that condition of a large class of 
ophthalmic patients who had suffered from chronic ciliary 
blepharitis. There is, however, an improvement over this class 
of patients, as there is no red border to the lid, nor is there any 
tendency to ectropion. This lid looks well: the upper one also 
looks perfectly normal,, with the exception of lashes absent 
from the inner and outer canthus edges. The end of the lower 
lid at the inner canthus would exhibit a few hairs, formerly 
belonging to the beard near the mouth, were they not care- 
fully plucked out as fast as they show themselves. 
The case offers six points of marked interest: 
1st. The successful removal of an ulcerated keloid growth, 
which is so seldom effected. FROM CONTIGUOUS SKIN. 
7 
The growth of twenty-seven years with the wattled cutane- 
ous hypertrophy so characteristic of the disease, had ulcerated 
at several points. When such a mass is cut away, as had been 
previously done from these eye lids, it so constantly reappears 
with the commencing cicatrization of the wound, that the tumor 
has been classified among the recurrent fibroids. In the present 
case, in which the entire surface from which the keloid had 
been removed, had been covered by healthy skin from a dis- 
tance, there has been so far no appearance of return of the 
disease. Although eight months have elapsed, the skin in its 
new locality remains soft, and to all appearances perfectly 
normal. The results in this case, suggest as a treatment for 
keloid or recurrent fibroids of the skin, the transplanting of a 
flap from the contiguous surface to cover the raw space after 
removal, and not allow the wound to granulate as the means of 
healing. 
2d. Large doses of the tinct. of the muriate of iron for the 
prompt arrest of traumatic erysipelas. 
When erysipelas attacks a recent wound, especially on the 
face, in old persons, the tendency to .a destructive course is very 
decided and suppuration at least, if not sloughing, is the sequel, 
that has very few exceptions. Such would have undoubtedly 
been the case in this instance, had not the treatment, found so 
efficacious in arresting erysipelatous inflammation, been re- 
sorted to. The prompt arrest of an attack of erysipelas by the 
administration of large doses of the tinct. muriate of iron is no 
new fact in surgery. For the past fifteen years it has proved 
so efficacious in my experience that I am no longer alarmed at 
the intrusion of erysipelas, in cases where it is desirable to se- 
cure quick union in the healing of wounds. Where the acid 
preparation of iron is given, in half drachm to one drachm dose 
every four hours, it can be relied on as a remedy which will, in by 
far the majority of cases, protect the patient against the threat- 
ened complication. After the use of the iron for twenty-four 
hours in this case, I had evidences in the reduction of the 
swelling that I had not misplaced confidence in the remedy, 
although the rapid inroads of the disease had marked an aggra- 
vated attack. 8 
MAKING LIDS OF LEFT EYE 
3. Silk sutures, well waxed, are more convenient and useful 
than metallic sutures in healing most wounds by the first 
intention. 
Metallic wires make awkward sutures, both to apply and 
remove, especially when eye lid wounds are approximated 
with them. As a rule, a well waxed thread will not readily 
imbibe the secretions from a cut surface, and as long as it will 
remain as a thread deficient in decomposable animal fluids, it 
is as innocuous as the metal thread, which produces no irrita- 
tion, because it does not imbibe. In face wounds, which unite 
so speedily, sutures accomplish their full work in two or three 
days, when they may all be withdrawn. In the above case 
some of the fine silk well waxed threads were left in ten days, 
merely to test their ability to irritate. When finally removed, 
the needle puncture had so closed up that the thread was 
tightly hugged by the healthy skin, without the slightest trace 
of suppurative action. 
4th. Nervous sensation in the scalp and forehead restored 
after complete loss by nerve section. 
The transverse incision across the forehead from one tem- 
poral prominence to the other, which enabled the lateral flaps 
to slide together and efface the excavation from which the skin 
for the manufacture of the upper lid had been taken, necessi- 
tated the division of both supra orbital nerves. This section 
caused the dead, benumbed sensation of the forehead and front 
of the scalp, which was the most prominent complaint of the 
patient during the healing of the wounds. In the sliding of 
the flap upon the frontal transverse incision the nerve string, at 
cut ends, must have been separated nearly half an inch. Some 
time after cicatrization was perfected the benumbed sensation 
gradually disappeared, and now, at the end of five months 
from the nerve section, the sensation to touch has been so per- 
fectly re-established that the patient responds immediately to 
the touch of a pointed instrument over any portion of the 
scalp above the transverse cicatrix. 
5th. Acquired sensitive impressions in the flaps, referring 
to their new locations. 
This is a very singular feature in this case of conservative 
and reproductive surgery. When the new eye-lids are touched FROM CONTIGUOUS SKIN. 
9 
with a sharp point, the lids being closed, so that the instru- 
ment is not seen, the point of pressure or the point touched, 
however slightly, without pressure being transmitted through 
the thickness of the flap to impress the deep nerves 'beneath 
the flap, was recognized at once in the new relation. The 
point with hair upon it from the beard of the face near the 
mouth would be called at once lower lid, when touched, and 
not cheek. The nose covering and upper eye-lid in no case 
was called forehead, where the skin eight months since belonged, 
but when touched was always referred to as upper lid or nose. 
6th. The case is of great interest and rarity when viewed as 
a double blepharo-plastic operation. 
The patching out of the surface over the lachrymal sac is 
not an uncommon operation in opthalmic surgery. The manu- 
facture of even half of a lid has often been effected at the 
hands of specialists. Even an entire lid may have been very 
successfully made from contiguous tissues; but very seldom do 
we find in the annals of surgery a destruction so complete, 
necessitating so extensive an oblation of the entire lower and 
two-thirds of the upper lids, so satisfactorily concealed by 
plastic operations.