REPRINTED KROM UNIVERSITY Medical Magazine. tNTtO VNMR THE AUSPICES OF. THE ALUMNI ANO FACULTY OF MEDICINE Of THE UNIVERSITY OF PENNSYLVANIA EDITORIAL STAFF EMwial Cammittea: »aam«aa»i..A wmcawa. m> CONTENTS. Fiwx, •««> .a. im.AjK nr NOVEMBER, 1806 DESCRIPTION OF A SUCCESSFUL OPERATION FOR BLEPHARO- PLASTY, EMBRACING THE OUTER HALVES OF BOTH THE UPPER AND THE LOWER LIDS BY A SINGLE SPLIT FLAP TAKEN FROM THE FOREHEAD FOR EPITHELIOMA. BY CHARLES A. OLIVER, A.M., M.D., PHILADELPHIA, One of the Attending Surgeons to the Wills Eye Hospital; one of the Ophthalmic Surgeons to the Philadelphia Hospital, etc. DESCRIPTION OF A SUCCESSFUL OPERATION FOR BLEPHAROPLASTY, EMBRACING THE OUTER HALVES OF BOTH THE UPPER AND THE LOWER LIDS BY A SINGLE SPLIT FLAP TAKEN FROM THE FOREHEAD FOR EPITHELIOMA.1 By Charles A. Oliver, A.M., M.D., Philadelphia, One of the Attending Surgeons to the Wills Eye Hospital; one of the Ophthalmic Surgeons to the Philadelphia Hospital, etc. During my fall, 1895, term of service in the eye-wards at the Philadelphia Hospital, A. K., a 66-year-old hostler, was admitted. He gave the following history: In May, 1864, during the last day of the battle of the Wilderness, in Virginia, between the Federal and the Confederate forces, he was struck at the outer angle of the right eye by a small piece of shell. From this wound, that never entirely healed, a growth, which slowly but steadily increased in size until both of the lids became involved, developed. This finally assumed a malignant type and presented exuberant granulations, which were painful, irregular in outline, and showed no tendency to heal. The family history was negative. For the past three years the 1 Paper read before the 1896 meeting of the American Ophthalmological Society. 2 Charles A. Oliver. patient had had a chronic diarrhea, the stools being thin and liquid, and averaging six to twenty a day. The growth, which was epitheliomatous in character, occupied the outer halves of both the upper and the lower lids, and extended laterally to some six or seven millimetres beyond the supposed position of the external canthus. Its oldest and densest portion seemed to be to the outer side. It bridged across the palpebral fissure without apparently reducing the commissural width. A probe could be readily passed beneath the growth into the conjunctival cul-de-sac, showing that the mucus membrane was undisturbed and untouched. The eyeball itself, which was uninjured in any way, performed its functions normally for age and refractive condition. There being no contraindications, on October io, 1895, while the patient was under the general anesthetic effects of ether, and with the kind assistance of my friend, Dr. George C. Harlan, and my resident surgeon, William H. King, and in the presence of my col- league, Dr. George E. de Schweinitz, I made the following operation for the growth and the filling in of the bared surface with the adjacent sound skin. As shown in the accompanying outline sketch, the area desig- nated as "tumor," and which represents the position and the shape of the growth, was excised in the triangle F B CD' B'. During this procedure care was taken to save every portion of the underlying conjunctiva. This was accomplished by dissecting the mucus mem- brane free from the inner edge of the ciliary border of the outer halves of the lids by a series of carefully-made incisions carried along the junction of the mucus membrane and the skin of the lids. This done, a large, irregular, triangular area, as shown in the sec- ond sketch was obtained. Embraced in the central portion of the inner thirds of this area there was a large quadrate flap of conjunctiva, which represented the entire mucus membrane surface of both the globe and the lids to the temporal side of the cornea, the bulbar portion being still adherent to the submucus tissues of the globe. The bared surface was freed from all shreds of tissue and masses of fat. Capillary oozing was checked by the moderate employment of hot stupes. A large-sized flap made of a height at its inner aspect equal to the base of the denuded triangular area was formed at G A A' FH. This was dissected loose, leaving the broad and well-nourished base G H. The tissues beneath H F B' were next dissected suffi- ciently to make the overlying area freely mobile. The large upper flap was slid into position, and the border F B was attached to F B' by a series of sutures which were so inclined as to bring the Successful Operation for Blepharoplasty. 3 two edges neatly together. The slit C E D was cut and the lower border E D was stitched to the conjunctival flap, which now ran from E' to D', thus making a ciliary border in the new outer half of the lower lid. The external canthus was next formed by a simi- lar stitch placed in the new external ang e. The ciliary border of the new half of the upper lid was made in a similar way, attaching the upper border of the split E C in the flap to the conjunctival bor- der E' C. The rest of the large flap was set into position, and the open triangular area in the forehead was reduced to a minimum by a number of fine superficial sutures. The tissues beneath the forehead were loosened so as to allow the skin of the forehead in the region of the operation to cover as much of the exposed surface as possible. 4 Charles A. Oliver. The reproduction of the general photograph shows the position and size of the surface that was left to heal by granulation. The field of operation was cleaned, dusted with powdered iodo- form, covered with a large square of antiseptic gauze, and protected by several turns of a narrow gauze bandage. The first dressing, which was made in two days' time, consisted as follows: In sopping off the gauze with sterile water; in thoroughly irrigating the whole operation area with warm sterile water ; in spray- ing the cicatrizing area and the stitch-wounds with a one-third strength solution of peroxide of hydrogen in water; in douching the conjunc- tival sac with a warm saturated solution of boracic acid; and in dust- ing the cicatrization-area with powdered acetanilid. In four days nearly all of the superficial stitches in the broadest portion of the flap were removed. The other sutures were gradu- ally gotten rid of, until on the 2/th of the month the last were cut out, these being those that joined the lower border of the conjunc- tiva to the adjacent skin. On the fifth day, at the suggestion of my resident surgeon, Dr. William H. King, the granulation area was dressed, as is sometimes done, with chronic ulcerous conditions in the lower extremities. The exposed surface was dusted with acetanilide. The sound skin around the free space was covered with several layers of gauze with a cen- tral perforation equal in size to the granulation area itself, thus affording a bandage which was protective without producing any pressure upon the delicate granulation tissue. On the fifth day a slight bagging of the lower outer base of the flap induced me to cut a quadrangular trap-door between two or three of the stitches. In this opening I had Dr. King spray the one-third strength solution of the peroxide of hydrogen daily in such a way as to force the material well beneath the flaps without producing any manifest damage to the parts. A few drops of pus upon the first two or three trials showed the wisdom of the procedure. On the 28th of the month, but eighteen days after the operation, the last stitch was taken out, and the field of operation was perma- nently exposed to the air. Two days before, a photograph, showing the first result of the operation, was taken by my friend, Dr. Frank Savary Pearce. When compared with the conditions four days before the oper- ation, imperfectly seen in the photograph, the difference between the two is plainly manifest. In April, 1896, more than half a year after the operation, the ex- ternal canthus was not dragged so much up and out. The eyeball was freely mobile, the patient was well able to cover the eye. The Appearance of growth before operation, and slanting situation of palpebral fissure immediately after operation. Sziccessful Operation for Blepharoplasty. 5 frontal cicatrix could barely be seen, and there was not the slightest vestige of the growth remaining.1 Temperature, pulse, and respiration remained normal throughout the after-treatment. The almost constant diarrhea with its necessary uncleanliness was one of the most disturbing things that was suc- cessfully combated. Remarks.-This case is reported fully, as the method of operation is most certainly a novel and a useful one. The patient, who was almost absolutely bald in the fronto-temporal region, seemed to pre- sent in this peculiarity an opportunity that was appropriate for the form of operative procedure that was adopted. The restoration of fully one-half of the lid area by an ordinary split skin flap; the accurate coaptation of the mucus and skin sur- faces so as to form a new lid border; the making of an artificial ex- ternal canthus; the almost total disappearance of any of the dis- figurements that were first noticeable; the thorough excision of the growth; the full movement of the globe in its various directions; all are but a few of the interesting factors in the permanent result of the case. The free and generous excision of the malignant mass ; the sin- gle split flap, totally different from that of Hasner for the restoration of an external canthus; the broad base of the large flap with its full and free vascularity ; the method of formation of a ciliary border and a properly-shaped and deeply-set conjunctival cul-de-sac, which is almost, if not quite, as extensive as its fellow ; the nearly infini- tesimal loss of mucus membrane; the method of preparing and setting the flap ; and the plan of superficial suturing, are all of interest, and seem to be of value in the technique of the operation. The bringing down of a second upper flap, so as to take away the cicatrizing tissues from the eyelids ; the production of an upward external dragging of the palpebral fissure, which, if it had not suffi- ciently fallen into proper position, I would have remedied by the placing of a second cicatricial area down and out from the external canthus just below the outer lower angle of the malar bone ; and the redundance of tissue introduced into the lids, which later was greatly lessened, may all seem to have been conditions brought into exist- ence that should be avoided in such cases. The facts, however, that the later results fail to evidence any such early discrepancies, seem to show that under ordinary circumstances they make but little or no difference in the question. The form of protective dressing adopted for the granulation 1 A later photograph taken just before the patient's death, a few months ago, unfortu- nately was a failure. 6 Charles A. Oliver. area; the simple method of cleanliness, and the endeavors to obtain as near asepsis as possible in a broken-down, unhealthy, and unclean subject; the avoidance of any dangerous and even ruinous pus-bear- ing channels by the little operative device and the faithful use of per- oxide of hydrogen ; the care and order in which first the superficial and later the deep stitches were removed; and the ingenious wall of gauze in which the granulation-area was enclosed, are but a few of the procedures that seemed to be of interest in the after-treatment of the case. The one curious feature in the case was the manner in which at first the orbicularis palpebrarum acted. The upper outer fibres which were situated upon the lower part of the cicatrix at times dragged the outer half of the lower eyelid up and out during the earlier stages of the healing process and gave the patient a most quizzical expression.