Chapter 6.7: The Eyelids

The eyelids present unique challenges to the surgeon—the dermis is very thin, with a near absence of subcutaneous fat in some areas. This provides only minimal tissue volume to aid in absorbable suture material breakdown, potentially increasing the chance of suture spitting or suture abscess formation. Moreover, the highly elastic eyelid skin also means that a disfiguring residual pull is possible, so that ectropion—while something to avoid at all costs—is only the most extreme outcome along a spectrum of lid pull abnormalities.

The unique challenges associated with eyelid repair means that some of the standard buried suturing techniques may be less useful in these locations, and the lack of significant tension along most eyelid repairs means that running or transepidermal techniques, which should be used sparingly in many locations to minimize the risk of scar spread, may be appropriate. Medial canthal eyelid repairs should sometimes be avoided altogether, as this area tends to heal well by secondary intention.

When absorbable suture material is used in eyelid repairs, 5-0 or 6-0 braided or monofilament suture material may be used. It is important to avoid using thicker suture material on the eyelids, as the large volume of suture material in knots relative to the thickness of the dermis may impede the process of suture material breakdown by hydrolysis. Fine P-3 needles are generally adequate for these repairs.

When transepidermal sutures are used, 6-0 or 7-0 monofilament is often the best. These locations may also heal well using fast-absorbing gut suture (or the newer rapidly absorbing synthetic sutures), where the disadvantage of higher tissue reactivity should be weighed against the benefit of utilizing a rapidly absorbing suture material that obviates the need for suture removal.

Despite the often thin dermis present on the eyelids, standard approaches such as the set-back dermal suture and the buried vertical mattress technique are often utilized. Care should be taken to avoid skimming the needle too superficially, leading to an essentially percutaneous repair (Figure 6-7).

In patients with a very thin dermis or with marked atrophy, placing absorbable sutures may be particularly challenging. In such cases, simple interrupted sutures may be used to easily approximate eyelid skin. Running variations, such as the simple running suture, may be used as well. While over-eversion of the eyelid skin should be avoided, transepidermal everting techniques, such as the running horizontal mattress or running diagonal mattress, may be used as well. Unlike repairs in anatomic locations under tension, the transepidermal closures may be used as a solitary approach for some eyelid closures under minimal tension.

When working on the lower eyelid at the eyelid-cheek junction, a marked difference in dermal thickness may be appreciated between the thin eyelid skin and the thicker dermis of the upper cheek. In such cases, the depth-correcting simple interrupted suture may be helpful to maintain precise wound-edge apposition.

Finally, the Frost suture may be used to mitigate the risk of developing ectropion due to tissue edema in the immediate postoperative period. It is important to recall that this approach will not help when ectropion is present; rather it is designed to minimize the chance that the postoperative edema and ecchymosis seen after lower lid surgery will lead to an iatrogenic ectropion. The benefit of placing a Frost suture should be weighed against the risk of the patient traumatizing the suture material, where an accidental pull could lead to a painful and possibly damaging outcome. Therefore, Frost sutures should only be left in place for a minimum period of time and should be covered with a wound dressing to avoid accidental tugging.