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).
Frequently used suturing techniques on the eyelids.
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.