Lecture: Management of Periocular Trauma and Scarring

DR LEE: Today we’re gonna — you know, the lecture, the topic was given as eyelid reconstruction, and in the US, this typically means, like, skin cancer reconstruction. But I know here in Jamaica, people are blessed with more pigment and fewer skin cancers, so we decided to kind of tailor the lecture a little bit more towards trauma, as opposed to skin cancer excisions and reconstructions. My colleague, Antonio Lucio Alvarez, is gonna actually give a talk as well. So he’s gonna focus a little bit more on the details of eyelid laceration repair. So I’ll very briefly touch on this, so I don’t duplicate his work, and then we’ll talk about scarring as well. Because that’s something that applies to all cases of trauma, and it’s something that can be easily managed outside of the OR. And it’s very important to the reconstructive and the healing process. And it’s also an area of interest for me personally. This is a patient of mine who — very commonly we have skin cancers that form on the eyelid, and this was a basal cell carcinoma. She had a fairly large segment taken out, and this was a rotational flap. We call it a reverse Tenzel flap. First we bring the lid margin together, but in order to do that, we have to mobilize a semicircular flap, release the superior crus of the lateral canthal tendon, to slide everything over. So we’re borrowing tissue from the temporal region. But again, we’ll save that for another lecture. Okay. So we have a series of audience response questions. The people on board the plane here have clickers, so you can answer this question. People at home, you can answer in your heads. But the question is: What must be done in an upper eyelid laceration when orbital fat is prolapsing? So A, repair the orbital septum, B, explore the levator aponeurosis, C, perform forced duction testing, and D, explore the trochlea? Oh, all right. So repair the orbital septum and explore the levator aponeurosis. It’s pretty much tied. I’m not gonna tell you the answer, because we’re gonna have a posttest quiz. So question number two: Periocular burns can cicatrize and contract over what time period? So several hours, several days, several weeks, or several months? Okay. So we see: It seems to be split between several days, several weeks, and several months. Okay. Which is not a complication of intralesional injection of a scar with the following medication? So triamcinolone, which is a steroid, hypopigmentation, or soft tissue atrophy, and 5-fluorouracil, skin necrosis and hyperpigmentation? 5-fluorouracil and hyperpigmentation. Okay, all right. Very good. Okay. So just to highlight the objectives for today, we’re gonna talk about general principles of managing periocular trauma, discuss potential sequelae of eyelid trauma, and we’ll discuss non-surgical management options for periocular scarring, and then also discuss surgical techniques for repairing periocular scarring as well. So first of all, we’re ophthalmologists. And when we see patients in the acute setting, sometimes they’ve already been managed by the emergency room doctors, but sometimes they come to our clinics, whether they should or should not. And it’s always important, I say, to evaluate the overall patient, and remember that we are physicians before we are ophthalmologists. So some of these patients with severe trauma — you want to look out for: What is their neurological status? If they’ve had brain trauma, and they’re neurologically not intact, that becomes a priority, more so than fixing their eyelid. Also, if they have a C spine injury, think about their neck. Here, this is an image of a C spine fracture causing compression of the spinal cord. And then certainly just remember basic things, like: What are their vital signs? Eyelid lacerations can be repaired — several days, if needed, or weeks later. So certainly consider the overall patient and the priorities. Then, after physicians, we are ophthalmologists. So we certainly want to check the eye and the orbit. Because if they have a ruptured globe, you really don’t want to be manipulating the eye and expulsing the contents of their eye. So first do your eye exam, a thorough eye exam, check everything, and then if it seems appropriate, again, then you can proceed with fixing the eyelid laceration, which, again, is not urgent. For patients who have contaminated wounds, you could consider giving them a tetanus shot. Certainly in cases where there’s been road accidents, and there’s a lot of gravel and dirt, you want to clean the wound and irrigate it extensively. The same applies for any type of chemical injury, of course. You want to get as much of the foreign bodies out as possible. Sometimes it’s a very tedious and laborious process. Sometimes you irrigate it, and it doesn’t come out, but you have to put in wet gauze, and then the particles are coming out on the gauze. So really take the time to do a good cleaning. And then finally you can evaluate for lid lacerations. And if there’s any tissue loss. The majority of times, there really is no tissue loss, even though it looks like there’s tissue loss. So if the eyelid is cut, it tends to splay apart. And it looks like there’s a chunk missing, and you think… Gee, I think that dog actually ate part of the eyelid! But it’s very rare that the dog actually eats the eyelid. It more commonly tears or avulses, and even blunt trauma can cause an avulsion of the eyelid. So I like to always categorize our different types of lacerations as oculofacial surgeons, so very often, for non-marginal lid lacs, people will actually not even call ophthalmology, sometimes. They’ll just call the emergency room doctor or the plastic surgeons, who honestly don’t study the eyelid as much as we do. They’re not as familiar with the anatomy. So here you see a beautiful diagram of the sagittal view of the eyelid and the orbit. And when we talk — I would say the danger is that when you see a non-marginal eyelid laceration, there can still be significant injury that needs to be repaired by someone who knows the anatomy. So if you look at the arrow over here, if you have a non-marginal laceration that penetrates above the level of the tarsus and the upper lid, you can actually go through the orbital septum, go through the fat, and actually transect the levator aponeurosis. And we have a patient later this afternoon who actually had just that. So he has complete ptosis. He had a lid laceration repaired, and he has almost no levator function at this point. So probably what happened is that he had the levator cut. Nobody explored it properly and repaired it. And as a result, his lid is completely ptotic. So even though it’s non-marginal, it can still be very dangerous, and in the same breath as we said explore the orbit, with eyelid laceration, you have to make sure that the globe hasn’t been penetrated as well. One thing I always tell my residents: If you ever see fat prolapsing out of a laceration, that means that the orbital septum has been violated. And if that’s been violated, there could be deep injury to the levator. So always, when you see fat, your kneejerk response should be to explore the levator, and if necessary, repair it. And you can actually take a look. You can have the patient look up and down. And if they have no movement, you can suspect that something’s going on. Now, the marginal lid laceration — most of you seem like you’ve already done these before. And like I said, Dr. Antonio Lucio Alvarez is gonna be spending a little bit more time later on today and tomorrow, talking about the details of lid laceration repair. But just briefly, in the diagram here, you see it’s very important to align the lid margin, and the three landmarks that I generally think of are the tarsus, so I like to sew through the meibomian gland orifices. Then the most anterior part is the lash line. So you align the lashes so they’re in a nice little row, and then right between that is the gray line, so you can put another aligning suture. And then what’s very critical is to place your lamellar tarsal closure bites, so in an upper eyelid, I typically like to place three. In a lower lid, I like to place two, and that’s really the strength layer that’s gonna hold everything together. Because if you close the lid margin with silk sutures, you’re gonna take those out typically after one to two weeks. If you don’t place good lamellar tarsal passes, everything can open up again. Canalicular lacerations are important, because we like to preserve that anatomy whenever possible. Generally we say it’s ideal to repair this within a few days after the injury, because after that, it becomes increasingly more difficult. And a couple pointers I’d like to give — having struggled with this, when I was first starting out as a resident — it’s very important to have excellent illumination. If you don’t have a headlight or good illumination, it’s extremely difficult to find the cut ends. And so again, we’ll cover that in a separate lecture, a little bit more. And typically we put a stent in place to preserve it. But I also say: You know what? It’s not the end of the world if just one of the canaliculi is cut. So remember that for our dry eye patients, we actually put in plugs or even seal off the lower lid punctum, and the canaliculus by proxy, because no tears can go down, and most patients do great. As long as you have one canaliculus and punctum open, the vast majority of patients are totally fine and don’t have epiphora. So we make a big deal about canalicular lacerations, but it’s not like a life or death thing. Especially if they have another canaliculus intact. But of course, we repair it whenever possible. And then finally this is more rare, but sometimes we see patients with more extensive facial lacerations, who are really gashed. And in those patients, I would encourage you to check their facial nerve function, because if the facial nerve is cut, it’s not game over. The ideal treatment of that is to directly repair the facial nerve. And you can have excellent improvement in facial nerve function. So we don’t typically do that very often, but call your facial plastics colleagues. They know how to repair facial nerves, and you sew the perineurium together and anastomose the nerve, and you can preserve that function. That’s very important to do, the sooner the better, whenever possible. So now let’s talk a little bit about periocular burns and scars. Scars and lacerations or burns. And this is, again, this is one of my topics of interest. And I’ve actually done some research that I’ll talk about a little bit later, about how we can rehabilitate scars and the scarring complications around the eyelid. So very importantly, I say — you know, sometimes we see patients in the trauma bay or acutely after the laceration, and we fix them, and we never see them again. So we never really see what happens to them weeks or months down the road. But the wound healing process and scar remodeling — I tell patients that occurs over a year. So if patients complain after a blepharoplasty, oh my incisions are a little bit thickened, I say: Don’t worry. Your scar is gonna improve over the course of a year. If you’ve ever cut your leg, you might know that the scar is initially a bit thickened. It’s a little bit red. And then it flattens, and it gets better and better over time. The same is true with any wound healing and any incision and any scar. But in terms of the cicatricial forces, this really develops and progresses over the first few months. So I always tell patients: You are not out of the woods once your laceration is repaired. Or if you had a burn, once the skin epithelializes, you’re still not out of the woods, because typically over the first three to four months, everything starts to tighten and contract, and if they look perfect on the table or after your surgery, they may look completely disfigured, if you see them back in three to four months. So there’s things that you can do. You have to follow these patients closely. And we’ll talk about ways to mitigate that. You really have to follow them and manage the postsurgical course, in order to have a good result. But certainly scarring around the eyelid — it can cause ectropion. Especially with burns. Because you have a wide surface area of contracture. Entropion, if there’s involvement of a full thickness laceration of the lid, and maybe when it was closed by the emergency medicine resident, they took big bites through the conjunctiva, and caused everything to cicatrize inwards, you can certainly have lagophthalmos, and it’s a cicatricial lagophthalmos. Very oftentimes, it accompanies cicatricial ectropion. You can sometimes have eyelid retraction, along with ectropion. And then there can be a lot of disfigurement from this. I’ll show you some photos, and patients of mine said: I look like a Halloween special. In the US, Halloween is when you dress up in a scary mask. And it can be really disfiguring. And so it’s very important, even if their cornea is fine, and they’re seeing fine, even if their lid position is normal, just a scar in this really prime aesthetic region around our eyes can be devastating. Especially for younger individuals. So we’ll also talk very briefly about types of scarring. Scars come in many, many different varieties. So especially in the Caribbean, in darker skinned patients, hypertrophic scars are very common, and keloids — so the difference between hypertrophic scars is that a hypertrophic scar is just when it gets thickened, but it doesn’t expand beyond the boundaries of the incision or wound. Keloids can grow like a mushroom. I’ve seen patients who had a little ear piercing, and they have a huge cauliflower-type scar, keloid, on their earlobe. So that’s when it goes outside the bounds. So most of the time, we’re talking about hypertrophic scars, because it’s very rare to have keloids on the face and on the eyelids. But that’s probably the most common type of scarring. But there can also be atrophic or depressed scars. For example, if incisions are not closed properly, and the skin edges are not everted and brought together, you can have a depressed scar, where it’s actually sunken inward, or there’s been tissue atrophy, and it’s depressed compared to the surrounding area. And then there’s a lot of characteristics of scars. So when there’s certain ways that we evaluate scars and different standardized scales, and some of the things we look at are the thickness and elevation of the scar, the pliability of the scar, the pigmentation of the scar, which goes along with redness, and also how widened — what’s the width of the base of the scar. So those are all things that you can kind of think about and consider documenting when you’re examining patients. So this is a patient who I just saw a couple weeks before I came here. And she had a fall. She just fell on the ground, cut her eyelid and face, and it’s not a marginal lid laceration. So she went to the emergency room, had it repaired by an emergency room resident or doctor, and this is what she looked like, just about two to three weeks after surgery. And so you can see she has this oblique scar. And you can almost imagine the forces pulling directly along that scar. So she has cicatricial ectropion, she has cicatricial eyelid retraction, you can see there’s more scleral show down below, and she also has lagophthalmos, and a lot of foreign body sensation, exposure keratopathy symptoms, so what I did was I said: First of all, you need to massage it like crazy. You want to massage it against the vector of pull. So do that as much as you can. I gave her intralesional 5FU injection, into the scar. I did fractional ablative laser resurfacing, which we’ll talk about a little bit later, and then after making these little laser holes in the scar, I topically applied 5FU, which goes down the holes and penetrates into the scar. So there’s a lot of different — as you can see just from this patient — there’s a lot of different ways and modalities of treatment that we can combine to give patients the best result. These are other patients that I’ve seen or taken care of. This is a patient who had extensive burn scars around the eyelid, and you can see she had some skin grafting done, to try to repair the cicatricial ectropion. She still has lagophthalmos. The eye still doesn’t close. And this is why I say that skin grafting and surgery is not always the solution for addressing cicatricial ectropion, because when you cut, especially if you cut into scar tissue, it’s gonna scar again. So that’s why we’ll talk about how you can manage these things non-surgically. And that’s often a better option than surgery. This is a patient of mine from Afghanistan — no, I’m sorry. From Iraq. Who had an improvised explosive device blow up in his face, and he had extensive facial burns, he had a lot of skin grafting, he lost his eyebrows and had eyebrow transplants, and even with all of this surgery and skin grafting, he still has lagophthalmos. Cosmetic — even if the eyes close, the aesthetic result is terrible. Devastating. He doesn’t look like the same person anymore. So how can we try to minimize scarring when we’re doing our laceration repairs? Or even after the laceration has been repaired, how can we try to improve the wound healing process? Which we talked about as being much longer than just when the surgery finishes. So first of all, I think it’s very important to choose the appropriate sutures for skin closure. Sometimes I’ve seen patients with eyelid lacerations that have been repaired with 3-0 and 4-0 prolene sutures. Those are way too big. Eyelid skin I typically close with 6-0 sutures. And if it’s on the cheek or on thicker skin away from the eyelid, I typically use 5-0. If you’re thinking about what is gonna be the best option for the patient in terms of the most beautiful scar afterwards, non-absorbable sutures are best. So nylon and prolene are great options. If you think about the dissolvable sutures, they don’t magically dissolve. The body breaks them down from your immune system through inflammation. And so your body is breaking this down. There’s more inflammation. And even in my blepharoplasty patients, I know that if I used a 6-0 fast-absorbing gut suture, the incision is gonna be a little bit redder, a little bit thicker, especially initially. I think eventually they almost even out, but certainly even on it’s gonna be better. So second point: Appropriate time of removal. So I’ve seen patients where it’s been left in for, like, 3 to 4 weeks, and that’s way too long. They can end up with track marks and other issues. So I typically take things out after 7 to 10 days, unless there’s a concern for infection or some other special circumstances. The idea to minimize the scar is that you want to have good deep layer closure, so there’s zero tension on the skin. That’s the same thing that we talk about when we’re doing something like a facelift. If you have a lot of tension on the skin, it’s gonna widen the scars. It’s gonna be visible scars. It’s not gonna look nice. And the same here. You have to use deep closures to have almost zero tension on the skin, and that way, you’re not gonna have this widened and hypertrophic scar. So one of my friends, who’s a swimmer, had a shoulder surgery, and this incision was right over the shoulder joint, and if you can imagine, we’re constantly moving our shoulder and putting tensile forces and stretch on that scar. She had the most widened and hypertrophic scar I’d almost ever seen. And I felt bad, because she’s a very attractive swimmer. But yeah. That just goes to show that you really want to try to minimize tension. There’s other thoughts. Sometimes if there’s an incision on the forehead, some people talk about actually doing Botox to the forehead, to minimize the frontalis function, because if you imagine you’re lifting your brows all the time, you’re actually stretching on that incision. So if you kind of paralyze the forehead with Botox, or at least minimize the movement, you are reducing that. Finally, then — not finally, but I also want to talk about how the skin likes to heal. So the skin likes to heal in a most environment. And whether that be with antibiotic ointment, with silicone gel, or even just plain old Vaseline, which is white petrolatum, skin heals better and faster in a moist environment. So in the US, pretty much most of the Mohs surgeons, or most dermatologists, when they do skin excision and closures of lesions, they’ve moved away from using antibiotic ointments. They just recommend Vaseline, because they’ve shown patients have better results and fewer complications and side effects and contact dermatitis. I typically still have patients use an antibiotic ointment for the first one to two weeks, but if they’re having irritation and they’re allergic to 10 or 12 different medications, I say: You know what? Just use Vaseline, and you’re gonna probably be fine. Silicone strips and creams. These are things that have been around for a while. Silicone has been shown to help flatten hypertrophic scars. There’s a lot of new silicone gel things that are on the market now. And these tend to help reduce the redness. And it’s not totally understood why and how this works, but the thought is that it reduces the stretch and the inflammation and keeps it hydrated, and various things that just improve the wound healing. And then finally, to improve the final appearance of the scar, you want to minimize ultraviolet light exposure. So if it’s around the eyelids, you use sunglasses, sunscreen, hats, avoid sun, and that’s gonna help the scar to improve faster. Okay. So now let’s talk about what things we as proceduralists and as physicians — what can we do in the clinic to help patients modulate their wound healing process and improve the appearance of the scar? So certainly we talked about eyelid massage. It’s very easy. It’s stretching the shortage of skin. So especially for the patient with cicatricial ectropion, cicatricial lagophthalmos, I have them do frequent eyelid massage, to just loosen up the skin and exert traction opposite the vector of pull of the scar. Intralesional injections of medications are very important. 5FU is something that we use in glaucoma surgery, because we know it inhibits scarring. It’s an antimetabolite that inhibits these fibroblasts that become hyperactive in the wound healing phase. So it can really release the traction, release the contractures, flatten hypertrophic scars. It’s a wonderful medication. Triamcinolone is another option. I’d say for my darker skinned patients, I generally try to avoid triamcinolone, and definitely avoid it in high doses, because it certainly can cause hypopigmentation, especially like the stuff we inject into the eye. Like 40 milligrams per milliliter of triamcinolone. That can certainly hypopigment things. You want to do 5 to 10 milligrams per milliliter, you would probably be okay. But I generally tend to be more conservative, especially in dark skinned patients. If it’s a lighter skinned patient like a Caucasian patient, you’re probably okay. But in dermatology, they have done split scar studies. So they’ve actually injected half the scar with 5FU, and half the side with triamcinolone, and what they’ve generally found is that triamcinolone can cause more widening of the base of the scar. They’re both effective in flattening the scar, but the steroids can widen the base of the scar, can cause tissue atrophy, can cause hypopigmentation, and also it’s more associated with telangiectasia formation in the scar as well. So generally the literature nowadays comparing 5FU to Kenalog — there’s been randomized controlled trials — 5FU generally tends to be preferred. Fractional ablative laser resurfacing is something that I’ve done some work in. And I’ve published a paper in our ophthalmic plastic and reconstructive surgery journal about the use of this laser resurfacing for cicatricial ectropion and lagophthalmos and periocular scarring. And I’ll show you some photos from that paper. And then this concept of laser-assisted drug delivery. That goes hand in hand with the laser resurfacing. And the concept is that the laser drills all these little channels into the scar, and then you drip this medication, just topically apply it, and it can penetrate deep into the scar. Much deeper than it ever would if the skin were intact. So let’s jump to a case. This is the first patient that I did this technique of laser resurfacing for scars on. So this is a 27-year-old patient. He came to me about 6 weeks after a severe motorcycle accident, where he had 2nd and 3rd degree burns to his face. So you can see his forehead is burned. The eyelids are burned. His cheek is burned. And about 3 weeks before he saw me, so 3 weeks after the burns, he started developing progressive lagophthalmos, foreign body sensation, tearing, his vision was slightly down, he had an exposure keratopathy. So here you can see he has cicatricial brow elevation. Because of the contracture of the forehead, it’s pulling his brow up, which in turn is causing secondary eyelid retraction as well. You can see that the upper lid is ectropic. You can see the tarsus underneath. You can see it’s very disfiguring, in terms of the pigmentation and the texture of the skin, and again, in the third photo there, you can see it’s very ectropic, the lash line is distorted, it doesn’t look good. And he said it’s still getting worse. So are we gonna cut on him and put a skin graft in right now? I’m not that excited to do that. I mean, it’s cutting through scar. It’s still getting worse. You’re gonna cause more trauma. So the traditional thing was: Well, wait 3 or 4 months. Wait ’til he’s all terrible. And stable. And then try to go and cut through the scar. But I think, as you’ll see, I think our paradigm is changing, and that’s not what I recommend anymore. Generally, I recommend that you have to start doing these interventions early, and when things are — typically I like to do my interventions about 3 or 4 weeks after the injury. But the earlier, the better. Some people are talking about even doing it like immediate postop, or 1 week after, at the time of suture removal. But earlier is better than later. So this is what I did. So this patient didn’t have any health insurance. We couldn’t even take him to the OR if we wanted to, or we would incur him thousands of dollars of bills. So what I did first was I injected some 5-fluorouracil mixed with triamcinolone, and you can see a few things. So his brow came down. His eyelid is no longer ectropic. There’s still a little bit of distortion of the lash line, but his eye actually can close now. So that’s pretty amazing, if you inject these cheap medications. I did three injections, spaced about one month apart. And he had significant improvement. But I would say he’s not… He was very happy, but he still was not thrilled with his appearance. You can see that there’s still extensive hyperpigmentation and redness. He did have a little bit of hypopigmentation from the triamcinolone. And the texture — he just doesn’t look like himself anymore. This is just a different shot, following those three injections. And you can see there’s still hypertrophic scars there, even though his lid position is better. And then this is him after doing four sessions of fractional ablative laser. As with laser-assisted delivery of the 5-fluorouracil. So dripping it down the holes. I just apply it immediately after the laser, and put a little bit of Vaseline on it afterwards. And you can see there’s significant improvement in the texture, the pliability of the scars, the pigmentation is improved, there’s further improvement of the lash line, so I think… At this point, he was okay going out in public again, and he felt really transformed. He’s not perfect, but it’s still a dramatic thing. And I would say that you cannot achieve this type of result by slapping a skin graft on there. It doesn’t do anything for the hyperpigmentation, and it’s prone to graft contracture and shrinkage and recicatrization. This is just another view from the side. You can see the improvement in the texture of the skin. And this is, again, just showing what you can achieve with just intralesional injection, but then what you’re able to do in terms of the texture, the pigmentation, and the tone of the skin with laser. I will say that intralesional injections are not a perfect solution, and it’s not that they cannot have complications as well. So as we saw over here, this was when I was just starting out, and I injected a little bit too much of a concentration of Kenalog, and so nowadays I would probably do a lot lower concentration, or maybe even skip the Kenalog. This is actually one of my friends, who was just starting out treating scars, and she injected her dad’s knee incision. And I think she injected a little too much, because there was skin necrosis, and you can actually see the deep tissue underneath. I was like… Shoot. I hope he doesn’t get a knee infection from this. But I think the knee and other parts of the body are less vascular than the faces. So I think it’s less — you have to be very careful injecting over joints and things. But still, it’s not impossible to have skin necrosis, if you inject too much 5FU as well. So you have to just be mindful that you don’t want to overdo it. Did you have a question? What concentration of 5FU? That’s a great question. So in the published literature, the typical 5FU concentration, when it comes out of the bottle, is 50 milligrams per milliliter. And people have published injecting it straight-up, and people have injected forming their own cocktail, diluting it half with normal saline, with 5FU, and so people have used lower concentrations. But they all seem to work. And then sometimes people will mix it in with just a very low dose — maybe like 5 or 10 milligrams per milliliter Kenalog with it. I use different concentrations. So I like to mix in a little bit of lidocaine with it, because as you’re doing the injections, they’re a little bit more comfortable. Because it does burn as you’re injecting it. So I mix in a little bit of lidocaine, and then sometimes I add in like about 5 to 10 milligrams per milliliter of Kenalog. But if it’s like a really hypertrophic, really aggressive-looking scar, I’ll typically inject it straight-up. If it’s just more of a mild scar, it’s not too bad, I’ll sometimes use a lower concentration. It’s very individualized. Question? Great question. How much volume do I inject? So that’s a very loaded question. So I’d say if it’s the entire forehead, periocular region, and cheek, you can inject a lot more than if it’s just a small, short linear incision. So it’s really dosed to the treatment area. Yeah. So if it’s like… Say, a small incision around the eyelid, I might inject maybe like about 0.3 to 0.5. Like in that patient who had the whole forehead and the cheek, I probably did about 2 or 2.5CCs of medication total. Across the whole area. Yeah. I mean, there’s different ways of injecting. So some people will inject little microboluses. Some people will inject in a retrograde fashion. So if you have a linear scar that’s hypertrophic, you can sometimes inject and inject as you’re coming out. A lot of these scars that are really thick, it’s hard — if you just inject it, and you try to push fluid, the tissue is so tight, it’s hard to inject. That’s why it’s very nice to inject and then inject retrograde. Because you created a needle tract, and then you’re injecting as you’re coming out. That’s the same way we do it when we’re injecting fillers for aesthetic purposes, a lot of times. It’s a safe way to do it. And the idea is that you want to deliver your medication throughout the entire volume of the scar. So if you have a scar that’s 3 or 4 millimeters thick, you want to be injecting some of the medication at the base of the scar, as well as midway through the scar. So think about that. You’re trying to deliver medication throughout the entire volume of that scar. Okay? This is another clinical example of a patient of mine who had a burn scar to the lower eyelid, and then you can see as it contracted he had some lower eyelid retraction. This is completely non-surgical, again. He had two sessions of laser resurfacing, with topical delivery of 5-fluorouracil. I can’t get into the full explanation of how the ablative lasers work, but you might say… Well, if you’re doing an ablative laser and drilling holes, why aren’t you causing more scarring? Or why are you not causing the tissue to contract? Because when we do laser resurfacing for aesthetics, it tightens the skin. So what you do here is that you have to use a very low density of treatment. So when I do the laser treatment for scars, I do only treat about 5% to 10% of the total surface area, and what dermatologists have found after doing skin punch biopsies after laser is that if you make these tiny holes, it actually can heal without a scar, and histologically, the scar tissue is replaced with more normal-appearing tissue. So that’s the paradox of creating an injury, but this injury can heal without a scar, when it’s a microinjury. This is another patient who had a trichophytic brow and forehead lift, and she had a little bit of redness and visibility of the scar, and this is after treating it with one session of laser, with laser-assisted delivery of Kenalog. You don’t have to worry about hypopigmentation as much with Kenalog if it’s just laser-assisted delivery. There’s a very small amount that drips down the hole. And then finally the surgical treatment for scars. We won’t get into the details of this, but classically, you release the scar tissue, create a recipient site for the skin graft, and then you harvest tissue from somewhere else in the body. So the best option for eyelid skin is eyelid skin. So if they have extra skin on the other side, you can do a blepharoplasty, take that skin, and use it to reconstruct the eyelid. Sometimes the patients don’t have a lot of extra skin, or maybe both sides have been burned. My next option is typically retroauricular skin, because it’s hidden behind the ear. It’s typically not sun-damaged, in patients who have had a lot of sun exposure. And you really can’t see the incision. And if patients are self-conscious about their ears being too visible, I say… Well, you get a free ear pinback from this procedure. It’s gonna pin your ears back, which some patients pay good money to have done. And then if that’s not enough, other options include supraclavicular skin, or even on the inner arm. You want to find skin that’s thin and hairless for the eyelid, whenever possible. Yes, question? Great question. So the question is: If you’re taking eyelid skin from the other side, are you gonna cause a problem for the other side? And the answer is: It depends on the patient. So if it’s a 15-year-old patient, they don’t have a lot of dermatochalasis, because they’re young. But if you have a 70 or 80-year-old patient, they’ve probably never had a blepharoplasty. They’re definitely gonna have some extra skin up there. So you have to evaluate the individual patient. So other options include Z-plasties, to kind of relax the tension along a certain vector. You can do rotational flaps, just like we do for eyelid reconstruction sometimes. Advancement flaps. And then sometimes if they have — I’d say lax facial tissue is your friend in reconstruction. So if they have significant facial laxity, you can do like a mid-facelift, and recruit tissue from lower down on the face to help with lid retraction and ectropion and what-not. So, in conclusion, eyelid trauma can have ocular and periocular sequelae, both with respect to the vision and closure of the eye, but also disfigurement and for the patient’s overall sense of self, periocular scarring can be managed with various non-surgical options that we talked about, including intralesional medication injections, massage, silicone cream, lasers. Fractional ablative lasers are kind of becoming what I believe is the new gold standard for scar rehabilitation. They can correct cicatricial ectropion and the retraction of lagophthalmos, as well as improve the textural, pigmentary, and overall appearance of the scar in ways that surgery cannot. And finally, surgical management certainly can be considered as part of a multiprong rehabilitative approach. So we use all of the techniques at our disposal, figure out what would be the best combination for our individual patient, and that’s how we’re gonna get them to have the best outcome. So let’s see if anybody learned anything. Back to our first question: What must be done in an upper eyelid laceration when orbital fat is prolapsing? Explore the levator aponeurosis. You do not need to close the orbital septum, unless there’s other reasons to suspect issues with trauma to the extraocular muscles. You don’t need to explore the other stuff. Periocular burns can cicatrize and contract over what time period? Excellent. So months. So it does contract over weeks, but it keeps contracting over months as well. Which is not a complication of intralesional injection? 5-fluorouracil does not generally cause any pigmentary changes in the skin. So it’s good for all skin types. All right. And thank you very much. That’s my email if you have any questions.