BLEPHAROPLASTY SINE PEDICLE. By EUGENE SMITH, M.D., MICHIGAN. JULY 26, 1880, I was consulted by S. J., of Detroit, who gave the following history: June 7, 1880, while at Kokoma, Colorado, he had an attack of severe phlegmonous facial erysipelas, which laid him up for five weeks. When I saw him, there was cicatricial ectropion of the right upper lid, the entire skin of the lid having sloughed, the palpebral border was drawn up and joined to the eyebrow. Discharging abscesses still existed under the angles of the inferior maxilla; the cornea of right eye had sloughed. After nearly three months' treatment with tonics, I operated October 19th, assisted by Dr. Eggeman, after the method of Dr. Wolfe, of Glasgow, who, I believe, was the first to suggest taking a large piece of the skin from the arm, and grafting it on the lid. The different steps of the operation were as follows: dissecting the palpebral border from the eyebrow by a longitudinal incision, the lid was drawn down and fastened by two sutures to the edge of the lower lid, both edges having been freshened with a view to their union, forming an artificial anchyloblepharon. The bleeding was very troublesome, and I found it necessary to twist two small arterial branches. The wound of the lid measured one and a half inches in length by one inch in width. I next removed a piece from the inner side of the arm, which measured one and a half by two inches, and consisted of skin and cellular tissue, placed it on a large plate, which had been heated quite warm, and with a Beer's cataract knife I very thoroughly scraped and shaved off the cellular and loose connectivetissues, and even a thin layer of the corium, all of which I found to be a difficult job. The graft was then placed on the lid, and, being too large, it was puckered in the centre sufficiently to bring the edges in situ, and sutures were put in to hold it in place. The parts were then covered with goldbeaters' skin, a compress of lint and a compress bandage, some pressure being made to keep the parts in place, and to prevent the lids moving. The dressings-except the goldbeaters' skin-were removed twenty-four hours later. The flap could be seen, apparently completely agglutinated to the lid. A fresh compress and bandage were applied, and left for twenty-four hours more, at which time all the dressings were removed. Considerable oozing of bloody serum had taken place from the inner angle of flap, at the point where the arteries were twisted, but the flap seemed attached throughout, and was very white. The third day the puckering of the flap had entirely disappeared; it was considerably thickened, and the epithelium macerated. There was a slight secretion of pus, and the border of the graft appeared, in places, of a bluish-brown color. The fourth day most of the epithelial layer was softened, and peeled off. The discharge was fetid, and a portion of the edge of the graft was gangrenous, which I removed with the scissors. After trimming off the sphacelated portion, the graft was found to be of a rose-color. The fifth day it was not dressed, and the sixth day considerable pus was found to have been secreted, and it was very fetid. The seventh day the darkened edge was again trimmed, and the flap bled, when pricked at any point. It continued to discharge, more or less, till November 1 it is covered with epithelium, and the patient opens and closes the eye about one-half, readily. The flap, which has been quite thick, is growing thinner. The grafted portion is less than one-half its original size. The wound in the arm was drawn together with sutures, after dissecting up the edges. In a previous attempt at the same operation, which failed, I think the failure was due to the imperfect manner in which the flap was prepared, the cellular tissue only being removed. From experience in these cases, I would urge the utmost care in shaving off the subcutaneous connective-tissue, as well as the cellular tissue; and even a thin layer of the cutis vera, for we thereby more thoroughly insure adhesion, by bringing the dermic cells more closely in contact with the wound. With regard to the advantages of this method of operating over the old methods, it seems as if comment is unnecessary. Somebody has remarked concerning it, that it does not require a second cosmetic lesion, to cure an existing deformity, as, for instance, taking a flap from the temple and forehead. I present a drawing (Fig. 1), made by myself, which fairly represents the case, previous to operation; also, a photograph (Fig. 2), taken April 23, 1881. |