Single-layered closure successful in lower eyelid reconstruction


A single-layered closure technique may work as well as a double-layered closure technique in lower eyelid reconstruction, a new study suggested.

A single-layered closure technique may work as well as a double-layered closure technique in lower eyelid reconstruction, a new study suggested.        

The approach could shorten operation time and reduce costs, wrote Jennifer S.N. Verhoekx, MD, PhD, and colleagues at the Rotterdam Eye Hospital in Rotterdam, The Netherlands. In addition, a grey line suture was rarely required to adjust the eyelid margin for either double- or single-layered closure, they found.

They published their findings in Acta Ophthalmologica.

When possible, clinicians usually treat small eyelid lesions with full-thickness pentagonal excision, followed by primary closure of the defect, Dr. Verhoekx and colleagues wrote.

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Usually surgeons employ a double-layered technique, closing the posterior lamella with absorbable sutures through the tarsal plate, and several authors advise a grey line suture, according to the researchers.

However, the researchers wanted to see if they could simplify the surgery. They retrospectively analyzed clinical data on 188 lower eyelids of 186 patients treated for a full-thickness lower eyelid defect between 2011 and 2014.

Of these, 82 eyelids had single-layer closure, and 106 had double-layered closure. No significant differences existed between the groups in age, sex, or clinical diagnoses.

The researchers saw all the patients postoperatively at 2 months. They excluded those who had re-excision with further reconstructive surgery within 2 months.

 The procedures


Two surgeons performed all the single-layered procedures, and two others performed all the double-layered procedures. Patients were allocated to one or the other with no pre-selection.

In the single-layered technique, the surgeons inserted a horizontal polypropylene 5.0 suture about 2 mm from the wound edge, just below the eyelashes, through the skin, orbicularis muscle and tarsal plate, just anterior to the conjunctiva.

They passed the needle on the opposite side through the tissues in a mirror-like fashion and gently tied the suture. They placed a second horizontal suture in a similar fashion 203 mm below the first.

If the length of the vertical defect warranted additional sutures, the surgeons placed these through the skin and orbicularis muscle as well.

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They used non-absorbable sutures and removed them 5 to 12 days later. In cases of insufficient apposition of the eyelid-margin wound edges, they placed a fast-absorbing polyglactin acid 7.0 suture in the grey line.

In the double-layered technique, the surgeons sutured the tarsal plate with two horizontally placed polyglactin acid 5.0 or 6.0 sutures, just anterior to the conjunctiva. They sutured the skin and orbicularis muscle with interrupted fast-absorbing polyglactin acid 7.0. When needed, they placed a grey line suture for optimal apposition of the eyelid-margin wound edges.

None of the eyelids in either the single-layer or the double-layer group suffered from dehiscence. And the researchers found no significant difference in notching, redness, conjunctivitis, trichiasis, symblepharon, or sicca between the groups.



Granulomas formed in four eyelids in the double-layer group and none formed in the single-layer group. While this difference was not statistically significant, researchers speculated the granulomas were more likely to form in the double-layer group because of using sutures that are absorbed rather than removed.

“The longer a wound closure material stays within the tissue, the more likely it is to cause tissue reaction and granuloma formation,” wrote Dr. Verhoekx and her colleagues.

The absorbable suture is intended to provide long-lasting support. But since they found no wound dehiscence in the group treated with the single-layer technique, the researchers argued that this long-lasting support is unnecessary.

They noted in most patients, adequate alignment of the tarsal plate provided optimal eyelid contour and continuous eyelid margin, without the use of a grey line suture.

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Dr. Verhoekx and her colleagues acknowledged that a retrospective study in which the patients were not randomly assigned and different surgeons performed the two procedures, fell short of the ideal study design. A randomised controlled trial would provide more convincing evidence.

They point out, however, that an earlier randomised controlled trial of the two techniques performed in dogs showed no significant difference between the techniques in function or alignment of the eyelids.

“In conclusion, the single-layered technique is a safe and effective method for closure of full-thickness eyelid defects following pentagonal block excision,” they concluded.  

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