|Year : 2021 | Volume
| Issue : 4 | Page : 388-389
Laissez-faire: A blessing in disguise during pandemic
Pratheeba Devi Nivean1, M Nivean1, Mohammed Sayee2
1 Department of Ophthalmology, MN Eye Hospital, Chennai, Tamil Nadu, India
2 Department of Ophthalmology, Arunai Medical College, Tiruvannamalai, Tamil Nadu, India
|Date of Submission||30-Mar-2021|
|Date of Decision||24-Jun-2021|
|Date of Acceptance||28-Jun-2021|
|Date of Web Publication||21-Dec-2021|
Dr. Pratheeba Devi Nivean
MN Eye Hospital, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Laissez-faire is a technique of natural healing of raw wound. It has not become popular or not considered as the first-line treatment in view of the unexpected cosmetic outcomes. However, this technique is being advised regularly for certain lesions where the regular reconstruction techniques are not feasible. We present this case in which the regular reconstruction failed and as a blessing in disguise during the pandemic natural healing happened in a beautiful way.
Keywords: Laissez-faire, lid reconstruction, natural healing
|How to cite this article:|
Nivean PD, Nivean M, Sayee M. Laissez-faire: A blessing in disguise during pandemic. TNOA J Ophthalmic Sci Res 2021;59:388-9
| Introduction|| |
Lid defects posttumor excision are conventionally repaired by lid reconstruction. An alternative to surgery is wound healing by secondary intention and is called laissez-faire. This technique was first described in 1957. However, the fear of unexpected cosmetic and functional outcome has not made this technique very popular. We present a case to illustrate the way we managed a large defect and how the natural healing helped him when the graft underwent necrosis.
| Case Report|| |
A 55-year-old male came to us with complaints of swelling in his left upper lid for 6 months. The swelling was small to start with, and then, it gradually progressed to attain the present size. The lesion also extended to the lateral aspect of the lower lid. On examination, the swelling measured 20 mm × 5 mm in the upper lid and 8 mm × 3 mm in the lower lid [Figure 1]. The lid margin architecture was lost, with loss of lashes over the lesion. Clinically, the findings were strongly suggestive of sebaceous gland carcinoma. There was no regional lymphadenopathy. Based on the clinical findings, the patient was advised excision biopsy with margin clearance under frozen section and lid reconstruction in the same sitting. The patient underwent excision biopsy with 5 mm margin. Margin clearance was obtained, and then, we decided to reconstruct.
|Figure 1: (a) External photograph of the patient in upgaze. (b) External photograph in straight gaze showing the lesion|
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Only one-fourth of the upper lid was left behind while one-fourth of the lower lid was lost after the excision. The lateral canthus was excised. There was loss of anterior and posterior lamella in the lower lid and upper lid. Hence, we planned buccal mucosal graft for posterior lamellae and forehead flap for anterior lamellae.
Buccal mucosa was harvested from the mouth after measuring the amount of graft tissue required. The forehead flap was raised and the anterior lamellae were sutured to the posterior lamellae. The lateral canthus was then formed [Figure 2]. Postoperative period was uneventful with no lagophthalmos and corneal exposure. Lid sutures were removed on the 10th day. During the 1st month follow-up, there were sloughing and graft rejection in the upper and lower lid [Figure 3]. The unhealthy tissue was removed, and the patient was examined again. There were lagophthalmos and exposure keratopathy, so we advised repeat reconstruction. Due to extended pandemic, the patient was lost to follow-up. When we reviewed the patient after 3 months to our surprise by natural healing (laissez-faire), the defect had healed well and the lagophthalmos had reduced with no exposure keratopathy [Figure 4].
|Figure 2: (a) Pictorial depiction of the eye showing bare area after excision biopsy. (b) Posterior lamella reconstruction with mucous membrane graft. (c) Anterior lamella with forehead flap, which is dissected to two near the base and used for both the lids. (d) Lateral canthal formation|
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|Figure 3: (a) External photograph showing graft necrosis. (b) External photograph after removal of slough showing exposure and lagophthalmos|
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|Figure 4: (a) External photograph showing complete closure of the eye due to laissez-faire. (b) External photograph in straight gaze|
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| Discussion|| |
Majority of surgeons allow healing by secondary intention for medial canthal and lesions of nose, but they do not prefer natural healing for lower lid lesions for cosmetic reasons. However, Morton had reported this technique being used for 75% lid loss. He had explained that the result is quite remarkable that this technique can be seriously considered for elderly patients and patients with systemic problems.
The role of secondary intention following excision of periocular skin tumors has been extensively studied by Shankar et al. They reported good results in 92%, and the common complications they encountered were scarring, granulation tissue, ectropion, hypertrophied scar, and prolonged healing time.
The main indications for this approach are for medial canthal lesions, after radiotherapy, unsuitable skin, in patients with precancerous conditions such as xeroderma pigmentosa, patients with poor health, and unfit for general anesthesia.
In our case, after the primary procedure, the graft and flap underwent necrosis, so the slough was removed and we advised secondary procedure as there was exposure of cornea and lower sclera. However, with time and natural healing with granulation tissue, the patient did not require secondary procedure.
| Conclusion|| |
Healing by natural intention should be considered as an alternative to certain lesions.
This technique always has a small risk of secondary surgical intervention if the healing is not adequate. Although it is not advisable for upper lid defects due to chances of exposure keratitis, we can still consider this for smaller upper lid defects.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Morton J. Secondary intention healing in lower eyelid reconstruction—a valuable treatment option. J Plast Reconstr Aesthet Surg 2010;63:1921-5.
Shankar J, Nair RG, Sullivan SC. Management of peri-ocular skin tumours by laissez-faire technique: Analysis of functional and cosmetic results. Eye 2002:16:50-3.
Collin JR. Eye lid reconstruction and tumour management. In: Colin JR, editor. A Manual of Systematic Eye Lid Surgery. Churchill Livingstone: Edinburgh; 1989.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]