Eyelid reconstruction

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CHAPTER 50 Eyelid reconstruction

Anthony G. Tyers

Chapter outline

INTRODUCTION 373

ANATOMY 373

GOALS OF SURGERY 376

INDICATIONS FOR SURGERY 376

PREOPERATIVE ASSESSMENT 376

ANESTHESIA 377

OPERATION TECHNIQUES 377

1 Direct closure 377

Complications 377

2 Direct closure with extra tissue laterally 377

a Lateral cantholysis 377

b Semicircular flap (Tenzel) 378

3 Skin grafts 379

a Full-thickness skin grafts 379

b Split-thickness grafts 379

5 Posterior lamellar grafts 382

a Oral mucosa 382

b Tarsal plate 382

c Other posterior lamellar grafts 382

6 Posterior lamellar flap 382

a Landolt–Hughes tarso-conjunctival flap 382

b Hewes tarso-conjunctival flap 383

7 Combined anterior and posterior flap 383

a Cutler Beard flap 383

8 Canthal support 384

a Fixation to the posterior lacrimal crest 384

b Periosteal flap 384

FURTHER READING 384

Introduction

Techniques of eyelid reconstruction share many basic principles with general plastic surgery. However, specific techniques have evolved to restore the unique anatomy, function, and appearance of the eyelids.

Anatomy

The basic structure of the eyelids is a composite of two layers, or lamellae – an anterior lamella of skin and orbicularis muscle and a posterior lamella of tarsal plate and conjunctiva. The gray line marks the junction of the lamellae at the lid margin (Figs 50.1, 50.2).

Fig. 50.1 Section through the upper eyelid.

From Tyers & Collin. Color Atlas of Ophthalmic Plastic Surgery. 2008, Elsevier, Butterworth-Heinemann.

Fig. 50.2 The canthal tendons.

From Tyers & Collin. Color Atlas of Ophthalmic Plastic Surgery. 2008, Elsevier, Butterworth-Heinemann.

The lids are supported at each end by canthal tendons which are attached to the tarsal plates and the orbicularis muscle. The medial canthal tendon is a complex structure, but its essential feature, for the purposes of eyelid reconstruction, is a firm attachment to the posterior lacrimal crest. The lateral canthal tendon attaches to Whitnall’s tubercle just within the lateral orbital rim (Fig. 50.3).

Fig. 50.3 Section through the lower eyelid.

From Tyers & Collin. Color Atlas of Ophthalmic Plastic Surgery. 2008, Elsevier, Butterworth-Heinemann.

The skin of the eyelids is very thin compared with skin elsewhere in the face and there is very little subcutaneous fat. In the periocular region beyond the eyelids the subcutaneous fat thickens and the lamellar structure of the lids is lost.

Fundamental principles

Eyelid lamellae

Both eyelid lamellae are essential for normal eyelid function. The minimum requirement is a covering lamella of skin and a lining lamella of mucosa. If the defect to be reconstructed involves the full thickness of the lid both lamellae must be reconstructed and at least one of them must have a blood supply or the reconstruction will fail due to ischemia.

Depth of defects

Partial-thickness defects in the eyelids involve the loss of one of the two lamellae. Beyond the eyelids a partial-thickness defect involves the skin and a variable depth of subcutaneous tissue.

Full-thickness defects of the eyelids include both lamellae. Beyond the lids a defect which exposes the underlying facial skeleton is considered full thickness.

Incisions

The ‘relaxed skin tension lines’ (Langer’s lines) mark the preferred direction of skin incisions anywhere on the body surface. In the periocular region they are generally parallel to the lid margins (Fig. 50.4).

Fig. 50.4 Relaxed skin tension lines around the eye.

From Tyers & Collin. Color Atlas of Ophthalmic Plastic Surgery. 2008, Elsevier, Butterworth-Heinemann.

Correctly placed incisions result in good healing with the least scarring.

Sutures

Absorbable and non-absorbable sutures in the range 4-0 to 7-0 are suitable for wound closure in the periocular region. Absorbable sutures are usually preferred for subcutaneous closure, but skin closure may be with absorbable or non-absorbable sutures.

Wound closure

The thin skin of the eyelids may often be closed with skin sutures alone, without separate closure of the subcutaneous layers. Occasionally, closure of the subcutaneous orbicularis muscle layer may be needed if the muscle retracts causing the wound to gape. In thicker skin, with a moderate subcutaneous fat layer, as in the cheek, brow or temple, the deeper layer requires closure before skin closure. This eliminates the deep space and prevents a sunken scar. Skin sutures, especially in thicker skin, should enter and exit the skin at right angles. This results in slightly heaped up wound edges, which further improves the scar.

The pattern of suturing varies. Interrupted sutures are the most common in skin and subcutaneous tissues. Continuous sutures may distort skin closure; a continuous interlocking suture prevents this.

Skin grafts

Grafts do not have a blood supply. A skin graft may be used to fill a partial-thickness defect in the eyelid or periocular region. In a full-thickness defect of the eyelid both lamellae must be reconstructed. As noted above, one lamella must have a blood supply. A skin graft (rather than a skin flap) may be chosen for the anterior lamella if the posterior lamella has been reconstructed with a flap. One lamella must have a blood supply.

The best match of skin graft color and texture in the eyelids is full-thickness upper lid skin. To harvest the graft, mark the upper lid skin crease and excise the required size of graft from the redundant skin superior to the skin crease. Do not excise too much skin – about 23 mm of skin between the brow and the lashes must be preserved to allow comfortable closure of the eye.

If upper lid skin is not available in sufficient quantity to fill the defect, alternatives include full-thickness postauricular or preauricular skin or skin from the supraclavicular fossa. A graft of split skin may be required if the defect is too large for the available full-thickness skin. Split skin is not the first choice in the periocular region – it contracts more than full-thickness skin and its color matches periocular skin less well.

Skin grafts on mobile recipient sites, such as the upper lid, should be fixed with a bolster and tie-over sutures. A temporary central tarsorrhaphy suture between the upper and lower lids adds extra immobility to the lids while the graft is becoming vascularized. The bolster and tarsorrhaphy suture are removed after a week.

Grafts on relatively immobile sites such as the lower lid, or temple can be fixed with simple pressure dressings that are removed at a week.

Skin flaps

Flaps have an intact blood supply. Several designs of skin flap are available in the periocular region. They include advancement, O-to-Z, upper to lower lid, nasojugal, transposed cheek, rhombic, bilobed, and glabellar. Most of these are ‘random pattern flaps’ with no specific, named blood supply. Glabellar flaps and some other, larger, facial flaps not included above are ‘axial pattern flaps’ that have a specific, named arterial and venous blood supply.

The plane of dissection to raise a flap in the face is within the layer of subcutaneous fat, avoiding the underlying muscle. Within the eyelids, which have almost no subcutaneous fat, the plane of dissection is usually just superficial to the orbicularis muscle. However, the muscle layer may be included if a thicker flap is required to fill a deeper defect.

The choice of flap design depends on the site and size of the defect. Whenever possible any tension through the flap should be designed to be transverse – parallel to the lid margins – rather than vertical or at an angle which risks lid margin malposition.

Posterior lamellar grafts

A graft is commonly used to reconstruct the posterior lamella of a full-thickness eyelid defect. There is a wide choice. Autogenous posterior grafts include oral mucosa, tarsal plate from the upper lid, hard palate, and ear cartilage. Non-autogenous posterior grafts include donor sclera (which carries a very small risk of transmitted infection) and alternatives, such as Vicryl mesh. Any posterior graft without a natural mucosal lining must be covered with conjunctiva to protect the cornea.

When a graft is used for the posterior lamellar reconstruction, the anterior lamella must be a skin flap. A skin graft cannot be placed on a posterior lamellar graft – one lamella must have a blood supply.

Posterior lamellar flaps

If a skin graft is to be used for reconstruction of the anterior lamella of a full-thickness eyelid reconstruction, the posterior lamella must be a flap with an intact blood supply. Few are available. The most commonly used is a tarso-conjunctival flap from the upper lid for reconstruction of lower lid defects (see Landolt–Hughes tarso-conjunctival flap below). An alternative for lower lid defects is the Hewes flap, which is an upper tarsal flap based laterally (see below).

Composite flaps

An alternative to the reconstruction of each eyelid lamella separately, is to use a composite flap of both lamellae. An upper lid defect may be reconstructed with a flap of full-thickness lower lid (see Cutler Beard procedure below). A lower lid defect cannot be reconstructed in this way with a full-thickness flap from the upper lid.

Goals of surgery

Eyelid function requires that the lids can open easily for vision and close comfortably for protection. To achieve this, the retractors of the upper lid (the levator and Müller’s muscles) and the protractor of both lids (the orbicularis muscle) must retain adequate function. The posterior lamella, lining the lids, must be smooth and the lids must lie accurately against the globe throughout their length. Lacrimal function, both the production and the drainage of tears, must be preserved whenever possible. Finally, the cosmetic appearance of the reconstructed eyelids should be as near normal as possible. This can be achieved through the choice of the correct procedures.

Indications for surgery

Eyelid reconstruction is most often required following tumor removal or trauma. If possible, reconstruction should follow immediately. Delay due to circumstances, or while awaiting a pathology report on clearance of a tumor, should be kept to a minimum. It should not exceed 4–5 days or early healing will compromise the result.

Occasionally, the functional or cosmetic outcome following reconstruction may be unsatisfactory. If early revision is not mandatory to protect the eye, it is desirable to defer revision for about 6 months to allow the scars to mature.

‘Laissez faire’ – allowing a defect to granulate and heal by secondary intention – is occasionally an option. It can achieve a cosmetic outcome in the inner canthus, especially after radiotherapy. It has also been used in the lids but with less consistent results.

Preoperative assessment

Following tumor excision, record the depth, site, and size of the defect. Is the lid margin involved? Are the canthal tendons and the lacrimal drainage apparatus intact? Assess skin quality and scarring. Tight skin, pre-existing cutaneous scars, or subcutaneous fibrosis may limit the mobility of any proposed skin flaps. Check that the blood supply of tissues involved in the reconstruction has not been compromised by previous surgery or radiotherapy.

Assess the lids following trauma in the same way. Apparent loss of tissue is often not confirmed at surgery. Trauma to the eye, the levator aponeurosis or muscles and nerves of the orbit and to other periocular structures, including the orbital bones, must be excluded.

Anesthesia

Local anesthesia is suitable for most ophthalmic plastic surgical procedures. Children and some adults require general anesthesia. General anesthesia may also be preferable for larger reconstructions in the periocular region because of the volumes of local anesthetic that would be required.

In addition to local anesthetic eye drops such as amethocaine 1% or oxybuprocaine 0.4%, injection of lidocaine 2% with 1 : 200 000 or 1 : 100 000 epinephrine (adrenaline) gives good anesthesia as either a local infiltration or as a regional nerve block. Periocular regional blocks include frontal, infratrochlear, infraorbital, facial, and retrobulbar blocks. Anesthesia lasts for about an hour. The addition of an equal volume of bupivacaine 0.5% prolongs the anesthesia. Warming the anesthetic to body temperature reduces the discomfort of injection.

Mild sedation with benzodiazepines such as oral diazepam or temazepam, or intravenous midazolam, can be helpful in anxious patients.

Operation techniques

1 Direct closure

a Small partial-thickness defects, not involving the eyelid margin, can often be closed directly. A single layer of sutures is usually adequate. Local skin undermining will reduce the tension across the closure. The direction of the wound should be along the relaxed skin tension lines whenever possible. This rule is amended for defects in the lower lid where the closure should be vertical (across the relaxed skin tension lines), rather than horizontal, to avoid downward traction on the lower lid.

b If the lid margin is involved, defects of up to a quarter of the lid length can be closed directly. In the elderly with lax lids, defects of up to one-third of the lid can be closed in this way.

Technique

• To close a lid margin defect, place a 6-0 or 7-0 absorbable suture through the tarsal plate on each side of the defect, just superficial to the conjunctiva, at the posterior lid margin. Tie this then place two or three further sutures to close the tarsal plate (Figs 50.5, 50.6); see also Clip 6.10.

• Place a lid margin suture through the gray line on each side of the defect. This can be tied on the surface of the lid margin (as in Fig. 50.5) or inverted and tied within the tissues on the surface of the tarsal plate a few millimeters from the margin (as in Fig. 50.6; see also the video clip). If the suture is tied on the surface leave it long and secure its end away from the cornea beneath the skin sutures.

• If necessary, place sutures to approximate the orbicularis muscle. Close the skin with interrupted sutures.

Fig. 50.5 Eyelid margin closure with an external gray line knot.

Redrawn from Collin. A Manual of Systematic Eyelid Surgery, 3rd edn. 2006, Elsevier.

Fig. 50.6 Eyelid margin closure with a buried gray line knot.

Redrawn from Collin. A Manual of Systematic Eyelid Surgery, 3rd edn. 2006, Elsevier.

Complications

The lid margin may heal with a small notch. If the notch is large, excise it after 6 months and resuture the defect.

2 Direct closure with extra tissue laterally

a Lateral cantholysis (Fig. 50.7) also included on the video clip

This procedure releases the lower limb of the lateral canthal tendon for lower lid defects. It may also be used in the upper lid. It mobilizes the lateral end of the lid so that up to one-third of the lid length may be closed directly.

Fig. 50.7 Lateral cantholysis.

Redrawn from Collin. A Manual of Systematic Eyelid Surgery, 3rd edn. 2006, Elsevier.

Technique

• Make a small, horizontal canthotomy at the lateral canthus.

• Identify the lower (or upper in an upper lid defect) limb of the lateral canthal tendon. To do this, develop the plane between the tendon and the conjunctiva posteriorly, and the tendon and the orbicularis muscle anteriorly. With the lateral part of the lid pulled medially the tendon is put on stretch and can be easily felt as a tight band in the tissues. Cut the tendon vertically and deepen this cut until the lower lid moves medially freely.

• Close the lid margin defect as described above. A single suture may be needed to close the lateral canthal wound.

Complications

Trauma to the lateral canthal tissues during dissection may result in a shallow depression in the lid margin laterally. If marked, secondary reconstruction with a small local flap may be needed.

b Semicircular flap (Tenzel)

This flap allows a defect in the lid margin of up to half its length to be closed directly. Skin overlying the lateral orbital rim is imported laterally allowing the lateral end of the lower lid to be moved further medially. The flap may be inverted for upper lid defects.

Technique

• Mark the flap from the lateral canthus, sweeping vertically upwards for about 22 mm then laterally for about 18 mm and finally vertically down to the original level (Fig. 50.8).

• Undermine the flap. In this case the dissection is just deep to the orbicularis muscle. Take care not to dissect lateral to the lateral orbital rim to avoid injury to the branches of the facial nerve.

• Identify and cut the lower limb of the lateral tendon to allow the lateral part of the lower lid to move medially.

• Close the lid margin defect as described above.

• Close the flap in two layers with a 6/0 absorbable suture taking care to close the lateral canthal tissues accurately.

Fig. 50.8 Semicircular flap (Tenzel).

Redrawn from Collin. A Manual of Systematic Eyelid Surgery, 3rd edn. 2006, Elsevier.

Complications

If the initial incision does not rise steeply from the lateral canthus a shallow depression will occur in the lateral lid margin.

Dissection too far laterally may risk damage to the branches of the facial nerve.

3 Skin grafts

As noted above, a skin graft may be used to fill a partial-thickness defect, or as the anterior lamella of a full-thickness defect when the posterior lamella has a blood supply.

a Full-thickness skin grafts

Technique

• Measure the size of the defect and cut a paper template. Use this to mark the selected graft donor site as described above.

• Cut the graft and dissect just deep to the dermis. Suture it into the recipient site and fix it as described above.

Complications

Hematoma beneath the graft, or infection, will risk necrosis. Adequate fixation, and an antibiotic if there is any local contamination, will reduce this risk. If the graft appears dark postoperatively, wait for several weeks – more of the graft will survive than seems likely at first.

b Split-thickness grafts

Technique

• A dermatome is the easiest way to cut a satisfactory split skin graft. The inner thigh is the most convenient donor site for most patients. Cut a moderately thin graft and dress the donor site with a non-adherent dressing for about 10 days until healing is well established.

• Fix the graft, with a bolster if necessary, as described above.

Complications

As for full-thickness grafts.

4 Skin flaps

As noted above, skin flaps may be used to cover partial-thickness defects or as the anterior lamella of a full-thickness defect, whether or not the posterior lamella has a blood supply.

a Advancement flap

Small defects can be reconstructed with the simple advancement of local skin. This can be used in the lower lid or cheek. The tension along the flap should be horizontal.

Technique

• Mark gradually diverging lines laterally from the superior and inferior edges of the defect. Undermine the flap and the adjacent skin within the subcutaneous fat layer. During the dissection, take care to avoid cutting any larger blood vessels supplying the flap (Fig. 50.9); also on the video clips).

• Advance the flap into the defect and close in two layers. If used to reconstruct a full thickness defect, usually in the lower lid, this flap must be lined with a posterior lamella, usually a graft (see above).

Fig. 50.9 Advancement flap.

Redrawn from Collin. A Manual of Systematic Eyelid Surgery, 3rd edn. 2006, Elsevier.

Complications

Necrosis of the flap is uncommon. Do not excise apparently ischemic skin – more survives than appears likely at the first dressing.

b O to Z rotation flaps

This useful technique for small, partial-thickness, circular defects creates two small flaps adjacent to the defect. The flaps are rotated in to meet in the center of the defect. The tension across the flaps is horizontal.

Technique

• Mark a gently curving line horizontally from the superior edge of the defect and approximately equal in length to the diameter of the defect. Mark a similar line horizontally from the inferior edge of the defect, but in the opposite direction (Fig. 50.10).

• Undermine the approximately triangular flaps created by the two lines. Undermine the adjacent skin.

• Rotate the flaps into the center of the defect and close in two layers.

Fig. 50.10 O to Z rotation flaps.

Redrawn from Collin. A Manual of Systematic Eyelid Surgery, 3rd edn. 2006, Elsevier.

Complications

Early local distortion of the skin adjacent to the reconstruction usually resolves during healing.

c Upper to lower lid transposition flap

The pedicle of this flap may be based laterally or, less commonly, medially, close to the canthus. It can be used for partial-thickness cheek or lid defects, or for the anterior lamella of full-thickness lid defects when it must be lined with a posterior lamella, usually a graft (see above). The defect should extend to the lateral end of the lower lid so that the flap can be rotated into it without bridging normal tissue.

Technique

• Mark the upper lid skin crease. This will be the inferior border of the flap. Measure the width of the defect and mark a second line this distance above the first line as the superior border of the flap (Fig. 50.11). Remember to leave 23 mm of skin in the upper lid between the brow and the lashes to allow comfortable eye closure.

• Extend the lower (skin crease) line laterally and downwards to the upper border of the defect. Extend the upper line, parallel to the first but slightly diverging laterally, to a point approximately level horizontally with the lateral canthus. Measure the length of flap required to fill the defect and converge the two lines medially in the upper lid to mark a flap of appropriate length.

• Raise the skin flap; orbicularis muscle may be included along the flap to the pedicle to improve the blood supply, which must be preserved.

• Close the upper lid and suture the flap into the lower lid defect in a single layer.

Fig. 50.11 Upper to lower lid transposition flap.

Redrawn from Collin. A Manual of Systematic Eyelid Surgery, 3rd edn. 2006, Elsevier.

Complications

As for advancement flap.

d Nasojugal transposition flap

This flap is useful for medial lower lid defects that do not extend medially onto the side of the nose. There must be space medial to the defect for the pedicle to remain in the plane of the lower lid.

Technique

• Mark a vertical line into the cheek from the medial edge of the defect. Assess the width of the defect and mark a second line medial to the first and parallel to it. Measure the length of the defect, remembering that it will be slightly shortened by closure of the defect created by raising the flap (Fig. 50.12).

• Raise the flap in the subcutaneous fat layer. Undermine the skin edges either side of the donor site and close it in two layers.

• Transpose the flap into the defect and suture it in two layers to complete the reconstruction. If this flap is used for the anterior lamella of a full-thickness lower lid reconstruction it must be lined with a posterior lamella, usually a graft (see above).

Fig. 50.12 Nasojugal transposition flap.

Redrawn from Collin. A Manual of Systematic Eyelid Surgery, 3rd edn. 2006, Elsevier.

Complications

The flap can be rather bulky. If excessive, it can be thinned at a later date when it is healed.

If the pedicle of the flap is placed too far medially, rising up the side of the nose and not in the plane of the lower lid, the reconstructed lid will be pulled away from the globe.

Otherwise as for advancement flap.

e Transposed cheek flap

This flap may be used to reconstruct lateral defects in the lower lid, up to its full length. It must be lined with a posterior lamellar graft, usually of oral mucosa.

Technique

• Mark a vertical line in the cheek from the lateral edge of the defect and equal in length to the defect. Assess the width of flap required to reconstruct the defect and mark a second line lateral to the first and parallel to it. The pedicle of the flap must be in line with the lower lid (Fig. 50.13).

• Mobilize the flap in the subcutaneous fat layer and undermine the edges of the adjacent skin.

• Close the vertical cheek donor site in two layers.

• Transpose the flap into the lower lid defect, having placed a posterior lamellar graft. Suture it in two layers, plus a single layer, if required, at the lid margin.

Fig. 50.13 Transposed cheek flap.

Redrawn from Collin. A Manual of Systematic Eyelid Surgery. 3rd edn. 2006, Elsevier.

Complications

This flap may be quite bulky. It can be thinned later if necessary.

f Glabellar flap

Inner canthal defects inferior to the medial canthal tendon are reconstructed with a full-thickness skin graft. Defects superior to the tendon may be reconstructed with a glabellar flap. Alternatives are the rhombic flap or the bilobed flap.

Technique

• Mark a line from the lateral edge of the defect to a point in the midline of the forehead 1–2 cm above the brows – the higher this point, the larger the flap.

• Mark a second line from this point to the medial end of the opposite brow (Fig. 50.14).

• Undermine the flap in the subcutaneous fat layer and transpose it into the defect. Trim the tip of the flap to ensure a good fit. Secure the flap in two layers. Place a deep suture between the flap and the periosteum of the anterior lacrimal crest to create a normal profile of the skin at the inner canthus.

• Undermine the forehead skin adjacent to the donor site. Close the forehead in two layers.

Fig. 50.14 Glabellar flap.

Redrawn from Collin. A Manual of Systematic Eyelid Surgery, 3rd edn. 2006, Elsevier.

Complications

The small fold at the base of the flap on the bridge of the nose will settle over several weeks. It can be revised later if necessary.

g Rhombic flap and bilobed flap

These flaps are used for small to medium sized defects in the inner canthus or temple. They can also be used elsewhere. The detailed design of these flaps is important (see Further reading).

5 Posterior lamellar grafts

Since they have no blood supply, posterior lamellar grafts must be covered with a skin flap, not a graft.

a Oral mucosa

Oral mucosa is used not only for reconstruction of the posterior lid lamella but also in socket reconstruction. See Chapter 56 for operative details.

b Tarsal plate

Grafts of superior tarsal plate may be used for reconstructing limited areas of the posterior lamella.

Technique

• Evert the upper lid over a Desmarres retractor and mark a line on the tarsal mucosa 4 mm from, and parallel to, the lid margin (see the upper lid in Fig. 50.15). Incise this line for the width of the defect then, from each end, cut vertically up to the superior tarsal border to create a flap of tarsoconjunctiva.

• Incise across the conjunctiva and Muller’s muscle just superior to the tarsus to release the graft. Suture it into the defect in a single layer being careful to leave no suture exposed posteriorly that could abrade the cornea.

• The posterior defect in the upper lid does not need to be closed.

Fig. 50.15 Landolt–Hughes tarso-conjunctival flap marked in upper lid.

Redrawn from Collin. A Manual of Systematic Eyelid Surgery, 3rd edn. 2006, Elsevier.

Complications

If less than 4 mm of marginal tarsal plate has been preserved, distortion of the upper lid margin may occur as the lid heals.

c Other posterior lamellar grafts

Alternative grafts are used less frequently for posterior lamellar reconstruction. See References for details of the surgical techniques.

6 Posterior lamellar flap

a Landolt–Hughes tarso-conjunctival flap

This posterior flap has a blood supply; the anterior lamella can therefore be reconstructed with a skin graft. Alternatively, a skin flap may be used if preferred.

Technique

• Create a flap of tarso-conjunctiva as described above for a tarsal plate graft but do not divide the pedicle of the conjunctiva and Muller’s muscle (see Fig. 50.15).

• Dissect between the tarsal plate and the underlying levator aponeurosis and turn the flap down into the defect, leaving the bridge of the conjunctiva and Müller’s muscle intact (Fig. 50.16).

• Suture it into the defect in one layer, being careful to leave no suture exposed posteriorly that could abrade the cornea. Reconstruct the anterior lamella with a skin graft or flap.

• The posterior defect in the upper lid does not need to be closed.

• 4–6 weeks later divide the bridge. The lid margin tissues do not usually need to be sutured.

• Following division of the bridge the upper lid may retract. This can be minimized by dissection between Muller’s muscle and the levator aponeurosis at the origin of the bridge in the upper lid; this reduces upward traction on the lid.

Fig. 50.16 Landolt–Hughes tarso-conjunctival flap sutured into lower lid defect.

Redrawn from Collin. A Manual of Systematic Eyelid Surgery, 3rd edn. 2006, Elsevier.

Complications

As for tarsal grafts.

Inadequate dissection to reduce upward traction may lead to upper lid retraction after the division of the bridge.

b Hewes tarso-conjunctival flap

This posterior lamellar flap has a pedicle based laterally, unlike the Hughes flap in which the pedicle is based superiorly. It also provides support for the lid laterally.

Technique

• Evert the upper lid. Measure 4 mm vertically from the lateral end of the superior tarsal border and extend this marking medially equal to the horizontal extent of the defect (Fig. 50.17).

• Cut the flap of full-thickness tarsus to include the superior tarsal border, leaving the pedicle attached laterally (to the lateral canthal tendon). Turn it down into the defect. Since it has a moderate blood supply it can be covered with either a skin graft or a skin flap.

Fig. 50.17 Hewes tarso-conjunctival flap.

Redrawn from Collin. A Manual of Systematic Eyelid Surgery, 3rd edn. 2006, Elsevier.

Complications

A web of tarsus may be visible at the lateral canthus. This can be divided, if necessary, when the reconstructed lid is healed.

7 Combined anterior and posterior flap

a Cutler Beard flap

This full-thickness flap of the lower lid, which does not include the lid margin, is used to reconstruct larger central defects in the upper lid.

Technique

• Measure the width of the upper lid defect and mark a line of this length 5 mm below the lower lid margin.

• Mark two further lines vertically inferiorly as far as the fornices (Fig. 50.18).

• Incise through the whole lid along these lines to create a full-thickness flap based inferiorly. The lower lid margin is preserved intact.

• Passing posterior to the lower lid margin, suture the flap into the upper lid defect in three layers: conjunctiva, levator aponeurosis, and skin (Fig. 50.19).

• After 4–6 weeks divide the pedicle at the level of the upper lid margin and restore the remaining flap into the lower lid, suturing it in two layers.

Fig. 50.18 Cutler Beard flap marked.

Redrawn from Collin. A Manual of Systematic Eyelid Surgery, 3rd edn. 2006, Elsevier.

Fig. 50.19 Cutler Beard flap advanced into upper lid defect.

Redrawn from Collin. A Manual of Systematic Eyelid Surgery, 3rd edn. 2006, Elsevier.

Complications

Fine skin hairs at the reconstructed upper lid margin may abrade the cornea. These can be removed with cryotherapy, or the lid margin can be supported with a secondary graft inserted between the layers of the upper lid. Ear cartilage and donor sclera are suitable.

8 Canthal support

If either of the canthal tendons has been removed the loss of lid support must be restored, especially for the lower lid, during reconstruction. Medially, the posterior lamella should be sutured to the periosteum overlying the posterior lacrimal crest. Laterally the attachment is to the periosteum around Whitnall’s tubercle or to a periosteal flap based within the orbital rim.

If the periosteum has been removed, alternatives medially include a miniplate secured to the bone or a transnasal wire. Laterally, holes drilled through the lateral orbital rim provide an anchor for supporting sutures.

a Fixation to the posterior lacrimal crest

Technique

• Place lacrimal probes in the canaliculi. Dissect posteriorly and medially, posterior to the caruncle and plica, to reach the lateral aspect of the lacrimal sac. The posterior lacrimal crest can be felt with the tip of the scissors as a ridge just posterior to the sac.

• Insert fine, round bodied needles on a 5-0 non-absorbable suture through the slightly thickened periosteum overlying the crest. The anchor should feel strong before inserting the needles into the medial tissues of the reconstructed posterior lamella.

b Periosteal flap

Technique

• Centered on the mid point of the lateral orbital rim, cut a flap of periosteum, 8–10 mm in vertical dimension and with its pedicle based just within the lateral rim. Extend the upper and lower cuts laterally just into the deep temporal fascia and join them to create the flap.

• Raise the flap with a periosteal elevator and suture it, in a single layer, to the lateral end of the posterior lamellar graft or flap.

Further reading

Borges AF. Relaxed skin tension lines versus other skin lines. Plast Reconstr Surg. 1984;73:144.

Codner MA, McCord CD, Mejia JD, et al. Upper and lower eyelid reconstruction. Plast Reconstr Surg. 2010;126:231e-245e.

Collin JRO. A Manual of Systematic Eyelid Surgery, 3rd edn. Edinburgh: Elsevier; 2005.

Lemke BN, Della Rocca RC. Surgery of the eyelids and orbit, an anatomical approach. Norwalk, CN: Appleton & Lange; 1990.

Levine MR, editor. Manual of Oculoplastic Surgery, 4th edn, NJ, USA: Slack Incorporated, 2010.

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