Eyelid reconstruction

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CHAPTER 50 Eyelid reconstruction

Anthony G. Tyers

Chapter outline

INTRODUCTION 373
ANATOMY 373
FUNDAMENTAL PRINCIPLES 374

Eyelid lamellae 374
Depth of defects 374
Incisions 375
Sutures 375
Wound closure 375
Skin grafts 375
Skin flaps 376
Posterior lamellar grafts 376
Posterior lamellar flaps 376
Composite flaps 376
GOALS OF SURGERY 376
INDICATIONS FOR SURGERY 376
PREOPERATIVE ASSESSMENT 376
ANESTHESIA 377
OPERATION TECHNIQUES 377

1 Direct closure 377

Technique 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
4 Skin flaps 379

a Advancement flap 379
b O to Z rotation flaps 379
c Upper to lower lid transposition flap 380
d Nasojugal transposition flap 380
e Transposed cheek flap 381
f Glabellar flap 381
g Rhombic flap and bilobed flap 381
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

See Video image

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).

image

Fig. 50.1 Section through the upper eyelid.

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

image

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).

image

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).

image

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

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