Robert G. Fante and Michael John Hawes

Introduction

During the past two centuries, hundreds of surgical procedures have been described for the purpose of eyelid reconstruction, perhaps because of the great value attached to the eyes and vision by our culture. The list of eponymous flaps and techniques is daunting for any student in this field, but rather than overwhelm the reader with their diversity, the goal of this chapter is to present a small number of reliably effective techniques that will address the majority of common clinical situations likely to be encountered. Given the wide audience for this book, this chapter concentrates on those procedures found to be most reproducibly useful among surgeons of different disciplines. Mastery of the concepts and surgical methods herein will also serve as a solid foundation for additional study of advanced procedures that may be best suited for unusual cases.

Physiology of the Ocular Anterior Segment

The mobile nature of the eyelids in ordinary use of the eyes, together with the importance of their supportive role in maintaining the air-tear interface at the cornea for crisp vision and their central role in conveying facial beauty and expression, creates substantial challenges for the reconstructive surgeon. Detailed understanding of the anatomy of the eyelids and ocular adnexa will aid the surgeon in selecting reconstructive approaches that will best restore ocular function while optimizing aesthetic outcome.

The normal adult eyelids frame an elliptical palpebral fissure measuring 8- to 11-mm vertically at the pupillary meridian by 30- to 33-mm horizontally. Inside the fissure, the ocular anterior segment composed primarily of conjunctiva, cornea, and iris is visible. The lower eyelid has a smoothly elliptical contour, but the upper eyelid contour is characterized by a tighter medial curvature culminating in an apogee at the medial border of the pupil. The palpebral fissure most commonly slopes upward from medial to lateral so that the lateral canthus is 2-mm higher than the medial canthus. Phenotypic variations exist, and senescence typically causes inferior dystopia of the lateral canthus; the position of the medial canthus is stable throughout adulthood. Minor aberrations in the size of the palpebral fissures, the contour of the eyelids, and the relative positions of the canthi dramatically affect the appearance of the eyes to an onlooker, and asymmetry is immediately apparent.

The upper and lower eyelids rest snugly on the ocular surface in all locations except medially, where the caruncle, composed of sebaceous glands, is interposed and partly covered. Conjunctiva on the surface of the globe is continuous with the conjunctiva lining the inner surface of the eyelids by means of a redundant fornix, most prominently superiorly and inferiorly, where it is supported by attachments to the eyelid retractor muscles and associated fascia. These relationships must be maintained or restored during reconstruction to preserve blink efficiency for corneal wetting and normal tear flow.

Tears are composed of three layers: an outer lipid layer from the meibomian glands in each eyelid; a middle aqueous layer from the main and accessory lacrimal glands located in the superolateral orbit and conjunctival fornices, respectively; and an inner mucin layer from goblet cells in the conjunctiva. Basal tear production is measured by Schirmer paper strips and topical anesthetic. Inadequate production is commonly augmented with artificial tears in older adults. Tear drainage occurs through the lacrimal outflow system in each medial canthus, and purposeful occlusion of outflow with silicone plugs in the lacrimal puncta is also useful to improve the tear film in patients with dry eyes. Minor ocular irritation related to eyelid malpositions after reconstruction can often be improved with these strategies for tear film enhancement.

Excessive tearing or epiphora can be a common problem after eyelid reconstruction, resulting in blurred reading vision and patient annoyance. A balance between tear production and outflow is normally regulated by reflex response to corneal sensation through a complex neural arc involving cranial nerves V and VII. Primary excess tear production is rare, but reflex overproduction in response to corneal irritation (known as exposure keratopathy) from eyelid malposition is common. Treatment is aimed at resolving the exposure by improving eyelid position and movement or by augmenting the tear film as discussed before. Prolonged exposure keratopathy results in corneal scarring or infection with loss of vision.

Interruption of tear drainage from damage to the lacrimal outflow system is common after eyelid reconstruction. The lacrimal puncta are normally in contact with the ocular surface and eversion or ectropion may occur, especially with lower eyelid reconstruction. The lacrimal canaliculi connect the puncta with the lacrimal sac, located posterior to the palpable anterior limb of the medial canthal tendon. The upper and lower canaliculi are encased in fibers of the orbicularis oculi muscle, which insert onto the lateral wall of the lacrimal sac. Contraction of the orbicularis oculi during blinking pumps the tears into the lacrimal sac. From there, the tears drain to the inferior nasal meatus via the nasolacrimal duct through the maxilla. Surgery in the region of the medial canthus frequently results in epiphora caused by injury to the canaliculi, the lacrimal sac, or the orbicularis oculi fibers that form the lacrimal pump. Primary repair of the canaliculi is obligatory when trauma or tumor excision results in their interruption.

Surgical Anatomy of the Eyelids

With a clearer understanding of the physiologic role of the eyelids in maintaining vision from the foregoing, more detailed review of eyelid anatomy is necessary to grasp the methodology of surgical eyelid reconstruction. Vertically, the palpebral fissure measures 8- to 12-mm, such that the upper eyelid rests 3- to 4-mm above the center of the pupil and the lower eyelid rests at the inferior limbus. The peak of the upper eyelid contour is medial to the pupil, whereas the lowest point of the lower eyelid contour is lateral to the pupil. Measurement of eyelid position is accomplished with the patient looking in primary gaze (straight ahead) and should be documented preoperatively and postoperatively. The upper eyelid crease is 6- to 12-mm above the eyelashes in blacks and whites (0-6-mm above the eyelashes in Asians) and is formed by the cutaneous insertion of the aponeurosis of the levator palpebrae superioris muscle. The lower eyelid crease is inconsistently present at approximately 3- to 5-mm below the eyelid margin. Additional useful measurements include the range of upper eyelid excursion, typically 10- to 15-mm, obtained by measuring movement of the upper eyelid margin from extreme downward gaze to extreme upward gaze, with the eyebrow fixed with digital pressure from the examiner. The presence and degree of failure of eyelid closure or lagophthalmos is also routinely measured, with notation if gentle or forced contraction of the orbicularis oculi is necessary for eyelid competence.

The multilaminar structure of the eyelids varies according to distance from the palpebral fissure. For the upper eyelid below the lid crease, the layers include the epidermal skin with minimal dermis, orbicularis oculi muscle, levator aponeurosis, tarsus, and conjunctiva. Above the lid crease, the layers include skin, orbicularis oculi, orbital septum, orbital fat, levator aponeurosis, Müller’s muscle, and conjunctiva (Fig. 17-1).

The lower eyelid has similar structures, except that the retractor (analogous to the levator muscle) is the capsulopalpebral fascia. This fascia is an extension of the inferior rectus muscle sheath that inserts at the inferior border of the lower eyelid tarsus and causes passive downward movement of the lower eyelid in downward gaze. A sympathetically innervated inferior tarsal muscle analogous to Müller’s muscle is also present in most individuals (Fig. 17-2).

The eyelid protractor is the orbicularis oculi muscle, concentrically arranged around the palpebral fissure. It is commonly divided into three sections. The pretarsal segment overlies the tarsal plates and attaches to the posterior lacrimal crest, deep to the lacrimal sac, together with the posterior limb of the medial canthal tendon. The gray line of the eyelid margin is formed by the innermost fibers of the pretarsal orbicularis. The preseptal segment overlies the orbital septum and attaches to the lacrimal sac itself and also to the anterior limb of the medial canthal tendon. Laterally, the pretarsal orbicularis contributes to the lateral canthal tendon, together with tendinous fibers from the tarsal plates. The pretarsal and preseptal orbicularis fibers together form the lateral canthal raphe. Finally, the orbital outermost segment of the orbicularis overlies the orbital rim and interdigitates with the frontalis muscle superiorly and the superficial musculoaponeurotic system inferiorly. Superiorly, there is a sub-brow fat pad between the orbital orbicularis muscle and the frontal periosteum of the superolateral orbital rim. Inferiorly, an analogous fat pad, the suborbicularis oculi fat, is between the orbital orbicularis and the maxillary periosteum.

The lateral canthal tendon anchors the tarsal plates posteriorly and superolaterally to Whitnall’s tubercle inside the orbital rim. The lateral eyelids are thus kept snugly against the globe in all positions of gaze. Medially, the medial canthal tendon is the centerpiece of medial canthal anatomy. The medial canthal tendon has an elastic lateral portion that supports the lacrimal canaliculi and then splits into anterior, superior, and posterior limbs, all of which blend with the lacrimal sac fascia.¹ The thick anterior limb inserts on the maxillary bone, and the superficial preseptal orbicularis muscle fibers insert on the anterior limb (Fig. 17-3). The superior branch extends to the lacrimal sac apex and covers the anterosuperior portion of the lacrimal sac.² The thin posterior limb forms the anterior fascia of the pretarsal orbicularis muscle and inserts on the posterior lacrimal crest formed by the lacrimal bone. It acts as a horizontal supporting band that posteriorly directs forces generated by the pretarsal muscle fibers. The lateral portion of the medial canthal tendon invests the fragile lacrimal canaliculi. Reconstruction at either canthus must re-create the deep attachments of the canthal tendons inside the orbit to avoid symptomatic eyelid malpositions.

Posterior to the orbicularis oculi muscle is the orbital septum, a multilayer fascia separating the superficial eyelid and skin adnexa from the orbit. It extends from the arcus marginalis of the orbital rim to the levator aponeurosis and capsulopalpebral fascia before their insertion on the tarsal plates. It is nondistensible and avascular, making it an excellent surgical landmark.

The tarsal plates are composed of dense connective tissue and house the meibomian glands that produce oil for the tears. The upper eyelid tarsus is 10- to 12-mm in height and tapers medially and laterally. It is 16- to 20-mm in length and approximately 1-mm thick. The lower eyelid tarsus is 4- to 5-mm in height but similar in length and thickness to the upper tarsus. Both are anchored medially and laterally to the orbital rim by the canthal tendons, as described before. The posterior surface in each case is lined with densely adherent conjunctiva.

In the upper eyelid, the levator muscle originates posteriorly in the orbit and is redirected by Whitnall’s ligament to insert on the anterior surface of the tarsus as a broad aponeurosis. Whitnall’s ligament runs horizontally from the trochlea to Whitnall’s tubercle and acts as a pulley for the levator. The levator muscle and aponeurosis are invested loosely by orbital fat anteriorly until the aponeurosis fuses with the orbital septum at or above its insertion at the tarsus. It is innervated by the oculomotor nerve (cranial nerve III).

The sympathetically innervated Müller’s muscle arises from the posterior surface of the levator at the junction of the muscle and aponeurosis and inserts onto the superior border of the tarsus. The insertion is associated with a rich vascular plexus. Loosely adherent conjunctiva lines the posterior surface of Müller’s muscle. Suspensory ligaments from the levator support the superior conjunctival fornix.

In the lower eyelid, the capsulopalpebral fascia arises from the inferior rectus, splits to envelope the inferior oblique muscle, and then inserts at the anterior inferior border of the tarsal plate. It has few attachments to the skin and so the lower lid crease is poorly formed. The capsulopalpebral fascia is loosely attached to the inferior forniceal conjunctiva posteriorly and the orbital fat anteriorly. The sympathetically innervated inferior tarsal muscle arises from the posterior surface of the capsulopalpebral fascia and inserts at the inferior tarsal border. Whereas loss of the normal attachments of the levator and Müller’s muscle to the upper lid tarsus causes ptosis, loss of the attachments of the capsulopalpebral fascia and inferior tarsal muscle to the lower lid tarsus commonly causes rotational instability of the lower eyelid and entropion.

The vascular supply to the region comes from the internal and external carotid systems. Branches from the ophthalmic artery in the posterior orbit pass forward as the anterior ciliary arteries and contribute to the superior and inferior tarsal arcades in the eyelids (Fig. 17-4). Branches from the facial artery supply the medial and lateral canthus and also contribute to the eyelid vascular arcades. Risk of eyelid vascular compromise exists if the arteries are interrupted both medially and laterally.

For the purposes of eyelid reconstruction, the anatomic layers can be divided into anterior and posterior lamellae. The anterior lamella is composed of the skin and eyelid protractor, the orbicularis muscle; the posterior lamella is composed of the conjunctiva, tarsus, and eyelid retractors. The orbital septum can be considered a middle lamella and is not typically reconstructed; however, prevention of contracture and tension in the orbital septum can avoid severe compromise to eyelid excursion postoperatively.

Anesthesia

Topical tetracaine 1% or proparacaine 0.5% eye drops are used to anesthetize the ocular surface and are repeated as needed for patient comfort. Frequent lubrication of the cornea with ophthalmic petrolatum ointment or hydroxypropyl cellulose eye drops will also improve patient comfort during and after surgery.

Local anesthesia with monitored sedation is usually preferred, although reconstruction of the lacrimal drainage system or very large defects may require general anesthesia. Lidocaine 1% with 1 : 100,000 concentration of epinephrine is mixed 1 : 1 with bupivacaine 0.75% for most cases. The addition of 150 units of hyaluronidase per 10 mL of local anesthetic greatly facilitates more rapid distribution and also enhances regional vasoconstriction from epinephrine. A 27- or 30-gauge needle is preferred for superficial infiltration, and injection technique should steer clear of subcutaneous vessels and the orbicularis muscle to avoid ecchymosis. Injection of small aliquots deeply inside the lateral orbital rim is helpful for lateral canthal tendon reconstruction, and subconjunctival infiltration with 1 to 2 mL is also generally useful in full-thickness eyelid reconstruction. An infratrochlear block may be used for surgery in the medial canthus, and cocaine 4% topically is expedient for intranasal anesthesia needed for passage of lacrimal stents.

Reconstructive Objectives

The primary objective of eyelid reconstruction is to reestablish functional eyelids that protect the eye and permit normal vision. Normal tear film maintenance necessary for corneal clarity and patient comfort is a corollary prerequisite. The most important secondary goal is normal or improved appearance because the periocular region is critical in interpersonal relations. Loss of eyelid tissue is caused most commonly by surgical excision of neoplasms but also by burns, trauma, necrotic infections, congenital colobomas, and medical interventions (such as steroid injections, cryotherapy, and irradiation). Surgical objectives include the following:

The single most useful reconstructive strategy to achieve most of these objectives is conversion of vertical surgical tension to horizontal tension in the eyelids whenever possible.

Surgical planning is facilitated by conceptually dividing the eyelids into anterior and posterior lamellae. The anterior lamella is composed of the skin and the orbicularis muscle; the posterior lamella is composed of the conjunctiva, tarsus, and eyelid retractors. For full-thickness defects, both lamellae usually require reconstruction. In these cases, at least one of the reconstructed lamellae typically must include a blood supply. Commonly used, reliable surgical techniques are listed in Tables 17-1 and 17-2 and involve various flaps and grafts. Selection will depend on the size, location, depth, and configuration of the defect. Some superficial defects may require only reconstruction of the anterior lamella, and choice of flap or graft is primarily dependent on the need to restore a mobile, cosmetically satisfactory eyelid or to restore normal canthal position. When necessary, reconstruction of the lacrimal tear drainage system is accomplished concomitantly.

Relaxed Skin Tension Lines

Relaxed skin tension lines (RSTLs) are a generally useful guide for the reconstructive surgeon in the attempt to minimize cutaneous scars.³ Around the eyes, these lines follow the lines of facial expression (Fig. 17-5) and are oriented horizontally in the upper and lower eyelid skin. Unfortunately, vertical tension created by closure of elliptical defects oriented along RSTLs in the eyelids has a substantial risk of creating iatrogenic cicatricial eyelid malpositions, including retraction and ectropion. Asymptomatic laxity in the medial and lateral canthal tendons, commonly present in the elderly, will permit downward migration of the lower lids. Similarly, ineffective senescent or neuropathic orbicularis muscle tone will predispose patients to lower eyelid ectropion or upper eyelid retraction and lagophthalmos. For these reasons, horizontal tension is usually preferred for closure of eyelid wounds, and the long axis of any ellipse will be perpendicular to the eyelid margin (Fig. 17-6). Excessive dermatochalasis in the upper eyelid that would otherwise require blepharoplasty may permit the use of horizontally oriented ellipses in the lid crease for some individuals. Conversely, for the glabella, medial canthus, eyebrows, and lateral canthus, use of RSTLs for wound orientation will produce satisfactory outcomes (see Fig. 17-6).

Local Skin Flaps for Superficial Defects

The simple ellipse is often used for excision of small facial lesions, including those in the periocular area. Whereas the long axis of such an ellipse is usually oriented parallel to RSTLs, ellipses are oriented perpendicular to RSTLs in the eyelids to minimize vertical tension and the risk of cicatricial ectropion. Because the ellipse sacrifices up to 160% of the surface area of the excised lesion of interest, modified ellipses such as the double S ellipse and O-Z plasty can be used to conserve normal tissue (Fig. 17-7).

Local skin flaps are preferred to free skin grafts for reconstruction of anterior lamellar defects in the periocular region for many reasons.⁴ Adjacent skin usually provides a better texture and color match than with grafts from distant sites, and flaps undergo substantially less contraction during healing. In addition, the rich vascular supply in the region permits the use of flaps that would be more tenuous in other parts of the body. Furthermore, the ample vascular supply of local flaps can be used to support free grafts for posterior lamellar reconstruction. Prior irradiation or multiple prior surgeries may reduce local circulation.

Rhomboid transposition flaps are the most useful adjacent skin flap in the periocular area, especially for medial⁵ and lateral canthal defects. The principles of design can be found in Chapter 11 of this text. Specific to this region is the need to avoid distortion of the eyebrow, eyelid crease, eyelid margin, and canthal angles. Common flap designs are shown in Figure 17-8. The vector of maximal wound closure tension must be parallel to the lid margin in the lower lid and most commonly in the upper lid as well. Maximal tension may be vertical in the lateral and medial canthal regions, provided the canthal position is not changed.

Other advancement and transposition flaps can be used to repair certain anterior lamellar defects (Figs. 17-9 to 17-12). Among those commonly used are the standard unipedicle and bipedicle rectangle-shaped advancement flaps and V-Y and Y-V advancement flaps. The unipedicle rectangular advancement flap is well suited to the region and can be used to close defects up to 25 cm². Cutaneous defects of the eyebrow or the anterior lamella of the medial upper and lower eyelids can be repaired with this flap. The resulting scars fall into or parallel to the lid creases and avoid injury to the lid margin. V-Y advancement flaps can be used to lengthen the palpebral fissure or to close donor sites.⁶ Y-V advancement flaps are useful in the management of epicanthal folds⁷ and scar contractures.

Healing by second intention is generally not an accepted strategy for eyelid wounds because the incidence of cicatricial ectropion is substantial. However, in the medial canthus, healing by second intention (or laissez-faire) is more often successful,8,9 especially if the defect is 1 cm or less in diameter and centered between the upper and lower eyelids.

During surgery to reconstruct superficial lower eyelid defects, if significant lower eyelid retraction or ectropion occurs, it is advisable to perform concomitant lateral canthoplasty to avoid postoperative eyelid malposition. Many canthoplasty methods have been described; however, simple horizontal tightening of the lateral canthal tendon with the lateral tarsal strip procedure¹⁰ is reliable and should be mastered by reconstructive surgeons working in this area.

Primary Closure of Full-Thickness Defects

Excision of eyelid scars and neoplasia as well as repair of colobomas frequently requires reconstruction of a full-thickness defect. In the simplest case, horizontal laxity of the eyelid and canthal tendons will permit direct closure under reasonable tension. This is usually possible with defects that involve 33% or less of the horizontal length of the eyelid, although some authors find it useful in up to 50% of the horizontal length.¹¹ A few additional millimeters can be gained with concomitant lateral canthotomy, although this may result in inferior displacement of the reconstructed lower eyelid. The advantage of primary wound closure is preservation of the eyelid margin and lashes in a single-stage procedure. As with repair of other multilaminar structures, the primary strategy is to restore tissue integrity by matching corresponding layers. Creation of (or conversion to) a pentagonal defect greatly eases this repair by eliminating standing cutaneous deformities. Establishing clean tarsal edges perpendicular to the lid margin ensures re-creation of reasonably normal eyelid contour without notching or misalignment.

Meticulous surgical technique is necessary and may require the use of loupes or an operating microscope. Avoidance of injury to the cornea is also obviously important and is eased with use of a corneal shield and topical anesthetic. Small Guthrie double hooks or Castroviejo 0.5-mm forceps can be used intraoperatively to assess the suitability of direct closure for a particular defect. If necessary, cantholysis is performed by first making a small lateral canthotomy incision with scissors or protected electrosurgical tip (e.g., Colorado needle) and next cutting the involved crus of the lateral canthal tendon. If medial tension is maintained on the eyelid segment, immediate release will be palpated and visually observed once cantholysis is complete. The canthotomy incision is typically left unclosed.

The first suture must establish perfect vertical alignment of the eyelid margin and should be replaced unless it is ideal. It is placed to approximate the tarsal edges just peripheral to the eyelid margin, at 90% depth, using a trapezoidal passage that places the knot farther from the margin than the deep suture pass (Fig. 17-13). A 5-0 or 6-0 polyglactin suture on an S-14 spatula needle is preferred, although Monocryl and polydioxanone sutures may also be used. Chromic and plain gut sutures dissolve too quickly to be useful for this deep closure. After the initial suture placement, additional interrupted sutures are placed to completely approximate the tarsus. The eyelid retractors (levator aponeurosis or capsulopalpebral fascia) are repaired similarly, avoiding full-thickness suture passage that will later abrade the cornea.

Once perfect vertical alignment has been established, anteroposterior alignment of lid margin structures must also be restored. Eversion of the eyelid margin wound is necessary to avoid notching and is accomplished during this phase of tarsal repair. The most consistently successful technique is to place a vertical mattress suture at the gray line, tied to create significant eversion. A 4-0 silk suture on a G-1 or G-3 needle is well suited to this application, and once tied, the ends are left long and incorporated into the skin closure to avoid corneal irritation (Figs. 17-13 and 17-14). Alternatively, 6-0 silk interrupted sutures can be placed at the gray line and the lash line to create wound eversion.

Repair of the orbicularis oculi is next performed with buried interrupted 6-0 polyglactin sutures. More horizontal wound tension is often appreciated with closure of this layer than with any other. Meticulous approximation here will result in a tension-free skin closure and the best possible scar.

Final closure of the skin will typically result in a vertical scar. Suture approximation can be accomplished with any 6-0 material; pleasing results have been obtained with nylon, polypropylene, silk, and even polyglactin. Arrowhead flap closure of the skin defect may result in a shorter scar¹² and is used when possible. Postoperative dressing consists only of erythromycin ophthalmic ointment, preferred for its low toxicity and allergenicity. Ointments or eye drops that contain steroids should be avoided. Removal of the vertical mattress silk suture at the lid margin is delayed for 10 to 14 postoperative days. Skin sutures may be removed earlier if desired. Examples of primary eyelid repair with the suture techniques discussed are seen in Figure 17-15.

Complications from primary full-thickness eyelid repair include notching of the eyelid margin, trichiasis, eyelid retraction, blepharoptosis, pyogenic granuloma, and corneal exposure. Risk of corneal ulceration and visual loss exists if sutures touch the cornea; hence, great care must be taken during the posterior lamellar closure and placement of eyelid margin eversion sutures.

Semicircular Flap Reconstruction of Larger Full-Thickness Defects

The Tenzel semicircular advancement flap is a useful technique in eyelid reconstruction and is well suited to close full-thickness defects of the eyelid that encompass 33% to 75% of the horizontal length of the lower eyelid and 30% to 66% of the upper eyelid. Initially described by Richard Tenzel in 1978,¹³ this flap is conceptually similar to the classic Mustarde cheek rotation flap¹⁴ for eyelid reconstruction but provides better dynamic reconstruction of the eyelid lamellae with considerably less tissue rearrangement. There are several variations in the technique that can be chosen on the basis of individual patient characteristics. In each case, the anterior lamella (skin and orbicularis muscle) and posterior lamella (tarsus and conjunctiva) of the eyelid are addressed in a single-stage operation (Fig. 17-16).

Indications for use of the Tenzel flap include full-thickness central or lateral eyelid defects of 30% to 75% of the length of the original lower eyelid margin and 30% to 66% of the upper eyelid margin. Such defects are commonly a result of trauma, micrographic surgery for skin cancer, or congenital eyelid coloboma. The Tenzel flap is most useful when there is adequate lateral canthal skin laxity and availability of at least a small segment of full-thickness eyelid on both sides of the defect. This flap can be used when there is no tarsus on the lateral side of the defect, but optimal results will require a periosteal flap or a posterior lamellar graft such as hard palate mucosa or auricular cartilage (see later). In cases with a history of previous irradiation or burn, the Tenzel advancement flap is preferred to grafting as the flap provides its own blood supply. In general, the final postoperative appearance of the flap is superior to reconstruction with a skin graft or the larger Mustarde flap.

After anesthetic infiltration, initial intraoperative analysis begins with estimation of the actual size of the defect by grasping the borders of the wound with fine-toothed forceps (e.g., fine Adson or 0.5-mm Castroviejo forceps) and pulling them together. If the borders are within 1- to 2-mm of one another, primary closure with lateral cantholysis may be all that is necessary. If the defect is 30% to 75% of the horizontal length of the lower eyelid (typically 29- to 33-mm overall) or 30% to 66% of the upper eyelid, the Tenzel semicircular advancement flap will probably be an excellent choice for reconstruction. For larger defects, the Hughes and Cutler-Beard flaps may be more effective.

Reconstruction of the lower eyelid by the Tenzel flap is as follows. Beginning exactly at the lateral canthus, a semicircular superior arching line is drawn with a diameter of approximately 20-mm extending toward the level of the lateral eyebrow line (Figs. 17-16 and 17-17). For upper eyelid reconstruction, the mirror image is used. Next, the tarsal edges are freshened as necessary so that they are perfectly perpendicular to the lid margin, sacrificing as little tissue as possible. A Bard-Parker No. 15 blade is used for the initial incision and dissection of the musculocutaneous flap. Limited electrodissection with a sharp tungsten needle may also be used, with the generator set on minimum blend. A lateral canthotomy incision is made beneath the musculocutaneous flap, and the inferior ramus of the lateral canthal tendon is cut to completely mobilize the lateral lower eyelid segment. The musculocutaneous flap is thoroughly undermined and advanced medially so that the lateral lid tissue is advanced to the medial edge of the defect. In most cases, there is adequate skin laxity in the lateral canthal/temporal region for development of a Tenzel flap, but increased tissue advancement can occasionally be gained with rapid intraoperative tissue expansion with a Foley catheter placed beneath the skin of the temple. Two 5-minute cycles of skin expansion are used before flap advancement.¹⁵

Careful approximation of the two tarsal edges is the most important part of the reconstruction. With use of 6-0 polyglactin on a spatula needle (e.g., S-14), the tarsal edges are united with an interrupted suture that precisely approximates the lid margin as described before. A second and third interrupted suture is placed to further approximate the tarsus.

Lid margin sutures are placed in the gray line to perfectly align the lamellae of the eyelid at the wound edges. When enough full-thickness eyelid tissue is available on either side of the wound, the preferred technique is to place a vertical mattress 4-0 silk suture at the gray line for improved eversion of the superior eyelid margin. If instead one edge of the wound consists of a very small portion of full-thickness eyelid, simple interrupted 6-0 silk sutures are placed at the gray line and the lash line. In either case, to avoid corneal irritation, the ends of the sutures are left long after tying so that later they can be incorporated into a knot inferiorly on the skin.

To prevent lateral sagging of the eyelid, lateral canthal fixation of the lateral flap tissue must be performed. A 4-0 polyglactin 910 suture on a semicircular needle (e.g., P-2, ME-2, OPS-5) may be used to secure the deep surface of the flap to the inner aspect of superolateral orbital rim periosteum. However, improved eyelid contour can be obtained by developing a periosteal flap¹⁶ from the lateral orbital rim that is left hinged at the arcus marginalis and sutured to the inner aspect of the musculocutaneous flap as far medially as possible. The periosteal flap must be based high enough (at least midpupil) to provide upward pull on the lid and should be angled superiorly 45° to follow the lower eyelid contour. It should be 8- to 10-mm wide, and the length is determined by measuring the distance from the lateral orbital bony rim to the lateral end of the tarsus. If necessary, adjacent deep temporal fascia may be incorporated by extending the periosteal incisions laterally. In all cases, the goal is to re-create a tight eyelid with proper posterior contour at the lateral canthus (Fig. 17-18).

For larger defects or for those without tarsus at the lateral edge, it may be necessary to provide extra stability to the lateral reconstructed lower eyelid by “backing” it with an auricular cartilage, hard palate mucosa, or nasal septal chondromucosal graft. Other alternatives include AlloDerm, preserved sclera, and tarsoconjunctival graft (see later) from the upper eyelid. Ear cartilage, hard palate, nasal septum, or other material is obtained in the usual manner and then cut in rectangular fashion to snugly fit into the space between the most lateral tarsal edge and the lateral orbital tubercle. Sutures of 5-0 polyglactin are then used to fix it in place at both ends. If a periosteal flap or mucosal graft is used laterally, conjunctival advancement is unnecessary. Otherwise, the musculocutaneous flap (or posterior lamellar graft) should be lined with conjunctiva by advancing it from the inferolateral fornix and suturing conjunctiva to the superior skin margin of the flap with running 7-0 chromic gut or polyglactin sutures.

After the flap has been advanced, the eyelid margin reapproximated, and lateral support obtained, the remaining incisions are closed in layers. A 5-0 or 6-0 polyglactin suture in buried interrupted fashion is used for muscle; 6-0 polypropylene, nylon, or silk suture is used for the skin. To prevent a standing cutaneous deformity, it may be necessary to excise a triangle of tissue inferior to the lid defect or to extend the skin incision required for the flap as a gently sweeping lateral curve.

Wound dressing consists of erythromycin ophthalmic ointment. Cotton gauze dressing is generally not necessary but may help prevent hematoma. If it is used, it should be applied carefully as a compression patch over the closed eyelids to avoid abrading the cornea. The patch can be removed in 1 or 2 days, and antibiotic ointment is then applied to the wounds and the eye twice daily. Erythromycin ophthalmic ointment is preferred as it is the least likely to cause corneal irritation or allergic reaction.

Complications of the Tenzel flap include eyelid notching, ectropion, lateral canthal webbing, trap-door deformity, and symblepharon formation (Fig. 17-19).

Free Tarsoconjunctival Grafts for Lower Eyelid Reconstruction

A free tarsoconjunctival graft can be used to extend the posterior lamellar reconstruction accompanying an upper or lower eyelid Tenzel semicircular flap. It also is an important alternative to the semicircular flap for repair of lower eyelid defects involving 33% to 80% of the lower lid in some situations. It was initially described in 1918 and has been popularized more recently.17,18 The free tarsoconjunctival graft avoids the lateral canthal dissection and rearrangement that can rarely result in deformity of the lateral aspect of the reconstructed lower lid when the Tenzel approach is used. It has an advantage over the Hughes tarsoconjunctival flap in that occlusion of the eye is avoided. It requires the harvest of a free tarsoconjunctival graft from the upper lid to repair the posterior lamella of a lower lid defect, with concomitant repair of the anterior lamellar defect with a musculocutaneous flap. A full-thickness skin graft can be used to repair the anterior lamella, provided an orbicularis muscle flap is advanced over the free tarsoconjunctival graft.¹⁹ A musculocutaneous pedicle flap will typically result in a better color and thickness match.

The free tarsoconjunctival graft is usually harvested from the ipsilateral upper lid, although it is possible to take it from the opposite upper lid, another advantage over the Hughes and Tenzel flaps. Local anesthetic is infiltrated into the area of the recipient lower lid defect and at the donor upper lid subcutaneously and above the superior tarsal border subconjunctivally. A 4-0 silk traction suture is placed in the donor upper lid margin, and the lid is everted over a Desmarres retractor or a cotton-tipped applicator. The desired graft is always a little smaller than the size of the original defect, which can be assessed by grasping both ends of residual eyelid margin tissue and bringing them together with skin hooks or toothed forceps. The width of the tarsoconjunctival flap will be slightly less than the measured size of the defect, so that there will be adequate horizontal tension in the reconstructed eyelid after postoperative canthal tendon relaxation to prevent late ectropion or retraction. The average vertical tarsal height varies on the basis of race; for whites, it is typically 10-mm in the upper lid and 4-mm in the lower lid, whereas in Asian patients these measurements are 8-mm for the upper lid and 5-mm for the lower lid.²⁰ The lower 4-mm of the upper tarsus (closest to the lid margin) must be preserved to prevent postoperative upper lid entropion or deformity. This works out well in most cases as only 4- to 5-mm of vertical height of the free tarsoconjunctival graft is required to replace the missing posterior lamella of the lower lid defect. Calipers and a marking pen are used to carefully outline the tarsoconjunctival graft before harvest. It is best to take the graft from the central portion of the upper lid, where the tarsus is highest, rather than to take it from the medial or lateral areas, where the tarsal height tapers. A No. 15 scalpel or No. 69 Beaver blade is used to cut through conjunctiva and tarsus inferiorly and on each end of the graft. Blunt-tipped Westcott scissors can be used to dissect the tarsoconjunctival graft away from the levator aponeurosis, which is left intact and disturbed as little as possible. Superiorly it is helpful to harvest an extra 2-mm of conjunctiva as this will help form the new lower lid margin. Müller’s muscle is transected at the superior tarsal border and dissected as little as possible. Hemostasis is achieved, and the harvest site is left to heal spontaneously (Fig. 17-20; see video).

The free tarsoconjunctival graft will have 4- to 5-mm of vertical height centrally. It may taper medially or laterally, depending on the horizontal size of the graft. The tarsoconjunctival graft is sutured to the medial and lateral aspects of the defect with 6-0 or 7-0 silk or polyglactin sutures, preferably with an S-14 spatula needle. It is important to set the top of the graft at or slightly above the residual eyelid margin. The extra conjunctiva that was harvested from the donor lid should extend above the reconstructed lid margin. Should the graft sit too low, an excavation in the reconstructed eyelid in the area of the graft may be seen postoperatively. The lower aspect of the graft should be joined to the lower lid retractors and conjunctiva unless the lower lid defect extends to the inferior fornix, in which case the lid retractors should be left recessed and only conjunctiva joined to the tarsoconjunctival graft to avoid retraction of the graft postoperatively.

The anterior lamella must next be reconstructed, preferably with a musculocutaneous flap. This can be harvested from the ipsilateral upper lid or sometimes advanced upward from below the defect. Musculocutaneous flaps have advantages including improved color and texture match for the reconstructed eyelid.²¹

Unfortunately, there are times when the defect is large and insufficient tissue remains to harvest a local flap. Full-thickness skin grafts taken from the preauricular, postauricular, supraclavicular, or upper inner arm areas are alternatives. However, there is hazard to laying a full-thickness skin graft on top of a free tarsoconjunctival graft. Because each of the grafts needs to acquire a blood supply to survive, some vascularized tissue must be brought between them. Orbicularis muscle is suitable for this task and can often be mobilized to cover the free tarsoconjunctival graft and also lay beneath the full-thickness skin graft. A 6-0 plain suture is used to join the orbicularis flap, the free tarsoconjunctival graft, and the skin graft at the lid margin (see Fig. 17-20 and video).

Potential complications from free tarsoconjunctival grafts include dehiscence of the graft; failure of the tarsoconjunctival graft, musculocutaneous flap, or skin graft; persistent redness of the reconstructed lid margin²²; infections; deformity of the upper lid donor site with buckling of the lid margin; corneal irritation from lanugo hairs; entropion or ectropion; and ptosis or retraction of the upper lid.

Hughes Tarsoconjunctival Flap for Lower Eyelid Reconstruction

Full-thickness defects will sometimes involve all or most of the length of the lower eyelid. The Tenzel semicircular flap is well suited for repair of smaller defects that are not amenable to primary closure. However, larger defects encompassing 66% to 100% of the lower eyelid are typically not satisfactorily repaired with a semicircular flap. William Hughes first described the tarsoconjunctival pedicle flap named for him in 1937.²³ The flap provides a relatively ideal posterior lamella replacement: vascularized autogenous tarsus lined with conjunctiva (Fig. 17-21). The anterior lamella is reconstructed with a full-thickness skin graft or a local advancement flap. Unfortunately, the Hughes flap causes temporary obstruction of vision until it is divided at a second-stage procedure, 7 to 45 days after the initial operation. Nevertheless, it continues to be a highly effective and popular technique for reconstruction of large lower eyelid defects.

Local anesthetic infiltration in preparation for the Hughes tarsoconjunctival flap reconstruction must include both the recipient bed in the lower eyelid and the ipsilateral upper eyelid. The upper eyelid is everted, and 1 mL of local anesthetic is injected subconjunctivally above the superior tarsal border with a 30-gauge needle. Another 1 mL is injected subcutaneously at the eyelid crease, and proparacaine 0.5% eye drops are instilled for corneal anesthesia.

The size of the lower eyelid defect is assessed by grasping both ends of residual eyelid margin tissue and bringing them together with skin hooks or toothed forceps. The width of the tarsoconjunctival flap is designed to be slightly less than the measured size of the defect. This ensures that there will be adequate horizontal tension of the reconstructed eyelid to prevent late ectropion or retraction after postoperative canthal tendon relaxation. In cases requiring total lower eyelid reconstruction, medial and lateral periosteal flaps are used for horizontal fixation of a tarsoconjunctival flap with maximal width.

Satisfactory postoperative upper eyelid stability and contour requires that the most inferior 4-mm of tarsus be spared. To begin harvest of the tarsoconjunctival flap, the upper eyelid is everted over a Desmarres or small vein retractor (see Fig. 17-21). Calipers and a surgical marker are used to create a line parallel to the eyelid margin 4-mm superiorly on the posterior tarsal surface. Markings are also made for the medial and lateral borders of the planned flap. A No. 15 scalpel or No. 69 Beaver blade is used to make a horizontal incision along the marked line full thickness through the tarsus only. If the incision is partial thickness, blunt Westcott scissors can complete the incision. In this location, the next tissue plane encountered is the levator aponeurosis, which should be left intact.

Dissection with blunt-tipped scissors proceeds superiorly in an easily maintained tissue plane at the anterior surface of the tarsus, posterior to the levator aponeurosis. At the superior border of the tarsus, continued dissection in this plane will leave both Müller’s muscle and conjunctiva in the flap. Although the enhanced blood supply by including the muscle may occasionally be desirable, it is generally a mistake to include Müller’s muscle in the flap as upper eyelid retraction will often result after flap inset. Instead, the plane of dissection transitions to subconjunctival, posterior to Müller’s muscle. Care must be exercised at the superior border of the tarsus to avoid injury to the vascular arcade. Transitioning from the anterior surface of the tarsus to the new plane of dissection can be facilitated by infiltration of 0.5 mL of local anesthetic to hydrodynamically separate the tissues. Dissection is then continued superiorly until the flap can be advanced into the lower eyelid defect without excessive wound closure tension. Cautery of conjunctival vessels is kept to a minimum, and bipolar forceps are safest for the underlying cornea.

The flap will usually have 4- to 6-mm of tarsal height centrally, with tapering of the tarsal tissue medially and laterally. With use of an S-14 spatula needle, the flap is sutured to the medial and lateral tarsal stumps of the lower eyelid defect (or periosteal flaps elevated for the purpose in total eyelid reconstruction) with multiple interrupted 90% thickness 6-0 polyglactin sutures. The repair should be such that the superior tarsal border of the flap approximates the presurgical lower eyelid margin. Conjunctiva and retractors are advanced from the inferior fornix and secured to the lower border of the tarsoconjunctival flap with multiple interrupted 6-0 polyglactin sutures. At this point, the cornea will be covered and protected by the tarsoconjunctival flap and the upper eyelid will rest at approximately midpupil height.

Next, the anterior lamella must be reconstructed with a full-thickness skin graft or musculocutaneous advancement flap. Use of bipedicle orbicularis flaps or a musculocutaneous advancement flap for the anterior lamella has advantages including improved color and texture uniformity and postoperative neurologically active muscle in the lower eyelid²⁴ that may prevent retraction. Often, however, there is inadequate local tissue for such flaps, and a full-thickness skin graft is necessary. Donor sites for skin grafts most commonly used include the ipsilateral or contralateral upper eyelid, preauricular²⁵ or postauricular skin, and supraclavicular skin. A template is developed to estimate the size of the required skin graft to include coverage of the tarsoconjunctival flap up to the desired height of the reconstructed eyelid. The full-thickness graft is harvested in the usual way, thinned of connective tissue and fat, and sutured to the recipient site. Running 6-0 or 7-0 chromic gut is used for the superior border of the graft, with fixation to the conjunctiva just above the superior tarsal border. Fixation at the medial, lateral, and inferior borders can be accomplished with the same suture, but 6-0 silk is preferred because it can be used to easily create a tie-over bolster (e.g., cotton dental roll, Telfa, and cotton wool). Alternatively, an ocular compression patch left in place for 36 to 48 hours has also been effective in ensuring success of the skin graft.

Postoperatively, the patient is instructed to use ophthalmic antibiotic drops (e.g., gentamicin, ciprofloxacin) applied to the eye and bolster, if one is present, four times daily. Because peripheral vision is obviously reduced, use of a metal eye shield is helpful to avoid inadvertent injury to the flap, graft, and involved eye from blunt trauma. Chromic sutures are left to dissolve, but silk sutures are typically removed at 1 week.

Inset of the tarsoconjunctival flap is commonly performed at 2 to 4 weeks²⁶ after the initial reconstruction, although reports indicate successful results as early as 1 week.²⁷ This second stage is performed with topical proparacaine 0.5% eye drops and 1% lidocaine with 1 : 200,000 epinephrine concentration for local anesthesia. A narrow malleable retractor or a grooved director is inserted under the flap to protect the cornea. The flap is separated at the intended position of the new lower eyelid margin with scissors or a No. 15 scalpel, angled to leave a small conjunctival frill on the lower eyelid. The new lower eyelid margin is trimmed of excess tissue as needed, and gentle hemostasis is achieved. The ideal position for the mucocutaneous junction that will form with healing is just anterior to the apex of the reconstructed eyelid so that the keratinized skin and lanugo hairs of the graft do not contact the cornea. It may be helpful to suture the conjunctival edge anteriorly with 7-0 chromic gut. The remaining flap tissue still attached to the upper eyelid is transected flush with the conjunctival surface while the eyelid is everted, and hemostasis is achieved. If Müller’s muscle has been included in the flap, adjustment in upper eyelid height and contour may be necessary. This is accomplished with blunt dissection superiorly on the anterior surface of Müller’s muscle and then fixation to the levator aponeurosis with absorbable suture. The eye is dressed with ophthalmic antibiotic ointment (e.g., erythromycin) or antibiotic eye drops, and the patient is instructed to continue use twice daily for 1 week. Examples of eyelid reconstruction by the Hughes tarsoconjunctival flap are shown in Figure 17-22.

Potential complications from Hughes tarsoconjunctival flap repair with full-thickness skin graft include failure of the skin graft, dehiscence of the tarsoconjunctival flap,²⁸ infections, persistent erythema of the reconstructed lower eyelid margin, corneal irritation from lanugo hair trichiasis, pyogenic granuloma, lower and upper eyelid retraction, notching of the reconstructed eyelid, symblepharon, entropion, ectropion, and upper eyelid ptosis (Fig. 17-23).

Tarsal Transposition Flap for Lateral Upper Eyelid Reconstruction

Defects involving up to 50% of the upper eyelid can be closed with a tarsoconjunctival transposition flap, as initially described by Kersten et al²⁹ in 1986. It is possible to combine it with a flap of periosteum from the lateral orbital rim to repair larger defects. It is a viable alternative to composite grafts, Tenzel semicircular flaps, and even the Cutler-Beard repair in lateral upper lid defects. It has the advantage of being a one-stage repair, using local vascularized eyelid tissue rather than grafts from the nose, ears, or other eyelids. It involves use of the ipsilateral remaining upper lid tarsus as a transposition flap to repair the posterior lamellar defect, followed by a musculocutaneous flap or skin graft for the anterior lamella.

The technique begins with local anesthetic administration to the involved upper lid subcutaneously, at the superior conjunctival fornix, and at the lateral canthus. A 4-0 silk traction suture is placed in the lid margin and used to evert the lid over a cotton-tipped applicator. An incision is planned in the remaining tarsus of the upper lid. A vertically oriented flap 3- to 4-mm wide and hinged at the eyelid margin is designed with a caliper and outlined with a marking pen. A No. 15 blade is used to incise conjunctiva and tarsus from the top of the tarsus to within 1.5- to 2-mm of the lid margin, after which the flap is sharply dissected free from its anterior attachments to the orbicularis oculi. The flap is then pivoted 90°. After transposition, there will be some tissue bunching at the lid margin, which can be carefully trimmed with fine scissors. The flap is sutured to the remaining soft tissue at the lateral canthus, or to a periosteal flap, with a 5-0 polyglactin suture on an S-14 spatula needle. The suture technique is important as dehiscence of this flap could lead to failure of the repair. A “crossed swords” method in which the two spatula needles of a double-armed suture are both passed through the tarsoconjunctival flap works well. Good purchase at the anchor point and avoidance of excessive tension on the flap are both important. The conjunctiva can usually be advanced to the superior border of the tarsoconjunctival transposition flap from the superior fornix and loosely fixed there with 7-0 chromic suture on a spatula needle. Existing attachments of the remaining levator aponeurosis are usually adequate for eyelid elevation so that manipulation of the levator is not necessary. The residual anterior lamellar defect can sometimes be repaired with a musculocutaneous advancement flap from the lateral aspect of the upper lid. If this is not possible, a full-thickness skin graft can also be used (Figs. 17-24 and 17-25; see video).

Potential complications include dehiscence of the tarsoconjunctival transposition flap, irregularity or notching of the reconstructed lid margin, upper eyelid retraction or ptosis, and failure of the musculocutaneous flap or skin graft.

Eyelid and Simple Tarsal Composite Grafts

Composite grafts can be harvested from the contralateral upper or lower eyelid to provide similar autologous tissue for reconstruction. The primary disadvantage of this approach is violation of the integrity of the normal eyelid. Composite grafts of tarsus and conjunctiva can be used for posterior lamellar reconstruction alone,¹⁸ or alternatively, composite grafts of conjunctiva, tarsus, and skin including the lid margin^30,31 can be used with an interposed blood supply to reconstruct short segments of the upper or lower eyelid. Microsurgical transfer of full-thickness eyelid free flaps has also been described in a rabbit model.³²

Free tarsoconjunctival grafts can be harvested from the contralateral upper eyelid and used to reconstruct defects up to two-thirds the width of the posterior lamella of the ipsilateral upper eyelid or either lower eyelid. The graft is obtained by use of techniques previously described. The graft is transferred to the defect and secured to the remaining eyelid tarsus with interrupted partial-thickness 5-0 or 6-0 polyglactin sutures so that it is perfectly aligned and a 2-mm-wide conjunctival free edge is positioned at the lid margin. If necessary, 4-0 polyglactin is used to attach the lateral edge of the graft to the lateral canthal tendon or to the periosteum inside the lateral orbital rim. The anterior lamella is then reconstructed with a musculocutaneous advancement flap (e.g., semicircular flap or transposition flap as described before).

In cases in which the full-thickness lower eyelid defect is shallow (e.g., 5- to 10-mm in height) and there is substantial lack of skin laxity for the creation of a flap, a modified composite eyelid graft can be useful. This graft consists of a pentagon of full-thickness eyelid harvested from the contralateral upper or lower eyelid from which the orbicularis muscle has been excised, leaving the skin, lashes, tarsus, and conjunctiva (Figs. 17-26 and 17-27). Its width is limited by the laxity in the donor eyelid, but typically at least 10-mm can be harvested in elderly patients. The graft is supported by the rich blood supply of adjacent orbicularis muscle that is mobilized into the space left by the excised muscle. The donor defect is closed according to the method described in the section discussing primary closure of full-thickness defects. The eyelid composite graft is transferred to the defect, and the tarsal edges are sutured in perfectly aligned position with partial-thickness 5-0 or 6-0 polyglactin interrupted sutures. Adjacent orbicularis muscle, typically from the inferior wound edge, is undermined and sutured into the space between the skin and tarsus with 6-0 polyglactin. The skin edges of the graft are then sutured to the borders of the recipient site with 6-0 silk, and a bolster or compression patch is applied over the closed lids for 24 to 36 hours.

Cutler-Beard Flap for Complete Upper Eyelid Reconstruction

Large defects of the upper eyelid can be challenging for the reconstructive surgeon because upper lid anatomy and function are complex. For maintenance of corneal integrity, crisp vision, and patient comfort, the upper eyelid must have a 5- to 10-mm range of movement and a dynamic blink. Restoration commonly requires a multistage approach in which an approximation of the normal tissues is first reconstructed, and then movement in protraction and retraction are added as required for vision and comfort. No single operation satisfactorily achieves all of the patient’s and surgeon’s goals when the defect is very large.

The Cutler-Beard lid-sharing flap³³ is probably the best available technique for total upper eyelid reconstruction. It is a skin-muscle-conjunctiva flap from the lower eyelid advanced into the upper eyelid defect. It involves temporary closure of the involved eye for 4 to 6 weeks (Fig. 17-28). The other major disadvantage of this flap is that the rigid posterior lamella is not usually replaced, which may result in instability of the reconstructed eyelid margin over time.³⁴ Free tarsoconjunctival grafts (as described earlier) or free autogenous hard palate mucosal grafts^35,36 can be used to provide posterior lamellar support to the flap³⁷ but are best added after flap inset so that corneal integrity can be monitored while risk of suture injury exists.

The edges of the upper eyelid defect are freshened to make them perpendicular to any remaining eyelid margin, and the horizontal width of the defect is measured while the edges are brought toward one another with skin hooks. Next, a horizontal line is drawn on the lower eyelid skin parallel to the lid margin but 5-mm inferior to permit an intact blood supply to the lower eyelid margin. This line is drawn 2-mm longer than the defect width, and then vertical lines are drawn extending inferiorly from either end for 15- to 20-mm. A 4-0 silk suture on a G-1 cutting needle is passed in a coronal plane through the gray line of the lower eyelid in two locations to serve as a traction suture. With the lid pulled superiorly over a Jaeger plate or similar lid guard protecting the globe, a No. 15 scalpel blade is used to make a full-thickness horizontal blepharotomy along the horizontal line. Straight scissors are used to create the vertical incisions that are carried to the inferior conjunctival fornix. Further inferiorly, the skin and orbicularis are undermined to create a composite advancement flap that includes conjunctiva and lower eyelid retractors.

The composite flap is then brought under the bridge of lower eyelid margin and sutured to the edges of the upper eyelid defect. The conjunctiva and lower eyelid retractors are sutured with 6-0 polyglactin to the remnants of tarsus or to the canthal tendons or periorbita medially and laterally. The borders of the orbicularis and skin are also approximated in layers with 6-0 polyglactin suture.

Flap inset is typically accomplished as a second stage 4 to 8 weeks after reconstruction, although successful inset at 2 weeks has been described.³⁸ A longer time may be necessary for tissue vascularization and stretching in patients who have had local irradiation or who have particularly tight wound closures. A horizontal mark is made on the skin 2-mm below the anticipated new upper eyelid margin. With the cornea protected by a narrow malleable retractor, the flap is cut with straight scissors angled so that the cut is more inferior on the conjunctival side. After initial hemostasis, the conjunctival edge is then sutured to the skin edge with 7-0 chromic suture, ensuring that the new upper eyelid margin is not keratinized. It may be necessary to excise a small wedge of orbicularis muscle to permit advancement of the conjunctival edge anteriorly. The inferior edge of the lower eyelid bridge is then freshened, and the base of the lower eyelid flap is sutured to the bridge in a layered fashion with buried interrupted 6-0 polyglactin for the conjunctiva and retractors and interrupted or running 6-0 polypropylene, nylon, or plain gut for the skin. The skin and orbicularis may need to be undermined to prevent lower eyelid ectropion, and any horizontal laxity should be repaired with a lateral tarsal strip procedure.

Canalicular Reconstruction

Defects in the medial upper and lower eyelids or medial canthus will frequently involve the lacrimal drainage system, especially the puncta and canaliculi. Primary reconstruction of these tissues will often prevent epiphora and the need for more extensive procedures, such as conjunctivodacryocystorhinostomy with Jones tube. In cases involving loss of the punctum and partial proximal canaliculus, simple monocanalicular or bicanalicular silicone lacrimal intubation may be adequate to maintain lacrimal drainage. However, complete loss of the canaliculi is difficult to manage primarily, and postoperative epiphora may be best prevented in these cases by primary endoscopic conjunctivodacryocystorhinostomy with Jones tube,³⁹ performed in conjunction with an ophthalmologist familiar with that procedure.

In cases in which there is only partial loss of the canaliculi or puncta, silicone intubation of the remaining lacrimal system should be performed.40,41 The Quickert-Dryden malleable silver probes and the Crawford olive-tipped probes attached to silicone tubing are commonly available and relatively easy to use for this purpose (Figs. 17-29 and 17-30). The probes should first be bent so that each forms a semicircle; this greatly facilitates retrieval from the inferior nasal meatus. One probe is then inserted into the proximal end of each remaining canaliculus or punctum. One at a time, each probe is then passed into the lacrimal sac until a firm “stop” is felt on the lacrimal bone. It is then redirected inferolaterally while gentle medial pressure is maintained. The probe will pass into the nasolacrimal duct and ultimately into the inferior nasal meatus, from which it is retrieved under headlight observation with a Crawford hook, Takahashi forceps, or other clamp. If the semicircular curve created before passage is ideal, the probe will often spontaneously exit from the naris. Once both ends have been passed in this fashion, the probes are cut from the silicone, and the two silicone ends are tied together with a square knot so that there is neither tension at the medial canthus nor a prolapse of the knot from the nostril. It can be fixed to the lateral nasal wall with 6-0 polypropylene suture or tied over a small silicone bolster to avoid excessive movement, but the surgeon must be careful to avoid tension at the medial canthus that will invariably cause undesired erosion of the remaining canaliculi. The silicone tubing is typically left in place at least 6 months. It can be removed by cutting the tube in the medial ocular commissure and then pulling sharply on one end or, if it is fixated in the nose, by pulling the knot out from the inferior nasal meatus.

References