General principles

There are a number of surgical procedures, which can be utilised to reconstruct eyelid defects. In general, where less than 25% of the eyelid has been sacrificed, direct closure of the eyelid is possible. Where the eyelid tissues are very lax, direct closure may be possible for much larger defects occupying up to 50% of the eyelid. Where direct closure without undue tension on the wound is difficult, a simple lateral canthotomy and cantholysis of the appropriate limb of the lateral canthal tendon can effect a simple closure.

In order to reconstruct eyelid defects involving greater degrees of tissue loss, a number of different surgical procedures have been devised. The choice depends on:

• The extent of the eyelid defect

• The state of the remaining periocular tissues

• The visual status of the fellow eye

• The age and general health of the patient

• The surgeon's own expertise.

In deciding which procedure is most suited to the individual patient's needs, one should aim to re-establish the following:

• A smooth mucosal surface to line the eyelid and protect the cornea

• An outer layer of skin and muscle

• Structural support between the two lamellae of skin and mucosa originally provided by the tarsal plate

• A smooth, nonabrasive eyelid margin free from keratin and trichiasis

• In the upper eyelid normal vertical eyelid movement without significant ptosis or lagophthalmos

• Normal horizontal tension with normal medial and lateral canthal tendon positions

• Normal apposition of the eyelid to the globe

• A normal contour to the eyelid.

Large eyelid defects generally require composite reconstruction in layers with a variety of tissues, either from adjacent sources or from distant sites, being used to replace both the anterior and posterior lamellae. It is essential that only one lamella should be reconstructed as a free graft. The other lamella should be reconstructed as a vascularised flap to provide an adequate blood supply to prevent necrosis.

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