Lower eyelid reconstruction

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Defects of the lower eyelid can be divided into those that involve the eyelid margin, and those that do not.

Defects involving the eyelid margin a) Small defects

An eyelid defect of 25% or less may be closed directly. In patients with marked eyelid laxity, even a defect occupying up to 50% of the eyelid may be closed directly. The two edges of the defect should be grasped and pulled together to judge the facility of closure. If there is no excess tension on the lid, the edges may be approximated directly. The lid margin is reapproximated with a single armed 5/0 Vicryl suture on a half circle needle. This is passed through the most superior aspect of the tarsus, ensuring that the suture is anterior to the conjunctiva to avoid contact with the cornea. This suture is tied with a single throw and the eyelid margin approximation checked. If this is unsatisfactory the suture is replaced and the process repeated.

Once the margin approximation is good, the suture is untied and the ends fixated to the head drape with a haemostat. This elongates the wound enabling further single armed Vicryl sutures to be placed in the lower tarsus. These are tied. The uppermost Vicryl suture is then tied. Improper placement or tying of the suture or too great a degree of tension on the wound will result in dehiscence of the wound. Next, a 6/0 silk suture is passed in a vertical mattress fashion along the lash line and a second suture along the line of the meibomian glands. These are tied with sufficient tension to cause eversion of the edges of the eyelid margin wound. A small amount of pucker is desirable initially, to avoid late lid notching as the lid heals and the wound contracts. The sutures are left long and incorporated into the skin closure sutures to prevent contact with the cornea.The conjunctiva is left to heal spontaneously without suture closure. The skin sutures may be removed in five to seven days but the eyelid margin sutures should be left in place for 14 days.

b) Moderate defects

Canthotomy and cantholysis - where an eyelid defect cannot be closed directly without undue tension on the wound, a lateral canthotomy and inferior cantholysis (Figures 6.11 and 6.12) can be performed.The inferior cantholysis is performed by cutting the tissue between the conjunctiva and the skin close to

Lateral Canthotomy

Figure 6.11 Lateral canthotomy.

the periosteum of the lateral orbital margin, with the lateral lid margin drawn up and medially.

A semicircular flap (Tenzel flap) (Figure 6.13) is useful for the reconstruction of defects up to 70% of the lower eyelid where some tarsus remains on either side of the defect, particularly where the patient's fellow eye has poor vision. Under these circumstances it is preferable to avoid a procedure which necessitates closure of the eye for a period of some weeks. A semicircular incision is made starting at the lateral canthus, curving superiorly to a level just below the brow and temporally for approximately 2cm.

The flap is widely undermined to the depth of the superficial temporalis fascia taking care not to damage the temporal branch of the facial nerve which crosses the midportion of the zygomatic arch. A lateral canthotomy and inferior cantholysis are then performed. The eyelid defect is closed as described above. The lateral canthus is suspended with a deep 5/0 Vicryl suture passed through the upper limb of the lateral canthal tendon or the periosteum of the lateral orbital margin to prevent retraction of the flap. Any residual dog ear is removed and the lateral skin wound closed with simple interrupted sutures.

Reconstruction Upper Lid

Figure 6.12 Inferior cantholysis.

Figure 6.11 Lateral canthotomy.

Figure 6.12 Inferior cantholysis.

Lateral Canthotomy And Cantholysis Residual Limb Dog Ear

Figure 6.13 Semicircular flap for reconstruction of defects of the lower eyelid: (a) semicircular flap delineated, (b) reformation of lateral canthus, (c) sutured flap.

Figure 6.13 Semicircular flap for reconstruction of defects of the lower eyelid: (a) semicircular flap delineated, (b) reformation of lateral canthus, (c) sutured flap.

c) Large defects

The upper lid tarsoconjunctival pedicle flap (Hughes' flap) (Figure 6.14) is an excellent technique for the reconstruction of relatively shallow defects involving up to 100% of the eyelid. With defects extending horizontally beyond the eyelids it can be combined with periosteal flaps from the canthi to recreate

Grey Line Opthalmology
Hughs Flap Hughs Flap

Figure 6.14 Hughes' flap: (a) following excision of lid lesion, (b) tarsoconjunctival flap raised from upper lid, and (c) sutured to posterior lamella of lower lid.

Figure 6.14 Hughes' flap: (a) following excision of lid lesion, (b) tarsoconjunctival flap raised from upper lid, and (c) sutured to posterior lamella of lower lid.

canthal tendons. Great care, however, should be taken in the planning and construction of the flap in order not to compromise the function of the upper eyelid.

A 4/0 silk traction suture is passed through the grey line of the upper eyelid which is everted over a Desmarres retractor. The size of the flap to be constructed is ascertained by pulling together the edges of the eyelid wound firmly and measuring the residual defect. A horizontal incision is made centrally through the tarsus 3-5mm above the lid margin. It is important to leave a tarsal height of 3^5mm below the incision in order to prevent an upper eyelid entropion and to prevent any compromise of the eyelid margin blood supply. The horizontal incision is completed with blunt-tipped Westcott scissors, and vertical relieving cuts are made at both ends of the tarsal incision. The tarsus and conjunctiva are dissected free from Muller's muscle and the levator aponeurosis up to the superior fornix.

The tarsoconjunctival flap is mobilised into the lower lid defect. The tarsus is sutured to the lower lid tarsus with interrupted 5/0 Vicryl sutures. The lower lid conjunctival edge is sutured to the inferior border of the mobilised tarsus with a continuous 7/0 Vicryl suture.

Sufficient skin to cover the anterior surface of the flap can be obtained either by harvesting a full-thickness skin graft or by advancing a myocutaneous flap from the cheek (Figure 6.15). This flap can be elevated by bluntly dissecting a skin and muscle flap inferiorly, toward the orbital rim, and incising the lid and cheek skin vertically. Relaxing triangles (Burrow's triangles) may be excised on the inferior medial and lateral edges of the defect. The flap of skin and muscle is then advanced with sufficient undermining so that it will lie in place without tension. This flap is then sewn in place with its upper border at the appropriate level to produce the new lower lid margin.

In the patient with relatively tight, non-elastic skin, such an advancement may

Reconstruction Upper Lid
Figure 6.15 Hughes' reconstruction with skin/ muscle advancement flap.
Hughes Flap Eye
Figure 6.16 Hughes' reconstruction with full-thickness skin graft.

eventually lead to eyelid retraction or an ectropion. In such cases, it is wiser to use a free full thickness skin graft from the opposite upper lid, pre-auricular area, retro-auricular area or from the upper inner arm area (Figure 6.16). The graft should not be taken from the upper lid of the same eye as the Hughes' flap, as the resultant vertical shortening of both the anterior and the posterior lamellae may produce vertical contracture of the donor lid. If possible, a flap of orbicularis muscle can be advanced alone after dissecting it free from overlying skin. This will improve the vascular recipient bed for the skin graft. If a full-thickness skin graft has been utilised, an occlusive dressing is applied for five to seven days. Skin sutures may be removed after five to seven days. The patient is instructed to massage the area in an upward direction for a few minutes, three to four times per day to keep the tissues supple and prevent undue contracture.

The flap can be opened approximately six to eight weeks (or longer if necessary) after surgery. This is done by inserting one blade of a pair of blunt-tipped Westcott scissors just above the desired level of the new lid border and cutting the flap open. It is unnecessary to angle the scissors to leave the conjunctival edge somewhat higher than the anterior edge. Traditionally this provides some conjunctiva posteriorly to be draped forward and create a new mucocutaneous lid margin, but this leaves a reddened lid margin which is cosmetically poor. It is preferable to allow the lid margin simply to granulate as the appearance is far better. The upper lid is then everted and the residual flap is excised flush to its attachment. If Muller's muscle has been left undisturbed in the original dissection of the flap, eyelid retraction is minimal and no formal attempt is needed to recess the upper lid retractors. The Hughes' procedure provides excellent cosmetic and functional results for lower lid reconstruction.

Free tarsoconjunctival graft - adequate tarsal support may be provided by harvesting a free tarsoconjunctival graft from either upper lid. The upper lid is everted as described above. The size of the graft needed is determined in a similar manner as well. Again, the tarsus is incised across the width of the lid, 3 to 4mm above the lash line, to prevent upper lid instability and lash loss. The flap is elevated by blunt dissection in the pretarsal space, and vertical cuts are made to the tarsal base. The tarsus is then amputated at its base and grafted into the recipient lower lid, as described above. Because this graft is inherently avascular, it must be covered by a vascularized myocutaneous advancement flap.

This technique is useful in lower lid reconstruction for a monocular patient, because it does not occlude the visual axis. If the surgical defect extends to involve the canthal tendons, the free graft should be anchored to periosteal flaps.

Periosteal flap - for the repair of lateral lid defects in which the tarsus and the lateral canthal tendon have been completely excised, a periosteal flap provides excellent support for the reconstruction. The periosteum should be elevated as a rectangular strip from the outer aspect of the lateral orbital rim, at the midpupillary level, to provide upward support. The flap should be 4 to 5mm in height, and the length can be judged based on the size of the defect to be reconstructed. The hinged flap is elevated and folded medially and secured to the edge of the residual tarsus or to the inner aspect of a myocutaneous flap with 5/0 or 6/0 absorbable sutures.

Mustarde cheek rotation flap - with the development and popularity of other reconstruction techniques and with the tissue conserving advantages of Mohs' micrographic surgery, the Mustarde rotational cheek flap is more rarely utilised than in the past (Figure 6.17). It is reserved for the reconstruction of very extensive deep eyelid defects usually involving more than 75% of the eyelid.

A large myocutaneous cheek flap is dissected and used in conjunction with an adequate mucosal lining posteriorly.The posterior lamella tarsal substitute is usually a nasal septal cartilage graft or a hard palate graft. The important points in designing a cheek flap are summarised by Mustarde in the following points.

• A deep inverted triangle must be excised below the defect to allow adequate rotation.

• The side of the triangle nearest the nose should be practically vertical. Failure to observe this point will result in pulling down the advancing flap because the centre of rotation of the leading edge is too far to the lateral side.

• The outline of the flap should rise in a curve toward the tail of the eyebrow and hairline and should reach down as far as the lobule of the ear.

Mustarde Flap

Figure 6.17 Mustarde flap: (a) delineated, (b) advanced following final reconstruction of posterior lamella, (c) skin sutures.

Figure 6.17 Mustarde flap: (a) delineated, (b) advanced following final reconstruction of posterior lamella, (c) skin sutures.

• The flap must be adequately undermined from the lowest point of the incision in front of the ear across the whole cheek to within 1cm below the apex of the excised triangle.

• Where necessary (in defects of three quarters or more), a back cut should be made at the lowest point, 1cm or more below the lobule of the ear.

• The deep tissue of the flap should be hitched up to the orbital rim, especially at the lateral canthus, to prevent the weight of the flap from pulling on the lid.

Cheek flaps can be followed by many complications, including facial-nerve paralysis, necrosis of the flap, ectropion, entropion, epiphora, sagging lower lid, and excessive facial scarring. It is very important to plan the design of the flap and to appreciate the plane of dissection to avoid inadvertent injury to the facial nerve resulting in lagophthalmos. Meticulous attention to haemostasis is important as is placement of a drain and a compressive dressing at the conclusion of surgery.

There are a number of alternative local periocular flaps which can be utilised for anterior lamella replacement It is important to respect a length-width ratio of approximately 4:1 where such flaps are not based on an axial blood supply to avoid necrosis. A particularly useful flap is that harvested from above the brow and based temporally It provides good vertical support but requires second stage revision. Other local flaps which are harvested from the lower lateral cheek area or the nasojugal area have the disadvantage of secondary lymphoedema which can take many months to resolve.

A flap can be used from the upper eyelid where there is sufficient redundant tissue. Occasionally the flap can be created as a bucket handle based both temporally and nasally. It is essential, however, to ensure that the creation of such flaps does not cause lagophthalmos.

Eyelid defects not involving the eyelid margin

If the lid border is spared and the tumour does not invade orbicularis or deeper tissues, a full-thickness section of lid does not have to be excised. If the lesion is small, the defect may be closed with direct approximation of the skin edges after undermining. It is important to close the wound to leave a vertical scar to avoid a post operative ectropion. In large lesions, a full-thickness skin graft may be necessary to prevent ectropion of the lower lid. If the lid is lax, this may have to be combined with a lateral tarsal strip procedure or a wedge resection in order to prevent a lower eyelid ectropion.

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