Reconstruction of upper eyelid tumour defects must be performed meticulously in order to avoid ocular surface complications. There are a number of surgical procedures which can be utilised to reconstruct an upper lid defect. It is important to select the procedure which is best suited to the individual patient's needs.
Lagophthalmos following reconstruction may cause exposure keratopathy, particularly in the absence of a good Bell's phenomenon. The problem is compounded by loss of accessory lacrimal tissue. Lacrimal tissue should be preserved when dissecting in the lateral canthal, lateral levator, and lateral anterior orbital areas. Poor eyelid closure is usually due either to adhesions, wound contracture, or to a vertical skin shortage. It may also be caused by overenthusiastic dissection of lateral periocular flaps with damage to branches of the facial nerve.
When levator function is preserved following surgical defects of the eyelid, ptosis can usually be avoided or corrected. It is important to carefully identify the cut edges of the levator and to ensure that the levator is reattached to the reconstructed tarsal replacement with a suitable spacer if required.
Eyelid defects involving the eyelid margin a) Small defects
As in the lower lid reconstruction, an eyelid defect of 25% or less may be closed directly and in patients with marked eyelid laxity, even a defect occupying up to 50% of the eyelid may be closed directly (Figure 6.18). The surgical procedure is as described above. It is important that the tarsal plate is aligned precisely and closed with 5/0 Vicryl sutures, ensuring that the bites are partial thickness to avoid the possibility of corneal abrasion. After closure of the tarsus, the eyelid margin is closed with
interrupted 6/0 silk sutures placed at the grey line and lash margin. All eyelashes should be everted away from the cornea. The ends of the margin sutures are left long and sutured to the external skin tissue to avoid corneal irritation.
b) Moderate defects
Canthotomy and cantholysis - where an eyelid defect cannot be closed directly without undue tension on the wound, a lateral canthotomy (Figure 6.11) and superior cantholysis (Figure 6.19) can performed. It is very important that the cantholysis is performed meticulously to avoid any inadvertent damage to the levator aponeurosis or to the lacrimal gland.
Semicircular flap - a lateral, inverted, semicircular flap may be combined with direct
Figure 6.19 Superior cantholysis.
closure for full-thickness defects of up to two thirds of the eyelid margin (Figure 6.20a, b and c). An inverted semicircle is marked on the skin surface, beginning at the lateral canthus and extending laterally approximately 3 cm. The skin and orbicularis muscle are undermined under the entire flap, and a superior cantholysis performed. The lateral aspect of the eyelid may then be advanced medially to cover the defect.
The posterior surface of the advanced semicircular flap may be covered by a tarsoconjunctival advancement flap from the lateral aspect of the lower eyelid. A vertical, full-thickness, lower eyelid incision is made, and the tarsoconjunctival advancement flap is prepared by excising the lower eyelid skin tissue and lash margin from the flap. The tarsus and conjunctiva may then be advanced superiorly into the lateral aspect of the upper eyelid flap. The lower eyelid defect may be repaired primarily, anterior to the tarsoconjunctival flap. The lateral tarsoconjunctival flap may be released in four to six weeks.
As an alternative to semicircular skin advancement, the advanced lower lid tarsoconjunctival flap may be covered with full-thickness skin tissue rather than a rotated, inverted semicircle.
c) Large defects
Sliding tarsoconjunctival flap - horizontal advancement of an upper eyelid tarsoconjunctival flap is useful for full-thickness defects of up to two thirds of the upper lid margin. The residual upper eyelid tarsus is bisected horizontally. The superior portion of the tarsus is advanced horizontally along with its levator and Muller's muscle attachments. The tarsoconjunctival advancement flap created is then sutured in a side-to-side fashion to the lower portion of the upper lid tarsus and to the lateral or medial canthal tendon. The lower portion of the upper lid tarsus remains attached to the orbicularis and skin tissue. After the horizontal tarsoconjunctival advancement, the external skin tissue is rebuilt by using full-thickness skin grafting or semicircular adjacent tissue advancement.
A Cutler-Beard reconstruction is useful for upper eyelid defects covering up to 100% of the eyelid margin. A three-sided inverted U-shaped incision is marked on the lower eyelid, beginning below the tarsus. The eyelid is everted over a Desmarres retractor and a conjunctival incision is made below the tarsus. A conjunctival flap is fashioned and dissected into the inferior fornix and onto the globe. The flap is advanced into the upper eyelid defect and sewn edge to edge with the remaining upper fornix conjunctiva using 7/0 Vicryl with care being taken to avoid corneal irritation (Figure 6.21a). The cornea is now protected.
Tarsal support to the upper eyelid is replaced by placing an autogenous auricular
cartilage graft, which has been suitably shaped, anterior to the conjunctival flap. The edges are sewn horizontally to either tarsal remnants or to periosteal flaps (Figure 6.21b). An incision is made through the lower eyelid horizontally below the tarsus and extended inferiorly to create a skin muscle advancement flap. The lower lid skin-and-muscle flap is then advanced to the upper lid to cover the cartilage graft (Figure 6.21c).
The lower lid tissue is advanced posteriorly to the remaining lower lid tarsal and lid margin bridge. The bridge flap is left intact for at least eight weeks prior to separation. When the bridge flap is separated, a full-thickness incision should be made through the flap at a position inferior to the lower lid bridge margin (Figure 6.21d). The conjunctiva and skin are then sutured directly in the newly separated upper eyelid tissue. The inferior margins of the lower lid bridge are freshened and reanastomosed to the remaining lower lid skin and conjunctival layers (Figure 6.21e). It is common for the lower lid to become very lax and to require a wedge resection at the second stage.
Full-thickness composite graft - a full-thickness en bloc section of tissue from the other upper eyelid may be transplanted into defects of the upper eyelid margin. The resection of the normal eyelid should be performed below the lid crease and should be done only when the remaining normal eyelid can be easily closed with direct closure. The lashes of the transplanted lid rarely survive. The overlying skin and orbicularis are removed and a rotation/advancement flap is fashioned to cover the graft.
Rotation and inversion of the lower lid margin and tarsus into an upper lid defect provides good lid function as well as lashes for the upper eyelid. This procedure is best used, however, for large upper lid defects. It necessitates complete reconstruction of the lower eyelid margin, utilising a lateral Mustarde cheek flap reconstruction combined with a hard palate or nasal chondromucosal graft for the reconstruction of the lower eyelid tarsus and conjunctiva. This technique is particularly useful for reconstruction of upper eyelid colobomata.
Figure 6.21 Cutler-Beard reconstruction (a) conjunctival flap in place, (b) ear cartilage graft in place, (c) first stage complete, (d) division of Cutler-Beard flap, (e) final stage.
aspect of the lower eyelid is then advanced medially through the use of a lateral Mustarde flap. The lower eyelid margin is then inverted and sutured into the upper lid defect. The lower lid rotation is closed medially, and the lateral aspect of the new lower lid margin is backed with a nasal chondromucosal composite graft or a hard palate graft. The bridge adjoining the upper and lower lids is separated after six to eight weeks. Although some surgeons use this technique with success, it is cumbersome and requires both lower eyelid construction and lateral facial advancement.
If a small skin defect can be closed directly this should aim to leave a vertical scar in order to prevent vertical contracture of the wound and secondary lagophthalmos or eyelid retraction. If direct closure of the tissue is not possible, a full-thickness skin graft may be placed over the defect to prevent lagophthalmos.
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