Eyelid Techniques

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Reconstructive designs for the eyelidsCraig N. Czyz, DO, FACOS,a Kenneth V. Cahill, MD, FACS,b Jill A. Foster, MD, FACSa,b

From the a Division of Ophthalmology, Section of Oculofacial Plastic Surgery, OhioHealth Doctors Hospital,

Columbus, Ohio; and thebDepartment of Ophthalmology, Division of Oculofacial Plastic Surgery, The Ohio State University, Columbus, Ohio.

General reconstructive principles unique to the eyelids may be used to guide successful eyelid and

periorbital reconstruction following tissue excision. Eyelid tumors involving the medial canthus region

and/or lacrimal system add to the complexity of reconstructive planning. The nature of the defect,

patient and tissue factors, and surgeon preference guides repair design choices. This article discusses

eyelid and periorbital reconstruction options.

2011 Elsevier Inc. All rights reserved.

KEYWORDSMedial canthus;

Eyelid tumor;

Reconstruction;

Graft;

Flap

Reconstructive surgical planning for the eyelids is influ-

enced by several factors including the nature of the defect,

the health and age of the patient, the availability, elasticity,

and integrity of surrounding tissues, and the surgeons ex-

perience and preferences. This article discusses eyelid and

periorbital reconstruction options.

In general, the following principles provide a guide to

successful eyelid and periorbital reconstruction:

1. If both anterior and posterior eyelid lamellae are to be

reconstructed, only one layer can consist of a graft; the

other must be composed of a vascularized flap. Although

the rich vascularity of the face and eyelids allows one to test

the boundaries of reconstructive principles used elsewhere

in the body, graft-on-graft reconstruction has a high failure

probability.

2. The surgeon must re-create adequate canthal fixation to

suspend the eyelid by the medial and lateral canthal tendons

3. Periocular wound tension lines may be taut in the hori-

zontal direction, but should be closed under a minimal

amount of vertical traction.4. The surgeon must perform any appropriate direct closure

of the defect prior to sizing a graft

5. Tissue characteristics should be matched as best as pos-

sible for grafts and flaps

6. Complexity of technique(s) with improvement(s) in out-

come should be well balanced.

In reconstruction of defects involving the eyelid margin, the

following goals help to create a successful outcome:

1. Development of an aligned and stable eyelid margin

2. Maintenance or creation of a conjunctiva-like poste-

rior eyelid surface

3. Provision of sufficient horizontal and vertical eyelid di-

mensions for maximal function4. Insurance of adequate eyelid closure to avoid exposure

sequelae

5. Insurance of optimal eyelid symmetry and cosmesis (tis-

sue of appropriate color, texture, and thickness).

Tumors involving the medial canthal region and/or lacrimal

system add to the complexity of reconstructive planning. The

literature is replete with reports of various types of skin-muscle

flaps to repair medial canthal defects.1-5 However, while pro-

viding surface coverage, many of these techniques fail to

address the issues of eyelid function and stability and to con-

sider the issue of lacrimal drainage. To properly design a

comprehensive surgical reconstruction plan, an intimateknowledge of the regions anatomy and function is crucial.

Clinical anatomy

Eyelids

The average distance between the upper and lower eye-

lids, the vertical palpebral fissure, is 8-10 mm in primary

Address reprint requests and correspondence: Craig Czyz, DO,

FACOS, 1100 Oregon Ave, Columbus, OH 43201.

E-mail address: [email protected].

Operative Techniques in Otolaryngology (2011) 22, 35-46

1043-1810/$ -see front matter 2011 Elsevier Inc. All rights reserved.

doi:10.1016/j.otot.2011.01.005
mailto:[email protected]:[email protected]:[email protected]


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(straight) gaze.6 The upper eyelid margin rests approxi-

mately 2 mm below the superior corneal limbus. The lower

eyelid margin should be at or 1 mm above the inferior

corneal limbus so that no sclera is visible between the

limbus and eyelid. The horizontal width of the palpebral

fissure from medial to lateral canthus is approximately

28-30 mm.7 The lateral canthal angle is positioned approx-

imately 2 mm higher than the horizontal meridian of the

medial canthal angle. The normal upper eyelid has a traveldistance of 14-16 mm from downgaze to upgaze.8 The

motion of the eyelids along with orbicularis contracture

provides the impetus for the lacrimal pump mechanism, the

disruption of which can result in epiphora.

Anatomically, the upper eyelid consists of seven distinct

layers (Figure 1). These layers from anterior to posterior are

(1) skin and subcutaneous tissue; (2) orbicularis oculi mus-

cle; (3) orbital septum; (4) orbital fat; (5) levator and Ml-

lers muscles (eyelid retractors); (6) tarsus; (7) conjunctiva.

The anatomy of the lower eyelid is similar to that of the

upper eyelid with two distinct differences. In the lower

eyelid, the capsulopalpebral fascia and inferior tarsal muscle

are analogous to the upper eyelids levator and Mllers

muscles, respectively. These lower eyelid structures are less

well defined and developed than their upper lid counter-

parts. The eyelids are divided into surgical units of anterior

and posterior lamella. The anterior lamella is composed of

skin and orbicularis oculi muscle and the posterior of the

tarsus and conjunctiva. The middle lamella is a conceptual

space consisting of everything between the anterior and

posterior lamella.9

The tarsi are firm, dense plates of specialized fibrous

connective tissue that serve as the structural support of the

eyelids.10 At its center, the upper eyelid tarsal plate has agreater vertical dimension (10-12 mm) than the lower eyelid

tarsal plate (4 mm).11 Both upper and lower tarsal plates

measure approximately 1 mm in thickness and taper toward

their attachments.12 The upper and lower eyelid tarsal plates

have sturdy attachments to the periosteum via the canthal

tendons medially and laterally (Figure 2). Mechanical dis-

ruption or involutional change of either supporting tendon

can result in displacement of the tarsi. The meibomian

glands, holocrine sebaceous glands that secret the oil com-

ponent of the tear film, are located within the tarsus.

The eyelid margin has a rectangular profile (Figure 3).

The cutaneous epithelium on the anterior surface and theconjunctiva of the posterior surface are separated by nonke-

ratinized epithelium. The gray line is visible along the

Figure 1 Cross-section of the orbital and periorbital anatomy.

Figure 2 Anterior view of deeper eyelid and periorbital struc-

tures.

Figure 3 Cross-section of the eyelid margin anatomy.

36 Operative Techniques in Otolaryngology, Vol 22, No 1, March 2011


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center of the eyelid margin. The gray color results from the

darker color of the superficial portion of the orbicularis

oculi muscle anterior to the tarsus, known as the muscle of

Riolan lying just deep to the epithelium.13 The gray line is

often confused with the mucocutaneous junction of theeyelid margin, which is actually located posterior to the

meibomian gland orifices along the eyelid margin. The gray

line is a surgically important landmark in reconstruction,

canthoplasty, and other surgical procedures involving the

eyelids.

The palpebral conjunctiva lines the posterior surface of

the upper and lower eyelids (Figures 1 and 3). The conjunc-

tiva that envelops the globe is the bulbar conjunctiva. The

fornices are the areas of transition between bulbar and

palpebral conjunctiva. Conjunctiva is composed of nonke-

ratinizing squamous epithelium. The conjunctiva contains

the accessory lacrimal glands of Wolfring and Krause andthe mucin-secreting goblet cells.12 The function of the con-

junctiva is to lubricate, support, and protect the ocular

surfaces.11

The upper and lower eyelids are highly vascularized by

an anastomosing network of vessels from the internal and

external carotid arteries.14,15 The exact formation of the

network seems to have mild anatomical variation between

individuals. This rich blood supply contributes to the high

survival rate of grafts and flaps in periocular reconstruction.

It also reduces the need to design flap construction based on

specific vessels.

Medial canthus

The structure of the palpebral fissure is maintained by the

tarsal plates in combination with the medial and lateral

canthal tendons (Figure 2). The medial canthal tendon is

formed by the merging of two tendinous arms originating

from the anterior and posterior lacrimal crests. The arms

fuse temporal to the lacrimal sac and then redivide into two

different arms that attach to the upper and lower eyelid

tarsal plates. The tendinous attachment at the anterior lac-

rimal crest is robust, whereas that of the posterior lacrimal

crest is delicate but crucial in maintaining a posterior vector

that aligns apposition of the eyelids to the globe.12

Lacrimal system

The lacrimal system comprises the puncta, canaliculi,

common canaliculus, lacrimal sac, and nasal lacrimal duct

(Figure 4). The puncta is located at the eyelid margin and

connects to the canaliculi in both the upper and the lower

eyelids. The upper eyelid punctum lies slightly nasal to the

lower eyelid punctum and they slightly protrude above the

eyelid margin. The canaliculi travel 2 mm vertically fromthe puncta and then turn medically to parallel the eyelid

margin for a total length of 8-10 mm. The upper and lower

canaliculi merge into a common canaliculus prior to enter-

ing the lacrimal sac in approximately 90% of patients, with

the remainder entering separately.16 The valve of Rosenmu-

eller lies at this junction, preventing regurgitation of fluid

within the lacrimal sac into the common canaliculus. This is

not a true valve but an orientation of the tissues that act

similar to a valve. The lacrimal sac is 12-15 mm in length

and lies within the lacrimal sac fossa, which comprises the

maxilla anteriorly and the lacrimal bone posteriorly. The

superior one third of the lacrimal sac is above of the medial

canthal tendon, while the remainder is below the tendon.17

The lacrimal sac fossa is adjacent to the middle meatus

within the nose usually at or just anterior to the tip of the

middle turbinate. The lacrimal sac drains into the nasal

lacrimal duct that is approximately 12-18 mm in length.

The nasal lacrimal duct empties into the nasal cavity

under the inferior turbinate with flow controlled by the

valve of Hasner.

Figure 4 Composite view of the lacrimal system anatomy. Mea-

surements indicate adults.

Figure 5 Medial canthal tendon defect. The entire medical can-

thal tendon was resected in this patient. A combination of mini-

plate and suture material has been used to reconstruct the medical

canthal tendon and superior and inferior arms (crus).

37Czyz et al Reconstructive Designs for the Eyelids


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Reconstructive considerations

Medial canthus

One of the primary tenets of cancer surgery is to com-

pletely remove the lesion and obtain margins devoid of

atypia without regard to the challenges it may present in

performing repair. This is especially critical in the medial

canthal region where spread of the primary tumor to the

nearby sinuses can in turn result in extension to the brain

and ultimately mortality. Tumor margins should be micro-

scopically evaluated and determined free of atypia before

reconstruction is undertaken.

Reconstructive planning in the medial canthal region is

complex because of the variety of structures that can be

involved, the unique contours, and the multitude of tech-

niques available. If the defect is restricted to the anterior

lamella, spontaneous granulation or full-thickness skin graft

(FTSG) can be employed, with FTSG being a more com-

mon and faster healing technique.18 For larger anterior de-

fects, or those lacking a vascular bed for FTSG survival,

various transposition or advancement flaps can be em-

ployed, such as a glabellar forehead flap or finger flap.1-5

When the defect involves full-thickness medial eyelid(s) or

sacrifice of the medial canthal tendon, the remaining eyelid

margin must be reapproximated and fixated to periosteum or

bone. Full-thickness eyelid defects involving more than50% of the lid rarely can be closed and reapproximated

primarily to the canthal tendon. In these instances both

anterior and posterior lamellar components must be ad-

dressed via lid-sharing techniques, free grafts, and flaps.

Defects involving the lacrimal system add a degree of com-

plexity and may require either primary microsurgical recon-

struction or delayed repair depending on the amount of

disruption and the nature of the excised tumor.

Facial plastic surgeons are familiar with skin grafting

techniques and the various flaps used in medial canthal

reconstruction. However, when eyelid reconstruction is in-

corporated into the repair, modifications to standard flap and

grafting techniques may be required. Full-thickness skins

grafts to the eyelids and canthus must be thinner than those

used on other areas of the face. Consequently, pre- and

postauricular grafts debrided of their subcutaneous tissues

work best. Advancement and rotational flaps of thicker

forehead and cheek tissue must also be thinned. This can

decrease their vascular perfusion, their ability to support a

posterior lamellar graft, and even their own survival. Ifnecessary, a flap can be thinned as a secondary procedure,

but this is disruptive in the canthal areas.

When the medial canthal tendon is disrupted or com-

pletely lost, the remaining eyelid portion of the tendon must

be fixated to the area of the tendenous origin to ensure

proper alignment and support of the eyelid(s). If any tendon

remains on the anterior or posterior lacrimal crest, direct

reattachment with braided, absorbable, polyglycolic acid

suture (Vicryl; Ethicon, Somerville, NJ) or monofilament,

nonabsorbable polypropylene (Prolene; Ethicon) suture is

possible. The anterior limb of the tendon can be disrupted

without causing malposition of the medial canthus if theposterior limb remains intact.19 When no tendon material

remains for anchoring the eyelid, suture can be used to

fixate the to the periosteum of the posterior lacrimal crest

(Figure 5). In cases where periosteum is absent or of insuf-

ficient quality, a titanium miniplate can be fixated to bone

Figure 6 Reconstructive options for eyelid defects. (A) Direct primary closure. (B) Direct primary closure with canthotomy/cantholysis.

(C) Adjacent tarsoconjunctival flap with FTSG. Note in B, the lid is everted over a Desmarres retractor. (D) Free tarsoconjunctival graft

and skin-muscle flap. (E) Bucket Beard lower eyelid vascular advancement flap with lamellar spacer graft and adjacent skin-muscle flap.

(F) Lower eyelid switch flap. (G) Glabellar/median forehead flap with free lamellar graft. T tarsus; C conjunctiva; TC

tarsoconjunctival.

Figure 7 Lid margin sutures. (A) The photograph illustrates the proper suture placement for classic direct lid margin defect closure.

Sutures can be seen in the tarsus (white) and lid margin locations (black). (B) Once sutures are tied, they are draped and secured by the skin

sutures to prevent corneal defects.



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and the tendon sutured to the plate.20 Alternatively, or when

the bony anatomy precludes use of a miniplate, transnasal

wiring may be employed. One must also take into account

the nature of the tumor, as metallic-based implants or wires

can produce artifact in future scans of the area.

Eyelids

Small defects of the upper and lower eyelidSmall eyelid defects (33% involvement) are repaired

by direct primary closure (Figure 6A). An additional 2-5

mm of advancement of the lateral portion of the lid can be

accomplished via a canthotomy, and cantholysis of the

superior or inferior arms of the lateral canthal tendon should

wound tension necessitate. Anterior and posterior eyelid

margin alignment and sturdy tarsal reapproximation are the

keys to a successful outcome.

Traditional techniques for eyelid reapproximation use

one or more deep sutures of 6-0 Vicryl to pull together the

two sides of the tarsus followed by margin sutures to bring

the eyelid margin together. The tarsal sutures are placed 4-5

mm peripheral to the eyelid margin and then are left loose

until the eyelid margin sutures are placed. Classic lid margin

sutures are placed in three locations across the lid margin:

from gray line to gray line, then lash line to lash line, and

then mucocutaneous junction to mucocutaneous junction

(Figure 7A). The tarsal suture(s) is tied to take traction off

the wound, and then the eyelid margin sutures are tied,

leaving long tails on the suture. The ends are then draped

Figure 8 Reconstructive options for lower eyelid defects. (A) Direct primary closure with canthotomy/cantholysis and semicircular

(Tenzel) flap. (B) Hughes upper eyelid tarsoconjunctival flap and FTSG. (C) Mustard flap with free lamellar graft.



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and tied into the skin sutures above or below the eyelid

margin (Figure 7B).

Moderate defects of the upper and lower eyelid

Moderate eyelid defects (33-50% involvement) can po-

tentially be reconstructed by direct closure with canthotomy

and cantholysis (Figure 6B). When sufficient horizontal lid

mobilization or tissue is not provided with canthotomy/

cantholysis, a semicircular rotational flap (Tenzel) can beconstructed with an arching incision above or below the

lateral canthal angle (Figure 8A). The flap is then advanced

medially, allowing the lid to be closed in a direct fashion. A

reconstructed lateral canthus is created by securing the re-

maining lid portion of the tendon to the intact arm of the

lateral canthal tendon. In the absence of the lateral canthal

tendon, the tendon may be re-created using lateral orbital

rim periosteum and deep temporalis fascia. To re-create the

lower tendon, the surgeon draws a rectangular flap oriented

obliquely superiorly toward the temporal hairline (Figure

9). The flap is always made a bit longer than one thinks is

needed. The scalpel incises the rectangular flap; then thetemporalis fascia is peeled off the muscle, and the perios-

teum is elevated away from the rim with a Freer elevator.

The flap is then flipped into the lower lid with the temporalis

fascia ending up on the medial location of the newly formed

lateral canthal tendon. The flap remains attached on the

internal aspect of the lateral orbital rim. The same technique

is used to re-create the upper lateral canthal tendon; only the

design of the original flap is oriented obliquely down toward

the earlobe and again is flipped so the posterior aspect of the

flap that was on the bone is now oriented anteriorly.

In cases where lid structural support is lacking, tarsal

sharing or tarsoconjunctival flap procedures can be used. An

adjacent tarsoconjunctival flap can be formed and advanced

supporting the posterior lamella (Figure 6C). In the lower

eyelid, the modest vertical height of the tarsus allows only

horizontal sharing if sufficient tarsus for lid stabilization is

to remain. Alternatively a free tarsal graft from the con-

tralateral upper lid or tarsal substitutes can be used. The

anterior lamella is then reconstructed with an adjacent ad-

vancement or transposition flap should the eyelid skin dis-

play sufficient laxity. In the lower eyelid, midface elevation

may also be required to prevent lower eyelid retraction and

ectropion.

Large defects of the upper and lower eyelidLarge eyelid defects (50% involvement) are the most

challenging reconstructions to design and perform. The

amount of tissue loss usually requires both grafting and

advancement of adjacent tissues. In defects of this size it is

paramount that the posterior lamella be addressed for the

resulting lid reconstruction to have sufficient structural sup-

port to function.

A free tarsoconjunctival graft can be harvested from the

contralateral upper lid to repair the posterior lamellar aspect

of the defect (Figure 6D). The anterior portion can be

composed of a sliding skin-muscle flap of adjacent eyelid

tissues if there is sufficient laxity. Alternatively an FTSGcan be harvested from the contralateral upper eyelid or other

preferred sources (pre/postauricular, clavicular). A slight

overestimation of tissues should be grafted as there is a

tendency for the reconstructed areas to retract.21

When sufficient tarsus or conjunctiva is not available, a

hard palate graft is a viable alternative that provides both

support and a posterior mucosal surface for the lower eye-

lid.22 Alternatively a nasal septal cartilage graft with intact

mucoperichondrium can be used.10 While these tissues are

successful in the lower eyelid, use in the upper lid is limited

by the propensity for corneal irritation caused by the rough-

ness of the surface of these grafts. If sufficient tarsus re-

mains for lid margin stability, oral mucosa or acellular

dermis can be grafted as a conjunctival substitute in fornix

reconstruction. When tarsus is deficient, ear cartilage cov-

ered with by vascularized conjunctiva can repair the poster

lamella along the lid margin. As previously noted, a vascu-

larized flap must be in apposition with any free graft.

Because of the movement of the upper eyelid, replace-

ment of the posterior surface often requires an ocular con-

junctival surface. The Cutler-Beard procedure consists of

advancing a full-thickness eyelid flap from the ipsilateral

lower eyelid including conjunctiva and skin. The counter-

part to the Hughes flap for lower eyelid defects, the Cutler-

Beard differs in that it classically performed many supply

tissues for both posterior and anterior reconstruction. While

convenient, lower lid deformity and upper lid entropion are

common complications. A secondary procedure is also re-

quired for flap division.

In a slightly more complicated procedure, the Bucket

Beard, some of the lower lid retraction complications of

the Cutler-Beard may be avoided using the vascularized flap

of the lower lid to provide conjunctiva and blood supply, but

moving the remaining skin from below the brow in the

upper lid in a bucket handle flap to become the new upper

eyelid margin23 (Figure 10A-G). A tarsal substitute of car-

tilage, tarSys (IOP, Costa Mesa, CA), or thick acellular

Figure 9 Lateral canthal tendon reconstruction. The gray lines

represent the outline of the periosteal flap created for tendon

reconstruction.



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Figure 10 Bucket Beard. (A) Near total upper eyelid excision. (B) A full-thickness incision is made in the lower eyelid as outlined. The

full-thickness flap is dissected leaving an intact bridge of eyelid margin including the marginal arcade vessel and tarsus. The image shows the flap

advanced under the eyelid margin bridge into the upper eyelid defect. A piece of acellular dermis material has been placed anterior to the conjunctiva to

serve as the middle lamellar support. (C) A bucket-handle flap is created using skin just below the eyebrow. (D) The bucket-handle flap is transposed

inferiorly over the conjunctival flap and acellular graft to re-create the upper eyelid margin and anterior lamella. (E) An FTSG is used to reconstruct

the brow flap harvest site. (F) In a second-stage procedure, the lower eyelid flap is separated with a scissors or blade. The bucket handle flap

becomes the new upper eyelid margin. The lower eyelid skin is reposited into the lower eyelid. (G) Appearance 6 months following second stage.



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dermis, should be sandwiched between the anterior bucket

handle flap and posterior lamella provided by the lower lid

Cutler-Beard flap. A skin graft is placed below the eyebrow

to replace the skin used for the bucket handle flap ( Figure

6E). When the eyelids are separated at two to six weeks, the

skin from the Cutler-Beard flap returns to the lower eyelid.

This technique diminishes the postoperative retraction seen

with a classic Cutler-Beard and results in a better contour of

the postoperative upper eyelid margin.A lower eyelid switch flap is another type of full-thick-

ness lower eyelid pedicle graft (Figure 6F). The lower lid

margin is rotated into the upper eyelid. While there is the

benefit of the lower eyelid lashes being in proper position

when rotated into the upper lid, there is a significant disad-

vantage in the form of the large lower lid defect that is

created. This defect must be repaired in a secondary proce-

dure with a posterior lamellar graft and a cheek rotation flap

to cover the anterior portion of the defect. There is added

risk of seventh nerve palsy from flap dissection as well as

lower lid retraction from the weight and subcutaneous tissue

contraction of the cheek flap.21 Additionally, a second pro-

cedure is required to sever the bridge approximately three to

six weeks after placement. This technique is primarily of

historical significance.

For combined defects of the upper eyelid and the medial

canthus, a glabellar (median forehead) flap may be rotated

to provide tissues for repair of the anterior lamella of the

upper lid and medial canthus (Figure 6G). The flap requires

primary thinning when used for upper lid repair and will

require a secondary procedure to take down the bridge flap.

The eyelid may also require secondary thinning procedures.

The skin type match is not as good as some of the alterna-

tives and care needs to be taken not to include hair follicles

if possible. If a significant portion of the upper lid is being

replaced, grafts or flaps of mucosal tissue are placed on the

backside of the flap. Medial canthal fixation of the tissue

helps to re-create the contour of the upper lid.

Large defects of the lower eyelid

The modified Hughes technique is often the procedure of

choice for large lower eyelid defects (Figure 8B). In the

Hughes technique, a vascularized flap of upper lid conjunctiva

and tarsus is created and advanced into the lower lid defect. It

is sutured into place to remaining tarsus or to the canthal angle

reconstruction. To prepare the flap, the upper eyelid is everted

over a Desmarres retractor and the tarsus is marked to protect

the 4 mm of tarsus along the eyelid margin (Figure 11A). The

remainder of the vertical height of the tarsus may be borrowed

for the lower eyelid. The scalpel is used to incise the tarsus, and

then the tarsus is elevated off the posterior surface of the

levator aponeurosis using a Wescott scissors. At the top of the

tarsus, the dissection plane continues, separating conjunctiva

from Mllers muscle. The conjunctiva is usually released up

to the junction of the aponeurosis and Mllers muscle. The

tarsus and the attached conjunctiva are then lined up with the

defect in the lower eyelid (Figure 11B). The edges of the tarsus

Figure 11 Tarsoconjunctival flap (Hughes). (A) The upper lid is everted over a Desmarres retractor and the dotted outline marks the

margins for flap dissection. (B) The flap is transposed into the lower eyelid defect, but not yet sutured. Note the alignment of the tarsal edges

vertically and horizontally. The conjunctival bridge obscures view of the ocular surface. (C) FTSG placed over the tarsoconjunctival flap

to repair the anterior lamellar defect. (D) The conjunctival flap is divided using a groove director to protect the ocular surface and a no. 11

blade to divide the flap.



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of the eyelid and the flap are trimmed to meet at right angles.Partial thickness bites of a 6-0 Vicryl suture align the remain-

ing tarsus in the eyelid with the tarsus of the flap. If the defect

in the lower eyelid is vertically extensive, there may be some

gap in the conjunctiva in the inferior cul-de-sac. It is better to

line up the tarsal edges to meet at the lid margin than to pull the

flap tarsus down in to the defect.

The anterior lamella is reconstructed with an FTSG taken

from contralateral eyelid or pre/postauricular area (Figure

11C). This results in a conjunctival bridge from the upper

eyelid across the pupil into the lower defect for two to six

weeks. Once the lower eyelid graft is revascularized, a second

procedure divides the flap (Figure 11D). It is sometimes nec-

essary to smooth over irregularities of the new eyelid at thetime of the separation. Amblyopia should be considered when

planning reconstruction involving eyelid closure in young chil-

dren.

The Mustard cheek flap works well for a large anterior

lamellar defect (Figure 8C). It can be considered a progression

of the smaller Tenzel rotational flap and used with any separateposterior lamellar repair technique. Consideration of this pro-

cedure should be made in any large lower eyelid defect when

eyelid closure is a concern such as a monocular state or chil-

dren with amblyopia risk. It has the advantage of being able to

repair defects with extensive vertical involvement that extend

down the lower lid into the cheek (Figure 12A, B). This may

also be needed in patients who have had a previous tarsal

conjunctival flap where the tissue is usually too tight for an

additional flap to work.

Combined upper and lower eyelid defects

Defects of any size involving both upper and lowereyelids are reconstructed following the same principles as

isolated lid defects. Similarly there is no alteration in the

decision-making process if medial canthal structures or the

lacrimal system is also involved. There exists no singular

flap that can address all full-thickness upper and lower

Figure 13 Lacrimal involvement of lower eyelid lesion. (A) Lesion excision of the medial lower eyelid involving the punctum and

canaliculus. The transected proximal end of the canaliculus can be seen (arrow). (B) A monocanalicular is placed in the distal opening of

the canaliculus and the lid defect is repaired. The mouth of the stent is usually seated in the punctum; however, since the puncta was

sacrificed with the lesion, the stent opening will serve as the new lower lid punctum (arrow).

Figure 12 Rotational cheek flap (Mustard). (A) Large lower eyelid defect extending inferiorly into the midface. (B) The Mustard flap

is rotated into position and a clavicular FTSG is placed in the defect created by rotation of the flap.



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Figure 14 Decision tree outlining surgical design options for upper and lower lid reconstruction with or without medical canthal,

tendinous, and/or lacrimal involvement.



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eyelid and medial canthus defects. Thus, a minimum of two

flaps is required for these types of combined defects.4

Lacrimal system involvement

Microsurgical repair of the lacrimal system can be com-

bined with various eyelid and medical canthal reconstruc-

tions. In the case of malignancy, until tumor recurrence can

be ruled out, lacrimal surgery that creates a pathway for

tumor spread into the sinuses or nasal cavities is avoided.

Length of clinical surveillance without signs of recurrence

prior to lacrimal repair varies depending on lesion type, with

melanoma and sebaceous cell requiring the longest interval.

Partial interruptions of the canaliculus of the upper or

lower eyelid can be repaired primarily with silicone intuba-

tion and surgical reanastomosis of the canalicular ends (Fig-

ure 13A, B). Some patients are asymptomatic if there is one

normal functioning canaliculus and good position of both

lids. If both canaliculi have been sacrificed, options are

tempered by the nature of the lesion and the remaining

tissues.

Crawford (JEDMED, St. Louis, MO) stents or Infant

Bika (FCI ophthalmics, Marshfield Hills, MA) intubation is

used for bicanalicular and Mini Monoka (FCI) or Mono-

Crawford (FCI) stents for monocanalicular stenting. Sili-

cone tubing can also be used to stent the upper and lower

lacrimal systems without the need to intubate the nasolac-

rimal duct. The silicone stents are generally left in place

three months and then removed. Silicone intubation as part

of the primary repair demonstrates a high success rate in

maintaining a patent, functional drainage system in the

absence of direct lacrimal system involvement.

24

Following primary reconstruction and sufficient tumor sur-

veillance, in cases where the patient has symptomatic epiphora

and primary lacrimal repair is unsuccessful or the nature of the

tumor does not allow for it, then a conjunctivodacryocystorhi-

nostomy with Jones tube placement can be offered. If the

patient is asymptomatic regarding tearing, further intervention

to reestablish a lacrimal drainage system is not required. Older

patients are less symptomatic with epiphora because of the

age-related decrease in tear function.25

Conclusions

It is nearly an impossible task to cover every permutation of

defects and the available reconstructive choices for this

highly complex facial region. The goal of this article is to

provide a summary of the pertinent anatomy, fundamental

reconstructive principles, and workhorse techniques

available for successful functional and cosmetic outcomes.

Figure 14 illustrates a decision tree outlining the recon-

structive options discussed.

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