UPPER AND LOWER EYE LID RECONSTRACTION

ZOREKH

• THE GOALS OF EYELID RECONSTRUCTION ARE (1) TO PROVIDE ADEQUATE EYELID FUNCTION. (2) TO AFFORD GLOBE PROTECTION (3) TO ACHIEVE ACCEPTABLE AESTHETIC RESULTS• UPPER EYELID SERVES A MORE IMPORTANT ROLE IN GLOBE PROTECTION

BECAUSE IT COVERS A GREATER AREA OF THE CORNEA.• COMMON INDICATIONS FOR RECONSTRUCTION IS DUE TO RESECTION OF

MALIGNANCIES IN UPPER EYELID AND TRUMA IN LOWER EYE LID.

• PARTIAL-THICKNESS LOSS-SKIN LOSS OF SKIN MAY BE CLOSED PRIMARILY OR REPLACED WITH FULL-THICKNESS SKIN GRAFTS TO PREVENT EXCESSIVE GRAFT CONTRACTION. SKIN FROM THE CONTRALATERAL LID IS THE BEST SOURCE FOR A THICKNESS MATCH. ALTERNATIVELY, POSTAURICULAR SKIN MAY BE USED. TIP: IT IS IMPERATIVE NOT TO CREATE TENSION ON THE LID WITH PRIMARY CLOSURE, BECAUSE THIS LEADS TO ECTROPION.-CONJUNCTIVACONJUNCTIVA IS BEST REPLACED BY ADVANCEMENT OF AN ADJACENT SLIDING TRANSCONJUNCTIVAL FLAP. WHEN THIS IS NOT POSSIBLE, GRAFTING IS NECESSARY. BUCCAL OR NASAL MUCOSA PROVIDES THE REQUIRED DONOR SITE ,NASAL MUCOSA TENDS TO CONTRACT LESS THAN BUCCAL MUCOSA (20% VERSUS 50%). SKIN GRAFTS ARE CONTRAINDICATED, BECAUSE SURFACE CHARACTERISTS IRRITATE THE CORNEA.GRAFTS OF CONJUNCTIVA ARE SUBJECT TO SIGNIFICANT CONTRACTION AND SHOULD BE AVOIDED.

-TARSUSLOSS OF TARSAL STRUCTURE USUALLY IS PART OF A COMPOSITE LOSS. IT SHOULD BE REPAIRED PRIMARILY ,CARTILAGE GRAFTS, OR ACELLULAR DERMAL MATRIX.

• FULL-THICKNESS LOSSUPPER LID DEFECTS UP TO 25%-30% OF THE LID MAY BE CLOSED PRIMARILY IN OLDER PATIENTS WITH SIGNIFICANT LAXITY, 40% DEFECTS MAY BE CLOSED PRIMILARLY. WHEN SIGNIFICANT TENSION IS PRESENT, LATERAL CANTHOTOMY AND CANTHOLYSIS MAY PROVIDE ADDITIONAL LAXITY FOR CLOSURE. TIP:PRECISE APPROXIMATION OF TARSAL PLATE IS CRITICAL FOR PROPER LID “SKELETAL” SUPPORT.

FLAP RECONSTRUCTION DEFECTS BETWEEN 25% TO 75%• TENZEL SEMICIRCULAR FLAPCOMBINING LATERAL CANTHOTOMY AND

CANTHOLYSIS WITH A LATERALLY BASED MYOCUTANEOUS FLAP ALLOWS CLOSURE OF DEFECTS OF UP TO 60% OF THE UPPER LID.

• LID-SHARING FLAP (MUSTARDE PEDICLED FLAP) USED FOR DEFECTS OF THE CENTRAL UPPER LIDFLAP DIVIDED ABOUT WEEK 6 AND DONOR SITE CLOSED PRIMARILY.

• DEFECTS OVER 75%• CUTLER-BEARD FLAP A TWO-STAGE PROCEDURE ENTAILS ADVANCEMENT OF

A FULL-THICKNESS LOWER LID FLAP PASSED BENEATH THE LOWER LID MARGIN AND SUTURED INTO THE DEFECTLACKS SUPPORT AT THE LID MARGIN AND REQUIRES CARTILAGE GRAFTING BETWEEN THE CONJUNCTIVA AND MUSCLE LAYERS,FLAP DIVISION PERFORMED AT 3-6 WEEKS.

• TEMPORAL FOREHEAD FLAP (FRICKE FLAP) WHEN ADEQUATE LID TISSUE IS UNAVAILABLE FOR DONOR TISSUE, TEMPORALLY BASED FLAPS MAY BE USEFULTISSUE QUALITY IS THICKER AND LESS IDEAL; IT SHOULD BE RESERVED FOR SPECIAL CIRCUMSTANCES.

• LATERAL CANTHAL DEFECTS PRODUCES A ROUNDED LATERAL CANTHUS AND A SHORTENED PALPEBRAL FISSURE.

SIMPLE DISRUPTION: PRIMARY REPAIR IF BOTH ENDS OF THE LCT ARE PRESENT.COMPLEX DISRUPTION: CANTHOPLASTY IF LATERAL END OF THE LCT IS ABSENT.-MEDIAL END PRESENT: SUTURE TO PERIOSTEURN OF LATERAL ORBITAL RIM -MEDIAL END ABSENT: USE LATERAL TARSAL STRIP OR PERIOSTEAL FLAP CANTHOPEXY FOR LCT LAXITY-SLIGHT OVERCORRECTION PREVENTS RECURRENCE. A LOCAL FLAP, REGIONAL FLAP, OR SKIN GRAFT CAN BE USED FOR SOFT TISSUE COVERAGE.

• MEDIAL CANTHAL DEFECTS RULE OUT INJURY TO THE CANALICULAR SYSTEM. SIMPLE DISRUPTION: PRIMARY REPAIR IF BOTH ENDS OF THE MCT ARE PRESENT COMPLEX DISRUPTION: CANTHOPLASTY IF MEDIAL END OF THE MCT IS ABSENT. *IF AVULSED, MAY REQUIRE TRANSNASAL WIRING (POSTEROSUPERIOR TO THE POSTERIOR LACRIMAL CREST) TO PREVENT POSTOPERATIVE TELECANTHUS. CANTHOPEXY FOR MCT LAXITY-SLIGHT OVERCORRECTION PREVENTS RECURRENCE. A LOCAL FLAP, REGIONAL FLAP, OR SKIN GRAFT CAN BE USED FOR SOFT TISSUE COVERAGE.

• LOWER LID DEFECTS OF UP TO 25%-30% OF THE LID MAY BE CLOSED PRIMARILY. IN OLDER PATIENTS WITH SIGNIFICANT LAXITY, 40% DEFECTS MAY BE CLOSED SIMILARLY. WHEN SIGNIFICANT TENSION IS PRESENT, LATERAL CANTHOTOMY AND CANTHOLYSIS MAY PROVIDE ADDITIONAL LAXITY FOR CLOSURE.FLAP RECONSTRUCTIONDEFECTS BETWEEN 25% TO 75%• TENZEL SEMICIRCULAR FLAP COMBINE LATERAL CANTHOTOMY AND

CANTHOLYSIS WITH A LATERALLY BASED MYOCUTANEOUS FLAP FOR CLOSURE OF DEFECTS OF UP TO 60% OF THE UPPER LID ADDITIONAL SUPPORT MAY BE PROVIDED WITH PERIOSTEAL FLAP, CARTILAGE, OR OTHER HOMOLOGOUS GRAFT.

TRIPIER FLAP MYOCUTANEOUS FLAP USED FOR PARTIAL-THICKNESS COVERAGE OF LOWER LID ORIGINALLY DESCRIBED AS A BIPEDICLED FLAP; MAY BE BASED ON A SINGLE PEDICLE TIP: DEFECTS THAT EXTEND PAST THE PUPIL USUALLY REQUIRE A BIPEDICLED TECHNIQUE TO PREVENT DISTAL NECROSIS.

• DEFECTS OVER 75%• HUGHES TARSOCONJUNCTIVAL FLAPTWO-STAGE PROCEDURE; TRANSFERS

CONJUNCTIVAL LINING AND A SMALL PORTION OF THE SUPERIOR TARSUS FOR SUBTOTAL OR TOTAL LOWER LID RECONSTRUCTION. SKIN COVERAGE PROVIDED BY FLAP OR FTSG; FLAP DIVIDED AT 4-6 WEEKS.

• CHEEK ADVANCEMENT FLAP (CLASSIC MUSTARDE)USEFUL FOR TOTAL LOWER LID RECONSTRUCTION TO PREVENT LID RETRACTION, CRITICAL TO PROVIDE TENSION-FREE MOBILIZATION OF TISSUE INTO TARGETED SITE AND LATERAL CANTHAL FIXATION

TIP:  ELEVATION OF A THIN FLAP IS HELPFUL.

• OTHER EG. MCGREGOR

• LOCOREGIONAL FLAPS IF ADEQUATE QUALITY LID TISSUE UNAVAILABLE, USE REGIONAL SOFT TISSUES IDEAL QUALITY TISSUE NOT PROVIDED BECAUSE OF THICKNESS

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