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Lower Eyelid Reconstruction

  • Author: Mounir Bashour, MD, PhD, CM, FRCSC, FACS; Chief Editor: Zubin J Panthaki, MD, CM, FACS, FRCSC  more...
 
Updated: Mar 12, 2015
 

Background

Eyelid tumor excision and trauma are 2 common causes of eyelid defects requiring surgical reconstruction.

A wide variety of surgical techniques is available (see reviews by Codner and Weinfield[1] and recent review by Mathijessen and van der Meulen[2] ), and the plastic or ophthalmic surgeon must be able to technically execute these techniques to close eyelid defects.

Preoperatively, several factors must be analyzed carefully, since they affect the surgical plan and outcome. These include the size and orientation of the defect, patient's age, vascular supply to surrounding tissues, biologic behavior of the tumor, previous treatment, age of the wound, and other factors, such as prior radiation treatment.

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History of the Procedure

Procedures for repairing eyelid defects most likely have been around since the earliest surgeries. Since the beginnings of the specialties of plastic and oculoplastic surgery, new techniques have been introduced, and further refinements and modification of these techniques have occurred with the progression of time.

For example, the Hughes tarsoconjunctival flap initially was described in 1937 for reconstructing full-thickness defects involving the central portion of the lower eyelid. The use of this flap has evolved, and the flap has been refined and modified over the last 60 years.

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Problem

Eyelid defects are classified according to size and location. A common way of breaking down full-thickness defects is as follows:

  • For young patients (tight lids)
    • Small - 25-35%
    • Medium - 35-45%
    • Large - Greater than 55%
  • For older patients (lax lids)
    • Small - 35-45%
    • Medium - 45-55%
    • Large - Greater than 65%

A typical defect may involve 50% of the central portion of the lower eyelid. Defects may involve the combination of eyelid and canthi. Involvement of the eyelid margin should be noted. If the eyelid margin is spared, closure by local flap or skin graft may suffice. Once the margin is involved, surgical repair must restore the integrity of the eyelid margin.

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Epidemiology

Frequency

Trauma is the most common cause leading to reconstruction of the lower lid. Basal cell carcinoma (BCC) is the second most common cause for eyelid reconstruction. It is the most common eyelid malignancy and accounts for approximately 90% of eyelid tumors.

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Etiology

As stated above, the 2 causes of defects requiring reconstruction are tumors and trauma.

BCC is the most common eyelid malignancy. Squamous cell carcinoma (SCC), sebaceous cell carcinoma (SebCC), and cutaneous melanoma are other neoplasms that involve the eyelids.

In addition to surgical excision of tumors, eyelid defects may result from trauma or burns, or they may be congenital.

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Presentation

Patients can present with a lid tumor for primary excision or after excision performed by another surgeon (commonly, after Mohs surgery performed by a dermatologist).

Patients also may present after acute trauma or for secondary reconstruction sometime after primary repair posttrauma.

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Indications

Reconstruction is indicated for all defects that may lead to secondary complications if not repaired. These complications may include lid notching, epiphora, corneal exposure, and lagophthalmos.

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Relevant Anatomy

Lower eyelid can be separated into 2 main layers or lamellae, anterior and posterior. The arterial anatomy of the eyelids and the importance to eyelid reconstruction has been described by Erdogmus and Gosva.[3]

Structures that must be considered in a description of lid anatomy are the skin and subcutaneous tissue; the orbicularis oculi muscle; the submuscular areolar tissue; the fibrous layer, consisting of the tarsi and the orbital septum; the lid retractors of the upper and lower eyelids; the retroseptal fat pads; and the conjunctiva. For more information about the relevant anatomy, see Eyelid Anatomy.

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Contraindications

Standard contraindications for surgical procedures apply.

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Contributor Information and Disclosures
Author

Mounir Bashour, MD, PhD, CM, FRCSC, FACS Assistant Professor of Ophthalmology, McGill University Faculty of Medicine; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD

Mounir Bashour, MD, PhD, CM, FRCSC, FACS is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American College of International Physicians, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, American Society of Mechanical Engineers, American Society of Ophthalmic Plastic and Reconstructive Surgery, Biomedical Engineering Society, Canadian Medical Association, Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, International College of Surgeons US Section, Ontario Medical Association, Quebec Medical Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jorge I de la Torre, MD, FACS Professor of Surgery and Physical Medicine and Rehabilitation, Chief, Division of Plastic Surgery, Residency Program Director, University of Alabama at Birmingham School of Medicine; Director, Center for Advanced Surgical Aesthetics

Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Association for Academic Surgery, Medical Association of the State of Alabama

Disclosure: Nothing to disclose.

Chief Editor

Zubin J Panthaki, MD, CM, FACS, FRCSC Professor of Clinical Surgery, Department of Surgery, Division of Plastic Surgery, Associate Professor Clinical Orthopedics, Department of Orthopedics, University of Miami, Leonard M Miller School of Medicine; Chief of Hand Surgery, University of Miami Hospital; Chief of Hand Surgery, Chief of Plastic Surgery, Miami Veterans Affairs Hospital

Zubin J Panthaki, MD, CM, FACS, FRCSC is a member of the following medical societies: American College of Surgeons, American Society for Surgery of the Hand, American Society of Plastic Surgeons, Canadian Society of Plastic Surgeons, American Council of Academic Plastic Surgeons, Miami Society of Plastic Surgeons, Medical Council of Canada, Canadian Military Engineers Association

Disclosure: Nothing to disclose.

Additional Contributors

Neal R Reisman, MD, JD Chief of Plastic Surgery, St Luke's Episcopal Hospital; Clinical Professor of Plastic Surgery, Baylor College of Medicine

Neal R Reisman, MD, JD is a member of the following medical societies: American Society of Plastic Surgeons, American College of Surgeons, American Society for Aesthetic Plastic Surgery, Lipoplasty Society of North America, Texas Medical Association, Texas Society of Plastic Surgeons

Disclosure: Nothing to disclose.

References
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  2. Mathijssen IM, van der Meulen JC. Guidelines for reconstruction of the eyelids and canthal regions. J Plast Reconstr Aesthet Surg. 2009 Jun 24. [Medline].

  3. Erdogmus S, Govsa F. The arterial anatomy of the eyelid: importance for reconstructive and aesthetic surgery. J Plast Reconstr Aesthet Surg. 2007. 60(3):241-5. [Medline].

  4. Rathore DS, Chickadasarahilli S, Crossman R, et al. Full thickness skin grafts in periocular reconstructions: long-term outcomes. Ophthal Plast Reconstr Surg. 2014 Nov-Dec. 30(6):517-20. [Medline].

  5. Ambrozová J, Mesták J, Smutková J. Reconstruction of the lower eyelid after excision of major tumours. Acta Chir Plast. 1993. 35(3-4):131-45. [Medline].

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  8. Boynton JR. Semicircle flap reconstruction "plus". Ophthalmic Surg. 1993 Dec. 24(12):826-30. [Medline].

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  13. Glatt HJ. Tarsoconjunctival flap supplementation: an approach to the reconstruction of large lower eyelid defects. Ophthal Plast Reconstr Surg. 1997 Jun. 13(2):90-7. [Medline].

  14. Hatoko M, Kuwahara M, Shiba A, Tanaka A, Tada H, Okazaki T. Reconstruction of full-thickness lower eyelid defects using a blepharoplasty technique with a hard palate mucosal graft. Ann Plast Surg. 1999 Jun. 42(6):688-92. [Medline].

  15. Holds JB, Anderson RL. Medial canthotomy and cantholysis in eyelid reconstruction. Am J Ophthalmol. 1993 Aug 15. 116(2):218-23. [Medline].

  16. Iliff CE, Iliff NT. Partial and total reconstruction of the lower eyelid. Ophthalmology. 1980 Apr. 87(4):272-8. [Medline].

  17. Jordan DR, Anderson RL, Holds JB. Modifications to the semicircular flap technique in eyelid reconstruction. Can J Ophthalmol. 1992 Apr. 27(3):130-6. [Medline].

  18. Leone CR Jr. Periosteal flap for lower eyelid reconstruction. Am J Ophthalmol. 1992 Oct 15. 114(4):513-4. [Medline].

  19. Lowry JC, Bartley GB, Garrity JA. The role of second-intention healing in periocular reconstruction. Ophthal Plast Reconstr Surg. 1997 Sep. 13(3):174-88. [Medline].

  20. Matsuo K, Sakaguchi Y, Kiyono M, Hataya Y, Hirose T. Lid margin reconstruction with an orbicularis oculi musculocutaneous advancement flap and a conchal cartilage graft. Plast Reconstr Surg. 1991 Jan. 87(1):142-5. [Medline].

  21. McCord CD, Nunery WR, Tanenbaum. Reconstruction of the lower eyelid and outer canthus. Oculoplastic Surgery. 1995. 119-44.

  22. Mehta HK. Simultaneous spontaneous and primary surgical repair of eyelids. Br J Ophthalmol. 1989 Jul. 73(7):488-93. [Medline].

  23. Miller EA, Boynton JR. Complications of eyelid reconstruction using a semicircular flap. Ophthalmic Surg. 1987 Nov. 18(11):807-10. [Medline].

  24. Papp C, Maurer H, Geroldinger E. Lower eyelid reconstruction with the upper eyelid rotation flap. Plast Reconstr Surg. 1990 Sep. 86(3):563-5; discussion 566-8. [Medline].

  25. Rohrich RJ, Zbar RI. The evolution of the Hughes tarsoconjunctival flap for the lower eyelid reconstruction. Plast Reconstr Surg. 1999 Aug. 104(2):518-22; quiz 523; discussion 524-6. [Medline].

  26. Steinkogler FJ. Reconstruction of the lower lid. Br J Ophthalmol. 1984 Jul. 68(7):507-10. [Medline].

 
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Direct layered closure of a lid margin defect, showing placement of tarsal sutures. A - Posterior lid margin; B - Gray line; C - Anterior lid margin.
Tenzel rotation flap with steps outlined.
A - A shallow defect involving almost the whole lower lid appropriate for closure using a modified Hughes flap. B - Preparing the Hughes tarsoconjunctival flap undermining the levator to the superior fornix and leaving at least 4 mm of tarsus for lid stability.
The flap is advanced and the upper tarsus sutured to the lower lid conjunctiva and lower tarsus as shown in detail in A.
Mustarde rotational cheek flap.
 
 
 
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