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Upper Eyelid Reconstruction Procedures

  • Author: Mounir Bashour, MD, PhD, CM, FRCSC, FACS; Chief Editor: Lars M Vistnes, MD, FRCSC, FACS  more...
 
Updated: May 03, 2015
 

Background

Tumor excision and trauma are 2 common causes of eyelid defects requiring surgical reconstruction. A wide variety of surgical techniques is available (see recent review by Mathijessen and van der Meulen[1] ) and the plastic or ophthalmic surgeon must be able to technically execute them to close the eyelid defects.

Preoperatively, several factors must be analyzed carefully, since they affect the surgical plan and outcome.[2] These factors 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 (eg, 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.

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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 upper eyelid. Obviously, 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 of 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

The upper 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

Lars M Vistnes, MD, FRCSC, FACS Professor of Surgery, Emeritus, Stanford University Medical Center

Lars M Vistnes, MD, FRCSC, FACS is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

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

  2. Codner MA, Weinfeld AB. Pr47 comprehensive eyelid reconstruction. ANZ J Surg. 2007 May. 77 Suppl 1:A71. [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. Yoon MK, McCulley TJ. Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure. Ophthal Plast Reconstr Surg. 2013 May-Jun. 29(3):227-30. [Medline].

  5. Wang YC, Dai HY, Xing X, et al. Pedicled lower lid-sharing flap for full-thickness reconstruction of the upper eyelid. Eye (Lond). 2014 Nov. 28(11):1292-6. [Medline]. [Full Text].

  6. Matsuo S, Hashimoto I, Seike T, et al. Extended Hair-bearing Lateral Orbital Flap for Simultaneous Reconstruction of Eyebrow and Eyelid. Plast Reconstr Surg Glob Open. 2014 Feb. 2(2):e111. [Medline]. [Full Text].

  7. Gu Y, Guo X, Wang T, Yu H, Yang W, Wang J. Reconstruction of total upper eyelid with prefabricated capsule-lined advancement flaps. J Craniofac Surg. 2013 May. 24(3):1038-41. [Medline].

  8. Achauer BM, Menick FJ. Salvage of seeing eyes after avulsion of upper and lower lids. Plast Reconstr Surg. 1985 Jan. 75(1):11-6. [Medline].

  9. Avram DR, Hurwitz JJ, Kratky V. Modified Tessier flap for reconstruction of the upper eyelid. Ophthalmic Surg. 1991 Aug. 22(8):467-9. [Medline].

  10. Beyer-Machule CK, Shapiro A, Smith B. Double composite lid reconstruction: a new method of upper and lower lid reconstruction. Ophthal Plast Reconstr Surg. 1985. 1(2):97-102. [Medline].

  11. Boynton JR. Subtotal reconstruction of the upper eyelid. A one-stage procedure eliminating temporary lid closure. Arch Ophthalmol. 1985 Feb. 103(2):288-9. [Medline].

  12. Carraway JH. Aesthetic approach to upper eyelid reconstruction. Clin Plast Surg. 1981 Apr. 8(2):237-41. [Medline].

  13. Divine RD, Anderson RL. Techniques in eyelid wound closure. Ophthalmic Surg. 1982 Apr. 13(4):283-7. [Medline].

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  15. Jordan DR, Anderson RL, Nowinski TS. Tarsoconjunctival flap for upper eyelid reconstruction. Arch Ophthalmol. 1989 Apr. 107(4):599-603. [Medline].

  16. Kadoi C, Hayasaka S, Kato T, Nagaki Y, Matsumoto M, Hayasaka Y. The cutler-beard bridge flap technique with use of donor sclera for upper eyelid reconstruction. Ophthalmologica. 2000. 214(2):140-2. [Medline].

  17. Kersten RC, Anderson RL, Tse DT, Weinstein GL. Tarsal rotational flap for upper eyelid reconstruction. Arch Ophthalmol. 1986 Jun. 104(6):918-22. [Medline].

  18. Leone CR Jr. Tarsal-conjunctival advancement flaps for upper eyelid reconstruction. Arch Ophthalmol. 1983 Jun. 101(6):945-8. [Medline].

  19. Mauriello JA Jr, Antonacci R. Single tarsoconjunctival flap (lower eyelid) for upper eyelid reconstruction ("reverse" modified Hughes procedure). Ophthalmic Surg. 1994 Jun. 25(6):374-8. [Medline].

  20. McGregor IA. Eyelid reconstruction following subtotal resection of upper or lower lid. Br J Plast Surg. 1973 Oct. 26(4):346-54. [Medline].

  21. Okada E, Iwahira Y, Maruyama Y. The V-Y advancement myotarsocutaneous flap for upper eyelid reconstruction. Plast Reconstr Surg. 1997 Sep. 100(4):996-8. [Medline].

  22. Petersen NC. Reconstruction of the upper eyelid ad modum Cutler and Beard. Acta Ophthalmol (Copenh). 1969. 47(1):228-33. [Medline].

  23. Pham RT. Reconstruction of the upper eyelid. Otolaryngol Clin North Am. 2005 Oct. 38(5):1023-32. [Medline].

  24. Putterman AM. Wedge resection of eyelid margin in the treatment of abnormal eyelid margins. Arch Ophthalmol. 1995 Nov. 113(11):1458-9. [Medline].

  25. Tenzel RR, Stewart WB. Eyelid reconstruction by the semicircle flap technique. Ophthalmology. 1978 Nov. 85(11):1164-9. [Medline].

  26. Wesley RE, McCord CD. Reconstruction of the upper eyelid and medial canthus. Oculoplastic Surgery. 1995. 99-117.

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(A) The correct pentagonal wedge excision that should be used in the upper lid. (B) and (C) Incorrect wedge excisions leading to lid notching and kinking.
Layered suture closure of lid margin defect.(A) Excision of lesion. (B) 6-0 Vicryl sutures through tarsus. (C) Either 6-0 silk or 6-0 gut sutures for the margins. (D) Skin closure with interrupted 6-0 silk or 6-0 gut sutures.
(A) Large upper lid defect. (B) Tarsus conjunctival flap fashioned. (C) Flap moved horizontally to fill in defect, with edges sutured to orbital rim and levator remnants. (D) Lid margin suture placed. (E) Skin graft placed.
Tenzel flap for upper lid.
Cutler-Beard flap.
 
 
 
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