eMedicine Specialties > Plastic Surgery > Eyelids

Eyelid Reconstruction, Upper Eyelid: Treatment

Author: Mounir Bashour, MD, CM, FRCS(C), PhD, FACS, Assistant Professor of Ophthalmology, McGill University; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD
Contributor Information and Disclosures

Updated: Jan 31, 2008

Treatment

Surgical Therapy

Upper eyelid defects involving one third or less of the horizontal length of the upper eyelid usually can be repaired by direct closure. Remember to use a pentagonal wedge excision in the upper lid when removing a large lesion; other wedge excisions can cause lid kinking, notching, and ectropion (see Image 1).

A superior lateral cantholysis adds horizontal mobility and allows closure of larger defects using direct tarsal suturing and closure (see Image 2).

Upper eyelid defects involving loss of one third to one half of the horizontal length of the upper eyelid require other techniques. One such technique is the sliding tarsoconjunctival flap (see Image 3). This is a variation of the modified Hughes procedure described for the lower eyelid (see Eyelid Reconstruction, Lower Eyelid). It is an excellent method for reconstructing medial or lateral defects of the upper eyelid, but it is not suited for repair of central defects.

Following resection, the remaining tarsus is used as structural support (posterior lamella), and a skin graft or local musculocutaneous flap is used for the anterior lamella. As in any eyelid reconstruction, canthal attachments must be secure and in proper position. Another possibility is to use a Tenzel semicircular flap designed for the upper lid (see Image 3). This technique involves the rotation of a semicircular musculocutaneous flap beginning at the lateral canthus, extending downward in a semicircular fashion. Details on this procedure can be found in the article Eyelid Reconstruction, Lower Eyelid.

The Cutler-Beard procedure is indicated for large central defects of the upper eyelid (see Image 4). This technique uses a full-thickness segment of lower eyelid tissue that is passed under an intact bridge, the lower eyelid margin. A full-thickness lower eyelid flap is sutured into the defect in the upper eyelid. As with the flap created in a modified Hughes tarsoconjunctival procedure, the Cutler-Beard flap occludes vision for 6-8 weeks and must be divided in a second stage of the surgical procedure. It, therefore, is not suited for patients sighted only in the involved eye or of amblyogenic age.

A free tarsoconjunctival graft from the patient's contralateral upper eyelid is another useful technique. A free graft of tarsus and conjunctiva is harvested from the contralateral side and is sutured in place with edges parallel to the edges of the defect. A vascularized anterior lamella is provided from adjacent tissue.

Follow-up

See the patient 1 day postoperatively for a routine check. If nonabsorbable sutures were used, the patient should return for suture removal in 1 week.

Complications

Eyelid marginal positional abnormalities usually are not serious complications but can be frustrating for both patient and surgeon, sometimes requiring further surgery for correction. Other complications of upper lid reconstruction include the following:

  • Marginal ectropion
  • Lateral tissue sag
  • Corneal injury
  • Orbital hemorrhage
  • Postoperative ptosis
  • Conjunctival scarring

Postoperative upper lid ectropion can result from anterior lamella shortening. Vertical shortage of upper lid skin is worsened by the effect of altered lid mobility. To avoid this, use full-thickness skin grafts during the initial reconstruction.

To avoid a postoperative orbital hematoma, meticulous cautery should be used, and ice compress dressings rather than tight pressure dressings should be used afterward, ensuring that visual acuity does not deteriorate.

In most instances, postoperative ptosis should not be reoperated on for 6 months, especially if progressive improvement is noted. This allows for potential spontaneous recovery of function.

More on Eyelid Reconstruction, Upper Eyelid

Overview: Eyelid Reconstruction, Upper Eyelid
Workup: Eyelid Reconstruction, Upper Eyelid
Treatment: Eyelid Reconstruction, Upper Eyelid
Follow-up: Eyelid Reconstruction, Upper Eyelid
Multimedia: Eyelid Reconstruction, Upper Eyelid
References
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References

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Further Reading

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Keywords

eyelid reconstruction, upper eyelid reconstruction, eyelid defects, surgical reconstruction of eyelid, eyelid tumor excision, eyelid trauma, superior lateral cantholysis, sliding tarsoconjunctival flap, Cutler-Beard procedure, free tarsoconjunctival graft, eyelid malignancy, eyelid surgery, basal cell carcinoma, BCC, squamous cell carcinoma, SCC, sebaceous cell carcinoma, SebCC, cutaneous melanoma

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Contributor Information and Disclosures

Author

Mounir Bashour, MD, CM, FRCS(C), PhD, FACS, Assistant Professor of Ophthalmology, McGill University; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD
Mounir Bashour, MD, CM, FRCS(C), PhD, 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, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Medical Editor

Neal R Reisman, MD, JD, Associate Chief, Department of Plastic Surgery, Clinical Associate Professor, St Luke's Episcopal Hospital, Baylor College of Medicine
Neal R Reisman, MD, JD is a member of the following medical societies: American Association of Plastic Surgeons, American College of Medical Quality, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society for Surgery of the Hand, Lipoplasty Society of North America, Texas Medical Association, and Texas Society of Plastic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics
Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Society of Plastic Surgeons, and Colorado Medical Society
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.

 
 
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