Lower Eyelid Reconstruction

Updated: Sep 20, 2022
Author: Mounir Bashour, MD, PhD, CM, FRCSC, FACS; Chief Editor: Zubin J Panthaki, MD, CM, FACS, FRCSC 



Eyelid tumor excision and trauma are 2 common causes of eyelid defects requiring surgical reconstruction.[1]

A wide variety of surgical techniques are available,[2, 3] 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.

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.


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.



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.


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.


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.


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.

Relevant Anatomy

The lower eyelid can be separated into two 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.[4]

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.


Standard contraindications for surgical procedures apply.



Imaging Studies

For significant trauma or large invasive tumors, consider imaging studies to exclude involvement of adjacent structures, orbit soft tissue, orbital bones, nose, sinuses, and zygoma.

  • CT scan of orbits and sinuses is the best imaging modality when looking at bony involvement.

  • MRI is the best imaging modality when looking at soft tissue involvement.

Other Tests

Lacrimal system exploration: Irrigation and possibly intubation may be necessary for protection or repair of the lacrimal drainage system, especially in medial trauma cases.



Approach Considerations

One school of thought, particularly for lower lid medial defects, is allowing defects to close by secondary intention. A study by Morton of 34 marginal lower lid defects that were permitted to heal via secondary intention found consistently high-quality cosmetic and functional results, with medial lid defects demonstrating especially good outcomes.[5]

Surgical Therapy

Repair of lower eyelid defects involving the eyelid margin and extending from one third to one half of the horizontal length of the eyelid margin requires advancement of adjacent tissue to effect closure. Direct closure of full-thickness defects (see image below) greater than one third of the eyelid may result in excessive tension in the wound, leading to wound dehiscence and eyelid notching.

Direct layered closure of a lid margin defect, sho 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 semicircular rotation flap

The author's choice to repair defects of moderate size is the Tenzel semicircular rotation flap (see image below). This technique involves the rotation of a semicircular musculocutaneous flap beginning at the lateral canthus, extending upward in a semicircular fashion. The flap is designed according to the size and location of the lower eyelid defect, and it must extend above the lateral canthal angle to ensure elevation of the lower eyelid during wound healing. Once the flap is rotated into position and sutured, adequate lateral canthal fixation must be achieved. Conjunctiva from the inferior fornix should be advanced or rotated into position to cover the posterior surface of the skin muscle flap. Skin closure of the semicircular donor site is the final step.

Tenzel rotation flap with steps outlined. Tenzel rotation flap with steps outlined.

Larger flaps can be backed with ear cartilage, nasal septal or alar chondromucosal grafts, or a free tarsoconjunctival flap. When used, these grafts must be fixated inside the lateral orbital rim to achieve lateral support for the newly reconstructed eyelid.

Tarsoconjunctival bridge flap (modified Hughes procedure)

Lower eyelid defects greater than 50% of the horizontal length of the eyelid may be repaired with a tarsoconjunctival bridge flap from the upper eyelid (see images below).

A - A shallow defect involving almost the whole lo 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 The flap is advanced and the upper tarsus sutured to the lower lid conjunctiva and lower tarsus as shown in detail in A.

This procedure effectively recreates the posterior lamella of the lower eyelid through use of a segment of upper eyelid tarsus and conjunctiva. Since the flap must be left in place from 4-6 weeks prior to second-stage separation, it is not suited for patients sighted only in the involved eye or of amblyogenic age. In such situations, a free tarsoconjunctival graft from the opposite upper eyelid is more appropriate. Hughes originally described a tarsoconjunctival flap involving the eyelid margin. This procedure no longer is performed.

The modified Hughes procedure is performed as follows. A 4-0 silk traction suture is placed in the upper eyelid margin. The upper eyelid is everted over a Desmarres retractor. Tarsus and conjunctiva of the upper eyelid are incised horizontally 4 mm proximal to the eyelid margin. At least 4 mm of tarsus must be left for lid stability and to prevent the complication of upper lid entropion. A tarsal conjunctival flap is developed by dissecting the tarsus and conjunctiva away from the levator aponeurosis and Müller muscle. Dissection continues superior to the level of the Whitnall ligament.

The bridge flap is advanced into the defect of the lower eyelid; it may be moved laterally or medially, depending on the location of the lower eyelid defect. Edges of the tarsoconjunctival advancement flap are sutured to the remnants of the medial and lateral tarsus of the lower eyelid. If the lower eyelid defect involves either the medial or lateral canthal angle, the tarsoconjunctival flap must be fixated appropriately either to the lateral orbital tubercle or to the posterior lacrimal crest.

After the flap has been secured in position, a full-thickness skin graft is placed over the anterior surface. Skin can be harvested from the upper eyelid or from the retroauricular area. Alternatively, a locally based random flap may be advanced over the posterior lamella to create the new anterior lamella. The flap is separated at 4-6 weeks. A grooved director is slid underneath the flap anterior to the cornea, and the flap is divided. Conjunctiva is sutured to the lower eyelid margin. The Müller muscle and the levator aponeurosis are dissected away from the overlaying skin and allowed to retract. This prevents postoperative upper eyelid retraction and lagophthalmos.

A retrospective study by Aggarwal et al of patients who underwent the modified Hughes procedure for lower eyelid reconstruction suggested that the use of an amniotic membrane graft in the operation can prevent the development of a hyperemic, hypertrophic eyelid margin. The study included 30 patients treated with modified Hughes surgery, 29 of whom received the membrane graft as part of the primary operation and one of whom underwent grafting during a revision procedure for a hyperemic eyelid margin. In each case, the graft was added to the mucocutaneous junction. Neither hyperemia nor hypertrophy was seen in the patients at mean 4.41-month follow-up. The investigators cautioned, however, that additional research, employing a greater cohort size and longer follow-up, is needed to confirm these results.[6]

Free tarsoconjunctival graft

Free tarsoconjunctival grafts from an upper eyelid also may be used to correct defects in the lower eyelid. This composite graft is harvested from the upper eyelid tarsus of the opposing eyelid or from the alternate upper eyelid. A marginal 4-mm strip of tarsus is left in the donor eyelid. The upper tarsal defect is not closed. Edges of the free tarsoconjunctival graft are sutured to the edges of the lower eyelid defect. Conjunctiva at the inferior border of the free tarsoconjunctival graft is sutured to the palpebral conjunctiva. The anterior lamella is reconstructed by a local musculocutaneous flap.

Mustarde cheek rotation flap

Lower eyelid defects involving the entire lower eyelid may be reconstructed using a Mustarde cheek rotation flap (see image below). This large skin muscle flap is rotated from the cheek to repair large lower eyelid defects. Incision begins at the lateral canthal angle, extends upward onto the temple, and swings posteriorly just anterior to the ear and then inferiorly across the mandible. Establishing good vertical height to this flap is important so the correct position of the lateral canthal angle can be achieved postoperatively. The posterior lamella of this flap must be reconstructed with a free tarsoconjunctival graft, a nasal septal cartilage graft, or with mucous membrane.

Mustarde rotational cheek flap. Mustarde rotational cheek flap.


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.


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

  • Marginal ectropion

  • Lateral tissue sag

  • Corneal injury

  • Orbital hemorrhage

  • Conjunctival scarring

  • Upper eyelid instability

Postoperative lower lid ectropion can result from anterior lamella shortening or lower lid laxity. Vertical shortage of lower lid skin is worsened by the effect of gravity and altered lid mobility. To avoid this, the surgeon should not hesitate to use full-thickness skin grafts during the initial reconstruction. Upper advancement flaps (cheek) are poor substitutes and often worsen the problem, although a suborbicularis oculi fat (SOOF) lift can be helpful. Lower lid laxity may result from excessive horizontal length of the lower lid (oversized grafts) or poor fixation at the lateral canthal tendon. These can be avoided by measuring the correct length of tissue using calipers, keeping the lower lid stretched to estimate the desired level of tension, and using a nonabsorbable suture fixed to the periosteum inside the lateral orbital rim above the midpupillary line.

Lateral lid sag occurs for much the same reasons as ectropion and can be avoided similarly.

In a study of patients in whom full-thickness lower eyelid reconstruction was performed, with a cheek rotation flap used for anterior lamella reconstruction, Abe et al reported that the risk of postreconstruction drooping deformity is increased if the excised tumor was in a medial location, over 50% of the horizontal width of the lower eyelid was involved in resection, and subcutaneous cheek tissue dissection extended below the zygomatic arch.[7]

Upper lid retraction can occur with the modified Hughes procedure. Careful dissection of the flap using a moist cotton-tip applicator and tenotomy of advanced Müller muscle can prevent upper lid retraction. If it occurs, it can be treated using a levator recession with or without spacer material. Upper lid instability results if the tarsal margin has been violated; leaving at least 4 mm of tarsus is essential for upper lid stability.

To avoid 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.

Outcome and Prognosis

Both function and cosmesis measure outcome. The outcome is poorer with greater initial defect. However, in general, all of the procedures described in this article have adequate, if not excellent, outcomes, even for the larger defects, if meticulous attention to detail is taken in the repair.

A retrospective study by Custer et al on five different techniques for lower eyelid margin reconstruction in patients who underwent Mohs surgery found that good to excellent functional results were obtained in 100% of patients, with good to excellent cosmetic results achieved in 87.1% of cohort members. The investigators reviewed primary closure, semicircular flap, dermal matrix graft, sliding tarsal flap, and tarsoconjunctival flap procedures. Tarsoconjunctival flap surgeries were more often associated with anterior lamellar deformities and the need for postoperative intervention. The incidence of lateral canthal deformities was greater with semicircular flaps than with other flap/graft techniques, but the incidence of eyelash disruption was lower. Dermal matrix grafts, semicircular flaps, and sliding tarsal flaps all had similar mean cosmetic ratings, with tarsoconjunctival flaps having a lower grading than these surgeries.[8]

A study by Rathore et al found good results with full-thickness skin grafts in eyelid reconstruction. The study, which included 100 Caucasian patients (60 with lower eyelid defects and the rest with upper eyelid or canthal defects), found that 94% of the group obtained good eyelid color match and that as many as 95% achieved good final eyelid position. Patients with late sequelae included four with lower eyelid graft contracture and 23 with hypertrophic scarring.[9]

Future and Controversies

No real controversies exist in this field. Future refinements or modifications of technique remain possible, although at a slower rate, and the use of artificial materials (ie, to use in place of skin and connective tissue) likely will be incorporated as they become available, especially for massive defects.