Upper Eyelid Reconstruction Procedures

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).

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.

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.

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.

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.

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.

Standard contraindications for surgical procedures apply.

For significant trauma or large invasive tumors, consider imaging studies to exclude involvement of adjacent structures, such as 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.

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

A literature review by Jennings et al looking at the repair of large (>50%) upper eyelid defects over a 10-year period found that the overall tendency was for surgeons to replace the posterior lamella with a graft (most commonly utilizing tarsoconjunctiva from the contralateral upper lid) and to replace the anterior lamella with a skin flap derived from the lower eyelid or the adjacent periorbital area. Bridging flaps from the lower eyelid were made up of skin; tissue from the skin, orbicularis, and conjunctiva; or tarsoconjunctiva. In nonbridging techniques, a tarsoconjunctival or substitute graft was typically utilized for the posterior lamella, while the anterior lamella was repaired with a skin flap.[4]

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 below).

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

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 below). 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 below). 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 below). 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 modified Cutler-Beard procedure has been recently described by Yoon and McCully.[5, 6]

Another modified version of the Cutler-Beard technique, as described by Bengoa-González et al, uses a tarsoconjunctival graft taken from the contralateral upper lid. The graft includes an extra 3 mm of conjunctiva from the tarsus’s superior edge, with this excess conjunctival side being “sutured superiorly to the conjunctiva [of the damage eyelid] or to the superior retractor muscles and laterally and medially to the margins of the defect or to the canthal tendon.” In this way, according to the authors, the posterior lamella is completely reconstructed. In a retrospective study of patients who underwent the procedure, Bengoa-González and colleagues found no occurrences of upper eyelid retraction, eyelid margin entropion, or graft retraction at mean 41.6-month follow-up.[7]

A study by Wang et al indicated that repair of full-thickness upper eyelid defects using pedicled lower eyelid–sharing flaps yields good results. The study, which included 13 patients who underwent the procedure immediately following tarsal gland carcinoma excision from an upper eyelid, found no recurrence, hypertrophic scar, bulky appearance, or lagophthalmos, at 1- to 18-month follow-up.[8]

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.

McVeigh and Caesar described an upper eyelid repair technique that uses a blepharoplasty flap to fix defects caused when a broad-based upper eyelid lesion situated between the eyelid crease and eyelashes is excised. This procedure involves marking the eyelid crease and drawing a line “perpendicular to the crease line along the aspect of the lesion closest to the” eyelid’s center, so that the eyelid is divided into four quarters. The lesion and the diagonally lying area are excised, with excess upper eyelid skin then used to create an advancement flap and the defect closed by moving the flap inferiorly.[9]

Matsuo et al described the successful simultaneous reconstruction of upper eyelid and lateral eyebrow defects using an extended lateral orbital flap that included sideburn hair. The flap, used on six patients with partial eyebrow and upper eyelid defects, included an orbicularis oculi muscle pedicle.[10]

Complete loss of the upper eyelid is a difficult problem to treat; a 2013 rabbit study[11] showed that it may be possible in the future to use tissue expanders with autogeneic conchal chondro-grafts.

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 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.

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

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