Upper Eyelid Reconstruction Procedures Treatment & Management

Updated: Feb 09, 2021
  • Author: Mounir Bashour, MD, PhD, CM, FRCSC, FACS; Chief Editor: Zubin J Panthaki, MD, CM, FACS, FRCSC  more...
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Approach Considerations

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]


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 below).

(A) The correct pentagonal wedge excision that sho (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.

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

Layered suture closure of lid margin defect.(A) Ex 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.

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.

(A) Large upper lid defect. (B) Tarsus conjunctiva (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.

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.

Tenzel flap for upper lid. Tenzel flap for upper lid.

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]

Cutler-Beard flap. Cutler-Beard flap.

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.


Outcome and Prognosis

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.


Future and Controversies

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.