Upper Eyelid Reconstruction Treatment & Management

Updated: Mar 29, 2016
  • Author: Maurice M Khosh, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Treatment

Surgical Therapy

In order to address the reconstructive options in an organized manner, eyelid defects are divided into anterior lamellar defects and full-thickness defects according to size.

Anterior Lamellar Defects

Partial-thickness defects smaller than 5 mm heal well by secondary intention. Defects involving less than half of the upper eyelid width can be closed with a variety of local flaps. Closure is much easier in older patients with skin redundancy. The flaps are raised as skin-muscle composites. The incisions are placed along the natural creases of the eyelid. In patients with superficial defects, remove the orbicularis fibers from the base of the defect prior to flap rotation. Avoid excessive tension along the wounds. The muscle layer is closed separately with 6-0 or 7-0 absorbable sutures, and skin is closed with 6-0 or 7-0 monofilament or 6-0 fast-absorbing catgut sutures. If excess tension causes lagophthalmos, other tissue, such as a skin graft, must be brought in for reconstruction. The skin of the opposite eyelid skin and preauricular area represent readily available sources for skin grafts.

In defects involving more than 50% of the eyelid, full-thickness skin grafting usually represents the best reconstructive option. When performing skin grafts, do not remove the remaining orbicularis from the base of the defect because this is an excellent source of vascular supply for the skin graft. The skin-graft bolster should be kept in place for 3 days.

Full-Thickness Defects

Full-thickness defects of the upper eyelid must be reconstructed in layers in order to allow normal function. Defects involving up to 25% of the lid width can be closed primarily. In older patients with significant skin laxity, this percentage can be higher.

Primary repair

For primary repair, the tarsal edges are first prepared by forming vertically oriented ends that can be directly approximated. A Burow triangle of eyelid skin is excised above the tarsal edges, thus forming a pentagonal defect. The lid is repaired in layers by first approximating the tarsal edges at the lid margin (gray line). Preferred sutures are 6-0 silk sutures because monofilament permanent sutures are not as soft and can cause conjunctival irritation. Next, the tarsus is reapproximated using 6-0 polyglactic sutures. Use 2-3 interrupted sutures with knots tied superficially. The skin is closed with 6-0 silk sutures. Keep the skin suture ends long so that they can be tied under the most superior suture. This helps to keep the suture ends away from the conjunctiva. The skin sutures are removed in 5 days, and the lid margin suture is removed in 7-10 days.

Tenzel flap

Larger defects of the upper eyelid that comprise up to two thirds of the lid width can be closed with a semicircular, or Tenzel flap (see the image below). In this procedure, extra skin is rotated from the lateral orbit and the defect is closed as described in primary closure. The flap starts from the lateral canthus and extends as a semicircle inferiorly to a diameter of 2 cm. The skin is incised down to the periosteum of the orbital rim. The upper limb of the lateral canthal tendon is cut to facilitate flap rotation. A Burow triangle is then removed from the superior edge of the defect to create a pentagonal defect. The primary defect is closed as described in the previous section.

After release of the upper lateral canthal tendon After release of the upper lateral canthal tendon and prior to closing the defect, the defect must be converted into a pentagonal shape by removing a triangular wedge at the top. This allows closure without a large dog-ear deformity.

If tension at the wound edges is excessive, the orbital septum, the levator aponeurosis, and the conjunctiva at the semicircular flap can be sequentially cut to relieve tension. The semicircular flap is closed by first placing a 5-0 monofilament permanent vertical mattress suture at the lateral canthus. The first limb of the suture is placed through the skin of the intact inferior lateral canthus and then brought out at the skin of the semicircular flap. The short limb of the vertical mattress is placed through the semicircular flap, the intact limb of the canthal tendon, and then the skin of the intact eyelid. The remainder of the flap is then closed with permanent sutures in interrupted fashion.

Cutler-Beard flap

Defects that involve more than 50% of the upper eyelid can be closed with an inferiorly based skin-conjunctival (Cutler-Beard) flap (see the image below), similar to the lip switch technique used for lip reconstruction. [1] The skin of the lower eyelid is incised horizontally below the inferior edge of the tarsus. The length of the incision corresponds to the size of the defect to be reconstructed. Make a full-thickness incision through the skin, lid retractors, and the conjunctiva. The cornea must be protected to prevent inadvertent injury. Full-thickness vertical incisions are made from the ends of the horizontal incision. The vertical length of the incisions depends on the vertical dimension of the upper eyelid defect and can be extended as far as the conjunctival fornix.

The width of the flap is equal the width of the de The width of the flap is equal the width of the defect. The incision is made 5 mm inferior to the lash line in order to avoid damage to the tarsal plate. At the time of flap release, care should be taken to protect the globe.

Closure of the defect can be accomplished with or without tarsal reconstruction. If tarsal reconstruction is not undertaken, the skin-conjunctival flap is passed under the lower eyelid tarsal bridge and secured to the edges of the defect in 2 layers. Absorbable sutures with knots away from the cornea are used to close the conjunctival layer. The skin-muscle layer is closed with permanent monofilament sutures, which are removed in 5-7 days.

In the Cutler-Beard flap, the missing tarsus is typically not recreated. When tarsal reconstruction is planned, several options are available for tarsal replacement, including a free tarsal graft from the contra lateral upper eyelid, septal cartilage, or auricular cartilage. A tarsal graft represents the best reconstructive option, in terms of consistency, thickness, and curvature.

The tarsal graft is harvested from the cephalic border of the intact tarsus. The upper eyelid is inverted, and the cephalic border of the tarsus is identified. The horizontal dimension of the graft is then marked. The vertical dimension of the graft is 5 mm at the cephalic border. At least a 5-mm caudal wedge of tarsus must be preserved to prevent secondary deformity of the donor side. The incision is through the conjunctiva and tarsus. Care must be taken to avoid damage to the overlying upper eyelid retractor and the skin. The donor area can be left open to heal. The harvested tarsus is denuded of conjunctiva and placed in between the skin and conjunctiva of the lower lid flap. The lateral edges can be secured to the remnants of native tarsus.

The second stage of the Cutler-Beard flap is performed in 4-6 weeks. During the second stage, the flap is divided and the upper eyelid is contoured to match the contra lateral eyelid. Protect the cornea while the flap pedicle is divided sharply at the level of the new lid margin. The incision is beveled superiorly to obtain more conjunctiva than skin. Ensure that the extra length of conjunctiva is 1-2 mm; this will be wrapped around the edge of the newly formed lid margin. The inferior edge of the lower tarsal bridge is sharply reopened, and the flap remnant is contoured for proper no-tension closure. The wound is closed in layers. Obviously, the reconstructed upper eyelid will lack lashes.

Orbicularis myocutaneous advancement flap

In older patients with large full thickness defects of the upper eyelid, orbicularis myocutaneous advancement flap (OMAF) represents another reconstructive choice. The posterior lamellar defect is first repaired with a mucoperiosteal graft from the hard palate. The hard palate graft should be made slightly larger than the defect to allow for postoperative shrinkage. Next, a triangular myocutaneous flap from above the defect site is advanced inferiorly in V-to-Y fashion to provide coverage anteriorly. The hard palate graft should be secured to the available edges of the tarsal defect with small cat gut sutures. The skin closure is accomplished with 6-0 monofilament permanent sutures which are removed after one week. [2]

The OMAF is advantageous for large full-thickness defects of the upper eyelid because it requires a single procedure, unlike the Cutler-Beard flap. Additionally, no visual obstruction exists with this procedure. However, retraction and ectropion are greater risks. Use of Z-plasty in the upper arm of the V-to-Y closure will lower such risks.

Tarsal plate

In a retrospective study of eight patients, Toft described a one-step method of repairing large upper eyelid defects using the contralateral upper eyelid tarsal plate to reconstruct the posterior lamella and a laterally based myocutaneous pedicle flap to reconstruct the anterior lamella. A free skin graft was used to cover the donor site under the brow. [3]

Regional flaps

In cases in which local flaps are not viable options for eyelid reconstruction, regional flaps can be used. Axially based flaps from the temporal region or the nose offer reconstructive choices for lateral or medial defects, respectively.

Cöloglu et al have described the axial bilobed temporal artery island flap for reconstruction of defects that involve the lateral canthus, including the lower and upper eyelids. [4] In this procedure, the superficial temporal artery (STA) is mapped with a Doppler. An appropriate bilobed island flap of forehead skin, based on the STA branches, is designed. Skin in the temporal area is elevated in a subcutaneous plane, and the feeding arterial supply (with a cuff of intact superficial temporoparietal fascia) is raised to the edge of the island skin flap. During this portion of surgery, avoiding the frontal branch of the facial nerve is important. The skin flap is then raised and attached to the feeding vessel.

The island flap is passed under a subcutaneous tunnel from the temple to the lateral canthus. Prior to inset of the flap, the posterior lamellar defect is reconstructed with a free mucosal flap form the nose or the mouth. The island flap is then inset into the skin defect site. The donor site is closed in V-Y fashion.

Scuderi et al published their results from a 10-year experience using the nasal chondromucosal flap for reconstruction of total and subtotal upper eyelid defects. [5] A flap of nasal periosteum with attached upper lateral cartilage and nasal mucosa is based on the dorsal nasal artery. This flap is used for posterior lamellar defect, and a skin graft is used for anterior lamellar repair.

Initially, a 2.5-cm incision is made vertically along the border of the lateral nasal subunit and the cheek. The periosteum is then incised, and a subperiosteal flap is raised in a lateral-to-medial direction up to the midline of the nose. Superiorly, the flap extends to the inner canthus and the glabella. Inferiorly, the flap reaches the lower margin of the nasal bones. Subsequently, a subcutaneous flap is raised from lateral to medial, just past the nasal midline. The subcutaneous flap is raised to the glabella superiorly, and beyond the lower margin of the upper lateral cartilage inferiorly. Distally, the flap is harvested including the cranial portion of the upper lateral cartilage with attached mucosa.

The extent of cartilage removal is determined by the size of the defect. The flap is then transposed to reconstruct the posterior lamella defect, flap mucosa is attached to the conjunctival margin, and the levator muscle is inserted into the cartilage portion of the flap. The anterior lamella is reconstructed with a skin graft harvested from the contra lateral upper eyelid or the post auricular area. A temporal is recommended. The donor site mucosal defect can be closed primarily or left to heal by secondary intention. The skin incision is closed with fine nylon sutures.

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Postoperative Details

Apply an ophthalmic antibiotic ointment to the surgical site at the conclusion of surgery, and a pressure patch is commonly applied. Pressure bandages are useful to reduce postoperative edema and bleeding and to immobilize the advanced tissue flaps or skin grafts. In addition, 4-0 silk traction sutures placed in the lid margin are useful in selected cases to keep the reconstructed eyelid stretched and to help reduce retraction of the tissues. The pressure patch, traction sutures, and stents for skin grafts are removed in 3-5 days. Antibiotic ointment application is continued until skin healing is complete. Oral antibiotics are routinely administered for patients who are immunocompromised or have reduced healing capacity.

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Follow-up

Most sutures are removed in 5-7 days. If during suture removal the wound becomes dehiscent, the remaining sutures are left in place for another week. Silk lid margin sutures are usually left in place for 10-14 days.

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Complications

A lid notch may develop at the junction of the direct lid margin closure because of excess tension or inadequate alignment. This can be revised with excision and direct closure.

Blunting of the canthal angle may develop after cantholysis or a semicircular flap technique and may be repaired with canthoplasty.

Symblepharon may develop if the raw surface of the inner aspect of the lid reconstruction is allowed to epithelialize. Although this does not usually require treatment, lysis of the symblepharon, a Z-plasty, or a mucous membrane graft may be necessary if the symblepharon is functionally significant.

Trichiasis can be eliminated with cryotherapy or epilation.

Ptosis can develop if the levator aponeurosis attachment is significantly disturbed. Repair with an aponeurosis advancement should be delayed for 4-6 months.

Lagophthalmos may result from upper lid retraction or inadequate orbicularis muscle tone. If topical lubricants do not resolve the problem, surgical revision or partial tarsorrhaphy may be indicated.

Epiphora may result from inadequate tear drainage due to punctal malposition, loss of components of the lacrimal drainage system, or deficiency of the lacrimal pump. Alternatively, epiphora may be caused by reflex lacrimation due to entropion, trichiasis, dry eyes, or exposure keratopathy.

Punctal and lid malposition may require surgical revision.

Defects of the lacrimal drainage system can be repaired with conjunctivodacryocystorhinostomy and Jones tube placement. Secondary lacrimal drainage system surgery should be delayed for at least a year after cutaneous malignancy excision to allow an observation period for possible tumor recurrence.

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Outcome and Prognosis

The surgical outcome for upper eyelid reconstruction is mostly dependent on the extent of the primary defect. Larger defects necessitate more complicated reconstruction with associated risks of complications. In general, reconstruction in older patients is easier because of the increased tissue redundancy and more laxity. The primary goal of upper eyelid reconstruction should be globe protection. Aesthetic results constitute a secondary goal.

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