84 Lower Eyelid Reconstruction

MEDIUM DEFECTS EXTENDING BEYOND THE MEDIAL CANTHAL ANGLE

In some cases, the defect will extend beyond the medial canthal angle into the medial canthus. It is best to fill in the defect medial to the medial canthal angle with an advancement flap, a rotation flap, or a graft, and simply advance the lid near the medial canthal angle. If the lid is advanced beyond the medial canthal angle, tarsus and lashes will be brought up toward the nose giving an unnatural appearance. It is only necessary to bring the tarsus and conjunctiva of the lower lid to the area of the caruncle. In cases in which the defect extends into the medial canthal area, the triangle of skin and muscle inferior to the fullthickness eyelid defect can be brought into the defect in the medial canthus as a skin muscle flap. The muscle layer beneath the superior aspect of the skin triangle remains attached so that the flap can be advanced superiorly. The tarsus of the remaining lower lid can be attached to elements of the medial canthal tendon if they exist, or can simply be attached to the skin muscle flap which is advanced into the medial canthal defect (216–223).

If this type of skin muscle flap is not appropriate, other rotation flaps, advancement flaps, or skin grafts described in Chapter 10 can be used to reconstruct the medial canthal area.

216

a

b

c

216: Medium-sized defect extending beyond the medial canthal angle. a:The dotted lines indicate the lateral canthal advancement flap and, inferior to the defect, the triangle of skin that will be converted to a myocutaneous island flap. b:The lower lid is brought medially to an area below the punctum of the upper lid.The rest of the defect is filled with the myocutaneous flap, which remains connected to the donor site by a muscle pedicle from the superior half of the island flap. c:The myocutaneous flap is sutured in place and the donor area re-approximated with a vertical closure.

219

221

217–223 Myocutaneous island flap. 217: Basal cell carcinoma involving the medial aspect of the right lower lid. 218: Defect extending beyond the medial canthal angle. 219: Myocutaneous island flap hinged to underlying muscle is brought into the defect beyond the medial canthal angle. 220: Lower lid is brought to the area of the caruncle. The flap is sewn into place and the defect inferior to the triangular flap repaired primarily. 221: Squamous cell carcinoma in the medial aspect of the left lower lid of a 30-year-old woman. 222: Sutures outline the myocutaneous island flap and the lateral advancement flap. Photo taken one day after surgery (compare to 216c). 223:Ten weeks following surgery.

220

222

223

d

224 Medium-sized defect in the lateral aspect of the lower lid.

a: Conjunctival-lined tarsal flap outlined in the superior lateral aspect of the upper lid tarsus.The tarsal flap remains attached laterally. b:The tarsal flap is rotated into the lower lid defect and sutured to the remaining tarsus and the lower lid retractors with interrupted 5-0 chromic gut sutures. c: A base-up triangle of skin and subcutaneous tissue is removed inferior to the eyelid defect, and a lateral advancement flap is fashioned. d:The skin muscle advancement

flap is sutured to the remaining lower lid tissues with deep absorbable sutures and small skin sutures.The tarsal flap is secured to the skin muscle advancement flap with 7-0 chromic gut mattress sutures.

The rest of the skin is closed as described for a lateral advancement flap (202d).

a

b

88 Lower Eyelid Reconstruction

231

233

233–233 A 50-year-old female with basal cell carcinoma involving the lateral aspect of the lower lid. 231: Note the loss of lashes and thickening in the lateral 6 mm (0.25 in) of the lower lid. 232:Two weeks following second stage of a Hughes procedure with a lateral advancement flap, as performed with the patient in 225. 233: Five years postoperative.

234 a: Medium defect in the lateral lower lid. b: Create a tarsoconjunctival flap from the lateral aspect of the upper lid. Bring it down to fit into the lower lid defect. c: Bring a lateral advancement flap to cover the tarsoconjunctival flap. Open in three weeks.

232

234

a

b

c

The author uses the tarsoconjunctival flap with a skin graft for central defects that will not close primarily. Occasionally, an advancement skin flap for the skin layer will be used. If closure of the eye for three weeks is a major problem for the patient, a lateral advancement flap will be used, but the lateral aspect will be lined with a tarsoconjunctival flap from the upper lid. This allows the eye to remain partially open during healing.

This section of the text will describe the various ways in which the author uses the tarsoconjunctival flap to close lower lid defects (236–268).

When the defect is in the central part of the lower lid, so that there is some tarsus on either side, the remaining tarsus on either side of the defect is grasped and the tarsal edges pulled toward each other to take up any slack. The defect is then measured with the tarsal edges pulled toward one another.

The upper lid is everted on a Desmarres retractor, and local anesthetic is given into the conjunctival area above the tarsus. An incision is made with the Ellman A-8 needle on ‘hemo’ or ‘cut/coag’, 4 mm (0.16 in) below the superior border of the tarsus. This horizontal incision is continued medially and laterally until the length of the incision equals the width of the defect. Vertical incisions beginning on either end of the horizontal incision are directed toward the superior fornix. Dissection is then continued toward the superior fornix to separate Müller’s muscle from the tarsus and conjunctiva. This maneuver is done with blunt tipped scissors. It must be performed very carefully to minimize the possibility of a buttonhole in the conjunctiva. The tarsoconjunctival flap is now fashioned. Care must be taken not to injure the suspensory ligament of the superior fornix (171), otherwise the conjunctiva may prolapse in front of the cornea. Müller’s muscle is quite vascular, and there is significant bleeding during this part of the procedure. The flap should now lie loosely on the globe when the eyes are in the primary position, so that it can be sutured into the defect without any tension.

If the inferior margin of the defect is no more than 4 or 5 mm below the lid margin, the tarsus of the tarsoconjunctival flap can be sutured into the defect by approximating each edge of the tarsus to the tarsus remaining in the lower lid. 5-0 chromic gut is used to suture the lateral aspect of the tarsoconjunctival flap to the remaining lateral and medial aspects of the tarsus in the lower lid. The inferior border of the tarsal conjunctival flap is sutured to the conjunctiva and lower lid retractors with interrupted 5-0 chromic gut sutures.

If the defect in the lower lid extends below the inferior tarsal border, the tarsus of the flap is still sewn to the remaining tarsus in the lower lid. There will now be a defect of conjunctiva below the tarsus of the flap. The inferior border of the tarsoconjunctival flap should be sewn to orbicularis muscle in the lower lid. The absence of conjunctiva inferior to the tarsoconjunctival flap will fill by conjunctiva sliding into the defect.

236–244 Medium defect in the left lower lid. 236:The defect. 237: Incision in the tarsus about 3 mm (0.15 in) below the superior

border. 238:Tarsoconjunctival flap created to fit the defect. 239: Flap sewn into the defect. Only 3 mm of tarsus has been removed in a horizontal fashion.This leaves some tarsus along the entire base of the defect.The tarsoconjunctival flap can then be sewn into this tarsus as well as the lateral and medial remaining tarsus. 240: Advancement skin muscle flap brought in from below the wound since the defect was shallow. 241, 242: Basal cell carcinoma in the center of the lower lid of a 40-year-old female. 243, 244: Four months following surgery. Note there are no lashes in the center of the lid before or after surgery. However, the lower lid margin and shape are cosmetically acceptable after surgery.

The skin layer can then be fashioned by using a full thickness free skin graft or by using an advancement flap. If there is sufficient skin inferior to the defect, the skin can be advanced superiorly. The lateral and medial aspects of the advanced flap are then sutured to the remaining skin, and the superior edge of the flap is sutured to the tarsal conjunctival flap with 7-0 chromic gut sutures. Several sutures of 5-0 or 6-0 chromic gut can be used to anchor the advancement flap to the tarsus of the tarsoconjunctival flap (236–244). Antibiotic ointment and a patch are applied.

A skin graft can be taken from an upper lid or from the retroauricular area (see Chapter 7: General Principles of Eyelid Reconstruction and Radiosurgery). After thinning the graft by removing subcutaneous tissue, it is secured to the surrounding skin with 6-0 mild chromic or 6-0 fast absorbing plain sutures. It is sutured to the deep tissues with absorbable sutures such as 7-0 chromic gut, and the superior aspect of the graft is sutured to the tarsoconjunctival flap with interrupted 7-0 chromic gut sutures. The graft should be placed in such a way that the superior edge will be at the desired lid margin. Antibiotic ointment and a patch with a nonstick dressing such as Telfa are placed on the eye.

263

264

265

Medium to Large Lower Lid Defects 95

MODIFICATIONS

If the defect in the lower lid involves three-quarters or more of the lower lid and the tarsus is sacrificed on one or both edges, a modification in the procedure is made. When initially beginning the tarsoconjunctival flap, the incision in tarsus is made so that approximately 20–25 mm (0.8–1.0 in) of upper lid tarsus is taken. Rather than continuing to take more upper lid tarsus and extending the incision to the lateral and medial aspect of the upper lid tarsus, the tarsal conjunctival flap is made with only 20–25 mm of tarsus. After the flap is dissected, the edges of the conjunctival flap above the tarsus are used as the lateral and/or medial borders of the tarsal conjunctival flap. In this way, tarsus is sutured to the lower lid retractors; but conjunctiva of the tarsoconjunctival flap may be sutured to the extension of the medial canthal tendon and/or the extension of the lateral canthal tendon (235h, i). The skin layer is then prepared as previously described.

Alternative method for lateral lower lid defect

If the defect is in the lateral third of the lid and extends to the lateral canthal angle, a tarsoconjunctival flap may be fashioned but the skin layer can be a lateral advancement flap (225–234). Once the tarsoconjunctival flap is in place, an incision is made from the lateral canthal angle laterally until enough skin can be mobilized to cover the skin defect. The superior edge of the skin is attached to the tarsoconjunctival flap with 7-0 chromic sutures with the knots away from the globe. The vertical incision is attached to the remaining lid with deep sutures of 5-0 chromic and absorbable or nonabsorbable sutures.

263–265 Modified Hughes procedure for basal cell carcinoma. 263: Basal cell carcinoma infiltrating 50% of the right lower lid. 264: Six weeks after modified Hughes procedure showing the thickened tarsal conjunctival flap. 265:Three and one-half months after modified Hughes procedure, right lower lid.