96 Lower Eyelid Reconstruction

Alternative method for medial or central lower lid medium defect

A triangle of skin and muscle, base up, is removed inferior to the defect. An incision is made in the lateral canthal angle and extended laterally for 20 mm (0.8 in) or more in the skin. The inferior horn of the lateral canthal tendon is released and a skin muscle flap is created. This allows the remaining lateral aspect of the remaining lower lid to be brought medially and sewn to the remaining medial lower lid. (The attachment technique is the same as for small lower lid defects, see 196–200.) The inside of this flap has no conjunctival lining from the lateral end of the remaining lower lid tarsus to the lateral canthus. A tarsoconjunctival flap from the lateral aspect of the upper lid can be brought down to line this flap (268). It is attached to the lower lid advancement as in the section for lateral lower lid defects (234b).

After the tarsus is re-approximated, the subcutaneous tissue of the advancement flap is attached to the periosteum just below the superior aspect of the wound (202c). The attachment is made with one or several 5-0 polyglactin 910 sutures. This maneuver will keep the lateral aspect of the lower lid from pulling downward, thereby preserving the proper angle of the lateral canthus. The lateral canthal angle can then be re-approximated with 7-0 chromic sutures, and the rest of the lateral wound is closed with a running 7-0 Prolene or 6-0 mild suture. A triangle of excess skin may be removed if necessary to allow a smooth skin closure.

Second stage Hughes procedure

At approximately three weeks after the initial procedure, the tarsal conjunctival flap is severed. This can be done with topical anesthetic, or the flap can be injected with local anesthetic. One jaw of a blunt tipped scissor is placed between the flap and the globe and the flap is opened flush with the lower lid margin (235j). The superior part of the flap is allowed to retract. The patient may be asked to sit up to evaluate the position and shape of the lower lid margin. Further trimming of the lower lid margin may be necessary to get the best possible shape. Antibiotic drops or ointment can be used for several days.

268

a

b

c

REFERENCES

1.Hewes EH, Sullivan JH, Beard C (1976). Lower eyelid reconstruction by tarsal transposition. Am. J. Ophthalmol., 81(4): 512–514.

2.Hughes WL (1945). Reconstruction of the lids. Am. J. Ophthalmol., 28: 1203–1211.

268 a: Medium defect in the lower lid. b: Outlined are the tarsoconjunctival flap in the upper lid, the lateral advancement flap in the lower lid, and the triangle of skin to be removed below the defect. c:The lateral advancement myocutaneous flap is mobilized medially so that the remaining lid can be reapproximated as in 202. A triangle of skin is removed and the closure done as in 196.The tarsoconjunctival flap is brought down to line the lateral aspect of the myocutaneous advancement flap, similar to 234b.

Many of the principles that apply to lower eyelid reconstruction apply equally well to reconstruction of the upper eyelid; however, there is one significant difference. If the lower lid is pulled taut, it rides closer to the globe or may ride somewhat inferior to the lower limbus. If the upper lid is pulled taut, it cannot be elevated by the levator muscle. Significant ptosis may ensue. It is, therefore, imperative that upper eyelid reconstruction be performed in such a way that the upper lid curve and laxity will persist after reconstruction is complete.

SMALL UPPER LID MARGIN DEFECTS

Small defects of 5–7 mm (0.2–0.3 in) in the horizontal dimension can usually be repaired with a primary closure (269). If there is sufficient tarsus on either side of the defect, a suture can be placed in the superior part of tarsus and one in the inferior part of tarsus to see if the wound comes together easily. The patient is then asked to look up and down, or the surgeon manually lifts the eyelid to be sure that postoperative ptosis will not occur due to a tight eyelid. A triangle of skin and subcutaneous tissue is removed above the defect. The base of the triangle is actually the superior border of the defect, and the height should measure approximately one and one-half times the base.

A 5-0 chromic gut or polyglactin 910 suture is placed in the inferior aspect, the middle aspect, and the superior aspect of the tarsus. Care is taken to keep the needle from penetrating conjunctiva so that the suture will not rub on the cornea during the healing phase. A 6-0 silk suture is placed through the wound at the gray line. Another 6-0 silk suture, which also passes through tarsus, is placed just superior to the lash line. A third 6-0 silk suture is placed 4 mm (0.16 in) superior to the lash line. The ends of the first two silk sutures are tied within the knot of the third suture to keep the sutures from rubbing on the cornea. The remainder of the skin is closed with a running 6-0 or 7-0 nylon suture.

If only one side of the defect has tarsus, the same principles apply. However, when the tarsus is sutured into the medial or lateral canthal tendon, care must be taken to approximate the lid margin edges, or to place the lid margin into the respective canthal angle so that the configuration of the upper lid and the canthal angle will be maintained.

269 Repair of small upper lid defect. a: Small upper lid defect. b: 5-0 chromic gut or 6-0 polyglactin 910 sutures are used to close the tarsal layer, and 6-0 silk sutures are used for the lid margin. c:The ends of the silk sutures of the lid margin are tied in a suture above the lid margin to prevent corneal irritation.

MEDIUM-SIZED UPPER LID

MARGIN DEFECTS

LATERAL ADVANCEMENT FLAP

Defects up to 15 mm (0.6 in) in horizontal dimension can sometimes be repaired with an advancement flap. (270–273). An incision is made in the lateral canthal angle extending laterally and inferiorly for 20–30 mm (0.8–1.2 in). This incision should be in a smile line if possible. The superior horn of the lateral canthal tendon is incised, and a skin muscle flap is fashioned so that the lateral aspect of the upper lid can be advanced medially. If there is tarsus on

both sides of the defect, the tarsus and the skin are closed exactly as in a primary closure. When the tarsal edges are sutured, the patient should be instructed to open the eyes so that any ptosis caused by insufficient upper lid laxity can be evaluated. If ptosis is present, the lateral canthal tendon should be further weakened, and the advancement flap extended until the patient can open the eye without residual ptosis. If after the tarsal edges are approximated there appears to be a wider palpebral fissure on the operated side, the canthal tendon should be tightened until the upper lid height is equal to the opposite side.

If the medial aspect of the defect is without tarsus, then the tarsal edge of the lateral aspect is sutured to the

271

272

273

271–273 Upper lid defect. 271:The defect measured about 10 mm (0.4 in) following basal cell carcinoma removal. 272: Repair of defect using an upper lid advancement flap as shown in 270. 273: Five weeks after surgery.

remains of the superior branch of the medial canthal tendon with interrupted 5-0 chromic gut or 5-0 polyglactin 910 sutures. The skin layer is then closed as in the primary procedure. The lateral canthal angle is closed with interrupted 7-0 chromic sutures, and the skin beyond the angle is re-approximated with running 6-0 or 7-0 nylon.

MODIFIED TARSOCONJUNCTIVAL FLAP

If a medium-sized defect is located in the lateral or medial aspect of the upper lid and direct closure with a lateral advancement flap does not seem to be sufficient, a modified tarsoconjunctival advancement flap can be used (274). The edges of the wound are pulled toward one another to estimate the minimum amount of horizontal distance that can be corrected without causing a postoperative ptosis. The upper lid is then everted, and a horizontal incision is made 4–6 mm (0.16–0.25 in) below the superior border of the tarsus, extending from the wound edge for a distance equal to the amount of horizontal dimension just

measured. At the end of this incision, a second incision perpendicular to the first is made in the direction of the superior cul-de-sac. The tarsoconjunctival flap is then fashioned in the same manner as for the modified Hughes procedure (235). The advanced tarsus is sutured to the remaining tarsus in the upper lid, and to the respective medial or lateral canthal tendon using interrupted 5-0 chromic gut or 6-0 polyglactin 910 sutures. These sutures should not penetrate conjunctiva, thereby avoiding corneal irritation. The skin layer, which can be a full-thickness skin graft or an advancement flap from an adjacent area, is sutured over the flap with small silk or nylon sutures. The skin layer must be placed in such a way that the skin will not rub on the cornea when the patient’s eyes are open. 7-0 chromic gut sutures can also be placed in the central area of the skin layer so that there will be a firm attachment between the two layers making up the reconstructed section of the eyelid.

For a medium-sized defect in the center of the lid, a

tarsoconjunctival flap could be used instead of a lateral advancement flap. Parallel vertical incisions are made in the tarsus remaining above the lid defect. These should be separated by the width of the defect so that the remaining

tarsus can be slid into the upper lid defect. This is essentially the same as a modified Hughes tarsoconjunctival flap, except the tarsus is brought into the upper lid defect rather than a lower lid defect (275–290).

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275–283 Modified tarsoconjunctival flap. 275: Basal cell carcinoma in the center of the right upper lid of a middle-aged female. 276: Full thickness defect after tumor removal. 277, 278:Tarsoconjunctival flap brought into the defect. 279: Advancement skin flap brought over the tarsus to form the skin layer. 280: Pre-operative photo. 281:Two weeks postoperative showing the curve of the upper lid similar to the preoperative photo.

As in the Hughes procedure, the conjunctiva is separated from Müller’s muscle so that only the conjunctiva connects the tarsus to the superior fornix. The lower edges of the tarsoconjunctival flap are sewn to the remaining edges of the lid margin tarsus with 5-0 chromic sutures. The sides of the tarsus in the flap are connected to the remaining tarsus with 5-0 chromic sutures with the knots buried away from the cornea. The skin layer is created with a retroauricular skin graft or an advancement flap from surrounding skin (290).

LARGE DEFECTS IN THE

UPPER EYELID

For defects greater than 25% of the upper lid, the method described in 290 can often be used. However, if there is little or no remaining tarsus or there is very little upper lid left, the Cutler–Beard procedure can be used.1 In this method, a full-thickness advancement flap from the lower lid is brought underneath a bridge of full-thickness lower lid margin and into the defect (291–300).

A horizontal incision is made through full-thickness lower lid about 5 or 6 mm (0.25 in) below the lash line. The length of this incision should match the horizontal

290

dimension of the defect in the upper lid. To determine this dimension, the edges of the upper lid defect can be brought toward one another, but care must be taken not to pull them closer than they would be with a normal upper lid curve and laxity. Vertical incisions are then made extending inferiorly from either end of the horizontal incision. These incisions are also through full-thickness lower lid. The flap of tissue that is now formed will contain skin, muscle, orbital septum, possibly fat, lower lid retractors, and conjunctiva. There will be no tarsus within this flap. It is important to leave about 5 or 6 mm of eyelid as a bridge so that the marginal artery will continue to supply the bridge, thereby keeping it viable.

The full-thickness lower lid flap is then brought underneath the bridge and sutured into the upper lid defect. If the upper lid defect includes the entire vertical dimension of the tarsus, the layer of conjunctiva and lower lid retractors is sutured to the layer of conjunctiva, Müller’s muscle, and levator aponeurosis in the upper lid. If some of the superior tarsus remains, then the conjunctiva–lower lid retractor layer is sutured to the tarsus and conjunctiva layer of the upper lid. Interrupted 5-0 chromic gut sutures can be used for this deep layer.

If tarsus remains on either side of the upper lid defect, the conjunctiva–lower lid retractor layer is sutured to the tarsal plate laterally and medially. If tarsus is not present in

one or both sides of the upper lid defect, then the con- junctiva–lower lid retractor layer of the advancement flap is sutured to conjunctiva and the medial and/or lateral canthal tendons. The skin muscle layer is then sutured to the skin muscle layer of the upper lid with interrupted 6-0 mild chromic or 7-0 polypropylene sutures.

A modification of this technique has been reported in which eye bank sclera is placed between the con- junctiva–lower lid retractor layer and the skin muscle layer of the advancement flap. The eye bank sclera is used to give stability to the upper lid postoperatively.2 Leaving the bridge flap intact for three months allows sufficient time for scar formation to occur. This cicatrix gives stability to the upper lid and essentially replaces the stability function of the tarsus.

The inferior edge of the lower lid bridge is allowed to granulate. Closing this lower edge might result in a compromised blood supply. Antibiotic ointment and a light dressing are placed over the eye. The dressing consists of a Telfa pad with the center cut out so that the bridge will have no pressure on it. A second Telfa pad is then placed over the first, and an eye patch placed over the second Telfa pad. Using this technique, the blood supply is not compromised by pressure on the bridge during the initial healing period. Telfa is used until the inferior aspect of the bridge has granulated, and then a simple eye patch is sufficient.

After three months have elapsed, the second stage of the procedure can be performed. The bridge flap is incised with scissors. One blade is placed between the globe and the flap. The scissors are angled so that there will be excess conjunctiva over the cornea after the flap has been opened. The inferior edge of the conjunctiva is then brought to the inferior border of the skin layer, and sutured in place with interrupted 7-0 chromic gut sutures. This is done to further ensure that conjunctiva, not skin, will rub on the cornea. The inferior aspect of the bridge, which has granulated, is then ‘freshened’ and the conjunctival layer of the remaining flap is sutured to the conjunctival layer of the remaining bridge. The skin muscle layer of the flap is sutured to the remaining skin muscle layer of the bridge. If excess skin is present, it is trimmed appropriately so that the lower lid skin will have a smooth closure. This reconstructs the lower lid. Antibiotic ointment and a dressing can be used for several days (98, 99; 292–309).

One of the advantages of the Cutler–Beard method is that the advancement flap stretches. There is usually sufficient lower lid tissue to be sutured back to the bridge without causing lower lid retraction or lower lid deformities (301–305). Although the question of lash transplants to the upper lid often arises, the author has not found this to be a useful procedure.

104 Upper Eyelid Reconstruction

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292–300 Cutler–Beard procedure for large basal cell carcinoma in the right upper lid. 292: Basal cell carcinoma on the lid margin. 293: Section of right upper lid placed on a sterile card and labeled to indicate the lateral, medial, and superior margins. 294: Defect remaining in the upper lid after the tumor has been removed. Blue lines in the lower lid indicate full-thickness flap to be fashioned. 295: Full-thickness flap in the lower lid is fashioned and pulled inferiorly to show the conjunctival lining of the flap. 296:The deep layer of the lower lid is attached to the remaining tarsal elements of the upper lid. 297: Deep layer closure has been completed. 298: Skin layer closure has been completed.The instrument demonstrates the path of the flap underneath the bridge, the inferior aspect of which has been left to granulate spontaneously. 299:Two weeks after surgery. 300: Five weeks after the second stage (four months after the initial procedure).

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301–305 Squamous cell carcinoma in the right upper lid of a 72-year- old male. 301:Tumor of the upper lid seen with the patient’s eyes closed. 302: Large defect in the upper lid remains after removal of the carcinoma.The defect extended beyond the upper lid tarsus medially, laterally, and superiorly. 303: Lower lid advancement flap in place three months after the initial procedure. 304: One year postoperative in primary gaze. 305: One year postoperative with normal closure and good corneal protection.

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Large Defects in the Upper Eyelid 105

300

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305