Summary Statement

The anterior lamella consists of the thin eyelid skin and the orbicularis oculi. At times, only these tissues are removed during the excision of the malignant tumor. The posterior lamella must be examined closely to ensure that it is intact.

32.1.1 Upper Eyelid

Upper eyelid defects after Mohs micrographic surgery can range in depth. Regardless of wound depth, the levator muscle is the key structure. The levator is responsible for the upper eyelid’s opening movement, and the areas surrounding it must be examined prior to initiation of any reconstructive procedure. Any defect within the muscle must be repaired in order to achieve proper eyelid function and globe protection. Prior to closure, the deeper tissues within the wound must be evaluated. If the orbital septum has been opened during the Mohs excision, the surgeon should gently explore the orbital fat and levator complex. Bleeding points and disruption of the tissues are key factors that need to be addressed. All bleeding points must be controlled to decrease the risk of retrobulbar hemorrhage. Next, the levator’s course and attachment are examined; any defects must be resolved prior to anterior lamellar closure. If the levator has been disinserted, it should be repositioned. Vertical lamellar 5-0 Merseline sutures may be used to reinsert the aponeurosis. Lamellar (partial-thickness) bites are key in eyelid reconstruction as full-thickness bites will cause corneal epithelial defects. Lastly, the lid height and contour should be compared to the other side for symmetry.

32.1.1.1 Primary Closure

A small defect may be closed primarily if lid distortion will not be induced. To avoid distortion, tension should be directed along a horizontal plane. This requires a vertical incision with undermining of the skin and subcutaneous tissues adjacent to the wound. Undermining should continue a short distance along the horizontal plane. The anterior lamella is undermined from the tarsal plate. Care should be taken to keep the septum intact. Undermining should be sufficient to allow for a

bility, the orbicularis is closed with buried, interrupted 7-0 Vicryl sutures. The skin is then closed with interrupted 7-0 nylon or Vicryl sutures.

If insufficient anterior lamella remains to allow for an undistorted closure, a full-thickness pentagonal wedge, including the anterior lamella defect, may be excised. A relative excess of posterior lamella will induce buckling of the margin so that the lid will no longer be in apposition to the globe. A pentagonal wedge procedure will prevent this relative excess. Additionally, a layered, primary closure provides the best tissue match, smooth lid margin, and continuous lash line.

To begin, a chalazion clamp is placed over the wound prior to incision to provide stability, hemostasis, and protection of the eye. Care must be taken to avoid trauma to the underlying globe. The wound edges are freshened and fashioned with a #15 blade into a pentagonal-shaped defect with the apex oriented inferiorly. The tarsal borders incisions should be sharp and perpendicular to the lid margin. The resulting fullthickness defect is closed primarily. Three interrupted 5-0 Vicryl sutures are placed at partial-thickness (lamellar) depth through the tarsal plate. Next, the lid margin is closed with a 4-0 or 5-0 silk vertical mattress suture through the meibomian gland orifices to provide anteroposterior alignment. This vertical lid margin suture induces puckering of the wound edges to prevent postoperative notching of the margin. The orbicularis layer is closed with interrupted, buried 7-0 Vicryl sutures, and the skin edges are closed with interrupted 7-0 Vicryl sutures. The ends of the silk sutures are left long and secured away from the wound on the lid skin with a 7-0 Vicryl suture.

If needed, a lateral canthotomy will provide 5–6 mm of medial advancement of the temporal eyelid margin if tension precludes proper lid margin reapproximation [1, 2]. To begin the canthotomy, a 4–5-mm horizontal incision through skin and orbicularis muscle is made with Stevens or Wescott scissors from the lateral canthal angle and directed toward the orbital rim. The tips of the scissors are used to identify the lateral attachment of the lid. The superior crus of the lateral canthal tendon is cut with a vertical incision. The incision allows for medial mobilization of the wound without excess tension. The conjunctiva should not be disrupted during the cantholysis. The incision is then closed with interrupted 7-0 Vicryl sutures.