32.1.2.3 Ellipse Sliding Flap

Another option for the closure of anterior lamella defects is the elliptical sliding flap [3]. The tissue around the defect is undermined in the suborbicularis fascial plane, advanced, and then closed primarily. A circular or ovoid defect can be converted into an ellipse to prevent dog-ear formation. Distortion of the surrounding tissue and the size of the resulting scar are minimized by orienting the ellipse parallel to the relaxed skin tension lines. Anterior lamella defects near the lid margin should not be reconstructed with this flap because ectropion or retraction may be induced by excessive perpendicular tension.

The defect should be incorporated into the ellipse with its long axis parallel to rhytids. The ellipse angle should be 30° with the long axis four times longer than the short axis. The skin and subcutaneous tissue are incised with a #15 blade and then undermined with Wescott scissors along the edges of the flap. Undermining is performed until the edges of the elliptical defect may be closed without tension. The subcutaneous tissue is closed with deep, interrupted 5-0 Vicryl sutures and the skin with interrupted 7-0 Vicryl sutures.

32.1.2.4 Unipedicle Flap

Another fruitful option for closing anterior lamellar defects of the lower eyelid is a unipedicle flap from the upper eyelid. The flap is hinged laterally overlying the canthus. Excess upper lid skin and orbicularis are harvested and then rotated into the lower lid defect. First, a flap based at the lateral canthus is outlined with a marking pen. The skin is incised with a #15 blade, and skin-orbicularis flap is dissected free from the underlying intact orbital septum. The flap is rotated inferiorly to fill the lower anterior lamella defect and secured with deep, interrupted 6-0 or 7-0 Vicryl sutures. The skin is closed with interrupted and running 7-0 Vicryl sutures. The unipedicle flap may leave the patient with a prominent area of tissue at the lateral canthus. If necessary, a second stage procedure 6–8 weeks later is undertaken to thin the base of the flap and remove this excess tissue.

32.1.2.5 Skin Graft

Full-thickness skin grafting is one option used to repair defects that are too large for primary closure. Splitthickness skin grafts are also not recommended in

reconstruction of the lower eyelid [5]. The ipsilateral upper eyelid is an excellent donor site (with similar caveats as previously discussed). Other sites include those discussed in the upper eyelid section. For very large defects, a combination of myocutaneous advancement flap and full-thickness skin grafting may be employed.

Summary: Full-Thickness Eyelid Defects

•Full-thickness defects may be closed primarily or with a combination of local tissue advancement and graft. The key principle in the repair of a full-thickness eyelid defect is that either the anterior or posterior lamella must have an inherent vascular supply. Two free grafts will not survive.

32.2Full-Thickness Eyelid Defects

Full-thickness eyelid defects involve the skin, orbicularis oculi, tarsal plate, and conjunctiva. The anterior and posterior lamellae must be addressed as two separate units, and one must have an inherent blood supply.

32.2.1 Upper Eyelid

32.2.1.1 Primary Closure

As described above, full-thickness eyelid defects may be closed primarily. The wound must be fashioned into a pentagonal wedge with the apex directed superiorly. Defects up to 30% of the central lid and up to 50% in older patients may be closed using this technique. Even, uniform wound closure requires that the tarsal defect extend perpendicular to the lid margin for its full length. The levator aponeurotic attachments should be preserved to minimize postoperative ptosis. If necessary, lateral canthotomy with superior crus cantholysis may be used to provide 3–5 mm of medial mobilization of the remaining lateral eyelid margin.

32.2.1.2 Free Tarsal Graft + Flap

Larger defects of the eyelid will require reconstruction of the anterior and posterior lamella separately.