Upper lid posterior lamellar defects may be addressed with a free tarsal graft from the contralateral upper eyelid. A large chalazion clamp is placed, and the donor lid is everted. A marking pen is used to outline a graft of appropriate length on the conjunctival surface. The inferior border should be parallel to and no more than 4 mm from the lid margin. The vertical height of the graft is determined by the vertical height of the tarsus. A #15 blade is used to incise the conjunctiva and full-thickness tarsal plate. The tarsus and its conjunctiva are dissected free from the overlying levator aponeurosis. Conjunctiva and Mueller’s muscle attachments are severed from the superior tarsal border with scissors so 2 mm of conjunctiva remains attached to the graft. The donor site is then allowed to heal secondarily.

The graft is soaked in antibiotic solution and then placed into the contralateral upper eyelid defect with the conjunctival surface in apposition to the globe. The superior edge of the graft with the conjunctival remnant lies along the new lid margin. The lateral edge of the graft is sutured to the tarsal remnant or the stump of the superior crus of the lateral canthal tendon with lamellar 5-0 Vicryl sutures. If there is insufficient tissue remaining laterally, the graft is secured to the lateral orbital rim at the level of the lateral orbital tubercle with interrupted 4-0 Vicryl sutures. The medial edges are then secured with interrupted lamellar 5-0 Vicryl sutures. The superior edge is attached to the superior forniceal conjunctiva and edges of Mueller’s muscle and levator aponeurosis with interrupted and running 7-0 Vicryl sutures.

If the free tarsal graft is insufficient to address the horizontal extent of the defect, it may be flanked by hard palate grafts (see below).

The anterior lamella may then be repaired with an advancement flap as outlined above. A free skin graft cannot be used; either the anterior or the posterior lamella must have an inherent blood supply to ensure tissue survival. Once the flap is in place, the conjunctival remnant is then advanced anteriorly and secured to the inferior flap skin edge with a running 7-0 Vicryl suture. This step is needed to reestablish the mucocutaneous junction along the newly reconstructed eyelid margin. To minimize postoperative retraction, the superior eyelid must be immobilized and kept on stretch. This is best accomplished with a temporary 4-0 silk suture tied over bolsters with traction directed inferiorly.

32.2.1.3 Hard Palate Graft + Flap

Various other tissues have been used to replace deficient posterior lamella if a free tarsal graft is not available or insufficient. These include hard palate grafts, nasal or ear cartilage grafts, donor sclera, and synthetic materials. Hard palate grafts are the method of choice to address deficient posterior lamella [6, 7]. The gingival surface of the roof of the mouth is an excellent donor site [8]. They provide a long lasting, rigid, and epithelialized surface. Hard palate grafts may be used in conjunction with free tarsal grafts if the entire upper eyelid must be reconstructed. In this case, the free tarsal graft should be placed centrally. Hard palate grafts should flank the tarsus medially, laterally, and superiorly.

When harvesting a hard palate graft, the central palatine raphe, anterior palatine rugae, and the area overlying the greater palatine foramen where the anterior palatine artery exits should be avoided. A graft of appropriate size and shape is outlined with a marking pen. The midline of the hard palate should be avoided. In most cases, rectangular-shaped grafts are harvested with a #15 or #64 blade. It is very difficult to thin the graft once it is free from the donor bed, thus the graft thickness should be taken into consideration during the initial dissection. The palatal periosteum is left intact to enhance healing of the donor site. Oxidized regenerated cellulose or microfibrillar collagen hemostat may be used to achieve hemostasis.

The graft is then soaked in antibiotic solution and trimmed to the appropriate dimensions. It is placed into the defect and secured to the tarsal remnants (or canthal tissue remnants or free tarsal graft) with interrupted partial-thickness 5-0 Vicryl sutures.

32.2.2 Lower Eyelid

32.2.2.1 Primary Closure

Primary closure with or without lateral canthotomy/ cantholysis is achieved as outlined in the previous sections. Closure must not induce tension as this will cause lower eyelid retraction.

32.2.2.2 Hughes Tarsoconjunctival

Flap + Graft/Flap

In the lower lid, deficient posterior lamella not amenable to primary closure may be addressed with a Hughes tarsoconjunctival flap [2]. A Hughes flap