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14.12 Flaps 201
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14.12.4.1 Principle and Considerations
The lower lid is sacrificed to reconstruct a functioning upper lid after total or
near total upper lid loss. It is a two-stage procedure. The longer the interval
between stages, the more margin expansion will have taken place and the smaller
the ultimate lower lid defect.
14.12.4.2 Case Selection
Total or subtotal upper lid loss.
14.12.4.3 Steps
1st stage (Fig. 14.18).
1. Mark and cut a full thickness lower lid flap that includes the whole tarsal plate.
Base it medially (Fig. 14.18a). It must be at least 5 mm wide to include the
peripheral vascular arcade.
Note: Although the flap can be based laterally this is less convenient and there is
more risk of canalicular damage.
2. Preplace a double armed 6/0 polypropylene suture in the cut lateral canthal
tendon (Fig. 14.18b).
Note: this modification was not included in Mustardé’s original description.
3. Rotate and anchor the tip of the flap, A, into the upper lid defect by suturing
1
the tarsal plate to the upper lid tarsal plate remnant, A
, or the medial canthal
tendon with a 6/0 absorbable suture (Fig. 14.18c). This causes the flap to fold
on itself and the margin to stick out at the bend because of its stiffness.
4. Starting medially, suture conjunctiva to conjunctiva with a continuous 7/0
absorbable suture as far laterally as is possible.
5. Identify the upper lid levator aponeurosis (using the pre-aponeurotic fat pad as
a landmark) and attach it to the flap tarsal plate edge with three interrupted
6/0 absorbable sutures.
6. Suture the recipient skin and orbicularis to the flap skin and orbicularis with a
6/0 interrupted or continuous suture (Fig. 14.18d). Start medially and progress
laterally as far as is possible. By this stage the eye will be obscured by the
folded lid margin flap. There will be a residual infero lateral defect.
7. Anchor the kinked proximal tarsal plate edge to the lateral canthal tendon with
the preplaced 6/0 polypropylene suture. Gradually tighten the suture to pull the
flap bend laterally as far as it will go (Fig. 14.18e).
Note: This modification was not part of Mustardé’s original description. The
addition of this suture induces tension which encourages tissue expansion.
8. Suture the lower defect in layers, starting medially and progressing as far
laterally as is possible (Fig. 14.18e).
9. Apply antibiotic ointment, a non-stick film, and an occlusive pressure dressing.
Leave this in place for 5–7 days. Subsequently apply antibiotic ointment twice
daily until the raw surfaces have healed.
202 14 Lid Reconstruction
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a
1
A
A
>5 mm
c
1
A
A
b
d
e
Fig.14.18 Lidswitchflap1ststage.a Plan a full thickness lower lid flap. b Cut the flap and place
a suture into the cut lateral canthal tendon. c Anchor the flap tip, A to the end of the defect, A
d Suture the flap into the defect in layers as far laterally as possible. e Anchor the bend in the flap
tarsal plate with the lateral preplaced suture
2nd stage (Fig. 14.19).
Delay this as long as possible to allow time for revascularization and tissue
expansion. 6–12 weeks is ideal.
1. Insert a squint hook into the lid margin flap bend and pull it laterally. Decide
where to divide the lid margin pedicle so as to have sufficient lid margin for
the new upper lid and mark it. Usually, this point is about 2/3 of the way from
the flap tip, i.e., 2/3 of the flap will remain as upper lid.
1
.
14.12 Flaps 203
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a b
c d
Fig.14.19 Lid switch flap 2nd stage. a Divide the healed flap roughly 2/3 from the tip. b Freshen
the edges and insert 2 double armed sutures into the lateral canthal tendon. c Anchor the lateral
ends of the divided flap to the lateral canthal tendon. d Suture the flaps in place laterally
2. Cut the flap at the marked spot with tenotomy scissors perpendicularly to the
margin (Fig. 14.19a).
3. Freshen up the healed lateral defect edges to separate the skin from the
conjunctiva.
4. Pre-place two double armed 6/0 absorbable sutures into the lateral canthal tendon which is marked by the polypropylene suture placed in stage one. The latter
should now be removed (Fig. 14.19b).
5. Reattach the divided flap ends at the margin with the pre-placed 6/0 sutures,
one for the upper and the other for the lower cut edge. These sutures reform
the lateral canthus (Fig. 14.19c).
6. Complete the flap transfer by suturing conjunctiva to conjunctiva and skin to
skin with 6/0 or 7/0 absorbable sutures (Fig. 14.19d).
7. Close the lower lid margin donor defect as much as possible and leave the rest
to granulate (directed ‘laissez-faire’).
8. Apply antibiotic ointment and an overnight pressure dressing.
Note: By allowing several weeks to elapse between the first and second stages it
is usually possible to reconstruct both the upper and the lower lids from the single
lower lid flap. The priority however is to attain a functioning upper lid which is
essential for sight, the lower lid being entirely optional. If the lower lid defect cannot
be closed leave it to granulate.
204 14 Lid Reconstruction
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14.13 Grafts
Free grafts are the simplest way of bringing additional tissue into an area. However,
their use is limited in two important respects. Firstly, they can only be applied
onto a vascularized bed from which they derive their new blood supply. Secondly,
they must survive long enough to establish this new vascular connection. In eyelid
surgery this limits them to full thickness (or split) skin, or conjunctival grafts,
where the host contact area is large in relation to the graft’s bulk and metabolic
requirement. The exception is dermis-fat grafts which are bulky in relation to their
contact area. They only survive thanks to the fat’s low metabolic rate, but even
then, the degree of fat survival is unpredictable, ranging from full retention to
total absorption.
For a graft to take it must be immobilised in intimate contact with its host bed
until new vascular channels establish. In eyelids this takes 5–7 days.
Grafts also shrink! This is hardly surprising as the graft-host interface fibrob-
lasts contract during the proliferative phase of wound healing. Split skin grafts
contract by about half their linear dimensions and full thickness skin by about a
third. For this reason, full thickness skin grafts are preferred for lid reconstruction.
Oversize the graft to compensate for the anticipated shrinkage and keep the host
bed on stretch during the haemostatic and inflammatory stages of wound healing.
Here I shall only describe skin grafting as this is the most required. The appear-
ance of healed skin grafts ranges from unnoticeable to unsightly and cannot always
be predicted. Warn the patient of this beforehand. It depends to a large extent on
the donor site chosen.
14.13.1 Skin Graft Donor Sites (Fig. 14.20)
The lateral upper lid is the preferred skin donor site for three reasons:
1. Best colour and texture match
2. Excess skin frequently available at this site
3. Easy access.
When there is insufficient skin available in the upper lid, I recommend the upper
inner arm as the next best site.
Advantages:
1. Plenty of hairless skin available.
2. Donor scar reasonably unobtrusive.
Disadvantages:
1. Poorer colour and texture match than lid skin.
2. Surgical access awkward.
14.13 Grafts 205
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a b
Fig.14.20 Skin graft donor sites. a Upper lid. b Upper inner arm
14.13.2 Alternative Sites
Postauricular and pre auricular skin are favoured by some but the former is awkward to access and initially interferes with the wearing of glasses and hearing aids.
Skin availability with the latter is limited by beard growth. If the supraclavicular
fossa is used the donor scar is quite noticeable in younger patients.
14.13.3 Skin Graft Harvesting (Fig. 14.21)
14.13.3.1 Principle
Choose an available donor site, excise the required size of full thickness skin, trim
off any subcutaneous tissue, and suture the defect.
14.13.3.2 Steps
1. Make a paper template of the skin defect (Fig. 14.21a).
2. Use the template to mark out the graft on the gently stretched donor site skin
(Fig. 14.21b).
3. Intumesce the donor area with a subcutaneous injection of local anaesthetic
with adrenaline.
4. Incise the skin with a no.15 scalpel blade along the graft outline (Fig. 14.21c).
5. Lift one end of the graft and dissect it free from the underlying tissue
(Fig. 14.21d). This may be done by scratching with the scalpel tip or using
Westcott scissors (keep the graft and donor bed stretched during this dissection
to avoid accidental graft perforation).
6. Wrap the graft over your finger, deep side out, and trim off excess subcutaneous
tissue with Westcott scissors (Fig. 14.21e).
7. Suture the graft into its recipient bed with a continuous 6/0 absorbable suture
(Fig. 14.21f).
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Fig.14.21 Skin grafting. a Make a template of the defect. b Mark the graft size on the donor site.
c Incise the graft. d Excise the graft. e Strip off unwanted subcutaneous tissue. f Suture the graft
into the recipient bed
8. Use a lid margin traction suture to ensure that the recipient bed remains
stretched and immobilized.
9. Apply a non-stick film, antibiotic ointment, and a pressure dressing. Leave the
dressing undisturbed for 5–7 days to encourage vascularization.
14.13.3.3 Notes
•
Many texts recommend perforating the graft in multiple places to prevent sub
graft haematoma accumulation. This is unnecessary if you achieve adequate
graft bed haemostasis and apply an effective pressure dressing. Similarly, I
deem the use of tie-over graft bolsters unnecessary. They merely serve to lift
the graft edges, while depressing the centre of the graft which can lead to a
crater-like profile.
References 207
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14.13.4 Split Skin Grafts
Split skin grafts are useful when large areas of skin need to be replaced. This is
seldom the case in lid surgery. Furthermore, split skin grafts contract much more
than full thickness skin, so I advise you not to use them.
14.13.5 Mucous Membrane Grafts
Mucous membrane is occasionally required to reconstruct a posterior lamella. It
is harvested from the mouth: from the lower lip, the cheek, or the hard palate.
Mucous membrane harvesting is not something a novice should attempt, so I will
not discuss it further.
14.14 Notes
•
There are, of course, many alternative and more complex ways of reconstructing lid defects, each with its own advantages and drawbacks. Some involve
discarding significant quantities of skin when compared to the original defect
size, to make them fit. Others involve extensive undermining. Both these practices go against my minimalist grain. The above basic selection should allow
you to manage most repairs simply and safely.
14.15 Take Home Message
•
The upper lid is essential, the lower optional.
•
Direct defect closure under tension gives the best outcome.
References
1. Thaller VT, Then KY, Luhishi E (2001) Spontaneous eyelid expansion after full thickness eyelid
resection and direct closure. Br J Ophthalmol 85:1450–1454
2. Thaller VT, Madge SN, Chan W et al (2019) Direct eyelid defect closure: a prospective study
of functional and aesthetic outcomes. Eye 33:1393–1401. https://doi.org/10.1038/s41433-019-
0414-2
Revision Surgery
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15
15.1 Overview
•
Avoid
•
Delay
•
Analyse
•
Transverse release-plasty.
15.2 Avoid
‘Getting it right the first time’ is this book’s mission. As a rule, a good primary
operation, be it for a lid malposition or a reconstruction, will avoid the need for
revision surgery. Yet despite our best efforts, reoperation is sometimes necessary.
Warn the patient of this possibility in advance.
15.3 Healing Shrinks
We know that healing tissues contract. Anticipate and allow for this shrinkage.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
V. Th a l l e r, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_15
209
210 15 Revision Surgery
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15.3.1 Pout
A linear scar will shorten. So, a lid margin which is smooth and flat at the end of
a repair (Fig. 15.1a) will most likely develop a notch during healing (Fig. 15.1b).
Therefore, in anticipation, create a pouting margin union at the end of surgery
(Fig. 15.1c) which smooths spontaneously during healing (Fig. 15.1d).
Fortuitously, when we directly close any defect the closure length exceeds
the defect diameter, as discussed in Chap. 12. This counteracts scar shortening
(Fig. 15.2).
Wound closures in thick skin, such as on the forehead and brow, tend to contract
perpendicularly to the surface causing a depressed scar. Make them pout with
vertical mattress sutures as described in Chap. 3.
a b
c d
Fig.15.1 Margin notch. When you make a margin repair flat at the end of surgery a alidmargin
notch develops b due to scar contraction. Making the margin pout by the end of the repair c results
in a flat margin on healing d
a
d
Fig.15.2 Scar lengthening. Direct closure of a lid defect diameter d a results in a scar length
≈1.5 × d b
b
≈ 1.5 x d
15.5 Delay (Fig. 15.3) 211
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15.3.2 Planes Contract
We create scar planes when we undermine tissues, raise flaps, or apply grafts.
These planes contract in area during healing. Graft bed contraction can result in
‘pin cushion’ distortion of what is initially a flat graft. Flap pedicles may “tube”
due to such contraction. Avoid this complication by keeping the graft or flap bed
expanded with lid margin traction sutures during initial healing. After a week, get
the patient to stretch the graft or flap by regular massage.
15.4 Faces Are Mobile
Try this experiment on yourself: place a finger anywhere on your face and observe
how far you can push the skin in all directions. With the face being so mobile
there is rarely any justification for undermining wound edges during lid surgery.
15.5 Delay (Fig. 15.3)
Avoid re-operating within a week, as early reoperation is usually accompanied
by excessive bleeding, and the local inflammation temporarily weakens the tissue
strength and suture holding ability (sutures tear out easily during this time).
Delay elective revision surgery as long as possible to allow time for scar matu-
ration and tissue remodelling to occur. Consider two months to be a minimum and
a six-to-twelve-month delay as ideal (assuming you can persuade your patients to
be patient for that long). While awaiting revision encourage patients to massage
Fig.15.3 Delay revision. Waiting may remove the need for revision surgery
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