Lower Eyelid Reconstruction

Key points

Anatomy

The eyelids protect and lubricate the ocular surface. The tear film and corneal interface is essential for vision. An inadequate tear film causes blurred vision, infection, and scarring, or even loss, of the eye. With each blink, tears coat the cornea, providing lubrication, essential nutrients, and oxygen to the ocular surface.

The eyelid is made up of anterior and posterior lamellae. The posterior lamella of the eyelid is lined with conjunctiva, a nonkeratinized epithelial mucous membrane

General principles of eyelid reconstruction

The end goal of any eyelid reconstruction is an aesthetically optimal restoration of anatomy and anatomic function with a minimum of surgical morbidity. Attention to reconstitution of the bilamellar eyelid structure is essential. The surgeon must create an anterior lamella of adequate and aesthetically appropriate skin, preserving dynamic orbicularis muscle function whenever possible, and create a posterior lamella replacing tarsus at the eyelid margin and providing for a smooth mucosal surface

Eyelid defects and reconstruction

When encountered with full-thickness eyelid defects, replacement of the anterior and posterior lamellae is required for adequate function. Marginal eyelid defects can be classified by the percent of the eyelid margin involved as small (<20%–30%), medium (30%–50%), or large (>30–50%). A range is applied in this classification to make the point that eyelid laxity, condition of the skin, and prior surgery may convert a small (ie, easily repaired) defect in an older patient with skin and eyelid

Lateral advancement flaps

• 1.

  The lateral canthal region and eyelid defect are infiltrated with local anesthetic with epinephrine.⁵ This repair can be performed under local anesthetic alone or with monitored sedation or general anesthesia.

• 2.

  Prepare and drape the surgical sites; place corneal protectors.

• 3.

  Mark a lateral canthotomy from the canthal angle 10 mm to 15 mm superior, then lateral from the canthal angle (Fig. 1). Make the skin incision with a #15 blade and open through the orbicularis muscle with Westcott scissors.

• 4.

Tarsoconjunctival flap (Hughes flap) to repair a lower eyelid defect (Stage I)

• 1.

  Anesthetize the involved upper and lower eyelids along with a donor site for a skin graft with local anesthetic with epinephrine.6, 13 This procedure can be performed under local anesthesia but is easier to perform under monitored sedation or general anesthesia.

• 2.

  Prepare and drape the full face including the donor site for the full-thickness skin graft (FTSG).

• 3.

  Place a corneal protector and measure the defect size.

• 4.

  Evert the upper eyelid and mark a transverse horizontal incision, leaving 2.5 mm to

Tarsoconjunctival flap (Hughes flap) to repair a lower eyelid defect (stage 2—3 to 6 weeks after initial placement)

• 1.

  Anesthetize the upper and lower eyelids with local anesthetic with epinephrine. This procedure can be performed with or without monitored sedation.

• 2.

  Prepare and drape the surgical site.

• 3.

  Using a skin rake, gently elevate the margin of the upper eyelid.

• 4.

  Determine the location to separate the lower eyelid tarsoconjunctival graft from the upper eyelid. (Note: in general, separate the tissue with 1–2 mm override on the lower eyelid, because the graft has a tendency to retract.)

• 5.

  Separate the upper and

Canthal defects and reconstruction

A lid margin laceration or defect extending medial to the puncta, a canalicular laceration, or defect must be suspected. The integrity of the lacrimal system is verified by probing with a Bowman probe. If a laceration or defect is present, canalicular stents are place during eyelid reconstruction.⁸ Stents are left in place for 3 to 4 months to ensure complete healing. Failure to repair damage to the lacrimal system results in persistent tearing that is challenging to repair, with more limited

Nonmarginal eyelid defects and reconstruction

There are many reconstructive options when closing nonmarginal defects in the periocular area. If the defect involves only the anterior lamella (skin and orbicularis muscle), repairs used elsewhere on the face are appropriate. If a skin defect is present, a skin graft (described previously) or tissue flap can provide an optimal outcome. For larger defects in the anterior lamella, larger flaps, such as the Mustarde cheek flap¹³ or rhomboid flaps,²⁰ provide both functional and cosmetically

Postoperative wound care

Wound care is similar for most periocular procedures. Ophthalmic antibiotic ointment is applied 2 times per day to the incisions and in the affected eyes at bedtime. Most patients do not tolerate ointment in the eyes throughout the day because it blurs vision. The use of artificial tears 3-6x/day may be needed. Contact lenses cannot be worn while ointment is used during daytime hours.

Current ocular medications, such as glaucoma medications, should be continued throughout the preoperative and

Complications

After eyelid reconstruction, patients may complain of blurred vision or ocular irritation. This may be secondary to a suture, tissue irritation on the ocular surface, or exposure keratopathy. Decreased orbicularis function may be encountered with lagophthalmos. In addition, swelling can cause mechanical ectropion. Persistent complaints of ocular irritation or vision changes mandate evaluation to ensure that there is no ocular pathology.

Excessive scarring can occur after reconstruction.

Summary

An understanding of the anatomy and function of the eyelids is required to provide the best functional and cosmetic outcome for periocular reconstruction. No one reconstructive technique repairs all defects. Knowledge of a range of reconstructive options allows surgeons to offer an optimal surgical plan to patients.