Lower Eyelid Reconstruction


Article Author:
Omar Ozgur


Article Editor:
Soheila Rostami


Editors In Chief:
Brian Downs
Ziad Katrib


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
4/29/2019 11:20:43 PM

Introduction

Proper function of the eyelids is necessary to maintain healthy globes. Patients with cancer or with traumatic injuries to the eyelids need special attention to preserve not only the cosmesis of the eyelids but also the function.[1][2]

Anatomy

An understanding of the anterior and posterior lamella of the eyelid is critical in eyelid reconstruction. The anterior lamella includes the skin and orbicularis oculi muscle, while posterior lamella includes the conjunctiva and tarsus. When reconstructing an eyelid, it is important to address reconstruction of both the anterior and posterior lamella. Free skin grafts or free tarsoconjunctival grafts can be used to replace either anterior or posterior lamella defects when they are attached to vascularized tissue, meaning free anterior or posterior lamella grafts can be performed only when the opposite healthy, and vascularized lamella remains. Free anterior and free posterior lamellar repairs are not commonly performed together because the vasculature would be compromised.

Indications

The most common eyelid skin cancer is basal cell carcinoma (BCC), which occurs more commonly on the lower eyelid. Eyelid cancer can be treated with carcinoma excision with frozen section control of the tissue margins, or alongside a Mohs surgeon to excise the lesion. Becuase of resection, lower eyelid reconstruction is a common problem faced in ophthalmic plastic surgery. Other types of cancers and trauma may also lead to lower eyelid defects. There are various techniques available for lower eyelid reconstruction, and these depend on the of the size of the defect as well as patient-specific factors.[3][4][5][6]

Personnel

It may be beneficial to work with a Mohs surgeon to excise a carcinoma thoroughly. Reconstruction by an oculoplastic surgeon should follow.

Technique

Small full-thickness eyelid defects, typically up to 25% of the width of the lid, can often be closed directly by opposing the two free edges. Direct closure typically requires closure in two layers, one layer to close the tarsus, and one layer to close the skin. The lid margin is usually closed with a horizontal mattress to provide wound edge eversion, to promote healing without a notch. In patients with very lax eyelids, sometimes larger defects may be closed in this fashion. For defects between 25% to 50% of the width of the lid, an option may include lateral canthotomy and inferior cantholysis to provide additional laxity, followed by direct closure. Lateral cantholysis allows the lateral lower lid to be stretched further medially to close a defect. A periosteal flap from lateral to the lateral orbital rim may also be performed to increase the amount of posterior lamella support, allowing a larger defect to be closed.

For medium-sized defects between 33% to 66%, a Tenzel semicircular musculocutaneous rotation flap beginning at the lateral canthus extending upward and laterally in a semicircular fashion may be used to recruit anterior lamellar tissue. The flap is then rotated into position over the eyelid defect. Although this flap addresses the anterior lamella defect (skin and muscle), it does not address the posterior lamella defect (conjunctiva and tarsus). A periosteal flap may be performed in conjunction to provide posterior lamella support and also to increase the ability to close a larger defect.

Finally, for large defects, a tarsoconjunctival flap, a Hughes procedure, may be performed for defects up to 100% of the lower eyelid. A tarsoconjunctival flap is a flap from the superior eyelid, including only a portion of the tarsus and conjunctiva, which is brought down and sutured into the lower eyelid defect. This provides a replacement for the posterior lamella. Commonly about 4 mm of the inferior tarsus of the lower lid is preserved, to maintain the stability of the upper eyelid. The anterior lamella can then be replaced by either local flaps if enough skin laxity is present, or with a full-thickness skin graft, typically from the upper lid. At the end of the surgery, a flap is present closing the upper and lower eyelids, usually leaving the patient unable to see out of that eye. A second stage procedure can then be performed typically around four to six weeks later to separate the lids, and to reform the eyelid margins. Alternatively, a Mustarde cheek rotation flap, similar to but larger than a Tenzel flap, can provide a larger anterior lamella replacement to reconstruct a larger lower eyelid defect.

Proper lower eyelid height and support are necessary to prevent post-operative ectropion and retraction. One may choose to perform a temporary tarsorrhaphy (to connect the upper to the lower eyelid) or a Frost suture tarsorrhaphy (to connect both eyelid margins to the brow) to further provide elevated support. If significant eyelid laxity is noted either pre-operatively or post-operatively, it may be necessary to perform an ectropion repair with a lateral tarsal strip procedure. This may be needed especially in conjunction with either a first or second stage Hughes procedure. This may also be necessary with a lower eyelid skin only defect, for example when a skin cancer excision does not include a defect of the posterior lamella if the lower eyelid is lax. Cicatricial changes with healing can sometimes predispose a lower lid to cicatricial ectropion.

Further, one may perform a mid-face lift to repair large defects of the lower eyelids and repair large anterior lamella defects. With this technique, the surgeon still needs the posterior lamella provided from either the upper eyelid (Hughes tarsoconjunctival flap) or possibly from hard palate graft to avoid closure of the eye, and then the anterior lamella will be provided via the mid-face.[7][8][9][10]

Complications

Complications can include graft or flap failure, scar tissue formation, dehiscence, infection, ectropion, recurrence, irregular eyelid margins leading to foreign body sensation, dry eyes, and a need for further surgery to optimize eyelid structure and function.

Clinical Significance

Customizing reconstruction is necessary to provide the proper surgery for each patient. For example, eyelid laxity is a factor that can determine what procedures are possible and most beneficial for a patient. Other factors to consider are the age of the patient and status of the other eye. For example, a Hughes flap may be avoided in a child if possible, as blocking vision for 4 to 6 weeks may lead to deprivation amblyopia if a child is in the amblyogenic age. Similarly, if a patient is monocular, and is unable to see out of the contralateral eye, if possible, it may be important to not block the seeing eye for four to six weeks with a Hughes flap.

Finally, as with any cancer treatment, it is important to maintain surveillance to monitor for recurrence of carcinoma.[11]

Enhancing Healthcare Team Outcomes

It is best to maintain a multidisciplinary team approach to the follow-up of these patients. Close surveillance is important to monitor for recurrence of carcinoma. Primary care nurse practitioners, physician assistants, and nurses should be involved in regular follow-up as well as the surgeon. [Level V]


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Lower Eyelid Reconstruction - Questions

Take a quiz of the questions on this article.

Take Quiz
For which of the following eyelid defects is healing by secondary intention a viable reconstructive option?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What malignancy most commonly leads to a surgical defect of the lower eyelid?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What type of lower eyelid reconstruction is typically performed for a defect up to 25% of the width the lower eyelid?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
How is a lower eyelid defect of 90% of the lower eyelid typically repaired?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Lower Eyelid Reconstruction - References

References

Min K,Lee JH,Kim SC,Choi JW,Oh TS, Quantitative Analysis of Paralyzed Lower Eyelid Elevation Technique: Suspension Sling versus Supporting Midcheek Lift. Plastic and reconstructive surgery. 2019 Apr;     [PubMed]
Lessa S,Sebastiá R,Pontello J, Lateral Canthal Clefts of the Eyelid. Ophthalmic plastic and reconstructive surgery. 2019 Mar 8;     [PubMed]
Patel BC,Malhotra R, Transconjunctival Blepharoplasty 2019 Jan;     [PubMed]
Hwang CJ,Eftekhari K,Schwarcz RM,Massry GG, The Aesthetic Oculoplastic Surgery Video Teleconference Consult. Aesthetic surgery journal. 2019 Feb 28;     [PubMed]
Xie A,Cao Y,Yu D, Combined Transverse Incision and Pouch Incision for the Correction of Medial Epicanthus. The Journal of craniofacial surgery. 2019 Feb 20;     [PubMed]
Hughes CD,Dabek RJ,Riesel JN,Baletic N,Chodosh J,Bojovic B, Short Runs for a Long Slide: Principalization in Complex Facial Restoration after Acid Attack Burn Injury. Craniomaxillofacial trauma     [PubMed]
Sandulescu T,Franzmann M,Jast J,Blaurock-Sandulescu T,Spilker L,Klein C,Naumova EA,Arnold WH, Facial fold and crease development: A new morphological approach and classification. Clinical anatomy (New York, N.Y.). 2019 May;     [PubMed]
Chen B,Liu J,Ni J,Zhou S,Chen X, Lower eyelid tension balance reconstruction: A new procedure for the repair of congenital epiblepharon with epicanthus. Journal of plastic, reconstructive     [PubMed]
Goddard L,Chesnut C, Simultaneous Lateral Tarsal Strip and Medial Spindle Procedures for Cicatricial Ectropion. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]. 2019 Jan 4;     [PubMed]
Pinto V,Zannetti G,Villani R,Tassone D,Cipriani R,Piccin O, Long Term Cosmetic and Functional Results of One Stage Reconstruction for Lower Eyelid Malignant Melanoma: A Single Centre Experience of Eleven Patients. Journal of maxillofacial and oral surgery. 2018 Dec;     [PubMed]
Tinklepaugh A,Husain Z,Libby TJ,Ciocon D, Management of a Lower Eyelid Defect. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]. 2018 Dec;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Surgery-Facial Plastics. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Surgery-Facial Plastics, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Surgery-Facial Plastics, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Surgery-Facial Plastics. When it is time for the Surgery-Facial Plastics board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Surgery-Facial Plastics.