You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > RECONSTRUCTIVE SURGERY Upper Eyelid ReconstructionArticle Last Updated: Jan 16, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Maurice M Khosh, MD, FACS, Clinical Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons; Private Practice, Head and Neck Surgical Group; Attending Surgeon, Lenox Hill Hospital, Manhattan Eye, Ear and Throat Infirmary, Columbia Presbyterian Medical Center, St Luke's-Roosevelt Hospital Center, Beth Israel Medical Center Maurice M Khosh is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, and Triological Society Editors: Anthony P Sclafani, MD, Director of Facial Plastic Surgery, The New York Eye and Ear Infirmary; Professor of Otolaryngology, New York Medical College; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Dominique Dorion, MD, MSc, FRCSC, Program Director and Division Chair, Professor of Surgery, Division of Otolaryngology, University of Sherbrooke, Canada; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: upper eyelid reconstruction, eyelid reconstruction, eye lid reconstruction, eye lid surgery, eyelid surgery, globe protection, eye malignancy, eye tumor, periorbital malignancy, eye cancer, periorbital tumor, periorbital cancer, Mohs micrographic surgery, Mohs' micrographic surgery, eye trauma, eyelid trauma, eye lid trauma, semicircular eyelid flap, Tenzel flap, semi-circular eyelid flap, skin-conjunctival flap, Cutler-Beard flap INTRODUCTIONSection 2 of 11
  The goals of eyelid reconstruction are 3-fold: (1) to provide adequate eyelid function, (2) to afford globe protection, and (3) to achieve acceptable aesthetic results. The functioning upper eyelid serves a more important role in globe protection than the lower eyelid because the upper eyelid covers a greater area of the cornea. The normal vertical excursion of the upper eyelid is approximately 12 mm, compared with 5 mm for the lower eyelid. Globe protection requires appropriate coverage by the eyelids and adequate tear lubrication. In upper eyelid reconstruction, an in-depth knowledge of the anatomy is an absolute prerequisite for success. The most common indication for upper eyelid reconstruction is defects due to resection of malignancies. The majority of tumor excisions in the periorbital region are performed via Mohs micrographic surgery. This method of resection provides a high certainty of negative histologic margins prior to reconstruction. Less often, eyelid reconstruction is indicated for traumatic injuries. In evaluating reconstructive demands for the upper eyelid, the anatomic defects must be carefully appraised. The vertical, horizontal, and deep dimensions of the eyelid injury or defect must be determined, and availability of regional and distant tissue for reconstruction must be evaluated. For further reading, see Medscape. INDICATIONSSection 3 of 11
Eyelid reconstruction is indicated in all but a few instances when defects are present. Healing by secondary intention is a viable option when the defect is confined to the medial canthus region. Small defects (<1 cm) in this concave area heal well by secondary intention. However, involvement of the lacrimal apparatus requires primary reconstruction. Small defects of the upper eyelid (<5 mm) that do not involve the lid margin or the canthus can be similarly allowed to heal without reconstruction. All other defects of the eyelid should be repaired. RELEVANT ANATOMYSection 4 of 11
The upper eyelid can be divided into 3 subunits: (1) the medial canthus, (2) the lateral canthus, and (3) the upper eyelid proper. The eyebrow is better categorized as a subunit of the forehead because its skin thickness, elasticity, and contour better match those of the forehead. Medial canthus The medial canthus contains the lacrimal drainage system and the medial canthal tendon. The medial canthal tendon is comprised of a fibrous extension of the tarsus, which inserts into the lacrimal crest of the lacrimal bone. At its most medial extension, the medial canthal tendon divides to surround the lacrimal sac located in the lacrimal crest. The 2 heads of the tendon insert into the anterior and posterior lacrimal crest. By surrounding the lacrimal sac, the medial canthal tendon heads impart a significant functional impact on the lacrimal pump. The lacrimal tendon is further supported at its insertion by a vertical component, which inserts above the lacrimal crest. Tears drain into the lacrimal sac through the superior and inferior puncta, which open 5-7 mm lateral to the canthal angle. The upper punctum extends superiorly 2 mm as an ampulla prior to assuming a horizontal direction towards the lacrimal sac. Lateral canthus The lateral canthus is located slightly superior to the medial canthus along the orbital rim. Deep to the eyelid skin and orbicularis muscle, a fibrous extension of the upper tarsal plate joins that of the lower tarsus to become the lateral canthal tendon. This inserts into the lateral orbital tubercle (Whitnall tubercle), located on the inner aspect of the lateral orbital rim. In the area of the lateral orbital tubercle, several other structures join the lateral canthal tendon to form the lateral retinaculum. These other structures include the lateral horn of the levator aponeurosis, the inferior suspensory ligament (Lockwood ligament), and the check ligament of the lateral rectus muscle. Upper eyelid The eyelid can be divided into the anterior and posterior lamellae. The anterior lamella is composed of skin and the orbicularis oculi muscle. The marginal arterial arcade is located 3 mm superior to the lid margin within the orbicularis fibers. The posterior lamella consists of the conjunctiva, the tarsus, the levator aponeurosis, and the Müller muscle. The peripheral arterial arcade is situated at the upper edge of the tarsus anterior to the levator aponeurosis. The anatomy of the upper eyelid becomes more complicated as one moves from the lid margin superiorly. Along the lid margin, the eyelid is composed of skin, pretarsal orbicularis, tarsus, and conjunctiva. The orbital septum and levator aponeurosis insert into the lower two thirds of the anterior tarsus. In the eyelids of whites, some of the levator aponeurosis fibers also insert into the upper eyelid skin below the level of the tarsal fold, to create the supratarsal fold. The upper eyelid above the tarsus is composed of skin, preseptal orbicularis, orbital septum, orbital fat, levator aponeurosis, Müller muscle, and conjunctiva. Below the orbital equator, the levator muscle assumes a more fibrous appearance and becomes the levator aponeurosis. The Müller muscle, which is a nonstriated, sympathetically innervated elevator of the upper lid, finds its origin on the posterior aspect of the levator muscle and inserts into the superior tarsal edge. The superior ligament of Whitnall is a fascial condensation along the upper aspect of the levator muscle. This ligament attaches to the trochlear fascia medially and to the fascia of the lacrimal gland laterally. CONTRAINDICATIONSSection 5 of 11
Upper eyelid reconstruction has few contraindications. In a patient with only one seeing eye, procedures that obstruct vision, such as the Cutler-Beard flap, should be abandoned in favor of those that maintain the ability to see. In patients with significant comorbidities, complex and time-consuming reconstructive procedures may be contraindicated because of the risks associated with perioperative cardiopulmonary complications. WORKUPSection 6 of 11
Lab StudiesStandard preoperative testing of cardiopulmonary function and blood parameters is necessary to avoid increased risk associated with a surgical procedure. Imaging StudiesImaging studies such as CT scan or MRI may be necessary to plan surgical excision of a tumor. They also may aid in predicting the extent of the defect and the availability of adjacent tissues for reconstruction. Other TestsPrior to surgical reconstruction of the upper eyelid, an evaluation by an ophthalmologist is indicated to determine visual acuity, lacrimation, and extraocular movement. TREATMENTSection 7 of 11
Surgical therapyIn order to address the reconstructive options in an organized manner, eyelid defects are divided into anterior lamellar defects and full-thickness defects according to size. Anterior Lamellar DefectsPartial-thickness defects smaller than 5 mm heal well by secondary intention. Defects involving less than half of the upper eyelid width can be closed with a variety of local flaps. Closure is much easier in older patients with skin redundancy. The flaps are raised as skin-muscle composites. The incisions are placed along the natural creases of the eyelid. In patients with superficial defects, remove the orbicularis fibers from the base of the defect prior to flap rotation. Avoid excessive tension along the wounds. The muscle layer is closed separately with 6-0 or 7-0 absorbable sutures, and skin is closed with 6-0 or 7-0 monofilament or 6-0 fast-absorbing catgut sutures. If excess tension causes lagophthalmos, other tissue, such as a skin graft, must be brought in for reconstruction. The skin of the opposite eyelid skin and preauricular area represent readily available sources for skin grafts. In defects involving more than 50% of the eyelid, full-thickness skin grafting usually represents the best reconstructive option. When performing skin grafts, do not remove the remaining orbicularis from the base of the defect because this is an excellent source of vascular supply for the skin graft. The skin-graft bolster should be kept in place for 3 days. Full-Thickness DefectsFull-thickness defects of the upper eyelid must be reconstructed in layers in order to allow normal function. Defects involving up to 25% of the lid width can be closed primarily. In older patients with significant skin laxity, this percentage can be higher. For primary repair, the tarsal edges are first prepared by forming vertically oriented ends that can be directly approximated. A Burow triangle of eyelid skin is excised above the tarsal edges, thus forming a pentagonal defect. The lid is repaired in layers by first approximating the tarsal edges at the lid margin (gray line). Preferred sutures are 6-0 silk sutures because monofilament permanent sutures are not as soft and can cause conjunctival irritation. Next, the tarsus is reapproximated using 6-0 polyglactic sutures. Use 2-3 interrupted sutures with knots tied superficially. The skin is closed with 6-0 silk sutures. Keep the skin suture ends long so that they can be tied under the most superior suture. This helps to keep the suture ends away from the conjunctiva. The skin sutures are removed in 5 days, and the lid margin suture is removed in 7-10 days. Tenzel flap Larger defects of the upper eyelid that comprise up to two thirds of the lid width can be closed with a semicircular, or Tenzel flap (see Image 1). In this procedure, extra skin is rotated from the lateral orbit and the defect is closed as described in primary closure. The flap starts from the lateral canthus and extends as a semicircle inferiorly to a diameter of 2 cm. The skin is incised down to the periosteum of the orbital rim. The upper limb of the lateral canthal tendon is cut to facilitate flap rotation. A Burow triangle is then removed from the superior edge of the defect to create a pentagonal defect. The primary defect is closed as described in the previous section. If tension at the wound edges is excessive, the orbital septum, the levator aponeurosis, and the conjunctiva at the semicircular flap can be sequentially cut to relieve tension. The semicircular flap is closed by first placing a 5-0 monofilament permanent vertical mattress suture at the lateral canthus. The first limb of the suture is placed through the skin of the intact inferior lateral canthus and then brought out at the skin of the semicircular flap. The short limb of the vertical mattress is placed through the semicircular flap, the intact limb of the canthal tendon, and then the skin of the intact eyelid. The remainder of the flap is then closed with permanent sutures in interrupted fashion. Cutler-Beard flap Defects that involve more than 50% of the upper eyelid can be closed with an inferiorly based skin-conjunctival (Cutler-Beard) flap (see Image 2) similar to the lip switch technique used for lip reconstruction. The skin of the lower eyelid is incised horizontally below the inferior edge of the tarsus. The length of the incision corresponds to the size of the defect to be reconstructed. Make a full-thickness incision through the skin, lid retractors, and the conjunctiva. The cornea must be protected to prevent inadvertent injury. Full-thickness vertical incisions are made from the ends of the horizontal incision. The vertical length of the incisions depends on the vertical dimension of the upper eyelid defect and can be extended as far as the conjunctival fornix. Closure of the defect can be accomplished with or without tarsal reconstruction. If tarsal reconstruction is not undertaken, the skin-conjunctival flap is passed under the lower eyelid tarsal bridge and secured to the edges of the defect in 2 layers. Absorbable sutures with knots away from the cornea are used to close the conjunctival layer. The skin-muscle layer is closed with permanent monofilament sutures, which are removed in 5-7 days. In the Cutler-Beard flap, the missing tarsus is typically not recreated. When tarsal reconstruction is planned, several options are available for tarsal replacement, including a free tarsal graft from the contralateral upper eyelid, septal cartilage, or auricular cartilage. A tarsal graft represents the best reconstructive option, in terms of consistency, thickness, and curvature. The tarsal graft is harvested from the cephalic border of the intact tarsus. The upper eyelid is inverted, and the cephalic border of the tarsus is identified. The horizontal dimension of the graft is then marked. The vertical dimension of the graft is 5 mm at the cephalic border. At least a 5-mm caudal wedge of tarsus must be preserved to prevent secondary deformity of the donor side. The incision is through the conjunctiva and tarsus. Care must be taken to avoid damage to the overlying upper eyelid retractor and the skin. The donor area can be left open to heal. The harvested tarsus is denuded of conjunctiva and placed in between the skin and conjunctiva of the lower lid flap. The lateral edges can be secured to the remnants of native tarsus. The second stage of the Cutler-Beard flap is performed in 4-6 weeks. During the second stage, the flap is divided and the upper eyelid is contoured to match the contralateral eyelid. Protect the cornea while the flap pedicle is divided sharply at the level of the new lid margin. The incision is beveled superiorly to obtain more conjunctiva than skin. Ensure that the extra length of conjunctiva is 1-2 mm; this will be wrapped around the edge of the newly formed lid margin. The inferior edge of the lower tarsal bridge is sharply reopened, and the flap remnant is contoured for proper no-tension closure. The wound is closed in layers. Obviously, the reconstructed upper eyelid will lack lashes. Postoperative detailsApply an ophthalmic antibiotic ointment to the surgical site at the conclusion of surgery, and a pressure patch is commonly applied. Pressure bandages are useful to reduce postoperative edema and bleeding and to immobilize the advanced tissue flaps or skin grafts. In addition, 4-0 silk traction sutures placed in the lid margin are useful in selected cases to keep the reconstructed eyelid stretched and to help reduce retraction of the tissues. The pressure patch, traction sutures, and stents for skin grafts are removed in 3-5 days. Antibiotic ointment application is continued until skin healing is complete. Oral antibiotics are routinely administered for patients who are immunocompromised or have reduced healing capacity. Follow-upMost sutures are removed in 5-7 days. If during suture removal the wound becomes dehiscent, the remaining sutures are left in place for another week. Silk lid margin sutures are usually left in place for 10-14 days. COMPLICATIONSSection 8 of 11
A lid notch may develop at the junction of the direct lid margin closure because of excess tension or inadequate alignment. This can be revised with excision and direct closure. Blunting of the canthal angle may develop after cantholysis or a semicircular flap technique and may be repaired with canthoplasty. Symblepharon may develop if the raw surface of the inner aspect of the lid reconstruction is allowed to epithelialize. Although this does not usually require treatment, lysis of the symblepharon, a Z-plasty, or a mucous membrane graft may be necessary if the symblepharon is functionally significant. Trichiasis can be eliminated with cryotherapy or epilation. Ptosis can develop if the levator aponeurosis attachment is significantly disturbed. Repair with an aponeurosis advancement should be delayed for 4-6 months. Lagophthalmos may result from upper lid retraction or inadequate orbicularis muscle tone. If topical lubricants do not resolve the problem, surgical revision or partial tarsorrhaphy may be indicated. Epiphora may result from inadequate tear drainage due to punctal malposition, loss of components of the lacrimal drainage system, or deficiency of the lacrimal pump. Alternatively, epiphora may be caused by reflex lacrimation due to entropion, trichiasis, dry eyes, or exposure keratopathy. Punctal and lid malposition may require surgical revision. Defects of the lacrimal drainage system can be repaired with conjunctivodacryocystorhinostomy and Jones tube placement. Secondary lacrimal drainage system surgery should be delayed for at least a year after cutaneous malignancy excision to allow an observation period for possible tumor recurrence. OUTCOME AND PROGNOSISSection 9 of 11
The surgical outcome for upper eyelid reconstruction is mostly dependent on the extent of the primary defect. Larger defects necessitate more complicated reconstruction with associated risks of complications. In general, reconstruction in older patients is easier because of the increased tissue redundancy and more laxity. The primary goal of upper eyelid reconstruction should be globe protection. Aesthetic results constitute a secondary goal. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Upper Eyelid Reconstruction excerpt Article Last Updated: Jan 16, 2008 | |||||||||||||||||||
