Lower Eyelid Reconstruction

Eyelid tumor excision and trauma are 2 common causes of eyelid defects requiring surgical reconstruction. ^[1]

A wide variety of surgical techniques are available, ^{[2, 3]} and the plastic or ophthalmic surgeon must be able to technically execute these techniques to close eyelid defects.

Preoperatively, several factors must be analyzed carefully, since they affect the surgical plan and outcome. These include the size and orientation of the defect, patient's age, vascular supply to surrounding tissues, biologic behavior of the tumor, previous treatment, age of the wound, and other factors, such as prior radiation treatment.

Procedures for repairing eyelid defects most likely have been around since the earliest surgeries. Since the beginnings of the specialties of plastic and oculoplastic surgery, new techniques have been introduced, and further refinements and modification of these techniques have occurred with the progression of time.

For example, the Hughes tarsoconjunctival flap initially was described in 1937 for reconstructing full-thickness defects involving the central portion of the lower eyelid. The use of this flap has evolved, and the flap has been refined and modified over the last 60 years.

Eyelid defects are classified according to size and location. A common way of breaking down full-thickness defects is as follows:

• For young patients (tight lids)

  • Small - 25-35%

  • Medium - 35-45%

  • Large - Greater than 55%

• For older patients (lax lids)

  • Small - 35-45%

  • Medium - 45-55%

  • Large - Greater than 65%

A typical defect may involve 50% of the central portion of the lower eyelid. Defects may involve the combination of eyelid and canthi. Involvement of the eyelid margin should be noted. If the eyelid margin is spared, closure by local flap or skin graft may suffice. Once the margin is involved, surgical repair must restore the integrity of the eyelid margin.

Frequency

Trauma is the most common cause leading to reconstruction of the lower lid. Basal cell carcinoma (BCC) is the second most common cause for eyelid reconstruction. It is the most common eyelid malignancy and accounts for approximately 90% of eyelid tumors.

As stated above, the 2 causes of defects requiring reconstruction are tumors and trauma.

BCC is the most common eyelid malignancy. Squamous cell carcinoma (SCC), sebaceous cell carcinoma (SebCC), and cutaneous melanoma are other neoplasms that involve the eyelids.

In addition to surgical excision of tumors, eyelid defects may result from trauma or burns, or they may be congenital.

Patients can present with a lid tumor for primary excision or after excision performed by another surgeon (commonly, after Mohs surgery performed by a dermatologist).

Patients also may present after acute trauma or for secondary reconstruction sometime after primary repair posttrauma.

Reconstruction is indicated for all defects that may lead to secondary complications if not repaired. These complications may include lid notching, epiphora, corneal exposure, and lagophthalmos.

The lower eyelid can be separated into two main layers, or lamellae, anterior and posterior. The arterial anatomy of the eyelids and the importance to eyelid reconstruction has been described by Erdogmus and Gosva. ^[4]

Structures that must be considered in a description of lid anatomy are the skin and subcutaneous tissue; the orbicularis oculi muscle; the submuscular areolar tissue; the fibrous layer, consisting of the tarsi and the orbital septum; the lid retractors of the upper and lower eyelids; the retroseptal fat pads; and the conjunctiva. For more information about the relevant anatomy, see Eyelid Anatomy.

Standard contraindications for surgical procedures apply.