eMedicine Specialties > Plastic Surgery > Eyelids

Eyelid Reconstruction, Lower Eyelid

Mounir Bashour, MD, CM, FRCS(C), PhD, FACS, Assistant Professor of Ophthalmology, McGill University; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD
Contributor Information and Disclosures

Updated: Jan 31, 2008

Introduction

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

A wide variety of surgical techniques is available (see review by Codner and Weinfield1), 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.

History of the Procedure

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.

Problem

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.

Etiology

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. (For information on the systemic treatment of metastatic cutaneous melanoma, please see this article on Medscape.)

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

Presentation

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.

Indications

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.

Relevant Anatomy

Lower eyelid can be separated into 2 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.2

Contraindications

Standard contraindications for surgical procedures apply.

Contents

Overview: Eyelid Reconstruction, Lower Eyelid
Workup: Eyelid Reconstruction, Lower Eyelid
Treatment: Eyelid Reconstruction, Lower Eyelid
Follow-up: Eyelid Reconstruction, Lower Eyelid
Multimedia: Eyelid Reconstruction, Lower Eyelid
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References

  1. Codner MA, Weinfeld AB. Pr47 comprehensive eyelid reconstruction. ANZ J Surg. May 2007;77 Suppl 1:A71. [Medline].

  2. Erdogmus S, Govsa F. The arterial anatomy of the eyelid: importance for reconstructive and aesthetic surgery. J Plast Reconstr Aesthet Surg. 2007;60(3):241-5. [Medline].

  3. Ambrozová J, Mesták J, Smutková J. Reconstruction of the lower eyelid after excision of major tumours. Acta Chir Plast. 1993;35(3-4):131-45. [Medline].

  4. Bartley GB, Putterman AM. A minor modification of the Hughes' operation for lower eyelid reconstruction. Am J Ophthalmol. Jan 1995;119(1):96-7. [Medline].

  5. Beyer CK, Bathrick ME. One-stage lower eyelid reconstruction. Ophthalmic Surg. Jul 1982;13(7):551-4. [Medline].

  6. Boynton JR. Semicircle flap reconstruction "plus". Ophthalmic Surg. Dec 1993;24(12):826-30. [Medline].

  7. Chandler DB, Gausas RE. Lower eyelid reconstruction. Otolaryngol Clin North Am. Oct 2005;38(5):1033-42. [Medline].

  8. Cohen MS, Shorr N. Eyelid reconstruction with hard palate mucosa grafts. Ophthal Plast Reconstr Surg. 1992;8(3):183-95. [Medline].

  9. Crestinu JM. Reconstruction of the lower eyelid. Plast Reconstr Surg. Oct 1988;82(4):720. [Medline].

  10. Custer PL. Tarsal kinking after Hughes flap. Ophthal Plast Reconstr Surg. Sep 1998;14(5):349-51. [Medline].

  11. Glatt HJ. Tarsoconjunctival flap supplementation: an approach to the reconstruction of large lower eyelid defects. Ophthal Plast Reconstr Surg. Jun 1997;13(2):90-7. [Medline].

  12. Hatoko M, Kuwahara M, Shiba A, Tanaka A, Tada H, Okazaki T. Reconstruction of full-thickness lower eyelid defects using a blepharoplasty technique with a hard palate mucosal graft. Ann Plast Surg. Jun 1999;42(6):688-92. [Medline].

  13. Holds JB, Anderson RL. Medial canthotomy and cantholysis in eyelid reconstruction. Am J Ophthalmol. Aug 15 1993;116(2):218-23. [Medline].

  14. Iliff CE, Iliff NT. Partial and total reconstruction of the lower eyelid. Ophthalmology. Apr 1980;87(4):272-8. [Medline].

  15. Jordan DR, Anderson RL, Holds JB. Modifications to the semicircular flap technique in eyelid reconstruction. Can J Ophthalmol. Apr 1992;27(3):130-6. [Medline].

  16. Leone CR Jr. Periosteal flap for lower eyelid reconstruction. Am J Ophthalmol. Oct 15 1992;114(4):513-4. [Medline].

  17. Lowry JC, Bartley GB, Garrity JA. The role of second-intention healing in periocular reconstruction. Ophthal Plast Reconstr Surg. Sep 1997;13(3):174-88. [Medline].

  18. Matsuo K, Sakaguchi Y, Kiyono M, Hataya Y, Hirose T. Lid margin reconstruction with an orbicularis oculi musculocutaneous advancement flap and a conchal cartilage graft. Plast Reconstr Surg. Jan 1991;87(1):142-5. [Medline].

  19. McCord CD, Nunery WR, Tanenbaum. Reconstruction of the lower eyelid and outer canthus. Oculoplastic Surgery. 1995;119-44.

  20. Mehta HK. Simultaneous spontaneous and primary surgical repair of eyelids. Br J Ophthalmol. Jul 1989;73(7):488-93. [Medline].

  21. Miller EA, Boynton JR. Complications of eyelid reconstruction using a semicircular flap. Ophthalmic Surg. Nov 1987;18(11):807-10. [Medline].

  22. Papp C, Maurer H, Geroldinger E. Lower eyelid reconstruction with the upper eyelid rotation flap. Plast Reconstr Surg. Sep 1990;86(3):563-5; discussion 566-8. [Medline].

  23. Rohrich RJ, Zbar RI. The evolution of the Hughes tarsoconjunctival flap for the lower eyelid reconstruction. Plast Reconstr Surg. Aug 1999;104(2):518-22; quiz 523; discussion 524-6. [Medline].

  24. Steinkogler FJ. Reconstruction of the lower lid. Br J Ophthalmol. Jul 1984;68(7):507-10. [Medline].

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Further Reading

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Keywords

eyelid reconstruction, lower eyelid reconstruction, Tenzel flap, Tenzel semicircular rotation flap, tarsoconjunctival bridge flap, modified Hughes procedure, modified Hughes flap, free tarsoconjunctival graft, Mustarde cheek rotation flap, free tarsoconjunctival graft, eyelid tumor, eyelid malignancy, eyelid trauma, eyelid defects, eyelid surgery, basal cell carcinoma, BCC, squamous cell carcinoma, SCC, sebaceous cell carcinoma, SebCC, cutaneous melanoma

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Contributor Information and Disclosures

Author

Mounir Bashour, MD, CM, FRCS(C), PhD, FACS, Assistant Professor of Ophthalmology, McGill University; Clinical Assistant Professor of Ophthalmology, Sherbrooke University; Medical Director, Cornea Laser and Lasik MD
Mounir Bashour, MD, CM, FRCS(C), PhD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American College of International Physicians, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, American Society of Mechanical Engineers, American Society of Ophthalmic Plastic and Reconstructive Surgery, Biomedical Engineering Society, Canadian Medical Association, Canadian Ophthalmological Society, Contact Lens Association of Ophthalmologists, International College of Surgeons US Section, Ontario Medical Association, Quebec Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose

Medical Editor

Neal R Reisman, MD, JD, Associate Chief, Department of Plastic Surgery, Clinical Associate Professor, St Luke's Episcopal Hospital, Baylor College of Medicine
Neal R Reisman, MD, JD is a member of the following medical societies: American Association of Plastic Surgeons, American College of Medical Quality, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society for Surgery of the Hand, Lipoplasty Society of North America, Texas Medical Association, and Texas Society of Plastic Surgeons
Disclosure: Nothing to disclose

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose

Managing Editor

Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics
Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama
Disclosure: Nothing to disclose

CME Editor

Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose

Chief Editor

Lars M Vistnes, MD, FRCSC, FACS, Professor of Surgery, Emeritus, Stanford University Medical Center
Lars M Vistnes, MD, FRCSC, FACS is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose

 
 
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