You are in: eMedicine Specialties > Plastic Surgery > EYELIDS Eyelid Reconstruction, Upper EyelidArticle Last Updated: Jan 31, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  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 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 Editors: Neal R Reisman, MD, JD, Associate Chief, Department of Plastic Surgery, Clinical Associate Professor, St Luke's Episcopal Hospital, Baylor College of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; 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; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Lars M Vistnes, MD, FRCSC, FACS, Professor of Surgery, Emeritus, Stanford University Medical Center Author and Editor Disclosure Synonyms and related keywords: eyelid reconstruction, upper eyelid reconstruction, eyelid defects, surgical reconstruction of eyelid, eyelid tumor excision, eyelid trauma, superior lateral cantholysis, sliding tarsoconjunctival flap, Cutler-Beard procedure, free tarsoconjunctival graft, eyelid malignancy, eyelid surgery, basal cell carcinoma, BCC, squamous cell carcinoma, SCC, sebaceous cell carcinoma, SebCC, cutaneous melanoma INTRODUCTIONSection 2 of 12
  Tumor excision and trauma are 2 common causes of eyelid defects requiring surgical reconstruction. A wide variety of surgical techniques is available, and the plastic or ophthalmic surgeon must be able to technically execute them to close the eyelid defects. Preoperatively, several factors must be analyzed carefully, since they affect the surgical plan and outcome.1 These factors 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 (eg, prior radiation treatment). History of the ProcedureProcedures 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. ProblemEyelid defects are classified according to size and location. A common way of breaking down full-thickness defects is as follows:
A typical defect may involve 50% of the central portion of the upper eyelid. Obviously, 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. FrequencyTrauma is the most common cause leading to reconstruction of the lower lid. Basal cell carcinoma (BCC) is the second most common cause of eyelid reconstruction. It is the most common eyelid malignancy and accounts for approximately 90% of eyelid tumors. EtiologyAs 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. ClinicalPatients 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. INDICATIONSSection 3 of 12
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 ANATOMYSection 4 of 12
The upper 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 CONTRAINDICATIONSSection 5 of 12
Standard contraindications for surgical procedures apply. WORKUPSection 6 of 12
Imaging Studies
Other Tests
TREATMENTSection 7 of 12
Surgical TherapyUpper eyelid defects involving one third or less of the horizontal length of the upper eyelid usually can be repaired by direct closure. Remember to use a pentagonal wedge excision in the upper lid when removing a large lesion; other wedge excisions can cause lid kinking, notching, and ectropion (see Image 1). A superior lateral cantholysis adds horizontal mobility and allows closure of larger defects using direct tarsal suturing and closure (see Image 2). Upper eyelid defects involving loss of one third to one half of the horizontal length of the upper eyelid require other techniques. One such technique is the sliding tarsoconjunctival flap (see Image 3). This is a variation of the modified Hughes procedure described for the lower eyelid (see Eyelid Reconstruction, Lower Eyelid). It is an excellent method for reconstructing medial or lateral defects of the upper eyelid, but it is not suited for repair of central defects. Following resection, the remaining tarsus is used as structural support (posterior lamella), and a skin graft or local musculocutaneous flap is used for the anterior lamella. As in any eyelid reconstruction, canthal attachments must be secure and in proper position. Another possibility is to use a Tenzel semicircular flap designed for the upper lid (see Image 3). This technique involves the rotation of a semicircular musculocutaneous flap beginning at the lateral canthus, extending downward in a semicircular fashion. Details on this procedure can be found in the article Eyelid Reconstruction, Lower Eyelid. The Cutler-Beard procedure is indicated for large central defects of the upper eyelid (see Image 4). This technique uses a full-thickness segment of lower eyelid tissue that is passed under an intact bridge, the lower eyelid margin. A full-thickness lower eyelid flap is sutured into the defect in the upper eyelid. As with the flap created in a modified Hughes tarsoconjunctival procedure, the Cutler-Beard flap occludes vision for 6-8 weeks and must be divided in a second stage of the surgical procedure. It, therefore, is not suited for patients sighted only in the involved eye or of amblyogenic age. A free tarsoconjunctival graft from the patient's contralateral upper eyelid is another useful technique. A free graft of tarsus and conjunctiva is harvested from the contralateral side and is sutured in place with edges parallel to the edges of the defect. A vascularized anterior lamella is provided from adjacent tissue. Follow-upSee the patient 1 day postoperatively for a routine check. If nonabsorbable sutures were used, the patient should return for suture removal in 1 week. COMPLICATIONSSection 8 of 12
Eyelid marginal positional abnormalities usually are not serious complications but can be frustrating for both patient and surgeon, sometimes requiring further surgery for correction. Other complications of upper lid reconstruction include the following:
Postoperative upper lid ectropion can result from anterior lamella shortening. Vertical shortage of upper lid skin is worsened by the effect of altered lid mobility. To avoid this, use full-thickness skin grafts during the initial reconstruction. To avoid a postoperative orbital hematoma, meticulous cautery should be used, and ice compress dressings rather than tight pressure dressings should be used afterward, ensuring that visual acuity does not deteriorate. In most instances, postoperative ptosis should not be reoperated on for 6 months, especially if progressive improvement is noted. This allows for potential spontaneous recovery of function. OUTCOME AND PROGNOSISSection 9 of 12
Both function and cosmesis measure outcome. Greater initial defects have poorer outcomes. However, in general, all of the procedures described in this article have adequate, if not excellent, outcomes, even for larger defects, if meticulous attention to detail is taken in the repair. FUTURE AND CONTROVERSIESSection 10 of 12
No real controversies exist in this field. Future refinements or modifications of technique remain possible, although at a slower rate, and artificial materials (ie, to use in place of skin and connective tissue) likely will be incorporated as they become available, especially for massive defects. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Eyelid Reconstruction, Upper Eyelid excerpt Article Last Updated: Jan 31, 2008 | ||||||||||||||||||||||||||||||||||||||||
