Eyelid Reconstruction

Question 1

What is healing by secondary intention best used for?

Answer 1

Small defect of anterior lamella only, especially in medial canthal region

Nasal bones resist scar contracture, improving outcomes.

Question 2

How should eyelid defects not involving the eyelid margin be repaired?

Answer 2

Direct closure oriented along tension lines or parallel to them

If not possible, use local flaps like V-Y advancement, bipedicled flaps, rhomboid flaps, and local rotation advancement flaps.

Question 3

What is the recommended repair for upper lid defects of anterior lamella? Is there a different approach based on size?

Answer 3

Repair with FTSG from contralateral upper lid if > 50% of the lid width involved
— If defects extend to multiple subunits of the OO, grafts for pretarsal and preseptal defects should be done independently.

If < 50% of lid width involved - perform primary closure with local tissue advancement.

Question 4

What is the best method to repair lower lid defects of anterior lamella?

Answer 4

< 50%: primary closure with local tissue advancement
> 50%: FTSG from upper lid or upper eyelid transposition flap (Fricke or Tripier)

Question 5

What is the repair strategy for lower lid defects involving less than 1/3 of the margin?

Answer 5

Repair by advancement of lateral lid using semicircular advancement or rotation flaps like Tenzel flap

Question 6

What are the options for full-thickness lower lid defects involving 1/3 to 1/2 of the margin? AKA up to 50% of the lid involved. Describe them.

Answer 6

CME: Use Tripier pedicle flap harvested from upper lid and transposed to lower lid . Can be unipedicle or bipedicled flap. (This was specific to margin involvement) - tripier flaps can be used for upper or lower defects (donor site from opposite lid obviously), and can be bipedicled which is necessary if defects extend past the pupil to avoid distal necrosis

Book & Janis: Primary closure (shown) with canthotomy and or cantholysis; or Tarsoconjunctival (Hughes) flap with FTSG

Question 7

How to repair full-thickness lower lid defects involving 50-75% of the margin? Describe it and key components of this process to prevent complication.

Answer 7

Use Hughes flap (tarsoconjunctival pedicle flap - based on tarsus of upper lid) + FTSG

-3-4 mm of upper lid tarsal height must be preserved to prevent ectropion.

Question 8

What is the first stage of the Hughes flap procedure?

Answer 8

Advance into the PL defect of lower lid left for 4-6 weeks, covered with skin flap or FTSG for AL

Can also use cheek advancement flap for AL.

Question 9

What is the second stage of the Hughes flap procedure?

Answer 9

Divide pedicle after 4-6 weeks

This reduces the risk of ectropion.

Question 10

What are some other options for full-thickness lower lid defects greater than 1/2? > 75?

Answer 10

> 50%: Full thickness pedicle flaps and free tarsoconjunctival grafts from contralateral upper lid with Overlying vascularized bipedicled skin and muscle flap. (Hughes is better).

> 75%: Composite graft (hard palate vs. septal cartilage/ mucosa) with cheek advancement flap

Question 11

What is the recommended flap for large anterior lamella defects of the lower lid?

Answer 11

Mustarde flap (cheek rotation flap)

Must also provide posterior lamella if interrupted so use either Hughes flap or 1 of the alternatives.

Question 12

What is the repair strategy for upper lid defects involving up to 1/3 of the margin (25-30%)?

Answer 12

Close directly

May require lateral canthotomy and/or superior cantholysis (separation of superior crus of the lateral canthal tendon) when up to 50%

Question 13

What is the procedure for full-thickness defects involving 1/3 to 1/2 of the upper lid margin (25-75% of lid width)?

Answer 13

Reverse Tenzel semicircular skin and muscle flap (aka local myocutaneous flap - alternatives include Tripier and Fricke flaps) + a composite graft (nasal septal cartilage- mucosa) for ML and PL.

Question 14

What is the procedure for full-thickness upper lid defects involving more than 1/2 of the margin (25-75% of lid width)?

Answer 14

Cutler-Beard procedure (w/ FTSG per book)

Involves a two-stage process with special considerations for tarsus replacement.

Question 15

What is involved in the first stage of the Cutler-Beard procedure?

Answer 15

Full thickness lower lid flap including conj advanced to upper lid by passing flap under bridge of lower lid margin

This includes conj, skin, OO, but no tarsus. A spacer graft is used to replace the tarsus component. This can be donor sclera, cartilage or ADM. ADM is becoming more common.

Question 16

What is the second stage of the Cutler-Beard procedure?

Answer 16

Divide pedicle 6-8 weeks later

Separate the flap such that the conjunctival surface is longer than the skin surface and is draped over the lid margin and sutured to the skin anteriorly to increase comfort.

Question 17

What is the recommended approach for medial canthal defects not involving the eyelid margin?

Answer 17

Local flap or secondary healing if evenly distributed above and below medial canthal tendon

Asymmetric distribution above and below the tendons can lead to ectropion or lower lid distortion

Question 18

What is required for large medial canthal defects? Describe your options.

Answer 18

Stabilize fixation of soft tissue and medial canthal tendon

May require drill holes, plates, trans nasal wiring, or periosteal sutures. Point of fixation should be posterior and superior close to the lacrimal crest apposition to corneal surface to avoid ectropion and lagopthalmos.
Use local flaps or glabellar flap if sufficient laxity, otherwise FTSG

Question 19

What is the repair strategy if up to 5 mm canaliculi are involved?

Answer 19

Repair with silicone stenting

This is crucial for maintaining function.

Question 20

What is required for larger medial canthal defects?

Answer 20

Lacrimal bypass surgery may be needed

This is deferred until after medial canthal soft tissue is healed.

Question 21

What is the procedure if there is total loss of canaliculi?

Answer 21

Conjunctivodacryocystorhinostomy may be necessary. A Pyrex glass tube (Jones tube) may be used.
If it extends into the paranasal sinuses, mucosa should be stripped and sinus obliterated to avoid mucocele or fistula development

Question 22

What is the general repair strategy for lateral canthal defects? What do you do when there is a large lower lid defects extending to the lateral canthus?

Answer 22

Some sort of lateral canthal support procedure should be done - at minimum canthopexy or canthoplasty if tendons in place

Restore proper position and secure tendons to lateral orbital rim
-Drill hole at Whitnall tubercle may be required for anchoring sutures if insufficient periosteum.
- Tendon should be secured 2 mm above the level of the medial canthus

For large lower lid defects that extend to the lateral canthus, lateral based tarsoconjunctival flaps or periosteal flaps used to reconstruct the posterior lamella + FTSG or local flaps (cheek advancement flap is good) for AL

Question 23

What are the complications of direct closure?

Answer 23

Notching at the margin and dehiscence

Must precisely approximate tarsus and minimize tension.

Question 24

What complications can arise from a Hughes flap?

Answer 24

Malposition like ectropion and upper lid retraction

Lower lid tightening may be performed at the second stage to reduce ectropion.
Reduce upper lid retraction by dissecting Muller muscle away from conj and no advancing it with the flap in the first stage. Resection upper lid retractors during the second stage.

Question 25

Describe the Tenzel flap and its use.

Answer 25

Used in lower lid defects involving < 1/3 of the eyelid margin. Tenzel flap is a laterally based flap that is elevated and rotated to repair full thickness defects. It requires lateral canthotomy for mobilization.

Question 26

What if the Cutler-Beard flap is not an option for upper lid reconstruction?

Answer 26

Use local transposition flap using skin and OO for AL, and a tarsoconjunctival graft from the contralteral upper lid for PL.

Question 27

What is the pertinent history to be obtained when examining an eyelid defect?

Answer 27

Hx of ophthalmologic conditions (dry eye, excessive tearing, vision problems, thyroid eye disease, Bell’s palsy) Personal/family hx of skin malignancy, sun exposure Hx of previous periorbital trauma/ surgery/ facial radiation Ophthalmic medications

Question 28

Describe the physical exam/ key descriptions items when analyzing an eyelid defect.

Answer 28

Can divide periocular region into zones - Zone 1: upper lid - Zone 2: lower lid - Zone 3: medial canthus - Zone 4: lateral canthus - Zone 5: multiple zones involved Determine layers lost (partial vs. full thick). And % of lid involved. Evaluate laxity of eyelid, canthal support, any involvement in lacrimal system Identify visible elements available for reconstruction Look at vascularity, scarring, radiation damage, severe actinic damage in periorbital region Evaluate eyelid function

Question 29

What diagnostic studies are required in eyelid reconstruction work up?

Answer 29

If lesion >> biopsy and confirm negative margins MRI useful to determine extent of tumor, and lymph node involvement, and aggressive tumor histology (peri neural invasion, deeply invasive)

Question 30

What consultations should be done for eyelid reconstruction?

Answer 30

Ophthalmology fo visual city and field testing. Schirmer test post-op.

Question 31

What are the key considerations in eyelid reconstruction/ the general approach? Describe the layers in the lid.

Answer 31

Need to reconstruct all missing layers - Anterior Lamella: Skin and OO muscle. Local or regional tissue flaps perfused for best color and texture match - Middle Lamella: Structural support layer of tarsus and septum. Proper anchoring of lid along medial and lateral canthus required. - Posterior Lamella: Conjunctiva. Best reconstructed with grafts from tarsus, mucosa, or hard palate Full thickness defects must use at least one flap for reconstruction (flap necessary to provide vascularity to the graft for the PL). ▀ Defects of up to 30% of the lid usually can be closed primarily. ▀ Defects of 30%–50% usually can be closed directly with addition of a lateral canthotomy and cantholysis. ▀ Defects of 50%–75% usually can be closed with myocutaneous advancement flaps. ▀ Defects 75% generally require bringing tissue from the opposite lid or adjacent regions(cheek, temporal, forehead). ▀ Newly reconstructed lids should be adequately anchored by canthal fixation or direct closure of eyelid margin to curtail postoperative sequelae.

Question 32

What is the recommended procedure for reconstruction a > 75% full-thickness defects of the upper lid?

Answer 32

Mustard flap (lower eyelid transposition): aka, lower eyelid reconstruction with cheek advancement. An eyelid switch/ share technique and cheek advancement for donor site closure.

Question 33

What is a concern with medial canthal injuries? Describe how to look for it.

Answer 33

The lacrimal system. Ensure it is intubated/ interrogated. Lower external puncture 6.5 mm from medial canthus, 0.3 mm in size and positioned dorsally to allow tear drainage. Upper puncture 5 mm from medial canthus so both punctures not in apposition.

Question 34

What is the approach to a multi-zone defect?

Answer 34

Corneal protection is main concern. Immediate coverage with myocutaneous or FTSG. Definitive recon may need to be staged.

Question 35

How common are complications in eyelid reconstruction? What are the main ones seen and how do you avoid them?

Answer 35

10% of cases and may require secondary surgery to address malposition. - Ectropion: All flaps should be designed with tension oriented horizontally. Perform lateral canthal support procedure when needed. Vertical vector will pull the eyelid >> increased risk of ectropion. - Entropion: Caused by deficient posterior lamella from scarring - Corneal abrasion: Lubricate eye and protect with eyeshield. Avoid contact of suture material with cornea - Suboptimal aesthetic outcome, ptosis, infection scarring

Question 36

What are critical errors in eyelid reconstruction?

Answer 36

Failure to identify extent of defect Reconstruction prior to confirming negative margins Not providing adequate vascular use for graft healing (no graft on graft.. needs flap) Incomplete evaluation of lacrimal system and canthal involvement

Question 37

What could be a cause of post-operative epiphora?

Answer 37

Common after lower lid surgery causes anterior displacement of the punctum d/t ectropion.