25.1 Goals

The repair of a large full-thickness upper eyelid defect typically created after the excision of an eyelid malignancy is a surgical challenge (Fig. 25‑1). Cutler and Beard in 1955 described a two-stage, eyelid-sharing procedure to reconstruct such defects involving greater than 50% of the upper lid width. ¹ The procedure encompasses advancing a composite full-thickness lower eyelid flap into the upper eyelid defect by passing it posterior to the remaining lower eyelid margin. The second stage of the procedure involves lysis of the flap and takes place 6 to 8 weeks after the first stage. The surgical goals are to reestablish the lid anatomy, as well as to attempt to retain function and cosmesis.

25.2 Advantages

The key advantage of this flap is that it is usable in nearly all large upper lid full-thickness defects. The flap has a good vascular supply that aids in its ultimate success. The lower lid donor tissue offers a suitable match in texture, quality, and appearance to the sacrificed upper lid. Lastly, the final outcome is often functionally and cosmetically acceptable to the patient.

25.3 Expectations

While this procedure does have its merits, the patient should be counseled that the surgery is challenging and complex and the final result will never act nor look like a completely normal upper lid, and in certain cases touch-up procedures may be warranted. The reconstructed lid tends to be relatively thick and immobile. Placement of a tarsoconjunctival graft from the contralateral upper eyelid to reconstruct the posterior lamella can improve upper eyelid stability. ^{2 ,​ 3 ,​ 4 ,​ 5 ,​ 6} Other possible complications include upper eyelid retraction or entropion, lower eyelid laxity or ectropion due to induced lid denervation, vascular compromise, lagophthalmos, lymphedema, keratopathy, and blepharoptosis. ²

25.4 Key Principles

• 
  

  To bring a full-thickness lower eyelid flap, harvested at least 4 mm beneath the lower eyelid margin, underneath the remaining lower lid margin “bridge” of tissue and over the globe to close the upper eyelid defect.

  
  
• 
  

  The flap is traditionally separated 6 to 8 weeks after the first stage.

  
  
• 
  

  One of this procedure’s main shortcomings is its lack of stability in the newly created upper eyelid due to the absence of tarsus. Eyelid retraction and entropion are potential complications if a posterior lamellar graft is not utilized as an adjunct.

  
  
• 
  

  The senior author (RS) has had success with the use of a tarsoconjunctival graft from the contralateral upper eyelid to reconstruct the posterior lamella in a modified Cutler-Beard procedure.

25.5 Indications

To reconstruct full-thickness defects of the upper eyelid that involve more than 50% of the eyelid width, judged to be too large for more conservative surgical strategies such as a modified Tenzel flap.

25.6 Contraindications

This surgery requires occlusion of the eye for a period of several weeks. Thus, it should be avoided in the better seeing eye of monocular patients and young children in whom occlusion amblyopia may develop.

25.7 Preoperative Preparation

Blood thinning medications are stopped for several days if possible with the help of the prescribing physician. The patient is brought to the operating room, placed in supine position, and given intravenous sedation. Alternative options for anesthesia include local anesthesia or general anesthesia in select patients. Tetracaine eye drops are delivered onto both ocular surfaces and the patient is prepped and draped in typical sterile fashion for ophthalmic surgery.

25.8 Operative Technique

• 
  

  Local anesthesia consisting of 50:50 mixture of 1% lidocaine with epinephrine 1:100,000 and 0.5% bupivacaine with epinephrine 1:200,000 (with added hyaluronidase) is injected subcutaneously to the medial, lateral, and superior remnants of the ipsilateral upper lid, the entire ipsilateral lower eyelid, and contralateral upper eyelid.

  
  
• 
  

  The medial and lateral upper lid remnants are pulled toward one another with forceps and the residual defect is measured horizontally with a caliper giving the “surgical width.”

  
  
• 
  

  The contralateral upper lid is then everted over a Desmarres retractor and the tarsal conjunctiva is marked, with the desired surgical width being 4 mm from the lid margin.

  
  
• 
  

  A tarsoconjunctival graft is then harvested using a Beaver 6700 mini-blade for initial incision through the conjunctiva and tarsus, and Westcott scissors finalize the graft excision. Hemostasis is achieved with direct pressure and the donor site is allowed to heal via secondary intention. The graft is placed in a moist gauze.

  
  
• 
  

  Using a caliper, a line parallel to the ipsilateral lower lid margin, and 5 mm below it to avoid the marginal arcade, is marked for the surgical width.

  
  
• 
  

  After a Jaeger lid plate is placed to protect the globe, a #15 Bard-Parker blade creates a cutaneous incision at the surgical mark and Westcott scissors finalize a full-thickness blepharotomy incision through the lower lid. Two relaxing incisions are then made in similar fashion medially and laterally in an inferior direction to the inferior fornix of the posterior lamella and orbital rim of the anterior lamella (Fig. 25‑2).

  
  
• 
  

  The tarsoconjunctival graft is then positioned with the conjunctival surface facing the globe and secured to the residual medial and lateral tarsal plate of the upper lid with two partial-thickness lamellar bites of 6–0 polyglactin sutures ensuring the host and graft tarsal margins are well aligned. The superior border of the graft is then secured to the cut edge of the upper lid conjunctiva with a running 6–0 polyglactin suture in lamellar fashion. All conjunctival sutures placed during this and subsequent steps should be done with care, ensuring all knots face anteriorly to minimize the possibility of posterior suture exposure toward the globe and suture keratopathy.

  
  
• 
  

  The flap is then secured into the upper lid defect in three layers. The conjunctiva is carefully dissected free from the lower lid retractor complex in the flap with Westcott scissors, and is brought superiorly underneath the bridge of remaining lower lid tissue, and reapproximated to the tarsoconjunctival graft inferior border with lamellar bites of running 6–0 polyglactin suture (layer 1, Fig. 25‑3).

  
  
• 
  

  The lower eyelid retractors and orbicularis complex in the flap are then secured to the cut edge of the levator aponeurosis with running 6–0 polyglactin suture (layer 2, Fig. 25‑4). The levator will often need to initially be dissected free of adjacent attachments in the upper lid for proper exposure. This closure will lead to the eventual formation of the upper lid crease and allow for upper lid excursion. If the aponeurosis has been excised completely, then the sutures should instead secure the levator palpebrae superioris muscle.

  
  
• 
  

  The skin of the flap is then secured to the upper lid skin with interrupted and running 6–0 silk suture (layer 3).

  
  
• 
  

  The cut edge of the lower lid bridge tissue is left to heal via granulation.

  
  
• 
  

  A healthy pink appearance to the lower lid bridge and flap skin signifies that the lower lid marginal arcade and vasculature of the flap have been preserved and the bridge, flap, and tarsoconjunctival graft should survive.

  
  
• 
  

  Antibiotic ophthalmic ointment is given to all surgical sites and a pressure patch is applied to the ipsilateral eye.

  
  
• 
  

  The second stage of the surgery is lysis of the flap and is usually carried out 6 to 8 weeks after the first stage.

  
  
• 
  

  Under intravenous sedation, the same local anesthesia mixture is injected subcutaneously to the lower eyelid bridge and flap.

  
  
• 
  

  A grooved director is placed deep to the flap through the medial and lateral palpebral fissures for globe protection.

  
  
• 
  

  The flap skin is cut with a #15 Bard-Parker blade, and Westcott scissors finalize lysis at a level of 1 to 2 mm below the desired height of the new upper lid margin, angling the scissor cut so that the conjunctiva is longer than the skin (Fig. 25‑5). This 1 to 2 mm segment helps to prevent potential postoperative eyelid retraction and keratopathy.

  
  
• 
  

  The upper lid conjunctiva is advanced anteriorly onto the newly created upper lid margin for about 2 mm with running 6–0 plain gut suture to create an anteriorly located mucocutaneous junction. This is to decrease the chance of keratinized skin or fine lanugo hair from the new upper lid margin causing keratopathy. If the flap is judged to have stretched since the first stage, excess superior flap tissue is carefully excised so that it could be secured to the lower lid bridge without laxity.

  
  
• 
  

  The granulation tissue of the lower lid bridge is then denuded using a #15 Bard-Parker blade and the superior edge of the flap is attached to the bridge in two layers with interrupted 6–0 polyglactin orbicularis oculi closure and running 6–0 plain gut suture skin closure. Antibiotic ophthalmic ointment is given to all surgical sites. Fig. 25‑6 shows a patient after the second stage of the Cutler-Beard flap.