33.1 Patient History Leading to the Specific Problem

The patient is a 56-year-old European woman who underwent excision of melanoma in situ from her left lower eyelid and cheek on two occasions over the previous year. The first excision was performed by a surgeon at her regional hospital with a local flap repair. The second excision was performed by the dermatology service at a tertiary center due to incomplete excision of the lesion at the time of primary surgery. The second excision was reconstructed with a combination of a transposition flap from the left preauricular region together with a full-thickness skin graft placed at the superior aspect of the flap, harvested from the supraclavicular region. The recovery for the second surgery was complicated by infection and partial graft loss.

The patient was unhappy with the appearance of her right lower eyelid. She denied any symptoms of exposure. She presented to the Plastic Surgery department requesting treatment to obtain better symmetry. Fig. 33-1 shows frontal and oblique views of the patient on presentation.

She was also unhappy with the appearance of her donor site scar. Fig. 33-2 shows the undesirable scar from her previous supraclavicular skin harvest. She therefore requested that an alternative donor site be selected for future surgery.

33.2 Anatomic Description of the Patient’s Current Status

The patient demonstrates significant left lower eyelid cicatricial ectropion. This is commonly due to shortening of the anterior lamella of the eyelid, which can be a result of tissue loss or scar contracture. Patients with ectropion commonly present with red or irritated eyes or a complaint of excessive tearing, especially if the punctum is pulled away from the globe.

In this case, review of the patient and the operative notes confirmed that previous resections had involved the anterior lamella only, with full-thickness skin and only partial orbicularis muscle resection. The likely cause of her ectropion was infection and subsequent graft loss from the lateral aspect of the left lower eyelid area. This region then healed by secondary intention and the subsequent scar contracture pulled the lower eyelid down and outward. Examination showed thick scar and a lower lid, which was unable to be manually repositioned into its anatomical position. The eye itself did not show any redness and the patient denied any symptoms of irritation or exposure. Surgical correction of the shortened anterior lamella was recommended. Due to the prior surgery, no local flap options from the cheek were available.

33.3 Recommended Solution to the Problem

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  Excise the thickened scar and release remaining anterior lamella tissue.

  
  
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  Measure the resulting defect and obtain appropriate full-thickness graft for reconstruction from upper eyelid(s).

  
  
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  Stent graft with tie over dressing.

  
  
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  Support the lower lid with horizontal tightening (canthopexy or canthoplasty as required).

33.4 Technique

The planned donor site is the ipsilateral upper eyelid. This donor site provides thin skin which is an excellent color and thickness match for the lower eyelid. It is also cosmetically favorable, with a well-hidden scar which potentially can provide the aesthetic benefit of an upper eyelid blepharoplasty. The upper eyelid crease is therefore marked preoperatively for future reference. A subciliary incision is planned at the superior aspect of the scarred area with a lateral extension to allow for canthal reset. Fig. 33-3 shows the extent of the incision planned preoperatively. Surgery is performed under general anesthesia, with local anesthetic infiltration. Flexible corneal protectors lubricated with eye ointment are placed to protect the globe. Following local anesthetic injection, incise with a blade through skin and orbicularis at the lateral aspect of the planned subciliary incision. With Westcott scissors, undermine medially in a subcutaneous plane along the planned subciliary incision and cut the skin as you progress. Extend your incision as far medially as required to reach normal, unscarred tissue.

With the orbicularis muscle exposed, dissection is performed inferiorly to allow release of the subcutaneous scarring (Fig. 33-4). I prefer to use needlepoint monopolar diathermy (“Bovie”) for this dissection. To assist with dissection, 4–0 silk sutures are placed through the ciliary margin and held superiorly to provide countertraction. Once the cutaneous release has been performed, any scarring or fibrotic attachments of the orbicularis muscles are also divided. After the complete release of all skin and muscle shortening, the maximum size of the defect under stretch is determined to facilitate appropriate donor skin harvest, as demonstrated in Fig. 33-5.

Prior to skin grafting, lateral canthal reset should be performed. Lateral canthopexy is performed in routine fashion with two core suture fixation from the lateral aspect of the lower eyelid to the medial aspect of the lateral orbital rim at an appropriate level to provide symmetry with the contralateral lower eyelid, as shown in Fig. 33-6. I prefer to use an absorbable, synthetic, braided suture such as 4–0 Vicryl, although permanent (nonabsorbable) sutures are also reasonable. Following canthopexy (Fig. 33-7), lid position and distraction are checked. In this case, lid distraction is less than 2 mm from the globe and the lateral canthal position was felt to be acceptable. However, if canthopexy did not provided an appropriately secure fixation, progression to formal canthoplasty would have been considered.

The maximum vertical height of the skin defect after canthopexy was measured at 13 mm. This height is then transposed onto the upper eyelid, measuring superiorly from the previously marked lid crease, with routine upper blepharoplasty planning. Nontoothed forceps are used to pinch the skin at the marks to estimate closure after skin removal. If it is felt that skin closure would be able to be performed without any tension or lagophthalmos, local anesthetic is infiltrated. Using a blade, incise through the skin of the upper eyelid as marked. With Westcott scissors, remove full-thickness upper eyelid skin and place it in a damp gauze sponge. Fig. 33-8 shows the upper eyelid skin after harvest. A thin strip of orbicularis oculi muscle can be excised from the donor site if necessary to facilitate closure. Following hemostasis, closure is performed with running 6–0 nonabsorbable monofilament suture.

While the 4–0 silk traction sutures maintain the cilial margin in a superior position, the full-thickness skin graft is secured in place with 6–0 absorbable sutures such as Vicryl Rapide or Fast Gut (Fig. 33-9). Paraffin gauze and paraffin-soaked cotton ball dressings are secured in place as a tie over dressing using 5–0 silk. The tie over dressing and upper lid sutures are removed 5 days postoperatively.