Introduction
In this chapter the direct closure of defects of the eyelid margin is described. Smaller defects may be closed directly without additional tissue. Larger lid margin defects may be closed directly with the addition of extra tissue from beyond the lateral canthus.
Lid margin defects that are too large to be closed directly require separate reconstruction of the anterior covering lamella and the posterior lining lamella. The following chapters describe reconstruction of these larger lid margin defects and closure of periocular defects that do not involve the lid margins.
Chapter 15 describes reconstruction of the anterior covering layer in larger defects of the eyelids or periocular region.
Chapter 16 describes reconstruction of the posterior supporting layer of the eyelids, including support at the canthi.
Chapter 17 describes reconstruction of full-thickness defects with full-thickness flaps which include both anterior and posterior layers.
Choice of operation
Eyelid defects, up to one-fourth of the lid length or up to one-third in elderly patients, can usually be closed directly without the addition of tissues from elsewhere ( 14.1 – 14.3 ). This is described in Sect. A. Defects up to about half the lid length can be closed directly with the release of tissues beyond the lateral canthus. These techniques are described in Sect. B. They are lateral cantholysis ( 14.4 ), lateral advancement flap ( 14.5 , 15.5 , 15.6 ), the Tenzel semicircular skin flap ( 14.6 ) and the McGregor cheek flap ( 14.7 ).
A good general rule is to plan closure in such a way that the overall tension in flaps is parallel to adjacent free borders – in this case the lid margins. This minimises the distortion of the lid margin due to the reconstruction. Tension should therefore be horizontal instead of vertical and scars ideally placed within the relaxed skin tension lines (see Chapter 2 , Section A).
Direct closure of the lid margin
14.1
Full-thickness eyelid margin excision – repair with surface knot at margin
Excision of lid margin tissue is needed to excise abnormal lid tissue or to tighten a lid horizontally. Two cuts are made at right angles to the lid margin. The distal ends of the cuts can be joined either with a V -shape cut ( 14.1 , 14.2 ) or with a transverse cut ( 14.3 ).
Direct closure of the lid margin aims to restore the lid margin without a notch. The principles also apply to repair of a lid margin laceration.
Mark the first two cuts at right angles to the lid margin. Join them to form a pentagon of lid tissue to be excised. Use scissors to make the cuts. Bleeding will be mainly from the tarsal arcades which lie on the tarsal plates, close to the lid margins, in the upper and lower eyelids. In the upper lid a second arterial arcade lies just superior to the upper tarsal border. Pinch the full thickness of the lid gently with forceps close to the wound to control the bleeding while the vessels are cauterised.
Place a 6/0 or 7/0 absorbable suture through the cut edges of the tarsal plate close to the lid margin but avoid including the conjunctiva. Tie the knot on the anterior surface of the tarsus. Place two more absorbable sutures through the edges of the tarsal plate in the same way.
Close the orbicularis muscle with three 6/0 or 7/0 absorbable sutures. Close the skin with interrupted 6/0 nonabsorbable sutures starting at the lash line. Use the uppermost suture to tie down the long end of the grey line suture.
Remove the skin sutures and the grey line suture at a week.
Exactly the same steps are followed for lid margin excision and repair in the upper lid.
14.2
Eyelid margin repair with a buried knot ( ) 
This modified technique is identical to the standard technique except that the lid margin suture is inserted with the knot placed within the tissues rather than placed externally at the lid margin ( Diags 14.1 , 14.2 ). An absorbable 7/0 suture (for example Vicryl) is used. The advantage of this modification is that there are no trailing suture ends to jeopardize the cornea and few sutures need to be removed postoperatively. This technique may be used in upper or lower lids.
Close the posterior lamella in the standard way ( 14.1c , d ) with fine absorbable sutures within the tarsal plate. To close the lid margin insert a 7/0 Vicryl suture from within the wound in the plane between the orbicularis muscle and the tarsal plate 2 to 3 mm from the lid margin. Pass the needle upward staying within the same plane to emerge through the grey line at right angles to the lid margin about 2 mm from one wound edge.
Pass the suture down between the orbicularis muscles and the tarsal plate to emerge again within the wound a few millimetres from the lid margin level with the point of entry of the suture in 14.2a .
Apparently severe lid trauma may also be repaired successfully with careful attention to accurate closure.
Alternative procedure
14.3
Lid margin closure with a transverse incision
In this technique transverse incisions are made to join the distal ends of the initial two lid margin incisions rather than a v-shaped incision ( 14.1 , 14.2 ). These are extended horizontally to allow direct closure of the defect. It is used in the lower lid only.
Having excised lid margin tissue and tarsal plate in the usual way with cuts at right angles to the lid margin, make full-thickness horizontal incisions medially and laterally just inferior to the tarsal plate.
If the lid heals with a large notch after completion any of the techniques of direct closure described, excise the notch and resuture the lid.
Trichiasis may follow inaccurate closure with a notch. If the notch does not require excision treat the lashes with cryotherapy (see Ch. 8 ). Otherwise excise the area and then resuture the lid.
Dehiscence of the wound usually follows a closure with excess tension. Remove the sutures and repair again. Alternatively, the defect will often heal satisfactorily by laissez faire. If it proves unsatisfactory, excise the scar and resuture the wound with any technique to reduce the tension.
Direct closure of the lid margin
14.1
Full-thickness eyelid margin excision – repair with surface knot at margin
Excision of lid margin tissue is needed to excise abnormal lid tissue or to tighten a lid horizontally. Two cuts are made at right angles to the lid margin. The distal ends of the cuts can be joined either with a V -shape cut ( 14.1 , 14.2 ) or with a transverse cut ( 14.3 ).
Direct closure of the lid margin aims to restore the lid margin without a notch. The principles also apply to repair of a lid margin laceration.
Mark the first two cuts at right angles to the lid margin. Join them to form a pentagon of lid tissue to be excised. Use scissors to make the cuts. Bleeding will be mainly from the tarsal arcades which lie on the tarsal plates, close to the lid margins, in the upper and lower eyelids. In the upper lid a second arterial arcade lies just superior to the upper tarsal border. Pinch the full thickness of the lid gently with forceps close to the wound to control the bleeding while the vessels are cauterised.
Place a 6/0 or 7/0 absorbable suture through the cut edges of the tarsal plate close to the lid margin but avoid including the conjunctiva. Tie the knot on the anterior surface of the tarsus. Place two more absorbable sutures through the edges of the tarsal plate in the same way.
Close the orbicularis muscle with three 6/0 or 7/0 absorbable sutures. Close the skin with interrupted 6/0 nonabsorbable sutures starting at the lash line. Use the uppermost suture to tie down the long end of the grey line suture.
Remove the skin sutures and the grey line suture at a week.
Exactly the same steps are followed for lid margin excision and repair in the upper lid.
14.2
Eyelid margin repair with a buried knot ( ) 
This modified technique is identical to the standard technique except that the lid margin suture is inserted with the knot placed within the tissues rather than placed externally at the lid margin ( Diags 14.1 , 14.2 ). An absorbable 7/0 suture (for example Vicryl) is used. The advantage of this modification is that there are no trailing suture ends to jeopardize the cornea and few sutures need to be removed postoperatively. This technique may be used in upper or lower lids.
Close the posterior lamella in the standard way ( 14.1c , d ) with fine absorbable sutures within the tarsal plate. To close the lid margin insert a 7/0 Vicryl suture from within the wound in the plane between the orbicularis muscle and the tarsal plate 2 to 3 mm from the lid margin. Pass the needle upward staying within the same plane to emerge through the grey line at right angles to the lid margin about 2 mm from one wound edge.
Pass the suture down between the orbicularis muscles and the tarsal plate to emerge again within the wound a few millimetres from the lid margin level with the point of entry of the suture in 14.2a .
Apparently severe lid trauma may also be repaired successfully with careful attention to accurate closure.
Alternative procedure
14.3
Lid margin closure with a transverse incision
In this technique transverse incisions are made to join the distal ends of the initial two lid margin incisions rather than a v-shaped incision ( 14.1 , 14.2 ). These are extended horizontally to allow direct closure of the defect. It is used in the lower lid only.
Having excised lid margin tissue and tarsal plate in the usual way with cuts at right angles to the lid margin, make full-thickness horizontal incisions medially and laterally just inferior to the tarsal plate.
If the lid heals with a large notch after completion any of the techniques of direct closure described, excise the notch and resuture the lid.
Trichiasis may follow inaccurate closure with a notch. If the notch does not require excision treat the lashes with cryotherapy (see Ch. 8 ). Otherwise excise the area and then resuture the lid.
Dehiscence of the wound usually follows a closure with excess tension. Remove the sutures and repair again. Alternatively, the defect will often heal satisfactorily by laissez faire. If it proves unsatisfactory, excise the scar and resuture the wound with any technique to reduce the tension.
Direct closure with extra tissue laterally
14.4
Lateral cantholysis ( ) 
This technique allows direct closure of most upper or lower lid defects up to one-third of the lid length.
Pull the lid medially to put the appropriate limb of the lateral canthal tendon on stretch. It can now be felt as a tight band just posterior to the orbicularis muscle. Expose this limb of the tendon by spreading scissors on either side of it.
Close the lid defect in the usual way (see 14.1 , 14.2 ). Close the lateral wound, skin to conjunctiva at the margin and skin to skin, with 6/0 sutures.
If the defect cannot be closed without undue tension the orbital septum between the lateral tarsal fragment and the inferior orbital rim must be cut to allow the lateral tissues to move further medially. To do this grasp the medial cut end of the tendon and pull it medially and slightly upwards to put the septum on stretch. Gently introduce scissors between the orbicularis muscle and the conjunctiva along the inferior orbital rim and cut the septum as far medially as necessary to allow release of the lid. With each cut into the septum the lid will be felt to ‘give’ and become more mobile.
A shallow depression in the lateral lid margin is due to poor support for the anterior lamella. To avoid this complication take care that the initial incision ( 14.4a ) does not stray downwards into the skin of the lower lid laterally.
14.5
Lateral advancement flap
Closure up to about one-third of the lid can be achieved with this flap (see 15.6 ).
14.6
Semicircular flap (Tenzel)
This technique allows direct closure of upper or lower lid defects up to about half of the lid length.
Mark the semicircular flap approximately 22 mm in the vertical and 18 mm in the horizontal direction. Begin the mark at the lateral canthus as a lateral continuation of the line of the lid which is to be reconstructed. Continue more steeply upwards (for reconstruction of the lower lid) or downwards (for reconstruction of the upper lid), curving the line to achieve the correct dimensions. Finish level with the canthus and no further lateral than the end of the eyebrow.
Make an incision along the mark and undermine the flap in the plane just deep to orbicularis muscle. Do not dissect lateral to the orbital rim. Reflect the flap to expose the lateral canthus.
