Lower Eyelid Reconstruction

N. Grace Lee

Summary

Cutaneous malignancies commonly occur on the lower eyelid. The eyelids are composed of an anterior and posterior lamella wherein one or both may be involved. It is important to be cognizant of the intricacies of the lower eyelid anatomy and reconstitute the involved layers in order to optimize the aesthetic and functional result. This chapter details the techniques that can be used for reconstruction of defects of the lower eyelid.

Keywords: lower eyelid, Mohs reconstruction, lamella, graft, flap, Hughes, Tenzel, Mustarde, advancement

5.1 Introduction to Lower Eyelid Reconstruction

Reconstruction of the lower eyelid has similar complexities as the upper eyelid. The eyelids are unique in that they are bi-layered and function to protect and lubricate the surface of the eye while being dynamic in nature. The skin and the orbicularis oculi muscle constitute the anterior lamella, while the posterior lamella is composed of the tarsal plate and conjunctiva. Therefore, in reconstructing defects of the upper and lower eyelids, both the anterior and posterior lamellae must be re-created, and the dynamic orbicularis muscle function should be preserved whenever possible.

Another complicating factor in eyelid reconstruction is the presence of the lacrimal drainage system, which is situated within the medial aspect of the eyelid (see Chapters 1 and 8, for more details). Damage to this system can result in permanent epiphora and whenever possible, the canalicular system should be restored.

As in other locations, the degree of laxity and elasticity of the eyelid determines whether primary closure is possible or if flaps or grafts are required. Lower eyelid marginal defects are characterized by the percent of eyelid margin involved, degree of non-marginal eyelid involvement, canthal involvement, lacrimal involvement, and the total size of the defect. Full-thickness eyelid defects that are large enough to require a graft of one lamella of the eyelid generally need a flap for the apposing lamella. It is not surgically viable to place a graft on a graft as neither lamella would have inherent blood supply and would likely undergo necrosis. The surgeon should also consider factors that affect healing and vascularization including cigarette smoking and previous surgery or radiation therapy to the area.

Of particular importance, the lower eyelid can become retracted after reconstruction, which can lead to lagophthalmos and exposure keratopathy. Lower eyelid defects must be closed with any tension on flap pedicles directed horizontally and, when possible, superolaterally in order to prevent lower eyelid retraction. Appropriate canthal fixation medially and laterally is critical to ensure proper position and contour.

5.2 Anterior Lamellar Defects

5.2.1 Secondary Intention

Small defects of the lower eyelid involving only skin and orbicularis muscle can be successfully managed by granulation alone. If the patient has minimal laxity of the lower eyelid and the defect is located superiorly on the lower eyelid (pretarsal), it is possible to allow secondary intention healing with minimal risk of ectropion or retraction (▶ Fig. 5.1). It is important to counsel the patient about this risk and that granulation and healing could take weeks to months.

5.2.2 Primary Closure

Small defects of the lower eyelid may be closed primarily, with undermining of the perimeter, as long as there is no vertical tension or vertical recruitment of tissue (▶ Fig. 5.2a-c). Primary closure is easiest if redundant skin exists adjacent to the defect, which is more common in the upper eyelid than the lower eyelid. In some cases, even a large defect can be closed primarily with undermining if there is enough laxity (▶ Fig. 5.2d-f). Undermining above the level of the inferior orbital rim must be done in the preseptal or subcutaneous plane whereas below the orbital rim, undermining should be done in the subcutaneous tissue plane. Significant wound tension should be avoided due to risk of dehiscence and propensity for scar formation along the incision line. Therefore, if tension remains present, additional or alternative

reconstructive techniques should be employed. In some patients, particularly with thick skin, dark pigment, or personal history of scar formation, permanent sutures should be considered and kept in place for 5 to 7 days. In the pretarsal and preseptal lower eyelid skin, 5-0 or 6-0 permanent or absorbable sutures are appropriate.

Fig. 5.1 Healing by secondary intention. (a) Right lower eyelid defect involving the lash line, margin epithelium, and orbicularis muscle. (b) Two months later, there is good epithelialization with some regrowth of lashes. (c) Infraciliary, anterior lamellar defect. (d) Excellent result after 3 months. (e) Anterior lamellar defect that is adjacent to the punctum (f) After 3 months, the area is well-healed without punctal ectropion.

Fig. 5.2 Anterior lamellar direct closure. (a) Appearance of small basal cell carcinoma at the lash line of the left lower eyelid. (b) After Mohs micrographic surgery, there is a pretarsal defect. (c) The defect was closed primarily with minimal undermining and results after 6 weeks are shown. (d) Concentric circles outlining the area of excision (outer circle). (e) Undermining and direct closure performed on a large defect involving skin and orbicularis. Note minimal vertical tension applied to the wound. (f) Six months postoperative result.

5.2.3 Cutaneous or Myocutaneous Flap

Cutaneous or myocutaneous flaps are very versatile and are often the best option to repair an anterior lamellar eyelid defect. Flaps are preferable to grafts in that there is no donor site morbidity and skin color and texture are well matched, since they are from adjacent sites. There is a high rate of successful healing due to the inherent blood supply of a flap, and there is a higher likelihood of good muscle function because of preserved innervation.

Horizontal Advancement Flap

Horizontal advancement flaps are useful in a broad range of lower eyelid defects involving the nonmarginal anterior lamella. Flaps from the medial side of lower eyelid defects may be somewhat difficult to advance due to the firm adhesion of the medial canthal tendon in the nasal region. However, laterally based advancement flaps that follow along the subciliary line and extend into the lateral canthal rhytids (“laugh lines” or “crow’s feet”) are particularly useful on the lower eyelid (▶ Fig. 5.3a-c). These flaps can be considered modifications of an H-plasty where bilateral flaps are raised on each side of the defect. Horizontal incisions are made through skin or skin-muscle at the superior and inferior apices of the defect. Depending on the size of the defect and the elasticity of the skin, both flaps are generally the same horizontal length as the defect and are advanced toward each other. These flaps can be elongated if tension remains. Burow triangles can also be excised on the outermost aspect of each flap to address standing cutaneous deformity formation if necessary. The edges of skin can then be approximated with either absorbable or permanent sutures. It is important to construct the flaps so that any tension on the lower eyelid is horizontal rather than vertical as to avoid lid retraction and ectropion. Another horizontally oriented advancement flap is the O-T flap (▶ Fig. 5.3d-e) where a circular defect can be closed with a subciliary incision and undermining of tissue. Much like the bilateral advancement flap above, a horizontal incision is made along the superior aspect of the defect. Then, both edges of the defect are advanced toward one another after significant undermining of the skin. A triangle is excised at the inferior aspect of the defect if a standing cutaneous deformity develops.

Rotational Flap

Rotational flaps can be very useful in their ability to control vectors and minimize vertical tension on the lower eyelid (▶ Fig. 5.3f-h). In patients who have a large anterior lamellar defect, a rotational cheek flap can be a useful option. A Mustarde cheek flap is designed as a large semicircular flap arching superiorly with an extensive dissection from the lateral canthus through the temple toward the ear.¹ The flap design begins as a subciliary incision from the lateral portion of the defect, to the lateral canthus, and then extending superiorly and laterally to the temple. Dissection on the eyelid portion is deep to the orbicularis muscle. Lateral to the orbital rim, the dissection is performed within the subcutaneous fat plane as the facial nerve courses deep to this plane (▶ Fig. 5.4). The flap is then rotated medially and can be secured into place with either 4-0 or 5-0 polyglactin sutures anchoring the flap to the periosteum of the orbital rim. Deep, interrupted 5-0 polyglactin sutures can be placed in a buried fashion at intervals along the flap to secure the position and relieve tension. Skin is approximated with a combination of interrupted and continuous running 6-0 suture (e.g., nylon and gut). There are other rotational flaps including rhombic and bilobed flaps described in Chapter 4 that can also be applied to the lower eyelid.

5.2.4 Upper-to-Lower Eyelid Transposition Flap

Transposition flaps for lower eyelid repair are harvested from the upper eyelid and are transposed down with a pivot point at the medial or lateral canthus of the eyelid. There are two particularly useful scenarios for this flap: (1) large, anterior lamellar defects where a skin graft cannot be used because of not wanting to patch a monocular patient and (2) after a tarsoconjunctival graft is placed and a vascularized flap is required. In designing and planning a flap that is laterally based, it is important to inform the patient of possible chronic lymphedema secondary to expected injury
of the lymphatic channels that coalesce at the lateral canthus before heading to the preauricular lymph nodes. Additionally, since skin is being removed from the upper eyelid, large flaps risk lagophthalmos and worsened dry eye due to iatrogenic anterior lamellar deficiency. The upper eyelid flap is designed after measuring the height of the lower eyelid defect. The upper eyelid crease is measured as in a blepharoplasty incision. The inferior aspect of the flap is placed in the upper eyelid crease and harvested superior to this. It is important to appropriately size the flap to minimize redundancy of the flap while avoiding tension on the edges of the wound. Please see details and accompanying figure below in the description for tarsoconjunctival graft.

Fig. 5.3 Anterior lamellar advancement/rotational flaps. (a) Moderately large nonmarginal lower eyelid defect involving skin and orbicularis. Advancement plan is outlined with dashed lines. (b) Immediately after advancement of flap (c) Postoperative month 2. (d) Circular defect along the right lower eyelid lash line. Planned O-T advancement in dashed lines. (e) Immediate postoperative result. (f) Large right lower eyelid lateral defect of skin and orbicularis. Plan for rotational flap. (g) Two weeks postoperative result. (h) Three months postoperative result.

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