Lower Eyelid Reconstruction
Sulen L. Chi, MD, PhD
DISEASE DESCRIPTION
Lower lid position and function are important determinants of ocular surface health and lacrimal drainage. Conditions that affect these determinants vary widely from trauma and cicatrix to defects resulting from the excision of neoplasms. The goals of lower eyelid reconstruction are to achieve appropriate lid position and a natural contour while preserving the functionality of lid closure and lacrimal egress.
MANAGEMENT OPTIONS
Observation may be appropriate for conditions that minimally affect the lower lid position. Carefully assess the lid for any potential ectropion, entropion, or retraction to develop. Predisposing factors include horizontal lid laxity (lower lid distraction of 5 mm or more), history of lid malposition, tissue defects of 5 mm or more, etc.
Surgical repair
INDICATIONS FOR SURGERY
Soft-tissue defects of the lower lid
Mohs micrographic excision defect
Primary lesion excision defect
Partial or full-thickness defect
Instability or dysfunction of lower lid that is refractory to conventional repair techniques
Severe cicatricial entropion
Severe lower lid retraction
Lower lid trauma
SURGICAL DESCRIPTION
Assessment of the size, depth, and location of the defect, integrity of the patient’s adjacent skin and potential flap/graft harvest sites, and degree of horizontal lid laxity all factor into determination of the surgical approach to closure. Selection of
technique in any given case will therefore depend on these factors as well as surgeon’s preference and comfort level; the guidelines given for selection of each technique are suggestions based on most typical practice patterns.
Surgical challenges arise from the individual nuances of defect size, tissue involved, and tissue quality unique to each patient. Often, a combination of various surgical techniques may be required to achieve closure.
The techniques described here generally apply to full-thickness defects. When assessing a partial-thickness defect, converting the defect to a full-thickness one often simplifies the reconstruction by simultaneously addressing horizontal lid laxity.
Direct Marginal Closure
Suitable if direct closure allows eyelid to rest in an appropriate position, resting within 1 mm of the inferior limbus. Generally useful for full-thickness defects less than 25% of lid margin.
Inject local anesthetic.
Prep and drape the patient in a sterile manner.
Excise, conservatively, around the wound edges to create a pentagonal defect.
Reappose the lid margin with forceps.
Align the lid margin using a 6-0 or 7-0 silk or polyglactin vertical mattress suture through the gray line; leave the tails long.
Close the tarsal defect by passing two to three simple interrupted partial-thickness 6-0 polyglactin sutures through the tarsal plate.
Return to the lid margin, furthering the alignment with a second vertical mattress suture of 6-0 or 7-0 silk or polyglactin through the lash line; leave the tails long.
An optional third vertical mattress suture through the meibomian gland orifices can be placed for reinforcement and to encourage further eversion of the wound edges.
If needed, close the orbicularis layer with 6-0 polyglactin interrupted suture.
Reapproximate the skin edges with interrupted 6-0 polyglactin or silk suture, tucking the long tails of the marginal sutures below.
There are numerous methods for closing margin-involving eyelid defects or lacerations. These are discussed in Chapters 20 and 21.
Cantholysis
When aligning the wound edges, if the lid slips beneath the globe from excessive horizontal tension, consider an internal cantholysis or external canthotomy and cantholysis for additional release.
Internal cantholysis
Using a needle tip monopolar cautery, create a 6 mm transconjunctival incision 4 mm inferior to the lateral edge of the tarsus extending laterally beneath the lateral canthal tendon.
Release the fibrous attachments of the lateral canthal retinaculum, allowing medial advancement of the lid.
External canthotomy and cantholysis
Using Westcott scissors or a needle tip monopolar cautery, open the lateral canthus, directing the incision slightly upward of horizontal (a horizontal incision may result in a downturned canthal angle).
Incise the inferior crus of the lateral canthal tendon.
Release additional tissues of the lower lid retractors and orbital septum if additional tension exists.
Anchor any flaps that are utilized for anterior lamellar coverage to the periosteum of the anterior and inner aspect of the lateral orbital rim using interrupted 4-0 or 5-0 nonabsorbable suture.
In the event that the periosteum of the lateral orbital rim is absent (eg, from the original excision or from previous surgeries), a drill may be used to create two holes in the lateral orbital rim. A nonabsorbable 4-0 suture can then be passed through the holes to affix the cut edge of tarsus to the inner aspect of the lateral orbital rim.
Tenzel Semicircular Myocutaneous Advancement Flap
Appropriate if canthotomy and cantholysis with direct closure would yield excessive horizontal lid tension. Generally suitable for full-thickness defects involving 25% to 50% of the lid margin. This technique replaces the tissue deficit with a skin-muscle flap from the lateral canthal region.
Mark a semicircular line from the lateral commissure arching superiorly toward the tail of the brow. The length and curvature of the incision will depend on the degree of release required. Avoid extending the incision beyond 20 mm lateral of the lateral commissure to prevent injury to the facial nerve (Figure 22.1).
Inject local anesthetic.
Prep and drape the patient in sterile manner.
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