Small defects in the upper eyelid can be allowed to heal by secondary intention. While there is no strict cutoff for size, defects less than 5 mm in size may granulate with minimal risk of eyelid retraction or unacceptable scar (▶ Fig. 6.1, ▶ Fig. 6.2). Larger areas have been allowed to heal by secondary intention with good result (▶ Fig. 6.3). Lesions near the margin but not involving the tarsus are good candidates for granulation. Contraction of these defects could result in eyelid retraction and/or lagophthalmos, resulting in a need for surgical revision.

When there is anterior lamellar tissue (skin and orbicularis muscle) missing but the posterior lamella (tarsus) is present, direct closure can be attempted. With the innate redundancy and laxity of upper eyelid tissues in many patients, direct closure may be possible for small- or medium-sized defects. Although not as critical as in the lower eyelid, eliminating vertical tension is preferred to prevent retraction or ectropion resulting in ocular exposure. Therefore, any tension vectors created during reconstruction should be oriented horizontally. Skin and orbicularis oculi muscle may need to be undermined then advanced if additional tissue mobility is needed to reduce wound tension.

Placement of incisions in the upper eyelid crease can be useful during reconstruction. In most patients, this crease is readily visible as a dominant fold in the upper eyelid skin. The advantages of incising along a preexisting anatomic landmark that
heals well in a generally hidden location are obvious. While an incision in this location does not guarantee a perfect result, it can minimize the risk of abnormally placed or multiple eyelid creases. This technique may be employed effectively for medial upper eyelid defects (▶ Fig. 6.4).

When direct closure cannot be completed, advancement flaps may be necessary. One common approach to gaining laxity for closure involves making a horizontal relaxing incision at the superior or inferior end of the defect (the “O”). This flap is created by undermining in the subcutaneous plane medial and lateral to the defect until sufficient laxity is gained to advance the tips of the flaps toward each other. The flaps are sutured to each other with interrupted sutures to distribute any tension across multiple points of fixation. Then the relaxing incision (i.e., eyelid crease) is closed in a running or interrupted fashion. The final appearance of the closed incision lines looks like a “T” (or inverted “T” if the relaxing incision is at the inferior end of the defect) (▶ Fig. 6.5, ▶ Fig. 6.6).

Similar to the O → T closure, sliding flaps recruit tissue from medial and lateral to the defect that are advanced toward each other. These flaps, however, consist of two parallel horizontal incisions that should be oriented parallel to the eyelid margin. Examples include an incision along the supraciliary line and eyelid crease or eyelid crease and sub-brow line (▶ Fig. 6.7, ▶ Fig. 6.4). In some cases, such as a very medial defect, a sliding flap that is limited to one side of the defect can be performed, since medial canthal skin is thicker and has less laxity than the upper eyelid (▶ Fig. 6.8).

For medium-size anterior lamellar defects, particularly in the lateral portion of the eyelid, a lateral semicircular advancement flap can be an excellent choice.¹ Analogous to use in the lower eyelid, this flap is drawn as a continuity of the upper eyelid like an inverted mirror image. The curvilinear incision should be continued downward toward the cheek then upward toward the temple. The length of the flap should be customized based on the laxity of skin and size of defect. Once drawn, a cutaneous or lipocutaneous flap can be elevated and undermined. After advancement into the area of the defect, it is sutured into place with a combination of interrupted sutures to anchor it into place (e.g., 5-0 nylon, polypropylene, or gut) and a running suture in the temple. In the lateral canthal region, this anterior lamellar dissection should not affect the lateral canthal tendon. During wound closure, an interrupted suture is placed at the lateral canthal periosteum to anchor the flap and prevent abnormal skin folds in this area. Precaution should be taken in the temple to remain in the subcutaneous plane to prevent injury to the facial nerve, which runs deep to the temporoparietal fascia. In the temple and cheek, unlike the eyelid, there is subcutaneous fat. Staying above or within this fat layer will maintain a safety margin away from the nerve (▶ Fig. 6.9, ▶ Fig. 6.10).

Glabellar flaps are useful for defects limited to the medial aspect of the upper eyelid. See Chapter 4 on medial canthal reconstruction for further description.

A variety of rotational flaps can be used in the upper eyelid (e.g., rhomboid and bilobed). These are generally not necessary, as the thinner eyelid skin is more easily stretched compared to the forehead or cheek. However, they can be employed successfully, particularly for the medial and lateral aspects of the upper lid, using the standard design recommendations in Chapters 4 and 7.