Upper Eyelid Reconstruction

DISEASE DESCRIPTION

There are several disease processes that necessitate upper eyelid reconstruction including trauma, chemical and thermal burns, infection, and cancer reconstruction.

MANAGEMENT OPTIONS

The decision-making process for which approach to use depends on the degree of horizontal lid laxity and the size and location of the defect along the lid margin. Primary closure is ideal and, when appropriate, should be the first choice. However, if there is a defect greater than 25% or if the wound is going to be under tension, a myocutaneous advancement flap (reverse Tenzel) should be performed in conjunction with primary margin closure. If the degree of the defect extends beyond what can be closed with a myocutaneous advancement flap, then grafts or transpositions of the tarsal plate along with a myocutaneous advancement flap, such as a Cutler-Beard flap, should be considered. A key principle in eyelid reconstruction is that the anterior and posterior lamellae should never both consist of free grafts — only one lamella in a reconstructed lid can be a free graft, whereas the other must be native tissue or a flap incorporating its own vascular supply. This will ensure adequate vascularity of the tissues, which is key to proper wound healing and graft survival.

INDICATIONS FOR SURGERY

Any defect in the upper lid, particularly margin-involving defects must be corrected to avoid exposure keratopathy and corneal decompensation. Specific indications are noted with each technique given here.

SURGICAL DESCRIPTION

FIGURE 21.1. Construction of pentagonal wedge of upper eyelid. The shoulders of the pentagon are at the level of the superior border of the tarsus.

Primary Closure of Upper Eyelid

Freshen the wound edges of the defect with a #15 blade or Westcott scissors. If the defect is irregularly shaped, construct a pentagonal wedge. Construct the pentagonal wedge so that the shoulders of the pentagon are situated at the level of the superior tarsal border (Figure 21.1). Failure to do this may result in buckling of the tarsus or notching of the lid margin.
Place a vertical mattress suture through the defect to properly align the lid margin and to provide good eversion of the wound edge (Figure 21.2). Pass a 6-0 silk suture through the gray line and exit through the wound edge at a depth and distance of approximately 2 mm. Pass the suture across the wound and through the opposite side of the wound edge at the same depth and distance. Pass the suture back across the wound to the original side in the same fashion but at a depth and distance of approximately 4 mm. Tie the suture and leave the tails long (20 mm) so that they can be secured under the skin sutures at the end of the closure to avoid corneal irritation.

FIGURE 21.2. Vertical mattress suture placement for lid margin repair.
Pass a single, interrupted 6-0 silk suture through the lash line at a depth and distance of 1 to 2 mm and leave the tails long (20 mm).
Pass 6-0 polyglactin sutures in a partial-thickness, interrupted fashion to realign the tarsal plate. At the superior border of the tarsal plate, incorporate the levator aponeurosis into the suture bite to prevent postoperative ptosis and to reestablish the contour of the upper eyelid.
Close the orbicularis with 6-0 polyglactin sutures in a buried, interrupted fashion.
Close the skin with 6-0 plain gut suture in an interrupted fashion. Before tying the superior-most skin sutures, lay the long tails of the silk sutures from the lid margin along the wound edge and tie the sutures over the silk tails to keep them away from the ocular surface.

Myocutaneous Advancement Flap (Reverse Tenzel) with Primary Lid Margin Closure

Mark a skin incision extending laterally from the lateral canthus. Construct it as a semicircle with a radius of 1 cm with its center 1 cm lateral to the lateral canthus (Figure 21.3). If the defect requires a larger flap, increase the radius and center the skin markings the requisite amount to match the radius. Alternatively, exaggerate the vertical length of the skin markings relative to the horizontal to form a more U-shaped skin incision.
Use a #15 blade to incise the marked skin area.
Elevate a myocutaneous flap with Westcott scissors. Release all fascial attachments, including the superior crus of the lateral canthal tendon to allow for adequate mobility of the flap. This will allow for proper alignment and ensure that there is no tension on the wound margin.
Close the margin as previously described in the section “Primary Closure of Upper Eyelid.”
Reattach the underside of the myocutaneous flap to the periosteum at the lateral orbital rim with deep, interrupted 4-0 polyglactin suture on a P-2 needle and 5-0 polyglactin on a P-3 needle.
Close the orbicularis for the length of the flap incision using 6-0 polyglactin in a buried fashion.
Close the skin with 6-0 plain gut suture in an interrupted fashion.

FIGURE 21.3. Skin markings for reverse Tenzel myocutaneous flap.

Horizontal Tarsoconjunctival Transposition Flap

Can be used to treat up to 40% defect in the upper eyelid when there is insufficient laxity to allow for an advancement myocutaneous flap, such as in younger patients, in those with previous surgery, or in those having severely actinic skin. Best for medial and lateral defects.

Place a 6-0 silk traction suture through the gray line of the remaining lid margin. Evert the upper lid over a Desmarres lid retractor.
Use a #15 blade to make a horizontal incision through the conjunctiva and tarsus 4 mm superior to and parallel with the lid margin, extending the incision laterally for a distance just greater than the width of the tarsal defect.

Free the tarsoconjunctival flap from the levator aponeurosis and Müller muscle with fine iris scissors. Undermine in this plane to allow for adequate mobilization of the flap (Figure 21.4).

FIGURE 21.4. Construction of the tarsoconjunctival transposition flap. A, Make a horizontal incision through the conjunctiva and tarsus 4 mm superior and parallel to the lid margin for a distance just greater than the length of the defect. B, At the end of the incision, extend the cut vertically to the superior border of the tarsus. Undermine the tarsus from the levator aponeurosis using fine iris scissors.

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