repairing lids in situation of tissue loss in lids

1. Lid reconstruction
PRESENTED BY:
DR. VANDANA SHARMA

2. Surgical anatomy
 Skin thinnest in eyelids
 No subcutaneous fat
 No or fine hairs present
 Attached to medial lateral palpebral tendons
 Dimensions of palpebral fissure:
 Vertical: 8 – 11mm
 Horizontal: 25 – 30 mm

3.  Lateral canthus lies 1-3 mm above medial canthus
 Highest point of palpebral fissure is at junction of medial and
central thirds
 Structures of lid margin:
 Cilia
 Grey line
 Meibomian ducts

4.  Intermarginal strip has sharp posterior border
 Tarsal plate is firmly attached to connective tissue and skin at
lid margin
 Muscles of the lids:
 Orbicularis oculi
 Levator palpebre superioris
 Corrugator supercilii
 Muller’s muscle

5.  Orbital septum
 Unites tarsal plate to supra and infra orbital margins
 Not uniform in thickness
 Pierced by vessels and nerves
 Medial palpebral tendon:
 Connects both tarsal plates with medial wall of orbit on lacrimal crest
 Gives origin to orbicularis oculi

6.  Lateral palpebral tendon
 Closely connected to tarsal plates, lateral raphe of orbicularis oculi
and lateral expansion of LPS
 Attaches on a tubercle about 3 mm posterior to orbital margin

7. General considerations before surgery
 Final shape and outline of features should be comparable on
both sides
 Patient’s general state of health should be known
 Local condition of the wound should be noted
 Skin defects in the lids should be covered by sliding adjacent
skin or using flap from redundant skin

8.  Lid margin should be preserved as much as possible
 Orbicularis muscle should be disturbed as little as possible
 Palpebral conjunctiva cannot be slided
 Line of skin sutures should not directly overlie cartilage and
bone grafts

9. Technique of suturing
 All blood clots and debris should be removed
 Sutures should be applied with 6 – 0 braided silk with spatulated curved
eyeless needle
 Slight eversion of cut edges should be done when sutures are tied
 Colour of skin edge should remain pink
 Sutures should be placed about 6 mm apart
 Skin wound of 3 – 4 mm along skin crease needs no suturing
 Wound of orbicularis at right angles to the muscle should be sutured with
6- 0 absorbable suture

10. Closure of full thickness lid margin
incision or wound
 Should be closed in layers
 Notching of lid margin should be avoided

12. Absorbable 6 – 0 suture is placed as
close to lid margin as possible
Single knot is tied and approximation
is assessed
2 more absorbable sutures are passed
through tarsal plate
Silk 6 – 0 suture is passed through
grey line and left loose
1st absorbable suture is then tied
Orbicularis is sutured
Grey line suture is tied and left long
Lash line is sutured
Skin is sutured and long ends of
previous sutures are caught in them

13. Deep subcutaneous knots
Burying a
subcutaneous knot Figure of 8 stitch

14. Reconstruction of eyelids, socket and orbit
 Local flaps
 Rotation
 Transposition
 Advancement
 Island
 Free grafts
 Skin
 Split skin
 Full thickness

15.  Hair bearing
 Mucous membrane
 Other like fat, bone, cartilage etc
 Pedicle grafts
 Expanded grafts
 Muscle grafts
 Free flaps

16. Local flaps
 Main sources are
 Forehead
 Glabella
 Cheek
 Transposition flaps such as Z plasty may be done
 Advancement flap such as V Y operation may be used
 In island flap, skin is raised in subcutaneous pedicle along
with blood supply from the pedicle and advanced over short
distances

17. Free grafts
 Skin grafts:
 Split skin grafts:
 Preparation of donor site
 Usually medial aspect of upper arm or thigh
 General anaesthesia is used
 Harvesting the graft
 Donor site lubricated with sterile liquid paraffin or petroleum jelly
 Donor skin stretched with skin graft boards
 Graft taken with skin graft knife

18.  Dressing donor site
 Dressed with tulle gras and melolin
 Light gauze bandage is applied
 Left undisturbed for 10 days
 Hemostasis achieved at recipient site
 Fixation of graft
 Graft stitched to edges of defect with fine silk
 Dressing with tulle gras and proflavine wool is sutured with the graft

19.  Post op care
 Inspection of dressing at 24 and 48 hrs
 Removal of sutures after 10 days

20.  Full thickness grafts
 May be taken from
 Redundant skin in upper eyelid
 post auricular skin
 Pattern of recipient area is taken
 Full thickness graft is taken and donor site is closed
 Skin flap is defatted
 Edges of graft are sutured to edges of the defect
 Proflavine bolster sutured

21.  Anchoring sutures may be applied
 Daily inspection of graft to ensure no seroma or hematoma is formed
 Stitches removed after 7 – 14 days

22.  Hair bearing grafts:
 Full thickness free grafts containing hair follicles
 Local scalp flaps containing hair

23. Temporal island flap for reconstruction of
eyebrow

24.  Mucous membrane:
 Conjunctiva
 Free conjunctival flaps
 Local transposition of conjunctival flap
 Buccal mucosa
 To cover defects in palpebral and bulbar conjunctiva after injury, burns
excision of neoplasms
 May be taken from inner aspect of lower lip or cheek

25.  Fat:
 Free fat grafts shrink to almost half of their size
 So not preferred for contour reconstruction
 Used to repair depressed scars
 Cartilage:
 Thin cartilage grafts needed to reconstruct tarsus taken from auricle
or nasal septum
 Cartilage grafts for reconstruction of orbital margins taken from rib

26.  Bone:
 Reconstruction of orbital floor is done with bone graft from iliac crest
 Periosteal layer should be retained with the grafts
 Fascia:
 Used in ptosis surgery
 Taken from fascia lata or extensor tendon of little toe

27. Pedicle grafts
 Consists of skin, and subcutaneous tissue along with its own
blood supply
 Skin of temporofrontal region is commonly used in eyelids
 Good color match
 May be hair bearing
 Have to be advanced in stages

28. Expanded flaps
 To cover large defects, flaps are expanded with tissue
expanders
 More complications are seen with these

29. Muscle grafts
 Microvascular transplantation of muscle will ensure its
survival at transplanted site
 Function can be retained by preserving nerve supply

30. Free flaps
 Transfer of skin flaps with their own arterial and venous
supply
 Direct anastomosis of arteries and veins is done under
operating microscope
 Large areas of skin, muscle and cartilage can be transferred

31. Lateral canthotomy
 Indications:
 To decompress orbit in cases with orbital cellulitis
 Correction of partial ankyloblepharon or blepharophimosis
 In cataract surgery for better exposure of globe as in deep socket
 Procedure:
 Skin at lateral canthus is made taut and lifted up
 Hemostasis is achieved by crushing with mosquito forcep

32.  One blade of a blunt ended scissors is passed into lateral fornix
 Scissors is closed thereby cutting the tissue
 Closure of canthotomy:
 One interrupted silk suture passed through the two cut ends is
sufficient

33. Cantholysis
 Indications:
 Reconstruction of full thickness defect for quarter of length of lid or
more
 Facilitate forward movement of lids in tarsorraphy
 Procedure:
 Dicision of one or both bands extending from tarsal plate to lateral
canthal tendon
 Division of orbital septum from orbital margin may also be done

34. Canthoplasty
 Lateral canthotomy is done
 Bulbar and froniceal conjunctiva is undermined
 Sliding flap of conjunctiva is carried through the skin 4 mm
lateral to extent of canthotomy
 Mattress sutures are passed between skin and conjunctival
flaps to cover the raw surfaces
 If conjunctiva is insufficient, free flaps may be taken

35. Canthal tendon operations
 Division and fixation of medial canthal tendon:
 Medial canthal tendon may get damaged due to injury or DCR
 May lead to downward displacement of medial canthus
 Repair:

36. Tendon is exposed
Anchored into a pre bored tunnel in
frontal process of maxilla
If the tendon is short, a non
absorbable suture passed at end of
the tendon is passed into the
tunnel, back into the tendon and
sutured

37. Replacement of
medial canthal
tendon
Narrow lamellar pedicle is cut from
upper tarsal plate
Reflected back on itself medially
over lower canaliculus
Free end is sutured to periosteum
over anterior iliac crest

38.  Division of lateral palpebral tendon:
 Done in rapidly progressive exophthalmos
 Procedure:
 Lateral canthotomy is done
 Lateral margin of orbit is identified
 Blunt ended scissors is spread posteriorly upto orbital tubercle
 Scissors is turned so that the blades open in vertical direction
 Tendon is engaged and cut

39.  Reconstruction of lateral palpebral tendon
 Fascia lata may be used
 Procedure:
 1.5 cm long incision is made at lateral canthus along skin crease
 Orbicularis is retracted
 Lateral ends of upper and lower tarsal plates are identified
 Vertical incisions are made into each tarsus 4 mm long, 3 mm from its
ends
 Tunnel of diameter 4 mm is drilled into orbital wall after retracting orbital
contents medially

40. Strip of fascia lata is split into ‘Y’
Base of y is passed into orbital
tunnel and emerging free end is
sutured over itself
Each arm of y is passed in the
buttonholes of the tarsal plates and
sutured over itself
Orbicularis incision is sutured over
itself with absorbable sutures
Skin is sutured with non absorbable
sutures

41. Closure of lid defects
 Small defects:
 Closed by advancement of adjacent skin or V – Y plasty
 Full thickness defect for quarter of length or less:
 Modified Wheeler’s operation is done
 Full thickness defect for more then quarter of length:
 Mustarde’s operation
 Upper lid rotation from lower lid
 Loss of more than half of eyelid
 Cheek rotation flap for reconstruction of lowerlid
 Lower lid rotation and cheek rotation flap for upper lid reconstruction

42. Modified wheeler’s
operation for lid
defects

43. Mustarde’s
operation for large
defects

44. Lower lid reconstruction

45. Tenzel’s
semicircular flap

46. Mustarde’s cheek rotation flap for lower
lid reconstruction
 Lower lid is reconstructed from cheek skin, nasal septum cartilage and nasal
mucosa

47. Mustarde’s cheek
rotation flap
Mobilisation of cheek flap
Nasal mucous membrane and septal
cartilage graft
• size of mucous membrane graft: 2.5
cm long and 1.5 cm wide
Fixation of cheek flap

48. Hughe’s
tarsoconjunctival
advancement graft

50. Reconstruction of upper lid
 Severe damage to upper lid is rare
 Immediately jeopardizes safety of the eye
 Points to be considered while reconstructing upper lid
 Should be lined with conjunctiva or buccal mucosa
 Should contain a supporting plate
 Should have a muscle action if possible in form of orbicularis or LPS attachment

51. Mustarde’s
rotation flap from
lower lid

52.  LPS may be torn in trauma
 Retraction is prevented by lateral attachments of the muscle
 Repair:
 Local anaesthetic is injected
 Site of torn aponeurosis is revealed by asking the patient to look up
 Aponeurosis is held in a clamp and sutured to anterior surface of tarsus with 4 – 0
absorbable sutures
 If primary repair has not been done timely, 6 – 12 months should be allowed to elapse
before attempting repair

53. Mustarde’s operation for reconstruction of
upper lid in 2 stages
 Broad based full thickness flap of lower lid is made
 Rotated into the defect as far as possible and sutured
 2 weeks later base of flap is cut and remaining flap sutured to remaining defect
 Lower lid is reconstructed with cheek flap and nasal septal cartilage and mucous
membrane
 Principles for creating lower lid flaps:
 If remnant of upper lid is present: hinge made on same side
 If defect is total or central: hinge is placed laterally
 Lacrimal punctum is not included in the flap

54. Mustarde’s
operation for
reconstruction of
upper lid in 2
stages

55. Cutler beard
technique

57. Neoplasm excision
 Proliferative type of BCC does not invade deeper tissues
 Lesions over lid margins also do not tend to involve tarsal plate
 2 different sets of instruments should be used for excision of tumor and plastic
repair
 Excision of neoplasm:
 Proliferative lesion 3 mm from lid margin: lid margin structures should be preserved
 Deeply infiltrative lesions: full thickness resection has to be done

58. Excision of neoplasms

59. Collar stud excision
with partial
tarsectomy
Done when main mass of lesion lies
away from lid margin with possible
involvement of tarsus at lid margin
Tarsal coloboma is closed with
interrupted absorbable sutures
Cantholysis may be used

60. Tarsal sutures are tied
Orbicularis bridge flap is sutuered
Full thickness skin flap is placed
over the defect

61.  Medial canthus reconstruction:
 When plane of excision is not upto periosteum: full thickness skin grafts are used
 When plane of excision is upto periosteum:
 V Y advancement of frontoglabellar flap for defect upto 10 mm
 Midline frontal pedicle for defect more than 10 mm

62. Frontoglabellar flap
Inverted V incision is given
Flap is mobilized
Defect is closed
Flap is sutures in Y shape
Free conjunctival or buccal mucosal
flap is attached to undersurface
Medial end is sutured to periosteum
Flap is cut in centre to create upper
and lower lid

63. Midline frontal pedicle flap
Incision is given on glabella
and flap is raised
Anterior end of flap is divided
so as to fit upper and lower
lid defects
Anterior end is lined by free
conjunctival or buccal
mucosal flap
Anterior end of flap is
sutured to the defects
Vertical incisions on forehead
are undermined,
approximated and sutured
Medial limit of graft is
marked
Tulle is passed beneath the
pedicle bridge
After 18 days, pedicle is cut at
marked site
Fibrous tissue from
undersurface is excised and it
is sutured back to frontal
region
Medial edge of graft is
sutured

64. Total loss of lower lid and partial loss of
upper lid
 Lower lid is reconstructed using cheek flap
 If medial half of upper lid is lost, midline frontoglabellar pedicle flap is used
 If lateral half of upper lid is lost, temporofrontal flap is used

65. Total loss of upper lid and partial loss of
lower lid
 If lateral part of lower lid is conserved it is rotated to medial side of upper lid
 Lateral part of upper lid is reconstructed with temporofrontal flap
 Lower part of lid is reconstructed with cheek flap
 When medial part of lower lid is conserved
 Lateral defect closed with cheek flap
 Upper lid reconstructed with supraorbital flap

66. Total loss of both eyelids
 Four stage repair is done
 Stage 1:
 Remnants of conjunctiva mobilized and sutured with absorbable suture to cover the
cornea
 Thin shaving of auricular cartilage may be placed to replace tarsus
 Bridge pedicles of orbicularis are placed over the eye
 Split skin graft is placed

67.  Stage 2:
 After 1 month, split skin graft is replaced with full thickness skin graft
 Stage 3:
 Eyebrow bearing transplants may be used for creating lash line
 1 – 2 mm skin is kept between the two lash lines
 Stage 4:
 After 3 – 4 months after 1st operation, tarsorraphy is divided

68. Bibliography
 Stallard’s eye surgery;7th edition
 Lids, orbits, extraocular muscles, volume 1; Von noorden