PRINCIPLES OF EYELID REPAIR Wounds should be copiously irrigated and explored, with the removal of any foreign material after local anesthesia Reconstruction should be done in layers as per correct anatomical orientation Wounds should not be extended to explore structures unless the exploration is for suspected foreign body The orbital septum if damaged should never be repaired-result incompromised eyelid excursion and even lagophthalmos

1. TRAUMA
2/June/2021
Dr Shayri Pillai
2ND Year Ophthalmology Resident
Liberia Eye Centre
JFK Memorial Medical Center
L V Prasad Eye Institute

2. EYELID
LACERATION

3. PRINCIPLES OF EYELID REPAIR
 Wounds should be copiously irrigated and explored,
with the removal of any foreign material after local
anesthesia
 Reconstruction should be done in layers as per correct
anatomical orientation
 Wounds should not be extended to explore structures
unless the exploration is for suspected foreign body
 The orbital septum if damaged should never be
repaired-result incompromised eyelid excursion and
even lagophthalmos

4.  We should avoid suture incorporation of the septum
during repair
 The presence of orbital fat raises the risk of deeper
injury and foreign bodies
 In brow lacerations, eyebrows should never be
shaved off as orientation of the brow hair will help
us in correct approximation

5.  Anterior lamellar defects not involving lid margin
should be repaired by primary closure
 Undermining of the surrounding skin -done to
mobilize skin for adequate closure
 Interrupted sutures with 6-0 vicryl may allow for
hematoma egress or infection drainage
 Primary repair of the levator aponeurosis is done
by repositioning it to the upper half of the tarsus
with permanent 6-0 or 7-0 suture material

6.  Repair deep tissues first
 Posterior lamella (tarsus, retractors, and conjunctiva)
repair is dependent on the extent of injury
 Conjunctival lacerations of 5 mm or less often do not
need to be repaired
 8-0 vicryl suture for larger conjunctival lacerations

7. Lacerations not involving the eyelid margin
Superficial eyelid lacerations involving just the skin
and orbicularis oculi muscle usually require only
skin sutures, with or without buried subcutaneous
sutures

8. Lacerations involving the eyelid margin
 Repair of eyelid margin lacerations -precise suture
placement and suture tension to minimize notching
of the eyelid margin
 Tarsal approximation and anatomical alignment of
the eyelid margin should be meticulous in order to
precisely repair the eyelid margin
 Eyelid margin is typically aligned by placing
interrupted silk sutures through the lash line,
meibomian gland plane, and the gray line

9.  Non marginal tarsal sutures are placed through the
height of the lacerated tarsus to strengthen the
margin closure and to avoid imbrication of the tarsal
edges
 Sutures should be partial thickness through the tarsus
without extension through the conjunctival surface
 Suture tails should be directed away from the ocular
surface

10.  Eyelid margin closure should result in a moderate
eversion of the well-approximated wound edges
 Resorbable, buried, vertical mattress sutures may be
used in the margin as an alternative to externally
tied sutures

13. Trauma involving the canthal soft tissue
 Trauma to the medial or lateral canthal areas is usually
the result of horizontal traction on the eyelid, which
causes avulsion at the eyelid’s weakest points, the
medial or lateral canthal tendon
 Lacerations in the medial canthal area require
evaluation of the lacrimal drainage apparatus, with
canalicular involvement confirmed by inspection and
gentle probing

15. The integrity of the inferior and superior limbs of the
medial or lateral canthal tendon -assessed by grasping
each eyelid with toothed forceps and tugging away
from the injury while palpating the insertion of the
tendon
Medial canthal tendon avulsion should be suspected
when there is rounding of the medial canthal angle
and acquired telecanthus

16. Treatment of medial canthal tendon avulsions depends
on the extent of the avulsion
 If the upper or lower limb is avulsed but the
posterior attachment of the tendon is intact-the
avulsed limb may be sutured to its stump or to the
periosteum overlying the anterior lacrimal crest

17.  If the entire tendon, including the posterior portion, is
avulsed but there is no naso-orbital fracture, the
avulsed tendon may be wired through small drill
holes in the ipsilateral posterior lacrimal crest
 If the entire tendon is avulsed and there is a naso-
orbital fracture, transnasal wiring or plating is
necessary after fracture reduction

18. Eyelid and Canthal Reconstruction
Eyelid reconstruction applies to defects resulting from
tumor resection as well as congenital and traumatic
defects
The choice of procedure- depends on multiple factors
-Patient’s age
-Comorbidities
-Condition of the eyelids
-The size and position of the defect
-The surgeon’s personal preference

19. Priorities in eyelid reconstruction are –
-Preserving eyelid function
-Developing a stable eyelid margin
-Ensuring adequate eyelid closure for ocular protection
-Maintaining adequate vertical eyelid height
-Creating a smooth, epithelialized internal surface
-Maximizing cosmesis and symmetry

20. The following general principles guide the practice of
eyelid reconstruction:
-One may reconstruct either the anterior or the
posterior eyelid lamella, but not both, with a graft; 1
of the layers must provide a blood supply (pedicle
flap)
-Direct the tension horizontally, while minimizing
vertical tension
-Maintain sufficient and anatomical canthal fixation

21. -Match tissue similar in color and thickness to each other
-Minimize the defect area as much as possible before
sizing a graft
-Request assistance from a subspecialist if necessary

22. Eyelid Defects Not Involving the Eyelid Margin
Defects not involving the eyelid margins can be repaired
by direct closure if the repair does not distort the eyelid
margin
If undermining of the surrounding tissue does not allow
direct closure, advancement or transposition of skin flaps
may be used
The tension of closure should be directed horizontally,
because vertical tension may cause eyelid retraction or
ectropion

23. Vertical tension may be avoided by placement of
vertically oriented incision lines
If the defect is too large to be closed primarily, techniques
utilizing advancement or transposition of local skin flaps
may be employed
The flaps most commonly used are rectangular
advancement, rotation, and transposition
Flaps usually provide the best tissue match and aesthetic
result, but they require planning in order to minimize
secondary deformities

24. Upper eyelid skin is often an acceptable option for
lower eyelid anterior lamellar defect repair
The final texture, contour, and cosmesis are typically
better with flaps as compared to skin grafts from sites
other than eyelid skin

25. Anterior lamella upper eyelid defects are best repaired
with full-thickness skin grafts from the contralateral
upper eyelid
Preauricular or postauricular skin grafts may be used,
but their greater thickness may limit upper eyelid
mobility
If flaps are not sufficient, lower eyelid defects are best
filled with preauricular or postauricular skin grafts

26. If skin is not available from the upper eyelid or
auricular areas, full-thickness grafts may be harvested
from the supraclavicular fossa or the inner upper arm
Grafts should be slightly oversized, because
contraction is likely to occur
Use of split-thickness grafts should also be avoided in
eyelid reconstruction-recommended only in the
treatment of severe facial burns when adequate full-
thickness skin is not available

28. Eyelid Defects Involving the Eyelid Margin
Small upper eyelid defects
Small defects involving the upper eyelid margin -
repaired by primary closure if this technique does not
place too much tension on the wound
Primary closure is usually employed when one-third or
less of the eyelid margin is involved
If a larger area is involved, advancement of adjacent
tissue or grafting of distant tissue may be required

29.  The superior limb of the lateral canthal tendon can be
released to allow 3–5 mm of medial mobilization of the
remaining lateral eyelid margin
 Care must be taken to avoid the lacrimal ductules in
the lateral upper eyelid
 Removal or destruction of these ductules may lead to
chronic dry eye problems in the patient
Postoperatively, the eyelid may appear tight and ptotic
due to traction, but it typically relaxes over several
weeks

30. Figure 11-9 Reconstructive ladder for upper eyelid defect. A,
Primary closure with or without lateral 288canthotomy or superior
cantholysis. B, Semicircular flap. C, Adjacent tarsoconjunctival flap
and fullthickness skin graft. D, Free tarsoconjunctival graft and
skin flap. E, Full-thickness lower eyelid advancement flap (Cutler-
Beard flap). F, Lower eyelid switch flap or median forehead flap.
(Illustration by Christine Gralapp.)

31. Moderate upper eyelid defects
Moderate defects of the upper eyelid margin (33%–50%
margin involvement) can be repaired by advancement of
the lateral eyelid segment and temporal tissue
The lateral canthal tendon is released, and a semicircular
skin flap is made below the lateral eyebrow extending
from the canthus to allow for further eyelid mobilization

32. The temporal branch of the facial nerve should be
avoided when incising the flap
Tarsal-sharing procedures involving the lower eyelid
may be required in younger patients with less eyelid
laxity

33. Large upper eyelid defects
Upper eyelid defects involving more than half of the
upper eyelid margin are likely to require eyelid-
sharing techniques
After a horizontal subciliary incision in the lower
eyelid tarsus, a fullthickness lower eyelid flap is
advanced into the defect of the upper eyelid behind
the remaining lower eyelid margin

34. This procedure requires a second procedure to open
the eyelids, and often results in a thick and relatively
immobile upper eyelid
Alternatively, a tarsoconjunctival flap from the lower
eyelid used in conjunction with an overlying skin graft
may result in better cosmesis
Eyelid-sharing procedures are less optimal in
monocular patients or in children in whom deprivation
amblyopia may be a concern

35. A free tarsoconjunctival graft taken from the
contralateral upper eyelid and covered with a skin–
muscle flap may be an option if adequate redundant
upper eyelid skin is present

37. Small lower eyelid defects
Small defects of the lower eyelid (margin involvement
of less than one-third) can be repaired by primary
closure
In addition, the inferior crus of the lateral canthal
tendon can be internally or externally released so that
there is an additional 3–5 mm of medial mobilization of
the remaining lateral eyelid margin

38. Reconstructive ladder for lower eyelid defect. A,
Primary closure with or without lateral canthotomy or
superior cantholysis. B, Semicircular flap. C, Adjacent
tarsoconjunctival flap and full-thickness skin graft. D,
Free tarsoconjunctival graft and skin flap. E,
Tarsoconjunctival flap Small lower eyelid defects
Small defects of the lower eyelid (margin involvement
of less than one-third) can be repaired by primary
closure (Fig 11-11). In addition, the inferior crus of the
lateral canthal tendon can be internally or externally
released so that there is an additional 3–5 mm of
medial mobilization of the remaining lateral eyelid
margin. 290from upper eyelid and skin graft (modified
Hughes flap). F, Composite graft with cheek
advancement flap (Mustardé flap). (Illustration by
Christine Gralapp.)

39. Moderate lower eyelid defects
Semicircular advancement or rotation flaps, which have
been described for upper eyelid repair, can also be used
for reconstruction of moderate defects in the lower
eyelid
The most commonly used flap in such cases is a
modification of the Tenzel semicircular rotation flap
Tarsoconjunctival autografts harvested from the
underside of the upper eyelid may be transplanted into
the lower eyelid defect for reconstruction of the
posterior lamella of the eyelid

40. When tarsal grafts are harvested, the marginal 4–5
mm height of the tarsus is preserved to prevent
distortion of the donor eyelid margin
Tarsoconjunctival autografts may be covered with
skin flaps or skin–muscle flaps
Cheek elevation (suborbicularis oculi fat lift) may be
required to avoid ectropion and vertical traction on
the eyelid
Alternatively, a tarsoconjunctival flap developed
from the upper eyelid and a full-thickness skin graft
can be used

41. Large lower eyelid defects
Defects involving more than half of the lower eyelid
margin -repaired by advancement of a
tarsoconjunctival flap from the upper eyelid into the
posterior lamellar defect of the lower eyelid
The anterior lamella of the reconstructed eyelid is
then created with an advancement skin flap or, in
most cases, a free skin graft taken from the
preauricular area, the postauricular area, or the
contralateral upper eyelid (modified Hughes flap)

42. The modified Hughes flap therefore results in
placement of a bridge of conjunctiva from the upper
eyelid across the pupil for several weeks
The vascularized pedicle of conjunctiva is then
released in a staged, second procedure once the lower
eyelid flap is revascularized, typically 3–4 weeks later

43. Eyelid-sharing techniques should be used cautiously in
children, because deprivation amblyopia may develop
Large rotating cheek flaps (Mustardé flap)can work
well for repair of large anterior lamellar defects, but
they may require a tarsal substitute such as a free
tarsoconjunctival autograft, hard-palate mucosa, or a
Hughes flap for posterior lamella replacement

44. Both the cheek rotation flap and the semicircular
rotation flap frequently result in a rounded lateral
canthus, which can be mitigated by creating a very high
incision toward the lateral end of the eyebrow, in which
the incision emanates from the lateral commissure.
Free tarsoconjunctival autografts from the upper eyelid
covered with a vascularized skin flap have also been
used to repair large defects. This type of procedure has
the advantage of requiring only 1 surgical stage and
prevents temporary occlusion of the visual axis.

46. Lateral Canthal Defects Laterally based transposition flaps of
upper eyelid tarsus and conjunctiva can be used for large lower
eyelid defects extending to the lateral canthus. These flaps can be
covered with free skin grafts. Semicircular advancement or
rhomboid flaps (Fig 11-14) can also be used to repair defects
extending to the lateral canthal area. Horizontal strips of
periosteum and/or deep temporal fascia left attached at the lateral
orbital rim can be swung over and attached to the remaining
eyelid margins for reconstruction of the entire lateral canthal
posterior lamella (Fig 11- 15). A Y-shaped pedicle flap of
periosteum can be used for reconstruction of the entire lateral
canthal posterior lamella of the upper and lower eyelids.

49. Medial Canthal Defects The medial canthal area is
typically repaired with full-thickness skin grafting (Fig
11-16) or via various flap techniques, although
spontaneous granulation of anterior lamellar defects
has demonstrated variable success. When full-
thickness medial eyelid defects are present, the medial
canthal attachments of the remaining eyelid margin
must be fixed to firm periosteum or bone. This fixation
may be accomplished with heavy permanent suture,
wire, or titanium miniplates. Defects involving the
lacrimal drainage apparatus are more complex,
requiring simultaneous microsurgical reconstruction and
possible lacrimal intubation or marsupialization. If
extensive sacrifice of the canaliculi has occurred in the
resection of a tumor, the patient may have to tolerate
epiphora until tumor recurrence is deemed unlikely,
after which a conjunctivodacryocystorhinostomy can be
consideredqa

51. Full-thickness skin grafts offer an excellent way to reconstruct the
medial canthus compared with the cicatrix resulting from spontaneous
granulation, and they are thin enough to allow for early detection of
tumor recurrence. Frozen sections and wide margins or Mohs
micrographic resection techniques should be performed at the time of
initial tumor resection to minimize the risk of recurrent medial canthal
tumors and the risk of orbital or lacrimal tumor extension. Large medial
canthal defects of anterior lamellar structures may be properly
reconstructed through the careful transposition of forehead or glabellar
flaps. However, such flaps can have the disadvantage of being thick,
thereby making early detection of recurrences difficult. In addition, they
may require second-stage thinning or laser resurfacing to achieve the
optimal cosmetic result. Mohs micrographic resection of tumors offers
the highest cure rates for eradication of medial canthal epithelial
malignancies.

60. Thank you!
Excellence Equity Efficiency
L V Prasad Eye Institute