This document summarizes eyelid reconstruction techniques for various types of eyelid defects. It begins by describing the anatomy of the eyelid and its blood supply. It then classifies eyelid defects and outlines approaches for different defect sizes, including primary closure, skin grafts, local flaps like Tenzel's semicircular flap and V-Y flap for defects up to 50%, and workhorse flaps like Hughes tarsoconjunctival flap and Mustarde's cheek rotation flap for larger defects up to 75%. For total eyelid loss, conjunctival flaps are covered with forehead flaps, with division later for eyelid formation. The goal is to restore the layered anatomy and function of the eyelid.

1. EYELID RECONSTRUCTION
-By B.Lakshmi preethi

2. Eyelid
• Eyelid is made of anterior lamella and
posterior lamella
Anterior lamella consist of
Skin
Orbicularis oculi
Posterior lamella
Tarsus
Conjuctiva

7. • Arterial supply
Arterial supply of lid comes from anastomosis
between internal and external carotid artery
Internal carotid artery Supplies lid through
terminal branches of ophthalmic artery via
dorsal nasal artery , supratrochlear artery , supraorbital
Artery ,lacrimal artery

8. • External carotid artery supplies via facia artery ,
Internal maxillary artery , superficial temporal artery .

9. • Venous drainage

10. Lymphatics
Lateral two third of upper eyelid
Lateral one third of lower eyelid
Lateral half of conjuctiva drains into preauricular lymph nodes
Remaing drains into submandibular nodes .These two groups drains
into deep cervical nodes

11. • Nerve supply
sensory nerve supply by Ophthalmic and maxillary division
of trigeminal nerve and motor nerve supply by facial nerve

12. Eyelid reconstruction
GOAL :
To restore the normal anatomy and function of eyelid .
AIM :
To restore the layer by layer alignment of the lid tissues.

13. CLASSIFICATION:
Anterior lamellar defects
Full Thickness defects upto 25 percent
Full Thickness defects of 25 to 50 percent
Full Thickness defects of 50 to 75 percent
Full Thickness defects of 75 to 100 percent ( total eyelid
defects)

14. • ANTERIOR LAMELLAR DEFECTS
There is Several options to repair skin and muscle
defects in the periocular region :
Healing by granulation
Primary closure
Free skin grafts
Myocutaneous advancement flap

15. Healing by Granulation ( laissez faire technique) :
This technique generally reserved for small , isolated
anterior lamellar defects in the pretarsal and medial canthal areas
away from important landmarks .
Skin graft and flap to medial canthus can often have
poor esthetic outcome.
Healing is prolonged affair taking a few weeks to months
and may be associated with scar contracture .
primary closure is generally better option

16. Primary Closure :
It is performed if enough reduntant skin is availabe
adjacent to defect.
Patients with wrinkled and sagging skin usually have
enough reduntant skin to allow primary closure of small defects .
It requires undermining of adjacent tissues ( level at
which undermining carried out is important , and it should done
cautiously to avoid damage to blood vessels and nerve ) .

17. Care needs to be taken when undermining any tissues in the
path of seventh nerve extending from tragus of ear to tail of eyebrow
While closing the wound , direction should be such as to avoid
any tissue distortion and maximize scar camouflage .

18. Free Skin Grafts :
Useful in large anterior lamellar defects that can’t be covered by
a myocutaneous flap
Full thickness skin grafts (FTSG) consist of entire thickness of
epidermis and dermis .It heals with less shrinkage compared to split
thickness skin grafts making the full thickness technique more suited
for eyelid reconstruction .
However, donor site should be matched in terms of colour,
thickness and texture.

19. Upper eyelid , retroauricular skin , preauricular skin ,
supraclavicular or upper inner arm skin are thus , the preffered sites for
harvesting FTSGs.
In upper and lower eyelids, underlying orbicularis provides an
excellent vascular bed for the graft .If it is absent , muscle should be
moved in from around the defect .
common complications are graft contraction and its sequele
like ectropian and lid retraction , graft hypertrophy , partial graft failure
image

20. Advantages of split skin graft is that a large area of skin may be
harvested because no skin closure required at donor site and can
survive on bare bone .
Inspite of these advantages split skin graft is rarely used because
of its poor skin colour match and shrinkage

22. Myocutaneous flaps
Advancement flaps fashioned from skin and orbicularis from the
periocular area offer the best possible match in terms of graft color,
thickness and vascularity.
It is useful to remember while closing any lower eyelid defect
that the tension on the lid at the end of the procedure should be
horizontal rather tha vertical to avoid any complication like ectropian or
lid retraction .

23. • Full thickness defects upto 25 percent
lid margin repair
lateral canthal defect less than 25 percent
medial canthal defect less than 25 percent

24. • Lid margin defect

25. A 6 0 silk vertical matress suture is
Passed through meibomian gland orifices to align the
lid margin and should be tightened to ensure slight
eversion .
This is followed by placement of anterior lid margin
Suture keeping the lashes aligned and another posterior marginal
Suture.

26. • Lateral canthal defect less than 25 percent :
lateral canthal strip – A strip is created from free available
edge of tarsus and sutured to periorbita over inner part of lateral
orbital wall

27. Medial canthal defect upto 25 percent
Canalicular laceration should repaired earliest after
trauma with monocanalicular or bicanalicular stents
Free medial edge of tarsus sutured with periorbita over posterior
lacrimal crest or medial edge of frontal process of maxilla

28. • Full thickness lid defect from 25 to 50 percent :
Tenzel’s semicircular flap
V-Y flap

29. Tenzel’s semicircular flap

30. Edges of defect is made perpendicular to lid margin .
An arching semicircular line is drawn from lateral canthus .
A lateral canthotomy is done and musculocutaneous flap is
undermined along the line drawn .
The flap is then rotated inward and edges of the lid defect can be
closed .
with the tissue mobilized adequately,primary lid defect is closed.
Lateral edge of the incision can be then closed directly with interupted
sutures .

31. V-y flap :
It is an alternative myocutaneous flap where the
Upper margin of flap is placed in line with lid crease .
The lateral flap is then mobilized medially on a
pedicle of Orbicularis

32. • Full thickness lid defect from 50 to 75 percent
lower eyelid
Hughes tarsoconjuctival flap
Mustardes cheek rotation flap
Upper eyelid
Tarsoconjuctival flap
Mustardes lid switch procedure
Median forehead flap

33. Lower lid defect - Hughes tarsoconjuctival flap :

34. The defect in lower eyelid is measure in its horizontal extent . A
corresponding flap of tarsus and conjuctiva is fashioned from upper
eyelid .
The tarso conjuctival flapis then brought down to bridge the gap in
the lower eyelid . Tarsus is anchored to residual Tarsus of lower eyelid
Anterior lamella is formed by mucocutaneous advancement flap .

35. • Mustardes cheek rotation flap :

36. This procedure involves making an arched incision from lateral
canthus ,drawn towards the hairline and then extending inferiorly
anterior to tragus .
The akin is undermined , a flap created and rotated to fill the
anterior lamella defect .

37. Upper eye lid repair –
Tarsoconjuctival flap

38. • Mustardes lid switch procedure :

39. It is creating a full thickness transposition flap from the lower lid
which is atleast 4mm wide ,which is rotated medially or laterally to
cover the defect in the upper lid
Advantages are
It provides more stable
Presence of eye lashes

41. • Median forehead flap:

42. • A vertically oriented skin flap is elevt from forehead area and rotated
into the lid defect .
• Used in massive tissue loss of upperlid .

43. • Full thickness eyelid defects of 75 to 100 percent
Full loss of thickness of upper and lower
eyelid defect
For large defect , mobilize conjuctival flap from remaining
Forniceal conjuctiva and securing over cornea
Anterior lamella formed midlineforehead flap
Division of new eyelid formed several weeks later.
Reconstructed eyelid have poor function in the setting of total
Upper eyelid and lower eyelid loss and multiple surgeries required to
improve the outcome.