Lower eyelid reconstruction following Moh's surgery can be challenging. This paper explains some of the thought process and procedures utilized to repair these defects.

1. | Scientific Article
Lower Eyelid Reconstruction Following Mohs Surgery
Matthew J. Schessler, MS-III dehiscence may also be necessary. (V2). The orbicularis oculi muscle,
West Virginia University School We discuss the functional anatomy of innervated by the facial nerve
of Medicine
the lower eyelid, necessary physical (VII), functions to close the eye
W.Thomas McClellan, M.D.
Plastic Surgeon exam components, and reconstructive and as the lacrimal pump.
Morgantown Plastic Surgery Associates techniques with patient examples. The posterior lamella includes
Additionally, we present an the tarsal plate and the palpebral
Abstract algorithm that integrates lamellar conjunctiva. The tarsal plate consists
Lower eyelid defects resulting from defects with surgical treatments. of dense, fibrous tissue that provides
Mohs micrographic surgery can be structural support to the eyelid
challenging to repair. These repairs are Anatomy of the Lower Eyelid and houses the meibomian glands
fraught with potential complication due to The lower eyelid’s anatomy is which secrete the sebaceous portion
the lower eyelid’s complex anatomy and complex and must be carefully of the tear film. Behind the tarsal
defect variability. A single “cookie-cutter”
treatment regimen does not exist because considered before reconstructive plate lies the palpebral conjunctiva,
patients and defects vary. Surgical surgery to prevent post-surgical a thin epithelial layer that contacts
closure techniques include primary complications such as entropion, the conjunctiva of the globe.
closure, eyelid advancement, rotational ectropion, canthal distortion, or The tarsoligamentous sling
flaps, full thickness skin grafts, and/or altered closure mechanisms. consists of the tarsal plates and
allografts. We present a discussion of
lower eyelid reconstruction including
The lower eyelid consists of two the canthal tendons. The sling
relevant anatomy, physical signs, and lamellae separated by the orbital supports the globe in the orbit
treatment options with examples. septum (some authors consider the and facilitates eyelid closure (2).
septum as the middle lamella in a The upper and lower eyelids meet
trilamellar system) (1,2). The grey line at the medial and lateral canthi.
Introduction is a visible demarcation between the Please see Figure 1 for a diagram
Eyelid defects resulting from Mohs anterior and posterior lamellae and of the tarsoligamentous sling.
micrographic surgery require careful corresponds to eyelash alignment. It The lateral canthus or retinaculum
consideration of the anatomy. A also aides in realigning the lower lid is not fully anchored to increase
thorough physical exam is required when repairing defects. The lower the lateral visual field. The medial
to properly identify, categorize, lid should oppose the globe at the canthus remains firmly anchored to
and implement the appropriate inferior limbus. Please see Figure 1 the frontal process of the maxilla. This
reconstructive treatment in order for a diagram of the eyelid lamellae. anatomical discrepancy predisposes
to minimize complications. Mohs Skin and the orbicularis oculi the lateral canthus to develop laxity
surgery is the optimal technique to muscle comprise the anterior lamella. and phimosis with age (1). This senile
remove basal and squamous cell The skin is very thin (less than laxity must be accounted for when
carcinomas from the lower eyelid and 1mm) yet houses numerous fine selecting a reconstructive treatment.
other anatomical structures where hairs and sebaceous glands. The Lacrimal secretions drain by
unnecessary resection would cause infraorbital nerve (V1) is the primary action of the orbicularis oculi muscle.
further disfigurement. Nonetheless, sensory innervation of the lower Secretions flow across the eye toward
these lower eyelid defects are lid with additional contributions the puncta near the medial canthus.
still challenging to repair. After a from the zygomaticofacial nerve Lacrimal fluid drains through the
thorough examination of the patient’s
defect, eyelid characteristics, and a
Figure 1.
Schematic diagrams of the bilamellar system of the lower eyelid (left) and the
physical exam, the optimal treatment
tarsoligamentous sling (right).
is selected. Common treatment
avenues are based on defect size
and include primary closure, Tenzel,
Hughes, or Tripier flaps. These can
be combined with full thickness skin
grafts (FTSG), human allografts,
or cartilage grafts. A canthoplasty
with a periosteal flap or a fascia lata
graft to correct lateral retinacular
September/October 2009 | Vol. 105 19

2. Scientific Article |
Figure 2.
Measuring eye prominence with a Hertel exophthalamometer (left) and classification of eye prominence based upon Hertel
measurements (right) (4).
Eye Prominence Deep-set Normal Prominent
Hertel measurement <15mm 15-17mm >18mm
puncta into the lacrimal canaliculi assess the defect, select the best should also be examined. Any history
and then into the lacrimal sac reconstructive technique, and of dry eye or Bell’s phenomenon
behind the medial canthal tendon. minimize complications. Lower should be noted. The lacrimal duct
The lacrimal sac empties into the eyelid tone, canthal tilt, closure system should also be examined.
nasolacrimal duct and then enters the mechanics, Hertel measurement, and When a lower eyelid defect precludes
nose via the inferior nasal meatus. lower lid/inferior limbus relationship a physical exam, examination of
are necessary to properly evaluate the the contralateral eyelid is helpful.
Physical Exam tarsoligamentous support structure. The anterior lid distraction test
A thorough pre-operative history Visual acuity, extraocular muscles, provides an objective measurement
and physical exam is necessary to light reflex, and accommodation of lower lid laxity. Lax eyelids can
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20 West Virginia Medical Journal

3. | Scientific Article
be distracted 6mm or more (3). Figure 3.
Older patients typically have 69 year-old woman with a 20% lower eyelid defect and 8mm of lid laxity.
greater eyelid laxity due to lateral Intraoperative photographs show primary closure of the original defect. Mohs defect
retinacular dehiscence and loss and proposed incision in green (left), pentagonal incision (center), and scar directed
of intrinsic elastic properties. laterally (right).
Globe prominence is measured
with a Hertel exophthalamometer
which quantifies the distance
from the cornea to the orbital rim.
More prominent eyes require
more canthal support (4).
The location and patency of the
lacrimal duct system should be
verified with medial wounds. Prior
to Mohs or reconstructive surgery
splinting tubes can be placed to Misdirecting scar forces laterally Tenzel flaps correcting up to 60%
identify or protect the ducts. reduces the inferior contracture force defects (6,7). First a flap is created
minimizing the risk for long-term beginning at the lateral canthus
Surgical Options ectropion. Please see Figure 3. and then extending upward in a
Partial thickness lower eyelid Defects of less than 25% can be semicircular pattern. A canthotomy
defects involving the anterior lamella reliably treated with primary closure is performed and the eyelid and
can be treated conservatively with or a Tenzel flap. The key determinant flap is advanced to directly close the
dressing changes and healing by is the patient’s lid laxity. If a patient defect (8,9). A canthoplasty must
secondary intention. These methods has significant lid laxity (>6mm with be performed to reset the lateral
are very successful in the medial anterior traction) or a slow lid snap canthus using a periosteal flap or a
canthal region. Buccal mucosa back test then primary closure is fascia lata graft. Please see Figure 4.
grafts are useful to repair margin indicated. Rotational advancement Twenty-five to 50% defects may
defects that contact the globe. flaps such as the Tenzel are better be repaired with a Tenzel flap or
FTSGs are an excellent choice for used in patients with less laxity. a Hughes flap (6). Tenzel flaps
submarginal defects lateral to the Ultimately, the goal is to align the yield better results when applied
puncta (2). The color and contour grey line and restore the lower to short, deep defects whereas a
of the eyelid are important because lid/inferior limbus relationship Hughes flap is a better treatment
subtle discrepancies are easily without significant laxity or tension. option for long, shallow defects.
identified at conversational distances. Tenzel flaps, also known as Hughes flaps, also called
The best donor site is excess rotational or semicircular flaps, tarsoconjunctival bridge flaps,
contralateral upper eyelid skin. are appropriate for patients with advance the tarsal plate and
However posterior auricular and moderate bilamellar defects, little conjunctiva from the ipsilateral
supraclavicular skin have excellent eyelid laxity, and normal lid snap upper eyelid to repair the defect in
color and contour similarity (2,5). back. These flaps can be used to the lower eyelid (10,11). This flap
Full thickness lower eyelid repair up to 50% defects with delivers a vascularized posterior
defects compromising both some authors reporting modified lamellae and is inset after 7-14
lamellae can be categorized by the
percentage of lid length affected. Figure 4.
These categories are <25%, 25%- 59 year old man with a short, deep 25% defect and little lid laxity (left). Schematic of
50%, and >50% defect (6). Defect a Tenzel flap combined with a periosteal flap for lateral canthal reconstruction (center
categorization aides in selecting left) with a postoperative photo (center right). Follow up picture at 6 weeks (right).
the best reconstructive technique.
A longitudinal scar will produce
a longitudinal force vector than can
contribute to ectropion of the lower
eyelid. To prevent this phenomenon,
the incision should be pentagonal
shaped and directed laterally (2).
September/October 2009 | Vol. 105 21

4. Scientific Article |
Figure 5.
55 year old woman with a long, shallow 75% defect (left), and a schematic showing
harvest of a Hughes flap (center left). Intraoperative photograph showing the inset
of the Hughes flap to repair the posterior lamella (center right) and postoperative Figure 6.
photograph after a FTSG to repair the anterior lamella (right). Intraoperative photographs showing a
Tripier flap design (left) and inset into an
anterior lamella defect (right).
days (12-13). Little donor morbidity In 1889 Tripier developed a and challenging reconstructive cases.
occurs if 3-4mm of superior tarsal bipedicled myocuntaneous flap Understanding lower eyelid anatomy
plate remains in the upper lid. To based on the orbicularis oculi and mechanics is essential to prevent
reconstruct the anterior lamella, a muscle (17). The flap is raised from complication. The ultimate goal of
semicircular flap or a FTSG can be the upper eyelid and transferred to lower eyelid reconstruction is to
used (13-15). Please see Figure 5. the lower eyelid while the defect restore the lid/limbus relationship
Defects greater than 50% require is closed primarily. This flap is while maintaining proper tension
separate reconstructive approaches an excellent choice to reconstruct and canthal tilt of the eyelid. Multiple
for both lamellae. Components of this the anterior lamella but must be flaps and grafts may be used in
bilamellar reconstructive approach used with a posterior lamella combination to achieve surgical
graft. Please see Figure 6. goals. Our algorithm categorizes
are determined by the vascularity
Commonly used posterior defects and guides in selecting
of the individual layers. Both
lamella grafts include hard palate, the best reconstructive option.
lamellae cannot be simultaneously
auricular cartilage, and acellular
repaired using grafts because
dermis. Hard palate grafts produce References
they will die due to lack of blood
the best aesthetic results with the 1. Nahai, F. The Art of Aesthetic Surgery:
supply (2). For example, a Hughes fewest complications (18). However, Principles and Techniques. Vol. 1. Chapter
flap can be used to reconstruct techniques using acellular dermal
19: Applied Anatomy of the Eyelids and
Orbit (Codner, MA, Hanna, MK). Quality
the posterior lamella with a FTSG matrix spacers (Enduragen) are Medical Publishing, Inc., St. Louis,
graft to repair the anterior lamella. rapidly improving and some authors Missouri. 2005. p. 625-650.
If a Tripier or a Mustarde flap is report aesthetic and functional results
2. Chandler DB, Gausas RE. Lower eyelid
reconstruction. Otolaryngol Clin North Am.
used to repair the anterior lamella similar to hard palate grafts (19-20). 2005 Oct;38(5):1033-42.
then a tissue graft can be used to Additionally, using acellular dermis 3. Nahai, F. The Art of Aesthetic Surgery:
reconstruct the posterior lamella. precludes the need for another Principles and Techniques. Vol. 1. Chapter
21: Upper and Lower Blepharoplasty
However, using an orbicularis surgical site (20). Please see Figure 7. (Codner, MA, Hanna, MK). Quality Medical
advancement flap to provide blood Publishing, Inc., St. Louis, Missouri. 2005.
supply, one can simultaneous Conclusion 4.
p. 679-718.
Nahai, F. The Art of Aesthetic Surgery:
reconstruct the anterior and Lower eyelid defects following Principles and Techniques. Vol. 1. Chapter
posterior lamellae using grafts (16). Mohs surgery can be complicated 20: Clinical Decision-Making in Aesthetic
Eyelid Surgery. Quality Medical Publishing,
Inc., St. Louis, Missouri. 2005. p. 651-678.
Figure 7. 5. Khan JA. Sub-cilial sliding skin-muscle flap
repair of anterior lamella lower eyelid
Intraoperative photographs showing potential graft harvest sites useful in eyelid defects. J Dermatol Surg Oncol. 1991
reconstruction. Hard palate (left), buccal mucosa (center left), auricular cartilage Feb;17(2):167-70.
(center right), and an acellular dermal matrix (Enduragen) spacer (right). 6. Gündüz K, Demirel S, Günalp I, Polat B.
Surgical approaches used in the
reconstruction of the eyelids after excision
of malignant tumors. Ann Ophthalmol
(Skokie). 2006 .
7. Levine MR, Buckman G. Semicircular flap
revisited. Arch Ophthalmol. 1986
Jun;104(6):915-7.
Please consult authors for additional references.
22 West Virginia Medical Journal

5. | Scientific Article
Figure 8.
Lower eyelid reconstruction algorithm which accounts for defect size, lower lid characteristics, and bilamellar reconstructive options.
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