Lower eyelid reconstruction aims to re-establish a functional eyelid with adequate protection of the eyeball and reasonable cosmesis. Direct closure can be used for up to 30-40% defects in younger patients with eyelid laxity. The Hughes procedure uses a tarso-conjunctival flap to reconstruct large posterior lamella defects but requires a second stage for anterior lamella coverage. The Tenzel slide uses a semicircular musculocutaneous flap to reconstruct large anterior lamella defects but requires posterior lamella coverage. Free tarsal grafts can be used to replace the posterior lamella while the anterior lamella is covered with a myocutaneous advancement flap.

1. Lower Eyelid Reconstruction
Dr. Suiyibangbe
M.Ch. 2nd year.
Plastic and reconstructive Surgery

2. Anatomy
Eyelid is traditionally described as a bilaminar
structure.
Anterior lamella-skin and orbicularis muscle.
Posterior lamella-tarsal plate, medial and
lateral canthal tendons, capsulapalpebral
fascia, lid retractors and conjunctiva.

3. Lower Lid Anatomy

5. Skin
Thinnest in the body, measuring about 0.3mm
in some areas.
Surgical incisions within the skin of the eyelid
generally heal with almost imperceptible
scarring.

6. Orbicularis oculi muscles
They lie behind the skin.
Encircles the periorbital region.
Originated from the medial canthus and the bone
of medial orbit and inserted at the lateral canthus
and lateral orbital rim.
Divided into palpebral & orbital regions
Palpebral region subdivided into pretarsal &
preseptal parts.
Responsible for lid closure

7. Orbital Septum
Fascial membrane which separates the eyelid
structures from the deep orbital structures
– Underlies posterior orbicularis fascia
– Defines anterior extent of orbit and posterior
extent of eyelid
Barrier that helps prevent the spread of
hemorrhages, infection, inflammation.

8. Orbital Septum
 Upper lid: OS inserts
into the levator
aponeurosis 2-5mm
above the superior
portion of the tarsus.
 Lower lid: OS inserts
into the lower edge
of the tarsus

9. Tarsal plate
Thin elongated plates of connective tissue
Contribute to form and support the eyelids
Closely related to the LPS, medial, lateral canthal
structures
Superior tarsus 8-10mm tapering to the sides.
Inferior tarsus 4 mm
The tarsal plate are attached by the medial and
lateral canthal ligament
The meibomian glands are approximately 20 in
each lid within the substance opening in a row of
tiny dots corresponding to the Grey line –
mucocutaneous junction

10.  Capsulopalpebr
al fascia is a
condensation of
fibroelastic
tissue anterior
to lockwood’s
ligament, which
joins with the
inferior tarsus.
 They serves as a
lower lid
retractor.

11. Conjunctiva
• Mucosal layer adjacent to the surface of the
eye.
• Palpebral portion lines inner surface of eyelid.
• Bulbar portion lines sclera

12. Canthal tendons

13. Lacrimal System

14. Blood supply

15. Nerve supply
Upper eyelid- lacrimal, supraorbital,
supratrochlear, infratrochlear nerve.
Lower eyelid- infraorbital and infratrochlear
nerve

16. Lymphatic drainage
Medial halves of the eyelid drain into the
submandibular nodes.
Lateral halves into the pre-auricular nodes

17. Indication
Trauma/burns
Congenital
Tumour

18. Aims
To re-establish functional eyelid
Adequate protection of the eyeball
Reasonable cosmesis

19. Requirements
Smooth mucous membrane internal lining to
maintain lubrication of the ocular surface and
avoid corneal irritation.
Skeletal support to provide adequate lid
rigidity and shape.
Proper fixation of the medial & lateral canthal
attachments of the lids for eyelid stability &
orientation.

20. In the reconstruction of both anterior &
posterior lamellae, at least one must have its
own blood supply
Techniques would depend on the size,
location, configuration, & depth of the defect
Superficial defect: only anterior lamella needs
to be repaired
Full thickness defect: needs reconstruction of
both layers

23. Lower Eyelid Reconstruction
• Direct Closure
• Lateral Cantholysis/canthotomy
• Hughes Procedure
• Tenzel Rotation Flap
• Tripier flap
• Free Tarsal Grafts
• Mustarde (rotation cheek) Flap
• Temporal forehead flap (Fricke)

24. Direct Closure
• 30% defects in young patients
• Up to 40% in older patients with more eyelid
laxity
• Lateral cantholysis provides additional 5 mm
• Tarsal defect should be squared
• Temporal slant to musculocutaneous layer

25. Lateral Cantholysis
• Split upper and
lower canthal
tendons
• Detach lower limb
(upper limb)
• Angle skin incision
superiorly
• Anchor muscle layer
to periosteum after
closure of defect

26. Hughes (TarsoConjunctival Flap)

27. Hughes
Flap
• Large, shallow
posterior lamella
defects of the
entire lid
• Vertical upper lid
to lower lid
sharing
• Anterior lamella
reconstruction
– Advancement
musculocutaneo
us flap
– Free skin graft
• Requires 2nd
stage procedure

28. Advantages
• Reconstruction of large
posterior lamella defects
• Composite flap (tarsus and
conjunctiva)
• Requires anterior lamella
coverage.
• Two stage procedure.
Disadvantages

29. Tenzel Slide
• Semicircular
musculocutaneous flap
• Flap must arch upward
• Fixation of muscle to
periosteum superior to
• canthal attachment avoids
droop of lid
• Additional support of
lateral lid can be
• achieved with periosteal
strip from lateral orbital
rim

30. Advantages
 Reconstruction of large
anterior lamella defects
Disadvantages
 No lash restoration.
 Requires posterior lamella
coverage.

31. Tripier Flap
• Anterior lamella defects
up to 100% of lower lid.
• Medially, Laterally or
Bipedicle.
• Thin donor skin.
• Two stage.
• Requires posterior
lamella coverage

32. Free Tarsal
Graft
• Free
tarsocunjunctiva
l flap
• Harvested from
ipsilateral or
contralateral lid
• Posterior
lamellar
replacement
• Cover with
myocutaneous
advancement

33. Mustarde Rotation Cheek Flap
• Good for very large defects
• Advantage – single stage procedure
• Preferable for patients with:
– Monocular vision
– Children with amblyopia
– Active corneal disease
– Glaucoma
• Disadvantages – lacks orbicularis, sagging, thick
donor skin, lower lid malposition, posterior
lamella coverage.

35. Fricke flap (Temporal)
Advantages
• Large anterior lamella
reconstruction.
Disadvantages
• Two stages procedure
• Donor skin very thick
• Risk of frontal branch
lesion

36. Temporal Forehead Flap (Fricke Flap)

37. Lateral Canthal Reconstruction

38. Lateral Canthal Reconstruction

39. Split finger flap
reconstruction of medial canthus

41. Take home message
Upto 30% of the lower lid can be closed primarily.
Lateral canthotomy or cantholysis can allow
primary closure of larger defects.
Skin only defect can frequently be reconstructed
with contralateral eyelid skin.
Conjunctival defect best reconstructed by
advancement of adjacent conjunctiva or buccal
mucosa or nasal mucosal graft.
Tarsal defects are best reconstructed by palatal
graft,conchal cartilage,nasal septal cartilage.
Prevention of tension with proper anchoring is
critical to prevention ectropion.

42. Thank you