Eyelid Reconstruction CME Article Dr. McClellan

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This is a CME article that appears in Plastic and Reconstructive Surgery, the gold standard of publications within the field. Reconstructing the eyelid can be difficult and complicated. This article discusses the various approaches to defects caused by cancer.

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Eyelid Reconstruction CME Article Dr. McClellan

  1. 1. www.PRSJournal.com288e R econstruction of the eyelids remains one of the most challenging areas in reconstruc- tive plastic surgery. Perhaps no other area of the human body provides such a delicate inter- play among anatomy, aesthetics, and function.1 In order to protect the underlying globe and vision, the eyelids require restoration of both function and appearance following eyelid repair. When presented with an eyelid defect, the surgeon should analyze the missing lamellar com- ponents and whether canthal support is com- promised. Special attention should be paid to the integrity of the lacrimal apparatus when the resection involves the medial canthal region. The reconstructive plan will be determined mainly by the size of the defect and the status of the sur- rounding periorbital tissue, particularly the oppos- ing lid if eyelid sharing is deemed necessary. Our reconstructive strategy favors a progression from direct closure, when possible, to using local flaps in combination with grafts for bilamellar recon- struction, to lid-sharing procedures. A single-stage reconstruction should be the goal without com- promising the aesthetic and functional results. This article provides a comprehensive review of eyelid anatomy and various reconstructive tech- niques in order to provide the reader with a vari- ety of options. SURGICAL ANATOMY OF THE EYELID Both the upper and lower eyelids are bilamel- lar structures, consisting of the anterior and poste- rior lamellae.2 The anterior lamella consists of skin and the underlying orbicularis oculi muscle. The eyelid skin is the thinnest in the body and transi- tions into a thicker eyebrow and cheek skin in the upper and lower eyelids, respectively. The orbicu- laris oculi muscle is loosely adherent to the skin and is divided into pretarsal, preseptal, and orbital seg- ments.3 Functionally, the medial inner canthal orbi- cularis, which is innervated by the buccal branch of the facial nerve, contributes to blinking, lower lid tone, and the pumping mechanism for the lacrimal apparatus. The extracanthal orbicularis, which is innervated by the zygomatic branches of the facial nerve, is responsible for eyelid closure, voluntary squinting, and animation.4 The pretarsal orbicularis Disclosure: Drs. Alghoul and McClellan have no commercial associations, financial interests, or con- flicts of interest. Dr. Pacella is on the speaker’s bu- reau for Lifecell Corporation. Dr. Codner receives fi- nances for research and consulting from Mentor and Syneron corporations and receives royalties for books published by Quality Medical Publishing and Else- vier. All conflicts have been reviewed and managed by accreditation volunteers. Copyright © 2013 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3182958e6b Mohammed Alghoul, M.D. Salvatore J. Pacella, M.D., M.B.A. W. Thomas McClellan, M.D. Mark A. Codner, M.D. Atlanta, Ga.; La Jolla, Calif.; and Morgantown, W.Va. Learning Objectives: After reading this article, the participant should be able to: 1. Demonstrate an anatomic approach to eyelid reconstruction. 2. Man- age common and complex eyelid defects by utilizing a reconstructive strategy outlined in the article. Summary: Reconstruction of the eyelids after excision of skin cancer can be challenging. Knowledge of surgical eyelid anatomy and appropriate preopera- tive planning are critical in order to perform eyelid reconstruction and mini- mize complications and the need for reoperation. The fundamental principle for full-thickness eyelid reconstruction is based on reconstructing the subunits of the eyelid, including the anterior and posterior lamellae as well as the tar- soligamentous sling.  (Plast. Reconstr. Surg. 132: 288e, 2013.) From private practice; the Division of Plastic and Recon- structive Surgery, Scripps Clinic and Research Institute; the Division of Plastic Surgery, West Virginia University; and Emory University. Received for publication May 16, 2012; accepted May 23, 2012. Eyelid Reconstruction Related Video content is available for this ar- ticle. The videos can be found under the “Re- lated Videos” section of the full-text article, or, for Ovid users, using the URL citations pub- lished in the article. CME
  2. 2. Volume 132, Number 2 • Eyelid Reconstruction 289e muscle is densely fixed to the anterior surface of the tarsus in both the upper and lower eyelids. The tarsal plate and conjunctiva form the pos- terior lamella. The tarsal plate is a unique compo- nent of the eyelid that provides structural support and should be replaced during reconstruction. It measures 1 mm in thickness and 25 mm horizon- tally by approximately 7 to 10 mm vertically in the upper eyelid and 3.8 mm in the lower eyelid.5 The lower lid inserts medially and laterally to the canthi, creating the tarsoligamentous sling. In the authors’ opinion, the tarsoligamentous sling is one of the most critical structures to reconstruct, representing the support structure of the lower eyelid (Fig. 1). The posterior reflection of the lateral canthal liga- ment inserts on Whitnall’s tubercle, which is found posterior to the lateral orbital rim.6 This posterior vector allows the eyelid to follow the convex curve of the globe. Disruption of the lateral lid and globe interface can lead to widening of the lateral scleral triangle, reactive conjunctival irritation, and lid malposition. The medial canthal ligament attaches to the anterior and posterior lacrimal crest. Disrup- tion of its attachments can lead to medial ectro- pion, epiphora, or telecanthus.7 The conjunctiva is composed of nonkeratinizing, stratified squamous epithelium and forms the posterior-most layer of the eyelid.3 The upper and lower eyelid retractor muscles are located immediately anterior to the conjunctiva. Of importance in upper eyelid recon- struction, the levator aponeurosis inserts on the anterior superior surface of the upper eyelid tarsus and sends fibers through the preseptal orbicularis to insert onto the dermis and form the upper eye- lid crease, 8 to 9 mm from the margin.3,5 The ophthalmic artery provides the majority of blood supply to the upper and lower eyelids, with contribution from the external carotid artery. Distal branches of the medial and lateral palpe- bral arteries (the latter are branches of the lac- rimal artery) coalesce to form the tarsal arcades. The upper lid has two arterial arcades; the mar- ginal arcade is located on the anterior tarsal sur- face 2 to 3 mm from the eyelid margin, while the peripheral arcade is on the upper border of the tarsus between Mueller’s muscle and the levator aponeurosis.3,5 Inferiorly, the marginal arcade (also called the inferior arcade) is located 3.8 mm inferior to the lower eyelid margin anterior to the tarsus. The lower eyelid does not have a periph- eral arcade3 (Fig. 2). The excretory component of the lacrimal system is located in the medial can- thal region. The puncta are the openings of the lacrimal drainage system and are located 6 mm from the inner canthus on the upper and lower eyelids. Tears pass through the puncta and drain into the vertically oriented ampulla, to the upper and lower canaliculi (oriented horizontally). Both canaliculi extend nasally and join to form a com- mon canaliculus in more than 90 percent of peo- ple, which connects with the lacrimal sac located in the lacrimal fossa. The lacrimal sac empties into the nasolacrimal duct, which opens endona- sally underneath the inferior turbinate8 (Fig. 3). PHYSICAL EXAMINATION AND SURGICAL PLANNING A thorough preoperative history and physi- cal examination are critical to a successful Fig. 1. The tarsoligamentous sling. Reprinted with permission from McCord CD Jr, Codner MA. Eyelid & Periorbital Surgery. St. Louis: Quality Medical Publishing; 2008.
  3. 3. 290e Plastic and Reconstructive Surgery • August 2013 reconstructive outcome. Preoperative history should include a discussion of any ophthalmic medication, visual acuity, dry eyes, Bell’s palsy, thyroid eye disease, and other ocular pathology. History of prior facial radiation and prior peri- orbital surgery should be obtained. A margin- controlled excision should be the goal to ensure adequate excision prior to a complex reconstruc- tion.9 Analysis of the defect should address the bilamellar structure of the eyelid, the tarsoliga- mentous sling, and the lacrimal drainage system. The surrounding periorbital tissue should be evaluated for vascularity, scarring, radiation dam- age, severe actinic damage, and overall laxity. Traumatic defects must be carefully assessed for peripheral zone of injury. Lower eyelid avul- sions can often create axial stretch injury on the canalicular mechanism, making intubation or cannulation extremely challenging. These injuries often require secondary lacrimal recon- struction. The size of the defect is estimated by gently approximating the edges with two forceps (Fig. 4). Full-thickness lower eyelid defects com- promising both lamellae can be categorized by the percentage of lid length affected. Although commonly published categories of eyelid defects range from less than 25 percent, 25 to 50 per- cent, and greater than 50 percent of the lid,10 this should be determined on individualized bases before a reconstructive technique is selected. Fig. 2. Arterial anatomy of the eyelid and periorbital area. Reprinted with permission from McCord CD Jr, Codner MA. Eyelid & Periorbital Surgery. St. Louis: Quality Medical Publishing; 2008. Fig. 3. Anatomy of the lacrimal apparatus. Reprinted with per- mission from McCord CD Jr, Codner MA. Eyelid & Periorbital Sur- gery. St. Louis: Quality Medical Publishing; 2008. Fig. 4. Eyelid wound edges are gently approximated with for- ceps to accurately estimate the size of the defect.
  4. 4. Volume 132, Number 2 • Eyelid Reconstruction 291e GRAFTS IN EYELID RECONSTRUCTION As a basic principle in plastic surgery, grafts should be used when there is an adequate vas- cular bed to enhance their survival. Therefore, combining a nonvascularized graft for one lamella with a vascularized flap for the other should be the rule. Both bilamellar reconstruc- tions can be done with grafts if orbicularis mobili- zation between the grafted areas (sandwich flap) can be achieved.11 The orbicularis muscle has an excellent blood supply and enhances the mobil- ity of the reconstructed lid.12,13 Anterior lamellar defects can be reconstructed with a full-thickness skin graft.14 Ideal donor sites include excess upper and lower eyelid skin and posterior auricu- lar, preauricular, or supraclavicular skin.11,15 Split- thickness skin grafts should not be used except in situations of extensive burns when the donor site is limited. Tarsoconjunctival grafts are an excel- lent choice for posterior lamellar reconstruction, since they possess the features of a normal eyelid (Therapeutic: Level III Evidence).16–20 They are harvested from the upper eyelid, leaving at least 3 to 4 mm of inferior tarsus to avoid upper lid deformity. The donor site heals spontaneously by secondary intention. Excellent results have been reported using tarsoconjunctival grafts for repairing defects of up to 75 percent of the eyelid length (Therapeutic: Level III Evidence).20 Over- sizing the graft should be avoided to prevent lax- ity, especially in lower lid reconstruction. Leaving a 2-mm conjunctival edge on the superior bor- der of the graft is useful in forming the margin of the reconstructed lid (Therapeutic: Level III Evidence).20 Hard-palate mucoperiosteal grafts can be used to replace the posterior lamella due to their ability to provide structural support and mucosal lining. They have been shown to pro- duce reliable results; however, donor-site mor- bidity can be problematic.21 Their use in upper Fig. 5. (Left) Upper eyelid defect with perpendicular markings on either side for planned vertical trimming of the tarsal plate prior to closure. The dog-ear is excised horizontally along the upper lid crease. (Right) Direct lid closure is illustrated with a gray line-suture to line up the edges and interrupted partial-thickness tarsal plate sutures. Reprinted with permission from McCord CD Jr, Codner MA. Eyelid & Periorbital Surgery. St. Louis: Quality Medical Publishing; 2008. Fig. 6. Direct closure of lower eyelid defect. (Left) A shallow full-thickness defect involving 15 percent of the lower eyelid. (Center) Direct closure of the defect directed laterally in the skin tension line. (Right) Immediate intraoperative result after closure.
  5. 5. 292e Plastic and Reconstructive Surgery • August 2013 eyelid reconstruction is controversial due to the fact that hard-palate mucosa is composed of keratinized, stratified squamous epithelium, which can irritate the cornea. Despite this, excel- lent results were reported for its use in upper eyelid posterior lamellar reconstruction, without complications.22,23 Other posterior lamellar graft options include nasal chondromucosa and auric- ular cartilage. The cartilage can be crosshatched if necessary to conform to the eyelid shape. Buc- cal mucosa is a good lining option; however, it lacks structural integrity and should be used in combination with cartilage. Finally, a tarsomar- ginal graft (composite eyelid graft) is composed of tarsus, conjunctiva, and the lid margin includ- ing the eyelashes. It can be used to reconstruct shallow defects (mainly of the upper lid). It is harvested as a full-thickness wedge from either the upper or lower eyelid and before insetting; the anterior lamella skin and muscle are excised, leaving only the margin with the eyelashes. The graft is usually 7 to 8 mm wide, and sequential grafts can be used for bigger defects. The ante- rior lamella is usually covered with a myocuta- neous flap. Survival of the eyelashes, however, is unpredictable, despite survival of the graft.11,25,26 DIRECT CLOSURE OF AN EYELID DEFECT Upper eyelid defects that are up to 20 percent of the lid in young patients and up to 30 percent in older patients can be repaired with direct clo- sure.24 When combined with cantholysis, defects of up to 50 percent of the upper lid can often be closed directly in the elderly. Excessive tension should be avoided because it can lead to postop- erative mechanical ptosis, which tends to improve in elderly patients.25 Smaller lower eyelid defects can be closed directly to avoid postoperative lid malposition and ectropion, which can result from excessive tension.11,26 The tarsal edges should be Fig. 7. (Left) An upper eyelid anterior lamellar defect involving the skin and orbicularis oculi muscle. (Center) The defect is recon- structed with a V-Y advancement orbicularis-skin flap. (Right) Postoperative view of the upper eyelid 6 weeks later. Video 1. Supplemental Digital Content 1, demonstrating lower lid reconstruction with a Tenzel semicircular flap and a periosteal flap, is available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/ A774.)
  6. 6. Volume 132, Number 2 • Eyelid Reconstruction 293e trimmed in a perpendicular fashion to the lid margin to facilitate approximation and to prevent postoperative tarsal buckling and upper lid con- tour deformity. A precise gray line 7-0 silk suture is placed to assess the amount of tension and line up the edges. When satisfactory alignment is achieved, the tarsal edges are approximated using interrupted 6-0 Vicryl sutures, making sure not to go through the conjunctiva (Fig. 5). Finally, the skin/muscle layer is closed with interrupted 7-0 silk sutures. Any excess skin superiorly forming a dog- ear is trimmed and closed horizontally along the upper lid crease. The same steps are followed for the lower eyelid, except that the incision should be directed laterally in the skin tension line (Fig. 6).26 (See Video, Supplemental Digital Content 1, which demonstrates lower lid reconstruction with a Tenzel semicircular flap and a periosteal flap, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A774.) LOCAL FLAPS The use of orbicularis myocutaneous flaps in their various designs (advancement, V-Y, rotational) has a better aesthetic result compared with full- thickness skin grafts for anterior lamellar recon- struction27 (Fig. 7). They can also be combined with posterior lamellar grafts and flaps for full- thickness reconstruction. For medium upper and lower eyelid defects ranging from 40 to 60 percent of the lid, the Tenzel semicircular flap is preferred as a workhorse flap.28,29 The flap is dis- sected in a suborbicularis plane, beginning at the lateral canthus and then extending superiorly or inferiorly in a semicircular pattern with a gentle slope. A lateral canthotomy is performed, fol- lowed by upper or lower cantholysis (depending on the eyelid being reconstructed), and the eyelid and flap are advanced medially to directly close the defect28,29 (Fig. 8). (See Video, Supplemental Digital Content 1, which demonstrates lower lid reconstruction with a Tenzel semicircular flap and a periosteal flap, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/ A774.) Closure is performed using the same prin- ciples mentioned above. A 4-0 Vicryl suture can be used between the cut edge of the Tenzel flap and the periosteum of the lateral canthus to recreate the lateral canthal angle. When this flap is used to repair a medial defect, a lateral tarsoligamen- tous reconstruction in the form of a lateral orbital rim periosteal flap or ear cartilage may be needed (Fig. 9). The McGregor flap has a similar concept to the Tenzel flap, but instead of a semicircle, Fig. 9. An illustration showing a Tenzel semicircular flap com- bined with a periosteal flap for both posterior lamellar recon- struction and lateral canthal support. Reprinted with permission from McCord CD Jr, Codner MA. Eyelid & Periorbital Surgery. St. Louis: Quality Medical Publishing; 2008. Fig. 8. (Left) A full-thickness shallow defect involving 40 percent of the lower eyelid. (Center) The defect is reconstructed with a Tenzel semicircular flap. (Right) Postoperative view of the lower eyelid 6 weeks later.
  7. 7. 294e Plastic and Reconstructive Surgery • August 2013 the flap extends directly posteriorly after an ini- tial slope, which makes it more of a transposition advancement flap.30 A Z-plasty is added laterally to reduce the tension and improve the scar appear- ance (Fig. 10). This flap is usually used for large V-shaped defects of the lower eyelid. Other local periorbital flaps used for anterior lamellar recon- struction include Blasius (Fig. 11), Imre (Fig. 12), Fricke (temporal forehead flap) (Fig. 13), and Tripier flaps (Fig. 14). (See Video, Supplemental Digital Content 2, which demonstrates total lower lid and medial canthus reconstruction with a tar- soconjunctival flap, a Tripier orbicularis myocuta- neous flap, and a rhomboid flap, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links. lww.com/PRS/A775.) TheMustardéflapcanbeusedforlargeanterior lamellar defects and total lower eyelid reconstruc- tion. This flap is a good option for reconstruction of deep vertical defects and complete lower lid cov- erage in a single procedure.31 A semicircular sub- orbicularis flap is developed at the lateral canthus and then extended laterally to the preauricular sulcus and elevated in a sub–superficial musculo- aponeurotic system or subcutaneous plane. The posterior lamella must be reconstructed separately with a graft, such as a tarsoconjunctival graft, ear cartilage, or acellular dermal matrix, followed by lateral periosteal fixation and medial advance- ment to close the defect (Fig. 15). It is the authors’ Fig. 10. (Left) Intraoperative view of McGregor’s transposition advancement flap with Z-plasty to reconstruct a deep V-shaped lower eyelid defect. (Right) Postoperative view 6 weeks later. Fig. 11. An illustration of the Blasius flap used for lower lid reconstruction. (Left) Preoperative design of a vertically oriented skin muscle flap with the base at the medial canthus. (Right) The skin-muscle flap is transposed superiorly and com- bined with a posterior lamellar graft for full-thickness lower eyelid reconstruction. Reprinted with permission from McCord CD Jr, Codner MA. Eyelid & Periorbital Sur- gery. St. Louis: Quality Medical Publishing; 2008.
  8. 8. Volume 132, Number 2 • Eyelid Reconstruction 295e preference, however, to use the Mustardé flap for reconstructing the cheek component of the defect and combine it with another flap (Tripier flap, for example) to reconstruct the lower lid component to preserve the aesthetic units. LID-SHARING PROCEDURES With the exception of the transposition tar- soconjunctival flap (Hewes flap), all lid-sharing procedures are two-stage procedures that are mainly used to reconstruct large, full-thickness eyelid defects (>60 percent). The Hughes tarso- conjunctival flap advances the tarsal plate and conjunctiva from the ipsilateral upper eyelid to repair a defect in the lower eyelid as a two-stage approach.32,33 This flap delivers vascularized poste- rior lamellae and is divided after 14 days.32 Little donor morbidity occurs if 3 to 4 mm of superior tarsal plate remains in the upper lid. To recon- struct the anterior lamella, a semicircular flap, vertical skin-muscle advancement, or full-thick- ness skin graft can be used (Therapeutic: Level IV Evidence).34 (See Video, Supplemental Digital Content 3, which demonstrates lower lid poste- rior lamellar reconstruction with a Hughes tar- soconjunctival advancement flap, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links. lww.com/PRS/A776.) A Cutler-Beard flap, on the other hand, advances a full-thickness flap (exclud- ing the tarsus) from the ipsilateral lower eyelid to repair a defect in the upper eyelid, also in a two- stage approach.35,36 When designing the flap, it is critical to leave at least 5 mm of full-thickness lower lid margin to maintain blood supply to the remaining bridge through the inferior arcade. A graft of ear cartilage is placed between the con- junctiva and the skin/muscle layers of the flap, and is sutured superiorly to the levator aponeu- rosis and medially and laterally to the residual tar- sus of the upper eyelid. The flap is divided and inset in 2 weeks (Fig. 16). A Mustardé lid-sharing pedicle flap is used in special situations where a patient who has a wide, shallow upper eyelid defect desires to maintain a lash line. The flap is rectangular in design, 5 mm in vertical width, and is taken from the center of the lower eyelid and rotated based on the inferior medial palpebral artery. The distal cut end of the flap is inset by Fig. 12. An illustration of the Imre flap used for lower lid reconstruction. (Left) Preoperative design of a rotational skin-muscle flap based laterally and inferiorly. A Burow's triangle is cut to eliminate the dog-ear. (Right) The final postoperative appearance. Reprinted with permission from McCord CD Jr, Codner MA. Eyelid & Periorbital Surgery. St. Louis: Quality Medical Publishing; 2008. Fig. 13. An illustration of the Fricke temporal forehead flap. Reprinted with permission from McCord CD Jr, Codner MA. Eyelid & Periorbital Surgery. St. Louis: Quality Medical Publishing; 2008.
  9. 9. 296e Plastic and Reconstructive Surgery • August 2013 suturing it to the medial edge of the defect. Divi- sion and inset are done in a second stage 2 weeks later.37 The Hewes transposition tarsoconjunctival flap is useful for isolated defects of the lateral can- thal area of the lower eyelid. It is harvested from the lateral aspect of the upper eyelid using the same principles of tarsoconjunctival graft/flap harvest. However, unlike the Hughes flap, which is based on blood supply from the superior fornix and advanced inferiorly, the Hewes flap is based on the peripheral arcade laterally and is trans- posed to the lateral defect of the lower eyelid in a one-stage approach38 (Fig. 17). (See Video, Sup- plemental Digital Content 2, which demonstrates total lower lid and medial canthus reconstruction with a tarsoconjunctival flap, Tripier orbicularis myocutaneous flap, and rhomboid flap, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A775.) The tarsal plate is sutured to the lower eyelid tarsus medially and secured to the lateral canthal tendon laterally. If the lateral canthal tendon is unavailable, then a periosteal flap can be utilized as discussed below. The anterior lamella is reconstructed in a manner similar to used for the Hughes flap. MEDIAL CANTHAL DEFECTS The medial canthal area poses a reconstruc- tive challenge due to the complexity of its various components. When planning reconstruction, the surgeon should determine the involvement of the following structures, from deep to superficial: (1) bone and sinus, (2) medial canthal tendon, (3) lacrimal drainage apparatus, and (4) soft tissue, Fig. 14. (Left) An intraoperative view of a right anterior lamellar defect involving 70 percent of the entire lower eyelid. (Center) The defect is reconstructed with a unipedicled Tripier flap, which is a skin-muscle transposition flap. (Right) Postoperative view of the lower lid 6 weeks later. Video 2. Supplemental Digital Content 2, demonstrating total lower lid and medial canthus reconstruction with a tarsoconjunctival flap, Tripier orbicularis myocutaneous flap, and rhomboid flap, is avail- able in the “Related Videos” section of the full-text article on PRS- Journal.com or, for Ovid users, at http://links.lww.com/PRS/A775.)
  10. 10. Volume 132, Number 2 • Eyelid Reconstruction 297e including the bilamellar medial eyelid. Exposed sinuses should be obliterated with pericranial flaps, especially if postoperative radiation is planned, to prevent the development of postoperative fis- tulae and infection.9 Bone grafts can be used as needed, particularly if they are deemed necessary for medial canthal support. A posterior anchor- ing point for the medial canthal tendon should be established.9,39 When the lacrimal system has been compromised following injury or cancer resec- tion, silicone tubes (e.g., Crawford tubes) may be placed to stent the ducts to prevent closure.4,9 Crawford tubes are used when either the superior or inferior canaliculi are involved but still have at least an intact portion that can be intubated. In instances where either canaliculi cannot be intu- bated or the lacrimal sac is involved, Jones tubes may be placed bypassing the lacrimal system.40 (See Video, Supplemental Digital Content 4, which demonstrates lacrimal system bypass with a Jones tube, available in the “Related Videos” sec- tion of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A777.) A sliding tarsoconjunctival flap from the upper lid is an excellent choice for posterior lamellar recon- struction of either the medial or lateral canthi, if Fig. 15. The Mustardé flap for anterior lamellar reconstruction of the lower eye- lid. (Above, left) A young patient with lower lid malposition after anterior lamel- lar reconstruction with a full-thickness skin graft. (Above, right) The skin graft is excised and the anterior lamellar defect is reconstructed with a Mustardé cheek flap mobilized with wide undermining. (Below, left) The flap is rotated into the defect. (Below, right) Postoperative results 6 weeks later.
  11. 11. 298e Plastic and Reconstructive Surgery • August 2013 adequate upper eyelid tissue is available.9 This flap can be used to reconstruct both the upper and lower lid components of the medial canthus at the same time.39 The anterior lamella can be recon- structed with a full-thickness skin graft or a variety of local flaps, including a rhomboid glabellar flap41 (Fig. 18) and a medially based upper eyelid myo- cutaneous flap (Therapeutic: Level V Evidence).42 (See Video, Supplemental Digital Content 2, which demonstrates total lower lid and medial canthus reconstruction with a tarsoconjunctival flap, Trip- ier orbicularis myocutaneous flap, and rhomboid flap, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A775.) Soft-tissue defects can also be reconstructed with a combi- nation of pericranial flaps and full-thickness skin grafts.43 Healing by spontaneous granulation is also acceptable and well established in medial can- thal reconstruction.9 Key sutures should be placed to direct the medial canthal tissue to oppose the globe during healing by secondary intention. TARSOLIGAMENTOUS SLING RECONSTRUCTION Addressing the lateral canthus is a critical step in eyelid reconstruction. Laxity in fixation will lead to a misdirection of the vectors of orbicularis pull, thereby predisposing to lagophthalmos on eyelid closure or ectropion in repose. Further- more, disruption of the lower lid/globe interface can lead to conjunctival irritation, chemosis, or canthal phimosis. Methods to address support include primary suturing to the inner lateral orbital periosteum, a drill hole fixation with can- thoplasty, or a periosteal bone flap. The technique of lateral canthal fixation is similar to that used in cosmetic blepharoplasty and has previously been described.44 It is useful in lower eyelids that possess minimal laxity with intact peri- osteal tissue of the orbital rim. Drill-hole fixation is utilized in revisional procedures where lateral periosteal tissue is diminutive.45 When directing the drill bit, it is important to direct a slight inward tilt, in an effort to optimize lateral lid/globe con- tact. A suture passer is often used to direct free suture from the inner rim to the outer rim. The periosteal bone flap is also a very reliable technique, not only for providing fixation at the lateral canthus but also for resurfacing the lat- eral posterior lamella when extended.46,47 In its design, a strip of periosteum is harvested from the external lateral orbital rim.. This flap consists of a strong layer that can be used to secure the lid to the lateral orbital rim, providing excellent appo- sition of tissue for canthal support to the globe. (See Video, Supplemental Digital Content 1, which demonstrates lower lid reconstruction with a Tenzel semicircular flap and a periosteal flap, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A774.) [See Video, Supplemental Digital Content 5, which demonstrates lower eyelid reconstruction with a periosteal flap, Tripier orbicularis myocutaneous flap, and Enduragen spacer (Tissue Science Labo- ratories, Aldershot, United Kingdom), available in the “Related Videos” section of the full-text Video 3. Supplemental Digital Content 3, demonstrating lower lid posterior lamellar reconstruction with a Hughes tarsoconjunctival advancement flap, is available in the “Related Videos”section of the full-text article on PRSJournal.com or, for Ovid users, at http://links. lww.com/PRS/A776.)
  12. 12. Volume 132, Number 2 • Eyelid Reconstruction 299e Fig. 17. (Left) Illustration showing a Hughes tarsoconjunctival flap for posterior lamellar recon- struction of a full-thickness lateral canthal defect involving both the upper and lower lids. (Right) A Hewes transposition tarsoconjunctival flap based laterally for posterior lamellar reconstruction of a full-thickness lateral lower eyelid defect. Reprinted with permission from McCord CD Jr, Codner MA. Eyelid & Periorbital Surgery. St. Louis: Quality Medical Publishing; 2008. Fig. 16. Total upper lid reconstruction with a Cutler-Beard flap. (Above, left) Full-thickness, nearly total upper eyelid defect. (Above, right) Cutler-Beard bridge flap is designed from the opposing lower eyelid. (Below, left) A full-thickness incision is made in the lower eyelid as shown, preserving at least 5 mm of full-thickness lower eyelid margin. (Below, right) The flap is advanced to the upper eyelid defect and sewn to the residual levator aponeurosis superiorly and the tarsal plate remnant medially and laterally. A forehead rhomboid flap is planned for medial canthal reconstruction.
  13. 13. 300e Plastic and Reconstructive Surgery • August 2013 article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A778.] The authors prefer the use of a permanent suture, as absorbable sutures may dehisce over time. If the tarsoligamentous sling is detached from the medial wall, the medial canthal tissue must be anchored posteriorly to the posterior reflection of the medial canthal tendon. This can be achieved by suturing it either to the stump of the posterior limb of the medial canthal tendon or to the peri- osteum (or periosteal flap) of the medial orbital wall. If there is no available periosteum, a suture anchor can be used to secure the medial canthal tissue to the posterior lacrimal crest. Other avail- able options include anchoring to a titanium miniplate and unilateral transnasal wiring. In situations where the entire posterior lamella of the upper or lower lid is absent, the retinacular attachments to the lateral and medial orbital rim must be reconstructed indepen- dently from lamellar reconstruction. This is also the case in disorders involving loss of lid tone, such as involutional or paralytic ectropion.48 Fas- cia lata and palmaris tendon grafts have been well described for the design of frontalis slings in treating congenital ptosis and can be utilized as a suspension grafts to reconstruct the tarsolig- amentous sling.49 Disadvantages include morbid- ity of the donor site, extended harvest time, and the structure of the fascia, which can fray when passed through a small, narrow opening. The palmaris longus tendon has also been described Fig. 18. (Left) An extensive full-thickness eyelid and periorbital defect involving the medial canthus along with 50 percent of the medial upper and lower eyelids and the lateral canthus. (Right) Use of a forehead flap for reconstruction of both the medial canthus and upper eyelid. Both residual lateral eyelids are advanced medially with superior and inferior semi- circular flaps. Video 4. Supplemental Digital Content 4, demonstrating lacrimal system bypass with a Jones tube, is available in the“Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A777.
  14. 14. Volume 132, Number 2 • Eyelid Reconstruction 301e for use in ptosis surgery, and the authors prefer its use for lower lid tarsoligamentous sling recon- struction.50,51 It is exceptionally easy to harvest as a full or longitudinally split graft and has mini- mal donor-site morbidity. Its narrow diameter is optimal for securing it as a loop graft around the medial canthal tendon, and it can be passed through a small drill hole for fixation in the lat- eral orbital rim. Furthermore, it is ideal for en bloc reconstruction of the Y-shaped component of the upper and lower lateral canthus.52 CONCLUSIONS Whenapproachingeyelidreconstruction,athor- ough understanding of surgical anatomy is impor- tant in planning a successful surgical approach. For the upper and lower eyelids, the anterior lamella, posterior lamella, and tarsoligamentous sling often require separate approaches for optimal functional reconstruction. The principles of when to use a graft, direct closure, a distant flap, or lid-sharing procedures are fundamentally sound. Mark A. Codner, M.D. Mark Codner Plastic Surgery 1800 Howell Mill Road, Suite 140 Atlanta, Ga. 30318 macodner@aol.com ACKNOWLEDGMENT The authors acknowledge Dr. Clinton McCord for his contribution of ideas and figures taken from the Eye- lid and Periorbital Surgery textbook. REFERENCES 1. McCord CD, Codner MA. Approach to eyelid recon- struction. In: McCord CD, Codner MA, eds. Eyelid and Periorbital Surgery. St. Louis: Quality Medical Publishing; 2008:495–508. 2. Codner MA, Hanna MK. Applied anatomy of the eyelids and orbit. In: Nahai F, eds. The Art of Aesthetic Surgery: Principles and Techniques. St. Louis: Quality Medical Publishing; 2005:625–650. 3. Amato MM, Monheit B, Shone JW. Eyelid anatomy. In: Tasman W, Jaeger EA, eds. Duane’s Anatomy. Philadelphia: Lippincott Williams & Wilkins; 2011. 4. McCord CD, Groessl SA. Lower-lid dynamics: Influence on blepharoplasty and management of lower-lid retraction. Oper Tech Plast Reconstr Surg. 1998;5:99–108. 5. McCord CD, Codner MA. Classical surgical eyelid anatomy. In: McCord CD, Codner MA, eds. Eyelid and Periorbital Surgery. St. Louis: Quality Medical Publishing; 2008:3–46. 6. Codner MA, McCord CD, Hester TR. The lateral cantho- plasty. Oper Tech Plast Reconstr Surg. 1998;5:90–98. 7. Leibsohn JM, Hahn F. Medial canthal tendon reconstruc- tion with nasal periosteum. Ophthal Plast Reconstr Surg. 1992;8:35–40. 8. Tanenbaum M, McCord CD. Lacrimal drainage system. In: Tasman W, Jaeger EA, eds. Duane’s Anatomy. Philadelphia: Lippincott Williams & Wilkins; 2011. 9. Madge SN, Malhotra R, Thaller VT, et al. A systematic approach to the oculoplastic reconstruction of the eyelid medial canthal region after cancer excision. Int Ophthalmol Clin. 2009;49:173–194. 10. 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;38:207–212. 11. Kakizaki H, Madge SN, Mannor G, Selva D, Malhotra R. Oculoplastic surgery for lower eyelid reconstruction after periocular cutaneous carcinoma. Int Ophthalmol Clin. 2009;49:143–155. 12. Doxanas MT. Orbicularis muscle mobilization in eyelid reconstruction. Arch Ophthalmol. 1986;104:910–914. 13. Sa HS, Woo KI, Kim YD. Reverse modified Hughes proce- dure for upper eyelid reconstruction. Ophthal Plast Reconstr Surg. 2010;26:155–160. 14. Shorr N, Goldberg RA, McCann JD, Hoenig JA, Li TG. Upper eyelid skin grafting: An effective treatment for lag- ophthalmos following blepharoplasty. Plast Reconstr Surg. 2003;112:1444–1448. 15. Khan JA. Sub-cilial sliding skin-muscle flap repair of ante- rior lamella lower eyelid defects. J Dermatol Surg Oncol. 1991;17:167–170. 16. Leone CR Jr, Hand SI Jr. Reconstruction of the medial eye- lid. Am J Ophthalmol. 1979;87:797–801. 17. Beyer CK, Bathrick ME. One-stage lower eyelid reconstruc- tion. Ophthalmic Surg. 1982;13:551–554. 18. Stephenson CM, Brown BZ. The use of tarsus as a free autog- enous graft in eyelid surgery. Ophthal Plast Reconstr Surg. 1985;1:43–50. 19. Hawes MJ. Free autogenous grafts in eyelid tarsoconjunctival reconstruction. Ophthalmic Surg. 1987;18:37–41. 20. Hawes MJ, Grove AS Jr, Hink EM. Comparison of free tar- soconjunctival grafts and Hughes tarsoconjunctival grafts for lower eyelid reconstruction. Ophthal Plast Reconstr Surg. 2011;27:219–223. 21. Li TG, Shorr N, Goldberg RA. Comparison of the efficacy of hard palate grafts with acellular human dermis grafts in Video 5. Supplemental Digital Content 5, demonstrating lower eyelid reconstruction with a periosteal flap, Tripier orbicularis myocutaneous flap, and Enduragen spacer, is available in the “Related Videos” section of the full-text article on PRSJournal. com or, for Ovid users, at http://links.lww.com/PRS/A778.
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