Eyelid Reconstruction from Cancer

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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.

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Eyelid Reconstruction from Cancer

  1. 1. | Scientific ArticleLower Eyelid Reconstruction Following Mohs SurgeryMatthew 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 eyeW.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 palpebralAbstract algorithm that integrates lamellar conjunctiva. The tarsal plate consists Lower eyelid defects resulting from defects with surgical treatments. of dense, fibrous tissue that providesMohs micrographic surgery can be structural support to the eyelidchallenging to repair. These repairs are Anatomy of the Lower Eyelid and houses the meibomian glandsfraught with potential complication due to The lower eyelid’s anatomy is which secrete the sebaceous portionthe lower eyelid’s complex anatomy and complex and must be carefully of the tear film. Behind the tarsaldefect 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 contactsclosure techniques include primary complications such as entropion, the conjunctiva of the globe.closure, eyelid advancement, rotational ectropion, canthal distortion, or The tarsoligamentous slingflaps, full thickness skin grafts, and/or altered closure mechanisms. consists of the tarsal plates andallografts. We present a discussion oflower eyelid reconstruction including The lower eyelid consists of two the canthal tendons. The slingrelevant anatomy, physical signs, and lamellae separated by the orbital supports the globe in the orbittreatment 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 retinaculumconsideration of the anatomy. A also aides in realigning the lower lid is not fully anchored to increasethorough physical exam is required when repairing defects. The lower the lateral visual field. The medialto properly identify, categorize, lid should oppose the globe at the canthus remains firmly anchored toand implement the appropriate inferior limbus. Please see Figure 1 the frontal process of the maxilla. Thisreconstructive treatment in order for a diagram of the eyelid lamellae. anatomical discrepancy predisposesto minimize complications. Mohs Skin and the orbicularis oculi the lateral canthus to develop laxitysurgery is the optimal technique to muscle comprise the anterior lamella. and phimosis with age (1). This senileremove basal and squamous cell The skin is very thin (less than laxity must be accounted for whencarcinomas 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 byunnecessary 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 towardthese 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 thethorough examination of the patient’sdefect, eyelid characteristics, and a Figure 1. Schematic diagrams of the bilamellar system of the lower eyelid (left) and thephysical exam, the optimal treatment tarsoligamentous sling (right).is selected. Common treatmentavenues are based on defect sizeand include primary closure, Tenzel,Hughes, or Tripier flaps. These canbe combined with full thickness skingrafts (FTSG), human allografts,or cartilage grafts. A canthoplastywith a periosteal flap or a fascia latagraft to correct lateral retinacular September/October 2009 | Vol. 105 19
  2. 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 I’m Dr. John Eastone and I choose HIMG because I wanted to work alongside some of the best physicians and health care providers in the area. At HIMG, we are a collection of talented and experienced individuals working together to deliver the absolute best in quality patient care. We like to say “I’m HIMG” because every member of our team is proud to carry the strong reputation of our operation in all that we do. We’d like you to consider becoming part of our team. Headquartered in Huntington, West Virginia, HIMG is the largest privately held multi-specialty group in the state. Our 150,000 square-foot facility and our business practices have been a model for many operations throughout the nation. We are currently recruiting physicians and mid- level providers in many areas and encourage you to contact us for a confidential review of the opportunities available. TM www.himgwv.com 5170 U.S. Route 60 East Huntington, WV 25705 (304) 528-4657 20 West Virginia Medical Journal
  3. 3. | Scientific Articlebe 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 defectretinacular dehiscence and loss and proposed incision in green (left), pentagonal incision (center), and scar directedof intrinsic elastic properties. laterally (right). Globe prominence is measuredwith a Hertel exophthalamometerwhich quantifies the distancefrom the cornea to the orbital rim.More prominent eyes requiremore canthal support (4). The location and patency of thelacrimal duct system should beverified with medial wounds. Priorto Mohs or reconstructive surgerysplinting 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 canthusSurgical 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 canthotomydefects involving the anterior lamella reliably treated with primary closure is performed and the eyelid andcan be treated conservatively with or a Tenzel flap. The key determinant flap is advanced to directly close thedressing changes and healing by is the patient’s lid laxity. If a patient defect (8,9). A canthoplasty mustsecondary intention. These methods has significant lid laxity (>6mm with be performed to reset the lateralare very successful in the medial anterior traction) or a slow lid snap canthus using a periosteal flap or acanthal 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 maydefects that contact the globe. flaps such as the Tenzel are better be repaired with a Tenzel flap orFTSGs are an excellent choice for used in patients with less laxity. a Hughes flap (6). Tenzel flapssubmarginal defects lateral to the Ultimately, the goal is to align the yield better results when appliedpuncta (2). The color and contour grey line and restore the lower to short, deep defects whereas aof the eyelid are important because lid/inferior limbus relationship Hughes flap is a better treatmentsubtle 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 calledThe 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 andHowever posterior auricular and moderate bilamellar defects, little conjunctiva from the ipsilateralsupraclavicular skin have excellent eyelid laxity, and normal lid snap upper eyelid to repair the defect incolor 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 posteriordefects compromising both some authors reporting modified lamellae and is inset after 7-14lamellae can be categorized by thepercentage 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 of50%, and >50% defect (6). Defect a Tenzel flap combined with a periosteal flap for lateral canthal reconstruction (centercategorization 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 producea longitudinal force vector than cancontribute to ectropion of the lowereyelid. To prevent this phenomenon,the incision should be pentagonalshaped and directed laterally (2). September/October 2009 | Vol. 105 21
  4. 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. 5. | Scientific ArticleFigure 8.Lower eyelid reconstruction algorithm which accounts for defect size, lower lid characteristics, and bilamellar reconstructive options. Drug or Alcohol Problem? Mental Illness? If you have a drug or alcohol problem, or are suffering from a mental illness you can get help by contacting the West Virginia Medical Professionals Health Program. Information about a practitioner’s participation in the program is confidential. Practitioners entering the program as self-referrals without a complaint filed against them are not reported to their licensing board. ALL CALLS ARE CONFIDENTIAL West Virginia Medical Professionals Health Program PO Box 40027 Charleston, WV 25364 (304) 414-0400 | www.wvmphp.org September/October 2009 | Vol. 105 23

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