Eyelid Reconstruction

Abstract

The goals of eyelid reconstruction are to provide adequate globe coverage, proper closing mechanics, preservation of tear film integrity, maintenance of an unobstructed visual field, and to recreate an aesthetically appealing eye. There are several requirements for an eyelid reconstruction to be considered "aesthetic." Both lids have to be in proper position, with normal palpebral fissure width and height. The eyelid margin should be distinct from the preseptal segment. Tissues must be thin to blend seamlessly with local skin. Finally, the canthal angles must be sharp and crisp. In this paper, we provide a practical guide to simplify eyelid reconstruction. This is not an exhaustive review of all available reconstructive techniques; instead, this is a description of the techniques we have found effective that together can address many eyelid defects.

Fig. 1.

The subunits of the periorbital region. LC, lateral canthus; MC, medial canthus; ULF, upper lid fold; ULPT, upper lid pretarsal.

Fig. 2.

The support structures of the eyelid that must be considered to maintain lower eyelid position. SOOF, sub-orbicularis oculi fat.

Fig. 3.

Pretarsal lower lid defect (Type I) (figure courtesy of Dr. Salvatore Pacella). A, A woman with a defect of the pretarsal lower lid, approximately one-third of the lid width. B, One-year postoperative result following closure by primary closure and lateral cantholysis. C, Oblique view of one-year postoperative result.

Fig. 4.

Pretarsal lower lid defect > 50% of lid width (Type I). A, A 63-year-old woman with a large defect of the pretarsal lower lid. B, Six-month postoperative result following reconstruction with a Hughes tarsoconjunctival flap, blepharoplasty skin–muscle flap, and lateral canthoplasty.

Fig. 5.

Lid–cheek junction defect (Type III). A, A 74-year-old woman with a small defect involving the skin and muscle of the lid–cheek junction. B, Design of a hatchet flap. C, Three-month postoperative result following a “hatchet flap” advancement flap reconstruction from the lateral cheek.

Fig. 6.

Lateral canthus reconstruction with crisscross canthoplasty. A, 85-year-old woman with a full-thickness defect of the right lateral lower lid, full-thickness pretarsal defect comprising 75% of the width. B, Additional margins excised intraoperatively resulting in lateral orbital area and canthal defect with loss of upper lid lateral canthal attachment. C, Reconstruction of the lower lid defect with Hughes tarsoconjunctival flap. D, Crisscross lateral canthoplasty using the lateral edge of the Hughes flap and lateral edge of the upper lid. E, Reconstruction of the anterior lamella with a blepharoplasty skin–muscle flap. F, Postoperative result following division and inset of the Hughes flap.

Fig. 7.

Medial canthus defect. A, A 59-year-old woman with a defect involving the skin of the medial canthus. The orbicularis oculi was completely intact. The reconstructive plan was to use a full-thickness skin graft harvested from the right upper eyelid. B, Intraoperatively following skin graft harvest and donor site closure. C, Intraoperative photograph after skin graft inset. D, 5.5-month postoperative result. One triamcinolone and one 5-fluorouracil injection were given during postoperative follow-up visits when the graft appeared raised to prevent hypertrophic scarring and epicanthal fold formation.

Fig. 8.

Lower medial canthus defect. A, A 77-year-old woman with a skin defect of the medial canthus. The superior and inferior canaliculi were probed and found to be completely intact. B, On-table postoperative result following full-thickness skin graft harvested from bilateral upper eyelids. C, Seven-month postoperative result. The skin graft was injected with 5-fluorouracil twice during follow-up visits before the photograph when the graft appeared slightly raised.