Surgical Strategies for Eyelid Defect Reconstruction: A Review on Principles and Techniques

Abstract

Reconstruction of eyelid defects, especially the posterior lamella, remains challenging because of its anatomical complexity, functional considerations, and aesthetic concerns. The goals of eyelid reconstruction include restoring eyelid structure and function and achieving an aesthetically acceptable appearance. An in-depth understanding of the complex eyelid anatomy and several reconstructive principles are mandatory to achieve these goals. Currently, there are multiple surgical treatment options for eyelid reconstruction, including different flaps, grafts, and combinations of them. This comprehensive review outlines the principles of reconstruction and discusses the indications, advantages, and disadvantages of currently available surgical techniques. We also propose our clinical thinking for solving specific clinical questions in eyelid reconstruction and offer perspectives on new potential methodologies in the future.

Keywords: Anterior lamella; Eyelid defect; Eyelid reconstruction; Periocular reconstruction; Posterior lamella; Tarsus.

Fig. 1

Anatomical structures of upper and lower eyelids. ROOF retro-orbicularis oculi fat, SOOF sub-orbicularis oculi fat

Fig. 2

Supporting system of upper and lower eyelids

Fig. 3

Mustarde cheek rotational flap. A Large vertical anterior lamella defect of the lower eyelid defect and planned incision design (dotted line). The incision runs laterally from the level of the lower eyelid and lateral canthus, superiorly into the temporal skin, and finally inferiorly toward the preauricular areas. B, C The flap is undermined in the subcutaneous or SMAS plane and rotated medially to cover the defect. To reduce the tension in the lid-cheek margin and avoid postoperative ectropion, the flap should be designed along the natural curve of the lower eyelid with a high takeoff from the lateral canthus to the temple before curving inferiorly. SMAS, superficial muscular aponeurotic system

Fig. 4

Tripier orbicularis myocutaneous flap (unipedicled). A Anterior lamellar defect involving 2/3 of the lower eyelid and planned incision design on the upper eyelid (dotted line). B The flap is elevated under the orbicularis muscle plane and pedicled on the orbicularis muscle laterally. C The flap is transposed inferiorly to cover the defect

Fig. 5

Fricke forehead flap. A Large lateral lower eyelid defect with long horizontal length and short vertical height and planned incision design on the forehead. The flap design should obey a width-to-length ratio of 1:2 to ensure blood supply to the flap tip. B, C The flap is elevated as a random cutaneous flap and rotated inferiorly to cover the defect

Fig. 6

Fricke cheek flap. A Large anterior lamella defect involving the entire length of the lower eyelid and planned incision design on the cheek. B, C The flap is undermined in the orbicularis muscle plane and rotated superiorly to cover the defect

Fig. 7

Tarsomarginal graft. A A full-thickness defect with a half-length of the entire lower eyelid. B A planned incision is designed 2 mm inferior to the eyelid margin. C The myocutaneous flap is dissected to expose the posterior lamella, and a tarsomarginal graft with a length half of the defect is harvested. D The donor eyelid can be closed with primary closure. E, F The full-thickness lower eyelid defect is reconstructed using two different techniques: the posterior lamella defect is repaired with the harvested tarsomarginal graft, and the anterior lamella defect is closed with a local Tenzel flap

Fig. 8

Tarsoconjunctival advancement flap. A A full-thickness upper eyelid defect involving the center upper tarsus and eyelid margin. B Planned incision design on the upper eyelid. C, D The residual center tarsus is cut vertically and mobilized on a conjunctival pedicle and advanced inferiorly to repair the posterior lamella part of the defect

Fig. 9

Tarsoconjunctival sliding flap. A A full-thickness defect involving the lateral lower eyelid and eyelid margins. B A tarsoconjunctival flap is designed on the medial residual eyelid. C, D The tarsoconjunctival flap is dissected in the posterior lamella plane and slides laterally to fill the posterior lamella defect

Fig. 10

Tarsoconjunctival sharing flap. A A laterally located full-thickness defect involving half the length of the lower eyelid. B A tarsoconjunctival flap is planned on the posterior lamella of the ipsilateral upper eyelid. C, D The flap is elevated and transposed with a lateral pedicle on the upper eyelid to fill the posterior lamella defect on the lower eyelid

Fig. 11

Hughes tarsoconjunctival flap. A A full-thickness defect involving the center part of the lower eyelid and eyelid margin. B Planned incision design on the conjunctiva surface of the upper eyelid. The flap is designed 4–5 mm from the upper eyelid margin, leaving a strip of the tarsus for structure support. C The flap is dissected in the posterior lamella plane and transposed inferiorly based on a superior conjunctiva pedicle. D The tarsoconjunctival part of the flap is advanced into the defect and sutured with the residual tarsus of the lower eyelid. E The anterior lamella defect is reconstructed with an FTSG. F The flap is separated after 2–4 weeks

Fig. 12

Cutler-Bread flap. A A full-thickness defect involving the center upper eyelid and eyelid margin. The planned incision design is marked 4–5 mm below the lower eyelid margin to preserve the blood supply and stability of the lower eyelid. B A skin-muscle-conjunctiva flap is elevated on the lower eyelid. C The flap is tunneled underneath the undisturbed lower lid tarsus. D The flap is separated into a myocutaneous flap and a conjunctival flap, and the conjunctiva flap is sutured along the defect to repair the conjunctiva defect. E An additional tarsal substitute (e.g., contralateral tarsus, cartilage, perichondrium) is applied to the conjunctival flap to repair the tarsal defect. The myocutaneous flap is covered onto the tarsal substitute and left attached for 2–4 weeks. F The pedicle is divided, and the remaining flap is replaced along the lower lid

Fig. 13

Tenzel semicircular rotational flap. A A large full-thickness defect involving the lateral lower eyelid and eyelid margin. The planned flap incision is designed in a semicircular fashion from the lateral edge of the defect out toward the lateral eyebrow line. B The flap is initially undermined in the orbicularis muscle plane within the orbital rim and later along the subcutaneous plane beyond the orbital rim. A canthotomy of the upper limb of the lateral canthus is selectively performed. C The remaining lid along the semicircular myocutaneous flap is rotated medially for primary closure of the defect. The myocutaneous flap is sutured to the lateral edge of the tarsus and secured to the periosteum at the lateral orbital rim to reestablish the lateral canthal height. The lateral canthal height can be reestablished with suture fixation to the superolateral orbital rim periosteum

Fig. 14

Mustarde lower eyelid sharing flap. A A full-thickness defect involving the center upper eyelid and eyelid margin. Planned incision design for a lower eyelid sharing flap and a lateral Tenzel rotational flap. B The lower eyelid sharing flap is dissected from the center portion of the lower eyelid and based on a medial pedicle. Simultaneously, the Tenzel flap is elevated, and a triangle-shaped tissue is planned for removal before the medial rotation of the Tenzel flap. C The Tenzel flap is rotated medially to repair the donor eyelid. D The lower eyelid flap is rotated superiorly to repair the upper eyelid defect. E, F The flap is divided after 2–4 weeks

Fig. 15

Schematic overview of eyelid defect reconstruction strategies for different conditions. FTSG full-thickness skin graft