Lower Eyelid Reconstruction

Dec 28, 2021 6 min read
Lower Eyelid Reconstruction

Lower Eyelid Reconstruction involve direct closure, graft, or flaps. This depends on the size, location, and depth of the defect.

5 Key Points


1. Eyelid Reconstruction focuses on the depth, size, & location of the defect.
2. Direct Closure is an option in low tension wounds
3. Skin is reconstructed by local flaps or full-thickness skin grafts
4. Tarsal plate is reconstructed by cartilage grafts or ADM
5. Conjunctiva is reconstructed by conjunctival flaps or mucosal grafts.


7 General Principles

These are general principles. Decisions are made on a case-by-case basis.

  1. Eyelid defects are assessed as a 3D object: depth, width, height, location.
  2. Try to replace "like with like".
  3. There is more than 1 way to reconstruct an eyelid - a case-by-case basis.
  4. The upper eyelid is generally not used in lower eyelid reconstruction.
  5. The lower eyelid has less skin laxity and more gravity than upper eyelid.
  6. Grafts need a vascularised cover with a flap, you should not graft on a graft.
  7. Healing by secondary intention is suitable for specific defects.

Lower Eyelid Reconstruction Assessment


Lower Eyelid Reconstruction Algorithm

There are 4 ways to reconstruct a lower eyelid: direct closure, graft, flap, or a combination. The decision depends on the depth, location, defect size, and patient factors.

There are 4 ways to reconstruct a lower eyelid: direct closure, graft, flap, or a combination. Each of these options has a further subset of options.

  1. Direct Closure
  2. Graft: skin, mucosa (buccal, nasal, palatal), cartilage, acellular dermal matrix.
  3. Flap: adjacent, local or regional flaps; cutaneous or myocutaneous.
  4. Techniques: Lateral Canthotomy/Cantholysis, Canthal Anchoring

It is essential to evaluate individual defects, analyze the missing components, and formulate a reconstructive algorithm. This is illustrated in the image below.

Lower Eyelid Reconstruction Options, Lower Eyelid, Reconstruction, Flap, Primary Closure, Graft, Mucosal Graft, Skin Graft, Hughes Flap, Tenzel Flap, Tripier Flap, Mustarde Flap, McGregor Flap, auricular cartilage graft, conchal cartilage graft
Lower Eyelid Reconstruction Options

Once you are aware of the reconstructive options, it's important to have an understanding of when to use them.

  1. Direct closure for partial or full-thickness defects with tension-free closure.
  2. Full Thickness Skin Graft: for anterior lamella defects
  3. Cheek/Forehead Flaps: anterior lamella resurfacing of a posterior lamella.
  4. Eyelid Flaps: posterior lamella reconstruction
  5. Mucosal Grafts: conjunctiva (advancement flaps preferred)
  6. Cartilage Grafts: tarsal plate (palatal graft is also an option)
  7. Accellular Dermal Matrix: tarsal plate

This is visualized below in the flow chart.

Lower Eyelid Reconstruction Options, Lower Eyelid, Reconstruction, Flap, Primary Closure, Graft, Mucosal Graft, Skin Graft, Hughes Flap, Tenzel Flap, Tripier Flap, Mustarde Flap, McGregor Flap, auricular cartilage graft, conchal cartilage graft
Lower Eyelid Reconstruction Algorithm

It is worth noting, healing by secondary intention is feasible in:

  • small defects of the anterior lamella
  • suited for medial canthal region (nasal bones resist scar contracture)
  • less suited for the middle region due to the risk of cicatricial ectropian.


Direct Closure of Lower Eyelid

Direct lower eyelid closure is suitable for both partial and full-thickness defects if achieved with minimal tension.

Direct closure of a lower eyelid defect is a suitable option if it can be achieved with minimal tension. It can be performed for both partial and full-thickness defects.

Traditionally, the following ratios have been suggested:

  • < 1/3 horizontal width in a standard patient
  • <2/3 horizontal width in patients with good skin laxity.

Primary Closure, Pentagonal Incision, Dog Ear Incision
Direct Closure in Lower Eyelid Reconstruction

To assist the primary closure, the following can be considered:

  1. Lateral cantholysis and canthotomy can add ~5mm advancement.
  2. A pentagonal incision creates a square-edged tarsal defect.
  3. A lateral dog-ear incision reduces the risk of ectropion.

There is a high risk of ectropion if the closure is too tight. Advantages of direct closure include:

  • No donor site morbidity
  • Lash continuity


Grafts for Lower Eyelid Reconstruction

Skin, cartilage, or mucosal grafts can reconstruct specific aspects of the lower eyelid.

The use of grafts in lower eyelid reconstruction is indicated for partial-thickness defects or as an adjunct to full-thickness defect reconstruction. There are 3 main types of grafts used.  

Full Thickness Skin Graft

  • A common option for partial-thickness defects of the anterior lamella.
  • Donor sites can be the contralateral lid or post-auricular area.
  • Contraindicated in conjunctival defects due to corneal irritation.
  • Not suitable for full-thickness defects.

Mucosal Graft

  • Can be used in conjunctival and tarsal plate reconstruction
  • Graft contraction is an issue (less in nasal compared to buccal mucosa)

Cartilage Graft

  • Can be used to reconstruct tarsal plate
  • Tarsal plate precision is key for structural lid support.


Flap Reconstruction of Lower Eyelid

Flaps for lower eyelid reconstruction are described by location (local or regional) or composition (cutaneous, myocutaneous) 

Flap reconstruction can be used for both partial and full-thickness defects of the lower eyelid. They can be used in conjunction with a graft. They can be skin-only (cutaneous) or skin-muscle (myocutaneous) and have enonymous names, as described below

Tripier Flap

  • A two-stage myocutaneous flap for partial-thickness anterior lamella defects.
  • Thin skin & orbicularis from upper eyelid is transferred to lower eyelid.
  • Designed as unipedicled or bipedicled (reduces risk of distal necrosis).
  • Useful if the defect is the majority of the lower eyelid.
  • Requires an intact or reconstructed posterior lamella.

Tripier Flap for Lower Eyelid Reconstruction, Tripier Flap, Lower Eyelid Reconstruction
Tripier Flap for Lower Eyelid Reconstruction

Tenzel semi-circular rotation flap

  • A laterally-based myocutaneous flap
  • Useful if the defect is the majority of the lower eyelid.
  • Lateral canthotomy is required to rotate the flap
  • Requires an intact or reconstructed posterior lamella (can be done with a periosteal flap from the lateral orbit)

Original Tenzel Publication for Lower Eyelid Reconstruction

Hughes tarsoconjunctival flap

  • Two-stage transfer of upper eyelid conjunctiva and tarsus
  • Useful if the defect is the majority of the lower eyelid.
  • Requires an intact or reconstructed posterior lamella (can be provided by flap or FTSG)
  • 3-4 mm of tarsal height in the upper eyelid donor site is preserved to prevent upper-lid margin distortion and entropion.

Modified-Hughes Advancement Flap

  • A composite advancement of the tarsus and conjunctiva
  • Useful for posterior lamella defects
  • Two-stage procedure
  • Requires intact or reconstructed anterior lamella.

Mustarde Flap

  • Cheek advancement flap
  • Useful if the defect is the majority of the lower eyelid.
  • Aim for tension-free inset with lateral canthal fixation.
  • Requires intact or reconstructed posterior lamella.  

Fricke Flap

  • Two-stage reconstruction useful soft-tissue overlying temporal area
  • Useful in anterior lamella defects
  • Risk of damaging the temporal branch of the facial nerve
  • Requires intact or reconstructed posterior lamella.

Flap reconstruction is supported through anchoring techniques. These include:

  • Lateral Canthus: direct fixation into the periosteum
  • Medial Canthus: direct fixation to connective tissue behind the lacrimal sac or nasal into periosteum.


References

  1. Codner, Mark A. M.D.; McCord, Clinton D. M.D.; Mejia, Juan Diego M.D.; Lalonde, Don M.D. Upper and Lower Eyelid Reconstruction, Plastic and Reconstructive Surgery: November 2010 - Volume 126 - Issue 5 - p 231e-245e
    doi: 10.1097/PRS.0b013e3181eff70e
  2. REVIEW ARTICLE| VOLUME 24, ISSUE 2, P183-191, MAY 01, 2016 Lower Eyelid Reconstruction John B. Holds DOI: 10.1016/j.fsc.2016.01.001
  3. deSousa J, Leibovitch I, Malhotra R, O’Donnell B, Sullivan T, Selva D. Techniques and Outcomes of Total Upper and Lower Eyelid Reconstruction. Arch Ophthalmol. 2007;125(12):1601–1609. doi:10.1001/archopht.125.12.1601
  4. Matsuo K, Hirose T, Takahashi N, Iwasawa M, Satoh R. Lower eyelid reconstruction with a conchal cartilage graft. Plastic and Reconstructive Surgery. 1987 Oct;80(4):547-552. DOI: 10.1097/00006534-198710000-00012. PMID: 3659164
  5. Eva H. Hewes, John H. Sullivan, Crowell Beard, Lower Eyelid Reconstruction by Tarsal Transposition, American Journal of Ophthalmology, Volume 81, Issue 4, 1976, Pages 512-514, ISSN 0002-9394, https://doi.org/10.1016/0002-9394(76)90311-1.
  6. Rafii, Amir A; Enepekides, Danny J Upper and lower eyelid reconstruction: the year in review, Current Opinion in Otolaryngology & Head and Neck Surgery: August 2006 - Volume 14 - Issue 4 - p 227-233
    doi: 10.1097/01.moo.0000233592.76552.d2
  7. Alghoul, Mohammed M.D.; Pacella, Salvatore J. M.D., M.B.A.; McClellan, W. Thomas M.D.; Codner, Mark A. M.D. Eyelid Reconstruction, Plastic and Reconstructive Surgery: August 2013 - Volume 132 - Issue 2 - p 288e-302e
    doi: 10.1097/PRS.0b013e3182958e6b
  8. Chang, Edward I. M.D.; Esmaeli, Bita M.D.; Butler, Charles E. M.D. Eyelid Reconstruction, Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5 - p 724e-735e doi: 10.1097/PRS.0000000000003820
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