Lower Eyelid Reconstruction

Lower Eyelid Reconstruction can be explained in relation to the defect or the type of reconstruction options. This article details direct closure, graft, or flaps to partial or full-thickness defects.
Lower Eyelid Reconstruction

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.

Lower Eyelid Defect Assessment

A lower eyelid defect should be assessed as a 3-Dimensional structure. The following should be noted:

  1. Location: medial, central or lateral ± canthus involvement.
  2. Size: 1/3, >1/3.
  3. Depth: skin, orbicularis, tarsus, conjunctiva or full-thickness
  4. Patient: skin laxity and quality
  5. Additional: lacrimal drainage system, contralateral eyelid evaluation

After the assessment, you should know what is "missing" to allow you to replace "like with like".

Lower Eyelid Reconstruction Assessment

Lower Eyelid Reconstruction Options

Key Point

There are 5 ways to reconstruct a lower eyelid: direct closure, graft, flap, secondary intention, or a combination. The decision depends on the depth, location, defect size, and patient factors.

There are 5 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: local or regional flaps; cutaneous, myocutaneous or tarsoconjunctival
  4. Combination of grafts and flaps
  5. Secondary intention for partial thickness defects ("laissez-faire")

These lower eyelid reconstructive options are visualised in the illustration 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

These options may be combined or used with other techniques, such as lateral canthotomy/cantholysis and canthal anchoring.

Tip: grafts should be covered with a vascularised cover flap. Don't place an avascular graft onto an avascular graft. 

Lower Eyelid Reconstructive Algorithm

Once you are aware of the reconstructive options, it's important to have an understanding of when to use them. The key indicator is if the defect is partial or full thickness.

  • Skin: primary tension-free closure, graft, flap, secondary intention
  • Conjunctiva: direct closure, advancement flap (preferred), graft
  • Tarsus: direct closure, graft, acellular dermal matrix.
  • Full-thickness: direct closure, flap, a combination of flap + graft.

Key Point: defects of anterior and posterior may lamellae require separate reconstruction.

The lower eyelid reconstruction algorithm 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 that healing by secondary intention is an option. It is described as "Laissez faire" - healing by secondary intention/granulation formation. Fox and Beard were the first to describe it. It is feasible in:

  • small defects of the anterior lamella
  • suited for the medial canthal region (nasal bones resist scar contracture)
  • less suited for the middle region due to the risk of cicatricial ectropion.
  • Simple absorbant dressing for 48 hours followed by eye drops for several weeks.

Tip: Direct closure, graft or flap is a potential option for all lower eyelid defects, except tarsal plate reconstruction (direct closure or graft only). 

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.

Bleeding may occur due to injury to the marginal artery, which often responds to compression.

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

  • No donor site morbidity
  • Lash continuity

Tip: Layered primary closure with a suture through the grey line or lash line should result in a good cosmetic outcome. The conjunctive does not always need to be sutured. 

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)
  • Donor sites include hard palate or buccal mucosa (lots of tissue so it can be useful is large conjunctival defect)

Cartilage Graft

  • It can be used to reconstruct tarsal plate
  • Tarsal plate precision is key for structural lid support.
  • Donor sites include auricular and septal cartilage.

Tarsoconjunctiva Grafts

  • Donor site is from the intact eyelid.
  • Similar to a Hughes Flap, but it is detached.

Tip: Posterior lamella grafts can be inset into the tarsal plate, canthal tendon or periosteum, depending on the location of the defect. 

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), skin-muscle (myocutaneous), tarsoconjunctival, or have eponymous names, as described below.

Tip: Nearly all periorbital flaps are elevated with submuscular dissection.

Anterior Lamella Reconstruction

Tripier Flap

  • 2-stage myocutaneous flap for partial-thickness anterior lamella defects.
  • Skin & orbicularis from the upper eyelid is transferred to the lower eyelid.
  • Designed as unipedicled or bipedicled (reduces the 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

Tip: consider a bipedicled Tripier flap if the defect crosses the other side of the pupil. This reduces the risk of distal flap tip necrosis. 

Tenzel semi-circular rotation flap

This is a laterally-based myocutaneous flap that is useful if the defect is <2/3 majority of the lower eyelid. The technique allows a step-wise process to an eyelid closure:

  1. A lateral canthotomy followed by a cantholysis (provides ~5mm)
  2. If a further 5mm is required, convert to a Tenzel flap.

The benefits of this flap include the following:

  • Versatile, relatively simple
  • It can be applied to the upper and lower eyelid.

Some literature suggests it requires an intact or reconstructed posterior lamella (which can be done with a periosteal flap from the lateral orbit). Anecdotally, the conjunctiva does not always need to be reconstructed because it will epithelialise.

Original Tenzel Publication for Lower Eyelid Reconstruction

Mustarde Flap (Cheek)

  • Cheek advancement flap for large defects
  • 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 (Temporal)

  • Two-stage reconstruction useful soft-tissue overlying temporal area
  • Useful in anterior lamella defects
  • Risk of damaging the temporal branch of the facial nerve
  • Limited by the fact it is introducing thick skin into the lower eyelid.
  • Requires intact or reconstructed posterior lamella.

McGregor Flap

  • Lateral advancement flap
  • Straddles subunits and requires dissection in 2 separate planes

Fun Fact: Other less commonly used flaps do exist - such as, Langenbeck and Quaba. 

Posterior Lamella Reconstruction

Hughes tarsoconjunctival flap (Upper Eyelid)

  • Two-stage transfer of upper eyelid conjunctiva and tarsus
  • Flap of tarsus and its attachment to Müller muscle is preserved to improve flap blood supply and reduce the risk of tethering that results in upper eyelid contraction.
  • Useful if the defect is the majority of the lower eyelid.
  • Requires an intact or reconstructed anterior lamella 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.
  • Division of the flap occurs within 3 weeks.
  • Limitations include: monocular for 3-4/52, corneal irritation, lid retraction and entropian.

Modified-Hughes Advancement Flap (Upper eyelid)

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

Hewes Tarsal Transposition Flap

  • Laterally-based tarsoconjunctival flap
  • Donor site closed directly
  • For defects extending into or involving the lateral canthus
  • Caution: similar sound but different spelling to Hughes Flap

Supportive Techniques

Anchoring Sutures

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.

Lateral Cantholysis

A lateral cantholysis mobilises the lower lid to reduce the tension on primary closures. One method for this to be performed is:

  • Lateral canthotomy to get access to the lateral canthal tendon
  • Division of the lower limb of the lateral canthal tendon ("a tight band")
  • A medial advancement after release (~5mm of advancement)

Fun Fact: The lateral canthal tendon attaches the upper and lower tarsal plates to Whitnall's tubercle inside the orbital rim deep to the septum.


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