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EYELID RECONSTRUCTION
FUNCTION OF THE EYELIDS
1. Protect the globe
2. Distribute tears
AETIOLOGY OF EYELID DEFECTS
1. Congenital: coloboma
2. Trauma, including burns
3. Neoplasia, including treatment: RT.
4. Infection
 Hordeolum/stye
a. External – infection of glands of Zeiss or Moll
b. Internal – infection of meibomian gland
 Chalazion - Painless chronic inflammation of secondary to blocked duct
a. Superficial - blocked Zeiss pilosebaceous gland
b. Deep – block meibomian gland
Eyelid tumours
1) Benign (37%)
a. seborrheic keratosis
b. nevi (intradermal most common)
c. dermoid cysts (lateral brow at line of embryonic closure)
d. vascular malformations
e. Neurofibromas
2) Malignant
a. BCC (12%)
i. More common on lower eyelid and medial canthus
ii. BCC eyelids 30x more common than SCC
b. SCC
i. Erythematous raised lesion with destruction of lashes
ii. May occur on inner conjunctival surface
iii. Metastatic potential of <1%
3) Sebaceous gland carcinoma
a. Third most common eyelid malignancy
b. Arise from meibomian gland or glands of Zeiss; 75% of all sebaceous
carcarcinomas arise periocularly
c. Usually in upper eyelid (2-3x more), 6th decade
d. most common presentation is a firm, slowly enlarging nodule of the upper
eyelid, often mistaken for a chalazion
e. Rarely associated with Muir-Torre syndrome or rhinophyma
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i. autosomal dominant condition with variable penetrance characterized by skin manifestations, including benign and malignant sebaceous neoplasms, keratoacanthomas, and internal manifestations
(eg, colonic polyps, low-grade visceral malignancies)
f. aggressive clinical course, with a significant tendency for both local recurrence and distant metastasis.
g. Often multifocal (intraepithelial pagetoid spread), frozen section or
mapping biopsies recommended
h. Treatment with >5mm margins, or Mohs
i. Eye involvement require exenteration
j. Recurrence rates in the 30%, usually within 5 years
k. Radiotherapy not considered curative
l. Metastasis occurs in 14-25% of cases, first to the draining lymph nodes
and then to distant sites.
4) Melanoma
a. Assess involvement of conjuctival and eye ?exenteration
b. Lesions involving the margin have a much worse prognosis – reason unclear unclear, but the presence of efferent blood vessels and lymphatics at
the margin as well as the repeated minor trauma from blinking may be related.
c. 100% mortality with DXT only as opposed to 14% with wide surgical excision
MANAGEMENT OF EYELID LOSS
 Eyelid loss may be complete or partial. It may involve one or more layers of the lid.
 2 layers: lammelae 1) skin /obricularis(external )
2) tarsus /conjunctiva (support and lining)
 With upper lid loss, there is the risk of corneal desiccation and a subsequent keratolytic
response that can result in loss of vision. This is less so with lower lid loss.
 Ocular protection is therefore important: artificial tears, ointment, surgery ASAP.
 Other methods that have been used are sectioning the inferior rectus muscle to allow
the globe to rotate up and moisture chambers.
Principles of Reconstruction
 Replacement of like with like.
 The use of similar available eyelid tissue to replace deficient tissue.
 3 layers need to be provided: skin, support and lining.
 The margin must be stable and not turn inwards or outwards.
 FT defects can be reconstructed with a flap to one lamella and a graft to the other or
with 2 flaps, but not with 2 grafts as vascularity will then be a problem. At least one
lamella should have blood supply to support the other.
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 The tarsal plate is not a solid plate of ct tissue, but rather consists largely of meibomian
glands. The free margin is a thickened flange whereas the rest is thin and does not
contribute to support.
 According to Mustarde, support is solely a function of the orbicularis muscle (ectropion can develop with paralysis of the orbicularis with an intact tarsus)
 He also stated that only 3/4 of the width of each lid requires reconstruction.
CLASSIFICATION
Zones of the eyelid and periorbital tissues. The eyelids and periorbital tissues can be divided into five surgical zones: zone I, on the upper eyelid; zone II, on the lower eyelid;
zone III, on the medial canthal region; zone IV, the lateral canthal region; and zone V,
outside but contiguous with zones I to IV. (From Spinelli, H. M., and Jelks, G. W. Periocular reconstruction: A systematic approach. Plast. Reconstr. Surg. 91: 1017, 1993)
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EYELID INJURIES - SIMPLE LACERATIONS AND MINOR LOSS
 The upper lid is the more important than the lower - responsible for 90% of closure.
 Minimal/conservative skin debridement
 Check for levator disruption (ptosis) and be wary not to include orbital septum in sutures otherwise tethering will result. Primary levator injuries are repaired.
 Where there is loss of < 25% (30% in the elderly with lax lids), of total lid volume,
primary closure can be done aligning various tissue layers. If undue tension then can
gained by lateral canthotomy
 Partial eyelid avulsions, d/t the excellent blood supply in the area, can usually be sutured back, even after some delay.
 Where there is the choice, vertical closure is better than horizontal as this reduces the
likelihood of ectropion or lagophthalmos. Eyelid skin heals well and the scar is usually not a problem. If it is, a Z-plasty done subsequently is easy and simple.
 Minimal debridement and primary closure is done for wounds without tissue loss.
 Proper alignment of tissue is all important. Loupes should be used. Usually the first
stitch is just through the free edge of the tarsal plate (6.0 Vi) with 2 or 3 sutures placed
similarly below to approximate the tarsus only. The orbicularis should be approximated loosely with a stitch or two. A 6.0 silk suture is then placed through the grey line
and left long to be tied in the loop of the next stitch or two of the lid skin so that it
does not abrade the cornea.
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 A lateral cantholysis can give one an additional 58mm of additional lower lid length which may aid
closure.
 Lateral canthotomy - full thickness horizontal cut
into lateral canthus).
 Lateral canthal tendon exposed as skin and conjunctiva dissected off.
 For lower lid defects, the lower half of the lateral
canthal ligament is divided; for upper, the upper
half. Put tension on the appropriate lid to define
the upper or lower limb of the lateral canthal ligament.
 The orbital septum may need to be freed to allow
closure.
 The eyelid defect should then be able to close
without tension and distortion.
 The lateral canthal skin is closed. (Conjunctiva to
skin if the lateral canthotomy wound is large).
 Don’t interfere with the medial canthus:
a) the lacrimal apparatus can be injured - epiphora
b) telecanthus due to unchecked force of the orbicularis
c) notching
d) ectropion
 Sutures should be removed early (3-4 days) to prevent granulomas and cysts.
 After removal of the sutures, support the lid for a further few days with tape.
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PARTIAL THICKNESS DEFECTS
1) Anterior Lamella - Skin
 Primary closure is usually best. If this is not possible, local flaps give a better cosmetic result than skin grafts. If there is a lack of local tissue (eg, burns), skin grafts will
have to be used. FTSG is preferable to SSG for both upper and lower lid.
 Upper lid loss  Upper lid requires mobility, therefore best replaced with thin graft.
Thin FTSG from contralateral upper lid is the best option.
 Lower lid loss  Lower lid requires stability, usually FT skin required: Wolfe graft
(post-auricular, pre-auricular, supra-clavicular, upper eyelid).
 Upper lid skin is advantageous because it is thin (like for like) and there is no subcutaneous fat.
 If upper lid skin is used it should be taken above the crease or laterally below the brow.
 Quilting helps immobilisation and multiple holes aid haematoma drainage.
 Medial canthal defects, if small can be allowed to heal by secondary intention.
 Local skin flaps that can used: V-Y from lateral nose/glabella region, local advancement flap, rotation flap, forehead flap, O-Z plasty, bilobed flap, transposition flap, etc.
 Lower lid plus cheek  Supraclavicular skin can be used.
 Composite grafts from the ear for anterior lamella plus tarsus have been used. Usually
a well matched piece of concha can be found. Conchal grafts for upper lid have been
criticised for being too thick, but they are an acceptable option for lower lid.
2) Posterior Lamella
Conjunctiva only
 Either advance the conjunctiva from the sulcus or use a free graft from the same or
contralateral eye.
 Conjunctival grafts are difficult to handle, tend to contract and may interfere with the
donor fornix. A doughnut shaped conformer should be used to extend the graft into
the fornix.
 An alternative to conjunctival grafts is buccal or nasal mucosal grafts - abundant,
simple and easy to use. Buccal grafts contract by 50%; nasal by 20% only(thicker).
 Never use skin as it is an irritant in the eye – hair and squamous epithelium.
Tarsal plate
 Composite free graft or flap from a variety of sources may be used (see below)
Conjunctiva and tarsus
i) nasal septal chondromucosal grafts
 recommended because of the strong hyaline cartilage of the nose, which is
closely associated with the mucus-secreting lining of the nasal mucosa
 turn mucosa anteriorly, so globe never comes into contact with skin
ii) upper lateral cartilage plus nasal mucosa
 may be taken as graft or as an islanded chondromucosal flap
iii) contralateral or opposing lid (graft or flap - tarso-conjunctival flap [qv])
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 only 14% of grafts with retain their cilia. Complications include upper lid
retraction, wound dehiscence, cicatricial ectropion, excessive lower lid laxity and notching of donor/recipient lid
iv) hard palate mucosal grafts
 in addition to mucous membrane, they contain a collagen matrix that provides ample support for the eyelid.
 enough to reconstruct whole lid
 undergo minimal shrinkage and are much more pliable than grafts of ear or
nasal cartilage
 keratinized palatal mucosal grafts undergo metaplasia to nonkeratinized mucosa over the first 6 months
v) periosteal flaps/ grafts
 harvested from lateral orbital rim
 left to reepithelialise
vi) tarsoconjunctival flaps
Skin and tarsus
i) conchal cartilage grafts
 good donor site
 Mobilisation of orbicularis into the recipient site improves graft take
FULL THICKNESS DEFECTS OF THE LOWER LID
The Lower lid Controversy
The sanctity or the upper lid:
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 Mustarde stated that the lower lid should be used to reconstruct the upper lid, and that
other sources be used to reconstruct the lower lid (eg, a chondro-mucosal graft from
the nasal septum).
 The upper lid is responsible for 90% of eye closure and is too important to be sacrificed for lower lid reconstruction.
 A static lower lid will still provide the support it is supposed to. Mustarde advocates
that the loss of part or the whole of the lower lid can be tolerated if the upper lid if fully functional but even small amt loss or contraction near the midline may lead to corneal exposure thus the upper lid should not be used for lower lid reconstruction
Like for like:
 Smith believes that lid sharing procedures, especially the tarsoconjunctival flap are
useful for both upper and lower lid reconstructions. In good hands they are safe and
the cosmetic and functional results better: no scars extending on to the face; like for
like. (This view is shared by most ophthalmologist)
Reconstruction according to size of defect
< 25%
1. Primary closure.
25-75%
1. Lateral cantholysis of the inferior crus of the lateral canthal tendon combined
with wedge resection or conchal cartilage graft or
2. Tenzel semicircular flap from laterally (defect < 50%).
3. McGregor flap (central defects)
4. Unilateral Tripier flap (lateral/medial defects)
75-100%
1. staged tarso-conjunctival flap from upper lid + SSG
2. Chondro-mucosal graft which can be covered by
a. Mustarde cheek advancement-rotation flap
b. Bipedicle Tripier flap from the upper lid (narrow defect)
c. Angle rotation flap
Conchal cartilage grafts
 Has been used alone for full thickness reconstruction
 graft perichondrium forms the posterior lamella
 epithelialisation in 3-4 weeks
 suture the conchal grafts to the tarsal plate above and the periosteum of the infraorbital
rim below to prevent graft displacement
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Hughes tarso-conjunctival flap
 good for central defects measuring 60-80% of total lid length
 Hughes originally described a tarsoconjunctival flap involving the eyelid margin. This
procedure no longer is performed.
 2 stage procedure.
 Ideal for lid defects of only 4-5 mm in height.
 1st stage: Flap of upper part of upper lid tarsus and attached conjunctiva, pedicled on
the Muller’s muscle and conjunctiva (original Hughes) or conjunctiva alone (modification) above, advanced to lower lid, sutured in place, covered with skin (graft or flap).
The upper lid is not sutured to the flap, but left to granulate.
 Some leave a rim of upper tarsus for re-attachment of the levator.
 At least 4 mm of tarsus must be left for lid stability and to prevent the complication of
upper lid entropion.
 2nd stage: 3weeks (Collin) / 6-9 weeks (McC)/3 months (Hughes) later the pedicle is
divided and the flap inset. Conjunctiva must meet skin on the outer, upper edge of the
reconstructed lower lid. The donor defect is covered by the advanced conjunctiva.
 The flap can also be based laterally and transposed into the lower lid defect ( see
achuer)
 The T-C flap can be 25% narrower than the defect, especially in the elderly with lax
lids. This also helps prevent later lower lid ectropion.
 Useful because elevates the lower lid between the two surgical stages.
 Eyelashes are absent on the reconstructed segment of lower lid.
 Can also raise a T-C flap as a medially or laterally based transposition flap.
Modification for the harvest of the flap:
1) cutting obliquely through the tarsus beginning at the conjunctival margin and extending to the anterior surface of the tarsus approximately 3mm above the lid
 better preserved the eyelash root bulbs
 created a thinner flap to be united with the lower lid conjunctiva
2) a step incision through the upper tarsus with the reattachment of the levator and
mullers muscle segments to the lower tarsal remnant with preservation of the upper lid margin with an incision through the lower tarsus 4mm behind the upper
border of the lid
3) one-stage lower eyelid reconstruction for the infirm or monocular patient - free
tarsoconjunctival graft. Anterior lamella that provides the vascular support for the
free tarsoconjunctival graft
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Crosslid flaps
 best for long, narrow defects of the lower lid margin.
 upper and lower margins of the tarsus are not taken in the flap.
 This composite flap is elevated from the central portion of the upper lid as a
uni(medial or lateral) or bipedicled flap
 Disadvantage: postoperative retraction of the lower lid and no lashes, but the presence
of lashes is not considered critical in the lower lid
 risk of injury to the more important upper lid must be weighed against the benefits of
this method.
Chondro-mucosal graft covered with cheek rotation-advancement flap
 For 25-100% defects
 Mustarde’s technique is to use septal cartilage and overlying mucosa as a graft for the
inner aspect of the lid (conjunctiva and tarsus) (or mucoperiosteum from hard palate)
and to cover this with a large rotation-advancement cheek flap.
 Others have used periosteum and allow to reepithelialise
 For total lower lid recon the graft should be approx 25mm long and 5mm thick. The
medial end is sutured to the residual tarsal plate or to the post refection of the medial
canthal tendon using 4.0 prolene The cheek skin flap must go high enough and posteriorly enough and is sutured to the periositeum of the malar area for greater support.
 The flap extends into the cheek in the preauricular area following a more gentle curve
similar to a facelift incision. The arc of rotation passes just below the lateral brow and
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can be extended into the neck with the removal of a burrows triangle in the lateral cervical region. The cheek rotation flap is then sutured to the ant limb of the medial canthal tendon ( in total lid)
 Tessier uses UL nasal cartilage and overlying mucosa instead of septal cartilage.
 Other local flaps can also be used: transposition flap from the nasal or lateral side, upper lid Tripier flap, forehead transposition flap.
 Complication of the cheek rotation flap include
1. Sagging or retraction of the flap
2. Ectropion of the lid margin which did not become evident until approx 2-3 years
after surgery
3. Flap ischaemia – apex of the flap where it extends on to the temporal skin that is
most likely to be lost
4. To improve blood supply to this area the plane of dissection of the cheek flap
should be deep to the SMAS
5. Trichiasis
6. lateral symblepharon
7. Rounded canthus and a marginal notch
 The two most influential factors in the outcome of the reconstruction were the design
of the flap and the composition of the graft used for lining and support
 Callahan and Callahan recommended a modification of the design of the flap (high arc
flap) to incorporate temporal skin from well above canthus lateral to the brow instead
of the usual arc passing immediately lateral to the brow
 Best graft was the nasal septal graft compared to the buccal mucosal flap
 Hitching sutures are also used to hitch the under surface of the flap to the periosteum
of the lateral orbital rim and lateral canthal tendon stump
 McGregor added a Z plasty to the cheek advancement flap used to repair defects 60 %
of the lower lid. The lateral Z technique incorporates a high arc necessary to avoid
sagging but does not interfere with the natural temporal hair line( Mr H likes this
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Mustarde cheek rotation (high arc design)
Transposition Z plasty flap (McGregor)
 McGregor described a orbital transposition flap
for central defect >60% resected as a wedge
 The flap is a skin flap extending from the lateral
canthal angle continuing laterally in a gentle
upward curve to the lateral temporal hair line
 A pre hairline incision is made inferiorly equal
in length and parallel to the edge of the lid deformity
 A z plasty is made along the transverse incision
to lengthen the lid margin corresponding to the
width of the wedge resection from the lower lid
 Following mobilization of skin flap a canthotomy is performed and the residual lateral lid margin is advanced medially
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 The tarsal plate and lid margin are reconstructed and the wedge is reconstructed following transposition of skin flap medially ( Mr H likes this flap)
 Angle rotation flap (Zide PRS 2005)

Tenzel’s semicircular rotation flap
 Full thickness defects 40-60%
 Best when at least 2 mm of tarsus remains on either
side of the defect
 Skin-muscle flap (under orbicularis)
 Begins at lateral canthus
 must extend above the lateral canthal angle to ensure
elevation of the lower eyelid during wound healing.
 Lateral canthotomy to lower half of lateral canthal
tendon
 Conjunctiva from the inferior fornix should be advanced or rotated into position to cover the posterior
surface of the skin muscle flap.
 Larger flaps can be backed with ear cartilage, nasal
septal or alar chondromucosal grafts, or a free tarsoconjunctival flap.
 When used, these grafts must be fixated inside the
lateral orbital rim to achieve lateral support for the
newly reconstructed eyelid.
Bipedicle flap from the upper lid
Skin and muscle - Tripier flap (1889).
 Used to cover a chondro-mucosal graft.
 Only useful for very narrow marginal defects.
 Muscle provides vascularity to flap and therefore
must be incorporated.
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 May be taken from upper or lower lid, but flaps raised from the lower lid require full
thickness skin grafts for closure of the donor defect.
 incision for flap elevation in the upper eyelid crease is extended medially and laterally
to meet the ends of the lower lid defect and the donor site in the upper lid is closed
primarily
 2-6 weeks later, the flap pedicles are returned to the upper lid.
 If unipedicled, however, it will not cross the pupil reliably.
Full thickness
 A bipedicle flap of skin, muscle, tarsus and conjunctiva has also been described (Anderson, 1987) and has the advantage of keeping the palpebral fissure open.
 Combination of Tripier and tarsal conjunctival flap have been used to reconstruct colobomas in Treacher Collins syndrome
Supratrochlear artery flap
 2 stage procedure
 most commonly transferred in combination with conjunctival grafts for the treatment of complex ectropion.
 Advantages of this method are excellent vascularity of
the tissues, versatility of flap design, and good color
match.
 Disadvantages are the slightly bulky and less pliable
coverage and the need for a second stage to divide the
flap pedicle.
Nasojugal island flap
 Single stage mucochondrocutaneous flap from the nasojugal fold
STA Island Flap
Tunneled island flap – skin taken just anterior to the hairline
Based on STA/V
Posterior lamella reconstructed using mucoperiosteum from hard palate.
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Temporalis Fascial flap
 Used in complex deformities where other local options are unavailable
 May be used with fascial slings for lower lid support
Paramedian forehead flap
 most distal aspect of the flap is tacked to the lateral orbital rim to help maintain adequate support of the reconstructed lower eyelid.
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FULL THICKNESS UPPER LID RECONSTRUCTION
 The upper lid is responsible for 90% of eye closure and function is therefore important.
 Mustardé believes that because defects of the upper lid up to one-quarter of the lid
length may be closed primarily, the reconstructed lid need only be three-fourths as long
as the original.
< 25%
Primary closure.
25-66%
Usually too large for primary closure.
1. Lateral cantholysis of the superior crus of the lateral canthal tendon either alone (defect < 30%) or combined with Tenzel semicircular flap
(defect < 50%).
2. Mustarde lid switch
3. Bipedicle Tripier flap from loose peripheral skin of the upper lid combined with muscle may be used for marginal defects. Lining of the Tripier flap may consist of nasal chondro-mucosa, palatal mucosa or tarsal
graft from the opposite upper lid
66-100%
1. Mustarde Switch Flap
2. Cutler-Beard advancement flap from lower lid
Marginal
ie, for defects of the lid margin. Upper part of tarsus still intact.
Bipedicle flap may be useful:
i. anterior lamella (Tripier flap)
ii. FT (anterior and posterior lamellae) flap.
 Otherwise, posterior lamella advancement (upper tarsus pedicled on
conjunctiva or conjunctiva and Muller’s muscle).
If anterior lamella flap, posterior lamella reconstructed with graft from nasal chondro-mucosa, palatal mucosa or tarsal-conjunctival graft.
If posterior lamella flap, anterior lamella can usually be reconstructed by
inferior advancement of lax upper lid skin.
Significant FT defects of the upper eyelid usually required reconstruction with FT
tissue from the lower eyelid (Mustarde lid switch or Cutler-Beard bridge flap) and
subsequent reconstruction of the lower lid. Marginal defects can be reconstructed
with tissue from higher up in the lid, either brought down as a bipedicled flap or as
a flap advanced on conjunctiva + Muller’s muscle.
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Mustarde lid switch (like an Abbe)
 First introduced by Esser (1919).
 Lower  upper. Based on marginal a. which runs 3-4 mm below the lid margin. The
pedicle should therefore be 5-6 mm in vertical height.
 The flap should consist of more than a 1/4 of the length of the lower lid so that the flap
can be adequately manipulated.
 Once transposed, the tarsus of the flap must be sutured to that of the native lid and to
the levator. Orbicularis and skin are closed.
 2-4 weeks later the pedicle of the flap is divided, the flap is inset and the lid margins
are revised.
 The method of reconstruction of the lower lid defect that occurs on division of the pedicle of the lip switch, depends on whether the defect is small or large.
 If small, lower lid is reconstructed during the 2nd op with a lateral canthotomy and cantholysis. If the lower lid defect is large (as it usually is), a composite graft and advancement of a large cheek flap is done.
Where to place the hinge - medially or laterally?
 The hinge can be either lateral or medial.
 According to McC, it is usually best to place the hinge on the side with the largest
remnant of upper lid. If there is no upper lid remnant, one must weigh up the pros and
cons.
 Pros and cons of medially vs laterally based flaps:
1. The blood supply of medially based flaps is better, especially since a cheek advancement flap from laterally is used for the lower eyelid defect.
2. The lateral pedicle is based on the temporal and canthal portions of the cheek advancement flap, whose blood supply is random
3. Laterally based flaps can have the lower lid mostly reconstructed at the first stage
making the 2nd stage a relatively minor procedure of division of pedicle and flap inset. Medially based flaps usually require the lateral cheek advancement reconstruction to be done as part of the 2nd stage and thus both stages are relatively big.
4. Laterally based flaps trace a smoother arc than medially based flaps.
 McC prefers laterally based flaps; the authors of SRPS medially based flaps because of
better blood supply.
 The upper lid tends to remain oedematous for a few weeks following transfer, but has
a stable margin and firm support.
 Advantages:
like tissue to replace the missing eyelid
large horizontal defects with significant vertical components can be repaired
the upper lid margin is duplicated precisely in the transferred margin of the lower lid,
for a continuous, smooth line at the leading edge of the lid
the period of occlusion is minimized.
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Cutler Beard Advancement flap
 Full thickness advancement flap from lower lid, preserving the lower lid margin and
tarsus
 Best for shallow FT defects of the upper lid (marginal defects).
 The defect is marked on the lower lid, 5 mm below the lid margin in order to preserve
both the tarsal plate and the marginal artery.
 Tarsal plate is therefore not transferred with the flap which may be problematic later as
the reconstructed upper lid lacks structural support and tends to retract.
 Because the reconstructed upper lid lacks support, entropion can develop. For this reason the flap has been modified to include skeletal support as a free graft of either autogenous cartilage or preserved sclera.
 The lower lid flap is outlined: full thickness of lid is taken; upper, medial and lateral
margins are incised. The flap is pedicled inferiorly and advanced deep to the retained
5 mm bridge of lower lid margin. To inset the flap into the upper lid defect suture it in
layers.
 The pedicle of the flap is divided at the 2nd stage done 6-8 weeks later. The upper lid
conjunctiva must be rotated over the free lid margin to prevent the skin on the outer
surface of the lid from coming into contact with the globe.
 The unused flap (that bit that passes under the bridge) is inset back into the lower lid
donor defect. The TE effect on the flap prevents later lower lid retraction.
Disadvantages
1. Eye remains occluded between stages (6-8 weeks)
2. Lack of tarsal support in flap (unless modified to include a graft)
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Composite Lid Grafts
 A composite FT graft can be taken from an unaffected lid to close defects of a lid, provided that the donor lid is not left with a defect.
 All layers must be sutured which can compromise vascularity of the graft.
 Best for more vertical rather than horizontal defects.
Lower lid tarsoconjunctival flap
 Hughes flap in reverse
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LATERAL CANTHUS RECONSTRUCTION
 Skin cancers in this region, because it is an embryol line of fusion, tend to be more aggressive and wide local excision must be ensured.
 Small defects can be closed by direct approximation.
 If residual defect  later lateral canthoplasty.
 If the defect is larger and involves both the upper and lower lids at the lateral canthus,
other methods must be considered:
1. Tarso-conjunctival flap from upper lid can be rotated-advanced into a lateral canthal lid defect and is the preferred method of closure.
2. Turnover flap from the periosteum and superficial tissues of the lateral orbital
margin can provide additional lateral support.
 Skin cover is obtained with either undermining and advancement, a rotation flap or a
skin graft.
MEDIAL CANTHUS RECONSTRUCTION
 Skin cancers in this region are frequently insidious, recognised late and inadequately
treated.
 The anatomy of the medial canthal region is more complicated than that of the lateral
canthal area:
1. lacrimal canaliculi, sac, etc
2. medial canthal tendon
3. caruncle
 Surgery here is therefore more complicated.
 Often there is complete or partial loss of these specialised structures as well as loss of
conjunctiva, tarsus and skin. The defect frequently extends down to periosteum.
Tarso-conjunctival flap from upper lid
 Flap advanced into the defect for lining and support.
 Transnasal wires attach the stump of the MCL to the flap.
 Cover is with FTSG as the nasal skin advances poorly.
 Tarsorrhaphy is done to splint the area.
 6 weeks later the FTSG is split to open the palpebral fissure.
 The lacrimal drainage system is extremely difficult to reconstruct. Silicone stents can
be left in place. Frequently, patients have post-op epiphora.
Glabellar V-Y advancement-rotation flap
Inverted V from medial end of eyebrow contralateral to defect up, and then continue
down to below eyebrow to defect.
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MEDIAL CANTHOPLASTY
 Complex anatomy.
 MCL formed from:
1. medial extension of upper and lower tarsus
2. medial portions of superficial and deep parts of orbicularis oculi muscle
 The lacrimal drainage system is intimately related to the area.
 To perform a proper medial canthoplasty, transnasal wiring through a large bony opening after a 360o release of the periorbita must be performed.
LATERAL CANTHOPLASTY
 Lateral canthus is more correctly termed the lateral retinaculum.
 It consists of:
1. Lateral horn of the levator
2. The lateral canthal tendon of the orbicularis oculi muscle
3. The inferior suspensory ligament (Lockwood)
4. The check ligament of the lateral rectus muscle
 Attaches to Whitnall’s tubercle, a small promontory just within the lateral orbital rim.
Indications for lateral canthoplasty
Varied.
1. For lower lid ectropion (cicatricial, atonic, paralytic)
2. For lateral canthal dystopia (lateral canthus and eye  on that side)
3. Epiphora
4. Corneal exposure
5. Aesthetic lower eyelid surgery
Methods
1. McLaughlin lateral tarsorrhaphy
 For mild degrees of orbicularis oculi palsy and lagophthalmos.
 A triangle of the anterior lamella (skin, muscle and eyelashes) is removed from the lateral 1/4 of the lower lid (from the grey line muco-cutaneous junction down).
 A similar triangle is removed from the posterior lamella (conjunctiva and tarsus) of the
upper lid (from the grey line up).
 The lower lid is thus drawn under the upper, effectively tightening and elevating it.
 The lashes are preserved on the upper lid for camouflage of lateral lid adhesion.
 The palpebral fissure’s horizontal length is reduced by this procedure and the lateral
visual field may be reduced.
 The elevation of the lateral canthus is minimal and it may even move down.
 Because of these disadvantages, the procedure has been superseded by others.
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2. Kuhnt Szymanowski lateral canthorrhaphy
 Laterally the lid is split at the grey line into anterior
lamella of skin and muscle and posterior lamella of
tarsus and conjunctiva.
 Excess posterior lamella is excised centrally (original) or laterally (modification by Fox) and the conjunctiva and tarsus re-approximated.
 Excess skin and muscle are excised and closed.
 The lower lid is thus shortened to bring it into contact with the globe.
 Entropion and trichiasis (d/t lid splitting) can occur.
 may be combined with a diamond shaped excision
near the medial punctum to correct punctal eversion.
 tendency to create a more rounded lateral canthal
angle, which may result in lid notching, phimosis,
and further tension on the lateral canthal tendon
without appropriate reinforcement
3. Simple excision of lid excess (Bick, 1966)
 Removal of FT temporal aspect of the eyelid.
 Tends to blunt the lateral canthal angle.
4. Dermal pennant (Edgerton and Wolfert, 1969)
 A pennant-shaped flap of lateral canthal skin is raised, de-epithelialised and fixed
through a drill hole in the lateral orbital bony rim.
 To this procedure, Montandon (1978) added a lateral lid tarsorrhaphy (lateral 1/2 to 1
cm of lid) which reduces globe exposure and tightens the lids.
5. Lateral canthal suspension
 Can be done via a bicoronal, facelift, conjunctival or lateral canthotomy approach.
 Many variations exist. Usually the lateral canthal ligament is exposed via a lateral
canthotomy, the lower limb of the lateral canthal ligament divided (cantholysis) and repositioned.
 This advantageously corrects the lower lid without affecting the upper.
 Tenzel passed the lower limb of the lateral canthal ligament through the upper limb
and fixes it with a periosteal suture. This suspends and horizontally shortens the lower
lid without blunting the angle of the lateral canthus.
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 particularly useful in correcting a negative vector relationship (when the globe is anterior to the lower eyelid and malar eminence) and for prevention of rounding of the lateral canthus, bowing of the lateral lower lid, and scleral show.
 Marsh and Edgerton used a pennant of periosteum to fix the lower limb of the lateral
canthal ligament.
6.
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Tarsal strip (Hamako and Baylis, 1980)
The amount of suspension and elevation is estimated.
A lateral canthotomy is done and the LCL is exposed.
As much of the lateral tarsus is exposed as is required. Skin, orbicularis and conjunctiva are stripped and the tarsus is divided laterally.
The tarsus is passed deep to the superior crus of the LCL and sutured to perisoteum.
A superiorly based lateral periosteal flap can be raised to secure the repair.
If there is associated vertical deficiency of the lids, this may need to be filled with an
autologous auricular or septal cartilage graft or a lateral canthal dermal flap which has
been de-epithelialised.
This is probably the procedure of choice as it allows great flexibility and control in the
reconstruction.
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 Some important points (regarding lateral canthoplasty in general) must be borne in
mind:
1) The lateral canthotomy approach is via a horizontal incision in the lateral canthus.
2) The lower lid is elevated to cover the lower 1-2 mm of the limbus.
3) The level of fixation to the periosteum is at the upper level of the pupil in the
neutral position.
4) As the lateral canthus is elevated, the incision line will be elevated medially
and slope away laterally. If bilateral lateral canthoplasties have been done, the
angle of this slope must be the same on both sides.
Reconstructing the lateral canthus
 Y graft of palmaris longus tendon has been used (Bachelor and Jobe, 1980).
 Temporalis fascia (for lateral canthal ligament and lower eyelid, Holt, 1984).
REFERENCES
1. McC
2. Collin
3. SRPS 7(14), 1994
4. Mustarde, Reconstruction of the Eyelids. Ann Plast Surg 11: 149-169, 1983.