PR47 COMPREHENSIVE EYELID RECONSTRUCTION (2007)

Introduction The central focus of eyelid reconstruct is the reconstitution of a dynamic protective covering for the cornea. The key to successful eyelid reconstruction is to properly assess the size of the defect and to separate the complex defect down into component parts or subunits. Since eyelid tissues retract in the presence of discontinuity, the residual lid margin has to be distracted under normal tension in order to assess the true size of the defect. In surgical planning, one must also assess the amount and location of inner and outer lamellar tissue absent. The inner lamella represents the conjunctiva, the tarsal plate, and the tarsoligamentous sling. The primary function is to provide lining and support to the lid. The most important region to reconstruct the inner lamella, the conjunctiva in particular, is centrally over the cornea in the upper lid. The outer lamella is represented by the skin and orbicularis oculi muscle. In the upper lid, the outer lamella has functional importance by enabling the dynamic blink to protect the cornea and prevent exposure. Small reconstructions may be carried out as a single stage, larger ones may require more than one stage. The fundamental principle is to utilize the following techniques for defects of increasing complexity and/or size 1) primary closure, 2) adjacent tissue, 3) lid sharing, and 4) regional or distant flap. Methods/Technique Depending on the size of the defect, direct closure may be possible. Upper lids with a defect of 1/3 or less of the horizontal length can be closed directly. The criteria for lower lid direct closure is 1/4 to 1/3 of the horizontal length. Closure under too much tension will cause mechanical ptosis in the upper lid and lid retraction in the lower lid due to the close line effect. A selective (upper or lower) canthotomy will provide an additional 3–4 mm of length through tissue recruitment. The next order of reconstruction is the semicircular Tenzel skin muscle flap. This option is for subtotal defects greater than 1/3. Depending on the design, this flap can be used for upper or lower lid defects. By recruiting lateral tissue, end‐to‐end closure of the wound is achieved centrally, while the original defect undergoes lateralization. The absence of lashes laterally is better tolerated than centrally. The next order of reconstruction involves lid sharing. Upper lid tissue used for lower lid reconstruction includes the Hughes flap which shares a part of the upper lid tarsal plate and conjunctiva. Total upper lid reconstruction uses the lower lid Cutler‐Beard flap with ear cartilage to replace missing tarsal plate. Both the Hughes procedure and the Cutler Beard Bridge Flap are two‐stage procedures that are divided 2 weeks after the initial lid sharing. The visual axis is obstructed for two weeks until the bridge is divided. The Hewes’ flap is a single stage reconstruction lid sharing for lower lateral defects. It is based on the superior vascular arcade. Distant flaps such as the Tripier, Fricke, and forehead or glabelllar flaps are used for large defects when other options are not possible. Results Over the past 12 years 218 eyelid reconstructions were performed. 75% were cancer related and 25% were trauma related. 50% were secondary reconstructions referred from other surgeons. The average age of the patients was 60 evenly distributed between males and females. 90% of the cancer related defects were created by a Moh’s surgeon. Upper lid defects represented 25%and lower lid defects represented 75%. The distribution of procedures used is as follows: 25% direct closure (selective canthotomy was often employed for direct closure), 40% Tenzel flap, 15% lid sharing flaps, 10% Hewes flaps, and 10% distant flaps. Mucosal grafts were required for secondary cases of the upper lid. 10% of patients required a revision surgery (other than planned bridge division). The most frequent complications were lid malposition, excess lateral orbital skin, and need for lacrimal reconstruction with DCR, Jones’ tubes or Crawford tubes. Permanent corneal damage or rupture was prevented in all cases. Conclusion Eyelid reconstruction simplified by breaking complex defects into their component parts. Algorithmic linkage of reconstructive method to shape and size of defect also assist with consistent successful results. Eyelid reconstruction balances the functional result of the reconstructve procedures as well as the aesthetic result in order to minimize morbidity.