The following discussion of eyelid reconstruction applies to defects resulting from tumor resection as well as congenital and traumatic defects. Several techniques may be appropriate for reconstruction of a particular eyelid defect. The choice of procedure depends on multiple factors, including the patient’s age and comorbidities, the condition of the eyelids, the size and position of the defect, and the surgeon’s personal preference. Priorities in eyelid reconstruction are
Eyelid Defects Not Involving the Eyelid Margin
Defects not involving the eyelid margins can be repaired by direct closure if the repair does not distort the eyelid margin. If undermining of the surrounding tissue does not allow direct closure, advancement or transposition of skin flaps may be used. The tension of closure should be directed horizontally, because vertical tension may cause eyelid retraction or ectropion. Vertical tension may be avoided by placement of vertically oriented incision lines.
If the defect is too large to be closed primarily, techniques utilizing advancement or transposition of local skin flaps may be employed. The flaps most commonly used are rectangular advancement, rotation, and transposition. Flaps usually provide the best tissue match and aesthetic result, but they require planning in order to minimize secondary deformities. Upper eyelid skin is often an acceptable option for lower eyelid anterior lamellar defect repair. The final texture, contour, and cosmesis are typically better with flaps as compared to skin grafts from sites other than eyelid skin.
Anterior lamella upper eyelid defects are best repaired with full-thickness skin grafts from the contralateral upper eyelid (Fig 11-8). Preauricular or postauricular skin grafts may be used, but their greater thickness may limit upper eyelid mobility. If flaps are not sufficient, lower eyelid defects are best filled with preauricular or postauricular skin grafts. If skin is not available from the upper eyelid or auricular areas, full-thickness grafts may be harvested from the supraclavicular fossa or the inner upper arm. Grafts should be slightly oversized, because contraction is likely to occur.
Use of split-thickness grafts should also be avoided in eyelid reconstruction. They are recommended only in the treatment of severe facial burns when adequate full-thickness skin is not available.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.