Surgical techniques employed for reconstruction of lower eyelid defects involving the margin must involve repair of both the anterior and posterior lamella with the goal of re-establishing the native relationship of anterior and posterior lamellae.
Defects involving up to half of lower lid
- Primary closure ("wedge repair") with or without internal cantholysis (and canthotomy) allowing medial mobilization of the lateral eyelid
- Lamellar repair/sutures of posterior lamella for strength
- Interrupted sutures to repair anterior lamella with care taken to override anterior lamella slightly over the posterior lamella and evert the defect, which will retract or flatten with healing
- Primary lamellar closure of the posterior lamella with extending a subciliary incision of the anterior lamella incorporating the defect.
- Then repair of the anterior lamella by using interrupted sutures to reoppose the anterior lamella to the posterior lamella, "distributing" any redundancy of the anterior lamella along the repaired posterior lamella.
- This avoids the redundancy of anterior lamella noted with "wedge repair."
- Exceptions in size may be made based on the laxity or lack of laxity of the lower eyelid skin.
Defects involving 2/3rds–3/4ths of lower lid
As always, repair must involve repair of both the anterior and posterior lamellae, re-establishing this relationship.
- Hughes and modified Hughes flap (tarsoconjunctival flaps from the upper eyelid)
- Method: An upper eyelid flap of tarsus and conjunctiva (posterior lamella) in conjunction with a skin graft or myocutaneous advancement flap (anterior lamella) is used to repair the lid defect.
- Advantages:
- Similarity of tissue to native lower eyelid
- Ability to repair larger defects
- Good vascular supply
- Disadvantages:
- Typically involves closure of the operative eyelid/occlusion of the eye for 4 weeks
- However, more recent literature supports earlier severing of the flap as soon as 7 days or 2 weeks.
- May require a skin graft, 2-stage procedure, postoperative erythema of the lower eyelid, and upper eyelid retraction and/or kinking
Figure 1. Hughes flap 1 of 4. Image courtesy Gregory J. Griepentrog, MD.
Figure 2. Hughes flap 2 of 4. Image courtesy Gregory J. Griepentrog, MD.
Figure 3. Hughes flap 3 of 4. Image courtesy Gregory J. Griepentrog, MD.
Figure 4. Hughes flap 4 of 4. Image courtesy Gregory J. Griepentrog, MD.
Figure 5. Free tarsoconjunctival. Image courtesy Michael J. Hawes, MD.
Figure 6. Hughes flap. Image courtesy Michael J. Hawes, MD.
Figure 7. Hughes preoperative. Image courtesy Rona Z. Silkiss, MD, FACS.
Figure 8. Hughes intraoperative. Image courtesy Rona Z. Silkiss, MD, FACS.
Figure 9. Hughes postoperative. Image courtesy Rona Z. Silkiss, MD, FACS.
Figure 10. Merkel Hughes preoperative. Image courtesy Rona Z. Silkiss, MD, FACS.
Figure 11. Merkel Hughes postoperative. Image courtesy Rona Z. Silkiss, MD, FACS.
- Hewes flap (tarsoconjunctival pedicle flap; temporal advancement flap)
Video 1. Video courtesy Michael J. Hawes, MD.
- Method:
- A tarsal transposition procedure that involves a transposition of conjunctiva and tarsus, hinged at the lateral canthal tendon, into a lateral lower eyelid defect
- Anterior lamella is reconstructed by an advancement skin-flap.
- Advantages:
- Does not require closure of the operative eyelids/occlusion of the eye
- Single stage procedure
- Excellent tissue match
- Disadvantages:
- Best suited for lateral eyelid defects but able to be used for central or medial defects when the lateral lower eyelid is preserved
- Rounding of lateral canthus
- Postoperative ectropion, particularly if the flap is too long
- Tenzel flap — semicircular rotational flap
- Method:
- A skin and muscle incision is begun at the lateral canthus and curves superiorly and temporally in a semicircular fashion.
- A lateral canthotomy is performed beneath the flap and the inferior portion of the lateral canthus is cut. This allows medial mobilization of the lateral eyelid and the margin defects and lateral canthus are repaired by primary closure.
- Advantages:
- Able to repair medial defects
- Good tissue match
- Able to provide more length due to the circumferential incision line
- Superior tension on the eyelid
- Palpebral fissure is open postoperatively
- No contralateral donor site
- Disadvantages:
- Best suited for central defects 1/2 to 3/4 of the eyelid, but can be combined with other techniques to repair all aspects of the lower eyelid
- Possible lateral canthal webbing, ectropion, lid notching, symblepharon, and tissue fullness of the lateral lid
- Unipedicle flap
- Method:
- Full-thickness unipedicle flap from the upper tarsal portion of the upper eyelid
- Best suited for shallow defects of the temporal lower eyelid
- Advantages:
- One-stage, single-pedicle, replacement of loss of tissue with identical tissue — skin, orbicularis, tarsus, conjunctiva
- Avoidance of upper eyelid retraction by graded recession of the levator and Muller's muscle
- Pedicle suspends and supports the eyelid, resulting in a decreased incidence of lower eyelid retraction, laxity, and ectropion (similar to Hughes).
- Open palpebral fissure postoperatively
- Disadvantages:
- Theoretical risk of upper eyelid retraction limited by levator and Muller's muscle recession
- Notching of the lower lid less ideal for medial defects
- Autologous graft
- Anterior lamella must be reconstructed from tissue with sufficient blood supply (flaps) to nourish the posterior lamella such as skin and muscle from the cheek and temporal regions, the mid-forehead, or the upper eyelid
- Must fixate to the periosteum if no tarsus remains medially or laterally
- Advantage: good support
- Disadvantages:
- Requires additional donor site and surgery for the patient
- Generally thick and immobile, providing less desirable eyelid function and cosmesis postoperatively
- Free tarsus: Medial can be combined with nasal-based, skin-muscle, pedicle flap, central or lateral lower eyelid defects.
Video 2. Video courtesy Michael J. Hawes, MD.
- "Sandwich technique":
- The orbicularis muscle adjacent to the defect is mobilized and the inner surface is covered by a free tarsoconjunctival graft from the ipsilateral or contralateral upper eyelid.
- The outer surface is covered with a free skin graft from the ipsilateral or contralateral upper eyelid.
- Nasal cartilage (fixate to periosteum if no tarsus remains, used with Mustarde cheek-rotational
- Auricular cartilage
- Hard palate
- Nonautologous (synthetic)
- AlloDerm — acellular, human dermal graft
- Permacol — biomaterial made from acellular, cross-linked, porcine dermal collagen
- tarSys — ideal for repair of retraction
Defects involving entire lower lid
- See previous section for details on method, advantages, and disadvantages.
- A Hughes tarsoconjunctival flap can be used in some cases, but the upper eyelid tarsal plate is narrow medially and laterally in most patients, and if medial and lateral canthal defects are simultaneously present, a tarsoconjunctival flap might not be able to span the defect, however, a combination of techniques can be employed.
- Autologous grafts: See previous section.
- Bipedicle full-thickness, upper-eyelid flap from the upper eyelid into lower eyelid anterior lamella defect
- Intraoperative adjustment of the donor eyelid height is performed by recessing the levator aponeurosis, which is necessary to avoid postoperative upper eyelid retraction.
Defects involving lacrimal system
- Assess for preservation or disruption of punctum, canaliculus, lacrimal sac intraoperatively by probing and irrigating (can use fluorescein for improved visualization)
- If disrupted, place
- Bicanalicular stent such as the Crawford stent through the entire nasolacrimal system
- Bicanalicular "donut" stent if a common canaliculus is present and no disruption distal to the common canaliculus
- Mini Monoka or other unilateral stent if only disruption of the lower system and unable to place other stents
- Repair remaining canaliculus with pericanalicular, absorbable sutures such as 7‑0 Vicryl.
- Repair eyelid as described above with the goal of re-establishing native relationship of anterior and posterior lamella and eyelid to facilitate drainage through the recreated lacrimal system.