Primary goals

• Re-establish functional integrity of the eyelid
• Good aesthetic result is desired, but secondary to eyelid function
• Provide adequate eyelid closure
• Protect the cornea and ocular surface
• Provide a smooth, epithelialized internal eyelid surface
• Ensure no lagophthalmos and complete closure of eye

Secondary goals

• Maintain normal eyelid movement and function
• Restore normal eyelid appearance
• Restore/preserve eyelashes
• Avoid distortion of major facial anatomical features, eyelid margin, medial and lateral canthi, if possible
• Provide adequate vertical eyelid tissue to protect cornea
• Provide adequate horizontal eyelid tissue
• Minimize vertical tension to avoid upper or lower eyelid retraction or ectropion with ocular exposure
• Maintain sufficient and anatomic medial and lateral canthal fixation

Indications

• Full-thickness eyelid defects following tumor resection or trauma
• Congenital coloboma
• Full-thickness eyelid margin defects after floppy eyelid surgery

Contraindications

• Relative
• Medical contraindications to anesthesia
• Recent external beam radiation
• Absolute
• Active soft tissue infection

Patient history

• Etiology of the defect
• Other medical conditions
• Diabetes mellitus
• Post radiation
• Smoking history
• History of self-trauma
• Medications (including anticoagulants, vitamin/herbal supplements, and immunosuppressives)
• Monocular status
• Keratoconjunctivitis sicca

Clinical examination

• Ocular evaluation
• Facial nerve function (orbicularis muscle function)
• Size and depth of tissue defect
• Laxity of adjacent tissue to determine ability to advance remaining eyelid tissues to close the defect
• Corneal and tear film integrity, tear meniscus
• Corneal sensation
• Involvement of lacrimal system
• Verify integrity of lacrimal outflow system
• Evaluation for potential skin graft donor sites
• Other eyelids
• Retro-auricular
• Preauricular
• Supraclavicular

Preoperative assessment

• Blood thinners, including bridging therapy
• Diabetes
• Cardiac and pulmonary history
• Smoking history
• Medical clearance

• Temporary patching to protect the cornea
• Tarsorrhaphy
• Suture
• Permanent
• Healing by secondary intention
• Only useful in upper lid if posterior lid margin remains intact

• Standard surgical instruments for eyelid and facial surgery
• Local, intravenous (IV) sedation or general anesthesia

Basic principles of eyelid reconstruction

• Choose the simplest technique
• Must reconstruct 2 (or 3) layers of the eyelid
• Anterior lamella
• Skin
• Orbicularis muscle
• Posterior lamella
• Conjunctiva
• Middle lamella
• Tarsus
• At least one layer (anterior or posterior) must supply blood supply from the adjacent tissue
• Skin flap
• Conjunctival flap
• Exception: composite graft
• "Full" thickness eyelid graft
• Orbicularis "bucket handle" can be used in some cases to provide vascular supply
• Attempt to preserve or reconstruct lashes whenever possible
• Determination of sufficient horizontal laxity for direct closure
• With 2 forceps, pull the opposing lid margin edges together
• If unable to bring together with minimal tension, proceed to additional reconstructive techniques (see below)
• Gentle hemostasis with bipolar and/or thrombin. Minimize coagulation at the base of any pedicle or advancement flaps in order to avoid flap necrosis.
• Gentle tissue handling without crushing flap edges
• Secure the base of the advanced flap in order to minimize tension on the edges of the flap-wound closure
• Interrupted sutures are preferable for most skin closures
• Partial-thickness bites for re-approximation of the tarsus are necessary to avoid suture irritation of the eye
• Younger patients (< 7 years) may require alternate flap design to prevent occlusion amblyopia; free tarsal conjunctival graft with orbicularis muscle skin flap

Approach based on defect size, surrounding tissue laxity

• < 25%: direct closure
• 25%–50%
• Lateral canthotomy/cantholysis with direct closure
• Periosteal flap to anchor tissue laterally if needed
• Composite graft
• With or without cantholysis
• With skin flap or orbicularis flap
• 50%–75%
• Combine above with Tenzel semicircular flap
• Local rotation skin flaps with posterior lamellar graft (i.e., hard palate)
• Temporal based bilobed flap
• Midline or paramedian forehead flap
• > 75%
• Modified Cutler-Beard flap
• Mustarde flap with rotation to upper lid
• Isolated lid margin rotation flap
• For reformation of upper lid margin with lashes in cases of shallow excisions
• Also for second- or third-stage reconstruction of the lid margin/lashes

Direct closure (< 25%)

• Reapproximation of the eyelid margin anatomical landmarks is essential.
• Eyelid margin closure with 2 or 3 sutures through the eyelash line and gray line
• Sutures secured anteriorly will avoid corneal abrasions.
• 6‑0 silk left long and anchored away from lid margin with an additional suture
• Absorbable sutures can be considered in infants and children or when avoidance of suture removal is preferred.
• Buried vertical mattress sutures using 6‑0 or 7‑0 vicryl provide both strength and wound edge eversion.
• Must see "eversion" of tissue edges at time of closure
• If not, the lid margin will eventually form a notch or divot
• If inadequate tissue eversion is observed, a vertical mattress suture is helpful.
• Proximal bites should be 1.5–2 mm from the wound edges.
• Distal bites should be 3–4 mm from the wound edges.
• Suture should exit/enter the deeper aspect of the wound equidistant from the lid margin distance.
• Can place as a buried stitch with a fast-absorbing 6‑0, or 7‑0 vicryl or similar suture
• Often 1 vertical mattress can be combined with additional external closures (i.e. 6‑0 silk) for additional contouring of the lid margin.
• Tarsal plate suture closure with interrupted partial-thickness absorbable sutures, not extending through the conjunctival surface
• After tarsal closure, examine the posterior (conjunctival) surface of the eyelid to confirm that the tarsus has been adequately reapproximated.
• If a large "gap" is visible, reposition the tarsal sutures.
• Orbicularis muscle closure with absorbing sutures (i.e., 6‑0 vicryl)
• Skin closure with interrupted, absorbable, or nonabsorbable sutures
• Close from lid margin upward.
• Rarely excise any dog-ear with a small burrows-triangle at distal end of closure.

Lateral canthotomy/cantholysis (25%–50%)

• Useful when wound is under slightly too much tension for direct closure
• Perform standard lateral canthotomy with superior
• Direct closure as above
• Can reform new lateral canthal angle with a buried absorbable polyglactin suture (optional)
• Lateral canthal skin closure with absorbable suture
• Do not initiate lateral canthotomy in larger defects that may require a semicircular flap (see below).
• In these instances, the semicircular flap should be fashioned first, then cantholysis is performed deep to the flap dissection plane.

Periosteal flap (25%–50%)

• Useful when lateral canthotomy/cantholysis is being performed and there is inadequate lateral tension during closure
• Such as if lateral upper lid not showing appropriate contour to the globe
• Limited use in upper lid reconstruction; may result in abnormal lateral contour
• Internally based flap shaped as a horizontal rectangle over the lateral orbital rim
• Periosteal flap remains attached inside orbital rim.
• Take care to make the flap of adequate size vertically, as the flap is often much smaller and may rip once elevated off bone.
• Standard dissection down to lateral orbital rim
• Crucial to avoid violating periosteum
• Mark the periosteal flap with a marking pen.
• At least 5–8 mm in vertical height
• 10–15‑mm length
• Keep base wide and anchored at the orbital rim.
• Incise with 15 blade, cutting cautery, or other incisional device.
• Elevate flap carefully with periosteal elevator.
• Extend incisions over and inside the orbital rim for 3–5 mm.
• Additional flap elevation with periosteal elevator
• Anchor the periosteal flap to the lateral lid tissue with buried absorbable suture.
• In cases of a larger periosteal flap, consider a free tarsoconjunctival graft or donor tissue graft (i.e., acellular human dermis) to reconstruct a smooth posterior surface.
• If performed, this graft should be placed posterior to the periosteal flap prior to periosteal flap attachment.

Composite eyelid graft (25%–50%)

• Graft allows reconstruction of lid margin with lashes and without necessitating temporary lid closure.
• Graft is harvested as a "full-thickness" graft from one of the other eyelids.
• Can be ipsilateral or contralateral
• Can be from upper or lower lid if contralateral
• Graft size should be chosen based on lid laxity at donor site.
• It will be smaller than the recipient site.
• The remaining tissue loss of the recipient site will be managed with tissue laxity and relaxing procedures as above.
• Canthotomy/cantholysis, etc. as indicated
• Donor site closure as described for standard lid margin reconstruction
• The graft cannot survive "full-thickness."
• Must debulk either skin or orbicularis to allow vascular perfusion from recipient bed
• Lid margin (including lashes), tarsus, and conjunctiva remain
• Suture debulked graft into recipient bed with standard full thickness repair (lid margin and tarsus) as outlined above
• Perform at both medial and lateral edges of the graft.
• Bring in either skin or orbicularis from surrounding recipient bed.
• Local skin undermining/advancement if needed
• Vertical relaxing orbicularis cuts if needed
• Skin closure as previously described

Tenzel semicircular flap (50%–75%)

• Best when defect size is closer to 50%
• For upper lid, semicircular flap is based superiorly, i.e., the flap curves inferiorly with the attached base superior.
• Mark the flap.
• Size considerations based on defect
• To avoid iatrogenic damage to the facial nerve branch as it crosses over the zygoma, the chord length of the flap should not exceed 20 mm from the lateral angle.
• Wide tissue undermining including surrounding tissue
• Gentle but complete hemostasis
• When needed, lateral cantholysis, release of lateral orbitomalar ligaments, and/or periosteal flap as described above
• Reconstruct posterior lamella with free tarsoconjunctival graft or donor tissue (i.e., acellular human dermis)
• Suture into lateral edge of lid margin defect.
• Anchor periosteal flap when indicated.
• Suture or fixate posterior lamella with fibrin sealant to underside of semicircular flap.
• Skin closure
• Mixture of absorbable and permanent sutures
• Adjust flap to minimize skin tension.
• 5‑0 suture at cardinal anchor points
• 6‑0 suture remaining closure
• Interrupted closure

Local rotation flaps (50%–75%)

• See flap formation and principals in related sections.
• These flaps (especially forehead) are thicker than the normal upper lid tissue.
• Distal portion of the graft can be thinned as needed.
• May require staged debulking over time
• Most are insufficient for upper lid reconstruction involving the lid margin.
• Posterior lamella needs to be reconstructed with a free tarsal graft or donor dermal tissue to avoid damage to the cornea.

Modified Cutler-Beard procedure (> 75%)

• The original procedure involved placement of a middle lamellar layer during second-stage reconstruction
• Modified approaches place the middle lamellar graft at the time of the primary procedure.
• The donor flap is marked on the lower lid.
• Mark horizontally 4–5 mm beneath the lid margin.
• Alternatively, the tarsal height can be measured on the posterior lower lid with calipers and that measurement transposed to the anterior eyelid.
• Vertical skin markings should maintain a wide base inferiorly.
• 4‑0 silk traction suture centrally
• Begin horizontal incision on the posterior aspect of the eyelid (just inferior to the tarsus).
• Gentle hemostasis (bipolar preferred)
• Continue the horizontal incision on the anterior eyelid.
• Through skin and orbicularis
• Connect with the posterior subtarsal dissection plane.
• Vertical relaxing incisions full thickness
• Divide the flap into anterior and posterior lamella.
• Skin and orbicularis anterior
• Conjunctiva posterior
• Advance both lamellae of the flap beneath bridge of lower lid margin toward the upper lid defect.
• Additional dissection (anterior and/or posterior lamella) as needed to bring the flap edge into the recipient bed under minimal tension
• Prepare the recipient bed.
• When possible, identify and partially dissect the levator aponeurosis/muscle from the superior aspect of the recipient bed.
• Suture the conjunctival flap into the recipient bed conjunctival edges with interrupted absorbable sutures.
• Try to minimize the amount of exposed suture that will be in contact with the ocular surface, i.e., as "partial thickness" as possible
• Whenever identified, suture the lower lid retractors/capsulopalpebral fascia from the leading edge of the advancement flap to the levator complex
• Harvest, size, and place a middle lamellar graft or donor tissue.
• Graft options
• Ear cartilage
• Nasal septal cartilage
• Autologous dermis
• Acellular dermal graft (Ophthal Plast Recon Surg 2005; 25:426-429)
• Other donor dermal tissue
• Achilles tendon (Ophthal Plast Recon Surg 2005, 267-70)
• Suture the superior aspect of the graft to the previously identified levator muscle/aponeurosis with absorbable suture.
• Suture the nasal and temporal edges to the recipient bed tarsus with partial-thickness absorbable suture.
• Suture skin and orbicularis into recipient bed.
• Additional dissection to minimize tension
• If needed, can dissect out an additional plane of orbicularis to suture separately into recipient orbicularis
• Flap division at 4–6 weeks
• Longer in smokers, diabetics, et al.
• Considerations
• If standard Cutler-Beard flap will not make a wide enough flap, the lateral canthal tendon may be released.
• Variations on the Cutler-Beard procedure
• Modified Cutler-Beard Flap with a free tarsal graft (> 75%)
• Free tarsal graft from contralateral upper lid (Eye, 2004).
• Follow steps above, but advance only the anterior lamella.
• Divide at 2 weeks.
• Secondary tarsoconjunctival graft (Ophthal Plast Recon Surg 2013, 227-30)
• "Traditional" first stage Cutler Beard without middle lamellar reconstruction
• At time of second stage division, divide the posterior conjunctival layer and allow to retract toward the superior fornix.
• Harvest a free tarsal graft from the contralateral upper lid and suture into the recipient bed.

Mustarde full-thickness rotation flap from lower lid (> 75%)

• Mark out a large Mustarde cheek and lower lid flap.
• Can be based medial or lateral (prefer lateral base)
• Large lateral semicircular flap base down (curve up)
• Surgically dissect Mustarde flap in standard manner.
• Will likely need to excise triangle of redundant tissue at most inferior aspect of flap
• Rotate the donor lid margin from the lower lid into the recipient bed of the upper lid.
• Prior to upper lid closure, assess the posterior surface of the rotated lower lid tissue.
• If significant exposure of "rough" tissue planes, consider conjunctival or mucous membrane grafting
• Donor tissue must rotate into recipient bed under minimal tension.
• Standard layered closure techniques as elsewhere
• If needed, second stage division and revision is performed after 4–6 weeks.

Unique and less-used reconstructive techniques

• Double composite grafts (50%–75%) (Ophthal Plast Recon Surgery 1985, 97-101)
• Refer to composite eyelid graft section above
• Choose 2 donor sites from any of the 3 uninvolved eyelids, i.e., if tumor is left upper lid, obtain grafts from 2 of the following: left lower lid, right lower lid, or right upper lid.
• Position the donor composite grafts (after skin removal) in the best anatomic position based on available tarsal height.
• Suture the grafts first to the adjacent recipient bed as described in composite eyelid graft section above.
• Suture the 2 grafts to each other centrally with standard lid margin followed by tarsal closure.
• Advance skin with local advancement flaps.
• Standard closure of full-thickness defects at all donor sites
• Helical composite sandwich graft (25%–75%) (Ophthal Plast Recon Surg 2002, 295-300)
• Composite donor graft from the helix of the ear
• Average graft size 20 x 10 mm in series of 13 patients
• Cartilage component of graft extends 3–4 mm beyond skin border of graft
• Improved vascularity and graft viability
• De-epithelialize skin of the inner curvature except for 2–3 mm that will form the new lid margin.
• Fashion a bipedicle conjunctival flap from the inferior fornix of the recipient eyelid.
• Suture the donor composite graft into the recipient bed in standard fashion.
• Advance the conjunctival flap over the deepithelialized tissue and suture to the new lid margin with 6‑0 plain gut suture.
• Close the donor site with a helical advancement procedure.
• Reverse modified Hughes procedure (> 75%)
• Leone described in 1983 a technique combining a tarsoconjunctival flap from the lower lid (started just inside the lower lid margin), brought into the upper lid defect to attach to the remaining upper lid tarsoconjunctival edge (Arch Ophthalmol 1983; 101(6):945-8).
• A skin graft was placed on the conjoined tarsoconjunctival flaps.
• The flap was opened at 4 weeks.
• Sa et al. described fashioning a tarsoconjunctival flap from the lower lid starting 2 mm beneath the lid margin (Ophthal Plast Reconstr Surg, 2010), i.e., 2 mm residual tarsus in the donor lower lid and 2–3 mm tarsus advanced into the upper lid defect.
• Suture the tarsoconjunctival donor flap with the tarsus at the upper lid margin.
• Relaxing incisions in the upper lid levator aponeurosis and suture to the superior edge of the tarsal flap
• Reconstruct anterior lamella with a local advancement flap or a full thickness skin graft.
• 17 patients included with average follow up of 23 months
• 5 secondary procedures performed
• Main concern would be inadequate tarsal support to both the donor lid as well as the recipient upper lid.

Postoperative instructions

• Avoid ice with any skin grafts.
• Some will avoid ice with local advancement flaps as well.
• Standard postoperative instructions
• Frequent artificial tear drops
• Avoid manipulating/rubbing the surgical site.
• Sleep with head elevated.
• Postoperative eye shield while sleeping
• Avoid strenuous exercise, bending, heavy lifting.

Medications

• Topical ophthalmic antibiotic ointment 2–3 times a day
• Some prefer combination antibiotic steroid ointment.
• Topical ophthalmic combination antibiotic/steroid drops
• In most cases with conjunctival involvement
• Oral antibiotics if surgical site patched or for extended operative time
• Gram positive or broad spectrum coverage
• Sulfamethoxazole/trimethoprim if concern for MRSA
• Oral narcotic combinations
• Monitor maximum doses of acetaminophen
• Avoid NSAIDS.
• Do not prescribe or prescribe lower dose if patient already taking narcotics.

Follow-up care

• Ocular evaluation with corneal and tear film inspection
• Suture removal
• Topical antibiotics
• Monitor patient for amblyopia, if coloboma repair in a young patient.

Intraoperative

• Hemorrhage
• Inadequate tissue to close the defect: will need to perform lateral canthotomy and superior cantholysis

Postoperative

• Infection
• Poor tissue approximation with eyelid margin irregularity
• Wound dehiscence or breakdown of tarsoconjunctival flap
• Corneal surface problems related to irregular eyelid margin and loss of tear film integrity
• Postoperative ptosis is usually secondary to edema and horizontal tightness and will often resolve.
• Corneal abrasion from lid margin sutures
• Lubrication
• Bandage contact lens
• Thickened, immobile upper eyelid
• Canthal distortion due to inadequate fixation or wound dehiscence
• Eyelid retraction with lagophthalmos and exposure keratitis

Prevention of complications

• Intraoperative control of hemostasis
• Diligent surgical technique with regard to wound tension and closure
• Confirm that marginal sutures are rotated away from corneal surface.
• Eye shield at night

Management of complications

• Infection
• Topical antibiotic ointment
• Oral antibiotics
• Culture
• Wound care
• Tissue loss/necrosis
• Gentle debridement
• Oral antibiotics
• Defer secondary repair as long as possible to avoid recurrence of tissue loss.
• Unless severe ocular surface exposure necessitates early repair
• Secondary reconstruction using principals outlined above
• Eyelid abnormalities (ptosis, ectropion, entropion, retraction, lagophthalmos)
• Defer secondary procedures for 3 months or longer whenever possible.
• Entropion will often need earlier repair if ocular surface compromised.
• Repair as described in respective sections.

(Ophthal Plast Recon Surg 1996; 103:s74-s95)

1837 Horner: triangular flap of cheek and upper lateral canthus to the lower lid

1870 Lawson: skin graft to correct ectropion

1875 Wolfe: skin graft from forearm to eyelid

1917 Filatov: tubed pedicle flap

1920's thru 1940's Wheeler: lid splitting, free skin grafts, lash grafting

1937 Hughes: lower eyelid reconstruction

1941 Mustarde: facial reconstruction flaps

1941 Mohs: Mohs micrographic technique

1951 Callahan: composite graft

1955 Beard: Cutler-Beard flap

1978 Tenzel: semicircular flap

1. AAO, Basic and Clinical Sciences Course. Section 7: Orbit, Eyelids, and Lacrimal System, 2013-2014.
2. AAO Monograph 8, Surgery of the Eyelids, Lacrimal System, & Orbit, 2nd edition, 2011.
3. Beyer-Machule C, Shapiro A, Smith B. Double composite lid reconstruction: a new method of upper and lower lid reconstruction. Ophthal Plast Reconstr Surg 1985; 1:97-102.
4. Hayek B, et al. Acellular dermal graft (AlloDerm) for upper lid reconstruction after cancer removal. Ophthal Plast Reconstr Surg 2005; 25:426-429.
5. Holloman E, Carter K. Modification of the Cutler-Beard procedure using donor Achilles tendon for upper eyelid reconstruction. Ophthal Plast Reconstr Surg 2005; 21:267-70.
6. Hsuan J, Silva D. Early division of a modified Cutler-Beard flap with a free tarsal graft. Eye 2004; 18:714-717.
7. Leone CR Jr. Tarsal-conjunctival advancement flaps for upper eyelid reconstruction. Arch Ophthalmol 1983; 101(6):945-8.
8. Patel B, Anderson R. History of Oculoplastic Surgery (1896-1996). Ophthal Plast Reconstr Surg 1996; 108:s74-95.Sa H, Woo K, Kim Y. Reverse modified Hughes procedure for upper eyelid reconstruction. Ophthal Plast Reconstr Surg 2010; 26:155-159.
9. Yildirim S, Gideroglu K, Akoz T. Application of helical composite sandwich graft for eyelid reconstruction. Ophthal Plast Reconstr Surg 2002; 18: 295-300.
10. Yoon M, McCulley T. Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure. Ophthal Plast Reconstr Surg 2013; 29: 227-230.