Continuing Education Activity
Proper function of the eyelids is necessary to maintain healthy globes. Patients with cancer or with traumatic injuries to the eyelids need special attention to preserve not only the cosmesis of the eyelids but also the function. This activity reviews the technique of lower eyelid reconstruction, its indications, contraindications, and potential complications.
- Review the anatomy of the lower eyelid.
- Describe the indications for lower eyelid reconstruction.
- Summarize the complications of lower eyelid reconstruction.
- Identify how care coordination among an interprofessional team to improve outcomes for patients undergoing lower eyelid reconstruction.
Proper function of the eyelids is necessary to maintain healthy globes. Patients with cancer or with traumatic injuries to the eyelids need special attention to preserve not only the cosmesis of the eyelids but also the function.
Anatomy and Physiology
An understanding of the anterior and posterior lamella of the eyelid is critical in eyelid reconstruction. The anterior lamella includes the skin and orbicularis oculi muscle, while posterior lamella includes the conjunctiva and tarsus. When reconstructing an eyelid, it is important to address reconstruction of both the anterior and posterior lamella. Free skin grafts or free tarsoconjunctival grafts can be used to replace either anterior or posterior lamella defects when they are attached to vascularized tissue, meaning free anterior or posterior lamella grafts can be performed only when the opposite healthy, and vascularized lamella remains. Free anterior and free posterior lamellar repairs are not commonly performed together because the vasculature would be compromised.
The most common eyelid skin cancer is basal cell carcinoma (BCC), which occurs more commonly on the lower eyelid. Eyelid cancer can be treated with carcinoma excision with frozen section control of the tissue margins, or alongside a Mohs surgeon to excise the lesion. Becuase of resection, lower eyelid reconstruction is a common problem faced in ophthalmic plastic surgery. Other types of cancers and trauma may also lead to lower eyelid defects. There are various techniques available for lower eyelid reconstruction, and these depend on the of the size of the defect as well as patient-specific factors.
It may be beneficial to work with a Mohs surgeon to excise a carcinoma thoroughly. Reconstruction by an oculoplastic surgeon should follow.
Small full-thickness eyelid defects, typically up to 25% of the width of the lid, can often be closed directly by opposing the two free edges. Direct closure typically requires closure in two layers, one layer to close the tarsus, and one layer to close the skin. The lid margin is usually closed with a horizontal mattress to provide wound edge eversion, to promote healing without a notch. In patients with very lax eyelids, sometimes larger defects may be closed in this fashion. For defects between 25% to 50% of the width of the lid, an option may include lateral canthotomy and inferior cantholysis to provide additional laxity, followed by direct closure. Lateral cantholysis allows the lateral lower lid to be stretched further medially to close a defect. A periosteal flap from lateral to the lateral orbital rim may also be performed to increase the amount of posterior lamella support, allowing a larger defect to be closed.
For medium-sized defects between 33% to 66%, a Tenzel semicircular musculocutaneous rotation flap beginning at the lateral canthus extending upward and laterally in a semicircular fashion may be used to recruit anterior lamellar tissue. The flap is then rotated into position over the eyelid defect. Although this flap addresses the anterior lamella defect (skin and muscle), it does not address the posterior lamella defect (conjunctiva and tarsus). A periosteal flap may be performed in conjunction to provide posterior lamella support and also to increase the ability to close a larger defect.
Finally, for large defects, a tarsoconjunctival flap, a Hughes procedure, may be performed for defects up to 100% of the lower eyelid. A tarsoconjunctival flap is a flap from the superior eyelid, including only a portion of the tarsus and conjunctiva, which is brought down and sutured into the lower eyelid defect. This provides a replacement for the posterior lamella. Commonly about 4 mm of the inferior tarsus of the lower lid is preserved, to maintain the stability of the upper eyelid. The anterior lamella can then be replaced by either local flaps if enough skin laxity is present, or with a full-thickness skin graft, typically from the upper lid. At the end of the surgery, a flap is present closing the upper and lower eyelids, usually leaving the patient unable to see out of that eye. A second stage procedure can then be performed typically around four to six weeks later to separate the lids, and to reform the eyelid margins. Alternatively, a Mustarde cheek rotation flap, similar to but larger than a Tenzel flap, can provide a larger anterior lamella replacement to reconstruct a larger lower eyelid defect.
Proper lower eyelid height and support are necessary to prevent post-operative ectropion and retraction. One may choose to perform a temporary tarsorrhaphy (to connect the upper to the lower eyelid) or a Frost suture tarsorrhaphy (to connect both eyelid margins to the brow) to further provide elevated support. If significant eyelid laxity is noted either pre-operatively or post-operatively, it may be necessary to perform an ectropion repair with a lateral tarsal strip procedure. This may be needed especially in conjunction with either a first or second stage Hughes procedure. This may also be necessary with a lower eyelid skin only defect, for example when a skin cancer excision does not include a defect of the posterior lamella if the lower eyelid is lax. Cicatricial changes with healing can sometimes predispose a lower lid to cicatricial ectropion.
Further, one may perform a mid-face lift to repair large defects of the lower eyelids and repair large anterior lamella defects. With this technique, the surgeon still needs the posterior lamella provided from either the upper eyelid (Hughes tarsoconjunctival flap) or possibly from hard palate graft to avoid closure of the eye, and then the anterior lamella will be provided via the mid-face.
Complications can include graft or flap failure, scar tissue formation, dehiscence, infection, ectropion, recurrence, irregular eyelid margins leading to foreign body sensation, dry eyes, and a need for further surgery to optimize eyelid structure and function.
Customizing reconstruction is necessary to provide the proper surgery for each patient. For example, eyelid laxity is a factor that can determine what procedures are possible and most beneficial for a patient. Other factors to consider are the age of the patient and status of the other eye. For example, a Hughes flap may be avoided in a child if possible, as blocking vision for 4 to 6 weeks may lead to deprivation amblyopia if a child is in the amblyogenic age. Similarly, if a patient is monocular, and is unable to see out of the contralateral eye, if possible, it may be important to not block the seeing eye for four to six weeks with a Hughes flap.
Finally, as with any cancer treatment, it is important to maintain surveillance to monitor for recurrence of carcinoma.
Enhancing Healthcare Team Outcomes
It is best to maintain an interprofessional team approach to the follow-up of these patients. Close surveillance is important to monitor for recurrence of carcinoma. Primary care nurse practitioners, physician assistants, and nurses should be involved in regular follow-up as well as the surgeon. [Level V]