Vol 11-R2- Eyelid

SRPS • Volume 11 • Issue R2 • 2010
the total eyelid width and is restricted to patients
with sufficiently lax lower eyelid skin. The authors
argued that it might be a one-stage alternative
to the modified Hughes flap. Defect sizes in the
study ranged from 5 to 10 mm vertically and from
10 to 22 mm horizontally. The orbicularis muscle
adjacent to the defect was mobilized, incised
vertically, and advanced. The inner surface was
covered with a free tarsoconjunctival graft, and the
outer surface was covered with a free skin graft.
The grafts were obtained from the ipsilateral or
contralateral upper lid. After 5 days of patching,
adequate vascularization and viability of the grafts
were noted in 11 of 13 patients, whereas partial
necrosis of the skin graft was noted in two. The
partial necrosis healed spontaneously, but marked
lower eyelid retraction developed in one of the
two patients. Follow-up examinations 1 year after
surgery revealed marked lower lid retraction (>2
mm) in only one patient; six patients had mild
lower lid retraction of ≤2 mm. Two patients
experienced ectropion and lower eyelid sagging
resulting from excessive horizontal eyelid laxity. The
conditions were successfully treated with additional
block excision. One patient experienced adhesions
between the upper and lower lid in the lateral
canthus. After division of the adhesions, the results
were good. The authors warned against using this
technique for patients with impaired vascularity
(e.g., patients who have undergone radiation
treatment, smokers, diabetics, and patients with
other vasculopathies). The authors have not applied
this technique for reconstruction of vertical defects
>10 mm because they suspect that could lead to a
high rate of postoperative lid retraction because of
vertical tension on the orbicularis muscle flap.
In the event of unilateral total loss of full
thickness of the upper and lower eyelids with
the globe remaining, preservation of vision and
adequate corneal protection are the primary goals;
secondarily, the eyelids need to be sufficiently
mobile to open and clear the visual axis. deSousa et
al. 133 described six cases. The cause of tissue loss was
traumatic avulsion in one case and tumor excision
in five. In addition to loss of both upper and lower
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eyelids, the medial and lateral canthal tendons and
canaliculi were lost. In the trauma case, primary
repair was achieved by using the avulsed tissues.
After tumor excision, a single anterior lamellar flap
was used with planned division postoperatively in
one case; the remaining four cases had separately
reconstructed upper and lower eyelids. In one case,
the posterior lamella was recreated by using a free
tarsal graft from the contralateral upper eyelid for
the upper eyelid and a hard palate graft for the
lower eyelid. Bipedicled flaps of the remaining
preseptal and orbital orbicularis were formed in
the upper and lower eyelids to cover the posterior
lamellar composite grafts. A single large free skin
graft from the supraclavicular fossa was placed over
the eyelids, and a central fenestration was created
to form the new palpebral aperture. The remaining
sub-brow defect was repaired by using a laterally
based forehead flap. In another case, a large nasal
septal chondromucosal graft was harvested and
divided to reconstruct separate upper and lower
eyelid posterior lamellae. A single midline forehead
flap was used for the anterior lamella. Flap division
was performed at 6 weeks, with restoration of a
small palpebral aperture. In one other case, the
authors created an islanded, pedicled suprabrow
forehead flap based on the anterofrontal superficial
temporal artery branch for the anterior lamella
of the upper eyelid. The flap was elevated on its
vascular pedicle and tunneled under the remaining
lateral canthal skin. A free tarsal graft was used
for the posterior lamella of the upper eyelid. A
midline pericranial flap was raised and tunneled
under the glabellar skin to form the lower eyelid
posterior lamella and to provide a blood supply
for an overlying free supraclavicular skin graft. The
reconstructed upper and lower eyelids were secured
together, leaving a small central palpebral aperture.
Graft necrosis occurred in three cases. In all cases,
lagophthalmos was present and the reconstructed
eyelids were stiff and immobile. Ptosis and lower
eyelid retraction occurred in half the cases, and
ectropion resulted in two cases. Useful vision was
retained in all cases.