REPAIR AND RECONSTRUCTION

Closure of Eyelid Defects JOSEPH J. ROSS,MD RANDALL PHAM, MD BACKGROUND.Repair of

eyelid defects can be achieved by an array of procedures. OBJECTIVE. To provide a basic approach to repairing eyelid defects. METHODS. Defects are categorized by size. The method of repair for each defect is described. CONCLUSION. By selecting the proper method of closure, with due consideration of the size, location, and configuration of the defect, the cutaneous surgeon can repair eyelid defects whilst maintaining the best possible function and cosmetic appearance. J Dermatol Surg Oncol 1992;18:1061-1064.

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epair of eyelid defects can be achieved by an array of procedures; a comparative description of these methods is beyond the scope of this I article. Instead, an attempt is made to provide the reader with a basic approach to repairing eyelid defects. We choose to categorize these defects by their sizes. The method of repair for each type of defect is described accordingly. Where appropriate, a discussion of the merit of a given method is included.

Goals and Principles The objectives of repairing eyelid defects are to preserve function and to restore a cosmeticallyacceptable appearance. To achieve these goals, a surgeon must be able to select the appropriate procedure for a given defect. Size, location, and configuration of the defect should be considered in this selection process. The size of the defect determines how much tissue is needed to reconstruct the eyelid. The availability of tissue will in turn determine the type of procedure to be performed. In terms of location, for example, the lacrimal system should be thoroughly evaluated if the medial canthal area is involved. Irregularly shaped defects may require trimming so that a good approximation of tissues can be achieved. The patient's age is also important because the skin of older patients is more lax than that of younger patients. Thus, in an elderly From the Department of Ophthalmology, Case Western Reseme University, Cleveland, Ohio. Address correspondence and reprint requests to: Joseph 1. Ross, MD, 16400 Hilliard Building, Lakewood, OH 44107.

0 1992 by Elsevier Science Publishing Co., lnc. 0148-0812/92/$5.00

patient, it is possible to close moderately larger defects by direct closure.

Surgical Techniques Closure of Defects Znvolving 50%or Less of the Eyelid The eyelid is generously vascularized and tissue ischemia rarely is a concern in the reconstruction of eyelid defects. Rapid tissue healing is also expected with good apposition of wound edges; infection is rare. Alignment of the lid margin is crucial in obtaining a satisfactory result. If the lower lid defect is extremely irregular, it may be trimmed with a blade or scissors.' Approximation of the posterior lamella is achieved by placing simple interrupted sutures, using 6-0 polyglactin sutures, starting from the inferior edge of the tarsus in the lower eyelid and from the superior edge in the upper eyelid (Figure 1).The suture should enter the tarsal plate anteriorly (3 mm from the lacerated edge) and exit only in partial thickness through the wound edge. The suture is then directed to the opposite edge of the wound and allowed to exit anteriorly, 3 mm from this edge. Care should be taken to avoid misalignment of the wound edges. Penetration of the tarsal plate must be avoided or corneal irritation may ensue. Anchoring of the edge of the lid margin is performed by placing a double armed 6-0 silk 3 mm into the depth of the lid and exiting 2 mm from the wound edge (Figure2).2 The opposite end of the suture is placed in the same manner in the other side. A second suture is passed through the tarsal layer in the same manner. Similarly, a third suture is then passed anteriorly at the level of the base of the lashes. At this point, the lid margin sutures are tied. The two posterior sutures are cut and left long enough to be buried under the anterior-most suture. This maneuver helps prevent the rubbing of these sutures against the cornea (Figure 3). Closure of the anterior lamella is achieved with simple interrupted sutures, using 6-0 silk.Selective suturing of the orbicularis is not necessary because the thin eyelid skin adheres well to the muscular layer beneath it,

Closure of Defects Involving 50 to 75% of the Eyelid In cases of moderate tissue loss, a lateral canthotomy A hemostat is placed over the latshould be perf~rmed.~ 1061

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Suture through posterior apex of tarsus /

Eyelid retractors sutured first

Figure 4.

Relaxing incision of lateral canthus.

Figure 1. Approximation of eyelid tarsus with 6-0 polyglactin

suture.

Figure 5. Cantholysis with cutting of inferior tendon. Figure 2. Approximation of eyelid margin with 6-0 silk sutures.

Figure 6. Semicircular pap dissection.

Figure 3.

Eyelid sutures tied away from the eye.

era1 canthus for 1minute. Sharp straight scissors are then used to make an 8 mm horizontal cut into the common crus of the lateral canthal tendon (Figure 4). If mobilization of tissue cannot be adequately achieved with canthotomy, cantholysis should be performed, in which the

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inferior limb of the lateral palpebral tendon is severed. After identifyingthis tendon by palpation, with one blade of the scissors behind the skin and orbicularis and the other blade in front of the conjunctiva, the tendon is cut with the scissors pointing inferolaterally (Figure 5). If a greater length of tissue is needed to fill the lid defect, a semicircularflap may be created at this time.' For a defect in the lower lid, a superior arching line is drawn, starting at the lateral canthus. For a defectin the upper lid, an inferior arch is outlined instead. An incision along the line is made and a flap of cutaneous tissue is dissected out (Figure 6). The flap is advanced medially and placed over the defect. Reapproximation of the mucocutaneous junction is performed using 6-0 polyglactin sutures. The lateral canthal angle is reconstructed by attaching the dermis of the new lateral canthus to the periosteum of the lateral orbital rim using a double armed 6-0 prolene suture. A running 6-0 silk suture is used to fix the conjunctiva to the new lid margin. Skin closure of the lateral canthal angle is carried out with interrupted sutures, using 6-0 silk. Ophthalmic antibiotic ointment should be applied to the wound three times a day for 1week and into the eye the night of surgery. Removal of lid margin sutures should occur approximately 10 days postoperatively.AU other cutaneous sutures may be removed in 4 to 5 days after repair.

ROSS AND PHAM 1063 CLOSURE OF EYELID DEFECTS

Figure 7 . Dissection of tarsoconjunctival pap.

Closure of Defects lnvolving 75%or More of the Eyelid Cutler-Beard Technique This procedure is reserved for defects that include 704b or more of the upper e ~ e l i dSkin, . ~ muscle, and conjunctiva from the lower lid are used to fill the upper eyelid defect. The flap of tissue from the lower lid is outlined. The size of this flap should be compatible with the defect in the upper eyelid. With a globe protector in place and using a #15 Bard-Parker blade, a horizontal incision is made 5 mm below the lower lid margin along the marked portion of the lower lid that is to be used to fill the defect. This incision should be at least 5 mm below the lid margin to preserve the marginal artery. Two posteriorly directed vertical incisions of 10 to 15 mm length are made. A through and through incision along the previous horizontal incision is made with straight Stevens scissors, leaving the conjunctivaledge slightly longer than the skin edge. This incision is then extended in the vertical direction along the previous incisions and may be lengthened toward the inferior orbital rim. The flap is advanced superiorly beneath the 5 mm lid margin left on the lower lid. The conjunctiva is sutured to any conjunctiva remaining in the upper lid using either interrupted or continuous 6-0 plain or chromic sutures. The capsulopalpebral fascia of the advanced flap is sutured to the levator or its aponeu-

Figure 8. Suturing tarsoconjunctival pap with 6-0 polyglactin sutures.

rosis using 6-0 vicryl sutures. Skin is closed using continuous 6-0 nylon sutures. The medial and lateral edges of the flap are sutured to the corresponding layers of the upper eyelid as outlined above. This flap is allowed to stretch over a period of 3 to 8 weeks. When the advanced flap becomes adequately lengthened and well vascularized with blood supplied from the adjacent upper eyelid tissue, it can be severed to create a new upper eyelid margin. With downward traction of the flap using a skin hook, a groove director is inserted beneath the flap. The new upper eyelid margin is outlined. Ample tissue should be left on the upper eyelid since retraction at a later date may result in exposurekeratitis. A

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flap to the inferior border of the 5 mm original lid margin left on the lower lid. A lid tightening procedure may be performed at this point if an ectropion is suspected to occur.

Figure 9. Advancement of skin flap.

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Figure 10. Sutured skin flap.

Modified Hughes Tarsoconjunctival Advancement Technique This technique is used to close defects that include 70% or more of the lower eyelid.6Skin and conjunctiva from the upper eyelid are used to fill the defect in the lower eyelid. A marking pen is used to outline the portion of the upper eyelid that will be used to compensate for the lower eyelid defect. Using a Desmarres retractor, the upper eyelid is everted and the tarsoconjunctival flap is created with a horizontal incision 5 to 6 mm from the lid margin (Figure 7). Miiller’s muscle is separated from the tarsus. The palpebral conjunctiva is in tum undermined from Muller’s muscle using blunt scissors directed toward the upper fomix. The combined tarsoconjunctival flap is then advanced into the lower eyelid defect and sutured with 6-0 polyglactin sutures (Figure 8). Sutures should first be placed at the four comers. A skin flap from tissue below the defect is created and advanced superiorly to fill the anterior lamina of the defect (Figures 9 and 10). In young patients, a skin graft may be necessary to fill the anterior lamina because the skin is not lax enough to be advanced adequately.’ After 6 to 12 weeks, the flap is divided to create a new lid margin (Figure 11).Sufficientstretching and vascularization of the flap must be secured before dividing the flap. The procedure is similar to the division of the Cutler-Beard flap as described above with the following exception: the conjunctiva is left 1 to 2 mm higher than the anterior lamella and is sutured to the skin using 6-0 chromic horizontal mattress sutures to prevent entropion caused by conjunctival retraction.

References

Figure 11. Severing of tarsoconjunctival flap.

superficial incision is made straight across the flap using a #15 Bard-Parker blade. A deep incision along the superficial incision is made with sharp blepharoplasty scissors. The conjunctival edge should be made slightly longer than the skin edge to prevent trichiasis. Reconstruction of the lower eyelid is achieved with reapproximation of the new lower eyelid portion of the

1. Phelps CD. Manual of CommonOphthalmicSurgical Procedures. Edinburgh: Churchill Livingstone, 1986:123. 2. Levine MR. Manual of Oculoplastic Surgery. Edinburgh: Churchill Livingstone, 1988:18. 3. Levine MR. Manual of Oculoplastic Surgery. Edinburgh: Churchill Livingstone, 1988:19. 4. Tenzel RR.Reconstruction of the central one half of an eyelid. Arch Ophthalmol 1975;93:125-6. 5. Cutler N,Beard C. A method for partial and total upper lid reconstruction. Am J Ophthalmol 1955;39:1-7. 6. Hughes WL. Reconstructive Surgery of the Eyelids. St. Louis: CV Mosby, 1943234. 7. Homblass A. Oculoplastic, Orbital, & Reconstructive Surgery, vol 1. Baltimore:Williams and Wilkins, 1988:630-642.

Closure of eyelid defects.

Repair of eyelid defects can be achieved by an array of procedures...
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