Volume 11 • Issue R2

EYELID RECONSTRUCTION

Marlene Morales, MD Rajat Ghaiy, MD Kamel Itani, MD

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Editor-in-Chief Reconstruction Topics Editor Emeritus F. E. Barton, Jr, MD Breast Reconstruction Cleft Lip and Palate Contributing Editors Craniofacial W. P. Adams, Jr, MD Eyelid Reconstruction S. M. Bidic, MD Facial Fractures G. Broughton II, MD, PhD Hand: Congenital S. Brown, PhD Hand: Extensor Tendons J. L. Burns, MD Hand: Flexor Tendons J. J. Cheng, MD Hand: Peripheral Nerves A. A. Gosman, MD Hand: Soft Tissue Hand: Wrist, Joints, Rheumatoid Arthritis K. A. Gutowski, MD Head and Neck Reconstruction R. Y. Ha, MD Lip, Cheek, Scalp, and Hair Restoration R. E. Hoxworth, MD K. Itani, MD Lower Extremity Reconstruction J. E. Janis, MD Nasal Reconstruction R. K. Khosla, MD Surgery of the Ear J. E. Leedy, MD Trunk Reconstruction J. A. Lemmon, MD Vascular Anomalies A. H. Lipschitz, MD Wounds and Wound Healing J. H. Liu, MD R. A. Meade, MD Cosmetic Topics J. K. Potter, MD, DDS S. M. Rozen, MD Blepharoplasty M. Saint-Cyr, MD Body Contouring: Excisional Surgery M. Schaverien, MRCS Body Contouring: Noninvasive, Liposuction, Fat Grafts Breast Augmentation A. P. Trussler, MD Breast Reduction and Mastopexy R. I. S. Zbar, MD Brow Lift Facelift Senior Manuscript Editor Dori Kelly Injectable Agents and Dermal Fillers

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Published as electronic monographs. SRPS • Volume 11 • Issue R2 • 2010

EYELID RECONSTRUCTION

Marlene Morales, MD Rajat Ghaiy, MD Kamel Itani, MD

University of Texas Southwestern Medical Center at Dallas, Dallas, Texas

INTRODUCTION be decreased in patients with blepharophimosis and When performing eyelid reconstruction, a thorough in patients with laxity or disinsertion of the lateral understanding of periorbital anatomy is critical. It or medial canthal tendon. is important to understand the function of each structure and its interplay. One must approach Skin and Eyelid Crease eyelid reconstruction with the goal of restoring the The eyelid skin has only six to seven cell layers functionality of the structure while achieving an and averages <1 mm thick.3 The thin keratinizing aesthetically pleasing result. epithelium is loosely attached to the underlying orbicularis muscle.4 The levator aponeurosis extends ANATOMY inferiorly to join the anterior surface of the tarsal In this section, we present summaries of the plate 3 mm superior to the lid margin, where it anatomy related to eyelid reconstruction. For forms its firmest attachment.2 further reading on eyelid anatomy, detailed When performing eyelid reconstruction, it is descriptions can be found in the 2008 text, Eyelid & important to successfully recreate the eyelid crease Periorbital Surgery, by McCord and Codner.1 for a better cosmetic result. The occidental upper eyelid crease is 8 to 9 mm superior to the eyelid Dimensions margin centrally in men and 8 to 11 mm superior The palpebral fissure is the space between the upper to the margin in women.5 The lid crease is a result and lower eyelid margins. Normally, the adult of fascial bands from the levator aponeurosis fissure is 27 to 30 mm horizontally and 8 to 11 mm extending anteriorly through the orbicularis oculi vertically (Fig 1).2 Many conditions can affect the to the skin. The lid crease typically is higher in palpebral fissure measurement; it can be vertically involutional ptosis and in levator dehiscence. increased in patients with Graves disease, decreased In the Asian eyelid, the upper eyelid crease is 2 in patients with involutional ptosis, and variable in to 3 mm superior to the margin and usually poorly patients with myasthenia gravis. Horizontally, it can defined. Three morphological types of Asian upper SRPS • Volume 11 • Issue R2 • 2010 eyelids have been identified: draws the tears from the common canaliculus into 1. single eyelid: no lid crease with puffiness the sac.11,12 The loss of the active component of tear 2. low eyelid crease: low-seated, nasally drainage is partially responsible for epiphora in tapered, inside-fold type of crease cases of facial nerve palsy. Malpositions of the lower 3. double eyelid: lid crease parallel to eyelid and the puncti can also lead to epiphora. the lid margin6 Along the length of the eyelid margin is the Jeong et al.7 found that there are three gray line, corresponding histologically to the most reasons for the absent or lower crease in the Asian superficial portion of the orbicularis muscle, the upper eyelid: muscle of Riolan, and to the avascular plane of the 1. The orbital septum fuses to the levator lid.2 Anterior to the gray line, the eyelashes or cilia aponeurosis at variable distances below arise. Posterior to the gray line are the orifices to the the superior tarsal border. meibomian glands. Meibomian glands are modified 2. Preaponeurotic fat pad protrusion and holocrine sebaceous glands that produce lipid a thick subcutaneous fat layer prevent secretions. Oil from the openings forms a reservoir levator fibers from extending toward the on the skin of the lid margin and is supplied to the skin near the superior tarsal border. tear film with each blink.2 Other glands found on 3. The primary insertion of the levator the skin of the eyelids are the sweat eccrine glands aponeurosis into the orbicularis muscle of Zeis and holocrine glands of Moll. and into the upper eyelid skin occurs closer to the eyelid margin in Asians. Orbicularis Oculi Muscle The lower eyelid crease is formed by the fascial The orbicularis muscle is arranged in concentric extensions of the capsulopalpebral fascia, which also bands and is the main protractor of the eyelid. It pass through the orbicularis oculi muscle and insert can be separated into orbital and palpebral portions. onto the skin.8 Lim et al.9 reported that in Asians, It is innervated by cranial nerve VII. Its antagonist, these fascial extensions do not extend to the skin; the levator, is innervated by cranial nerve III. The therefore, a palpebral crease is not found. Kakizaki orbital portion is involved in forced eyelid closure. et al.10 stated that the reason for the indistinct The palpebral portion can be divided into pretarsal lower lid crease in Asians is the higher or indistinct and preseptal parts (Fig. 2).13 The palpebral portions septum fusion, the anterior and superior orbital are involved in involuntary lid movements, such as fat projection, and the overriding of the preseptal blinking.13 orbicularis muscle. The pretarsal orbicularis attaches medially to the anterior and posterior arms of the medial Eyelid Margin and Lacrimal Pump canthal ligament to surround the lacrimal sac, The eyelid margin has several significant structures. and the superior and inferior lacrimal canaliculi Both the upper and lower eyelid margins have a are found within its muscle fibers. It plays a vital punctum medially. The punctum opens into the part in the lacrimal pump mechanism. Laterally, canaliculus of the lacrimal system. Tears drain via the pretarsal orbicularis joins the lateral canthal the canaliculi and into the nasolacrimal sac and ligament at the Whitnall tubercle. The preseptal and then to the lacrimal duct by both an active and a orbital components attach medially to the medial passive mechanism. The lacrimal pump actively canthal ligament and laterally to the zygoma, lateral sucks tears into the lacrimal sac with each blink. to the orbital rim. In addition to the formerly The contraction of the orbicularis muscle brings mentioned attachments, the orbital orbicularis the lower punctum medially, closes the ampulla, attaches medially to the maxillary and frontal bones and displaces the lateral wall of the lacrimal sac and extends peripherally to overlie the orbital rims. laterally, creating a negative pressure in the sac. This A small segment of the orbicularis oculi muscle,

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Figure 1. Landmarks of the external eye. The palpebral fissure is approximately 27 to 30 mm wide and 8 to 11 mm high in the adult. (Reprinted with permission from Cibis.2)

Figure 2. Upper eyelid anatomy. (Reprinted with permission from Kersten.13)

3 SRPS • Volume 11 • Issue R2 • 2010 called the muscle of Riolan, is separated from the conjunctiva becomes freely mobile in the fornices. pretarsal component by the eyelash follicles and The bulbar conjunctiva lines the sclera and forms the gray line along the eyelid margins.14,15 terminates at the limbus. Muzaffar et al.16 reported that the orbicularis- retaining ligament is a bilaminar septum-like Orbital Septum structure attaching the orbicularis oculi to the The orbital septum lies beneath the orbicularis inferior orbital rim. The attachment is weakest muscle and consists of a thin sheet of connective centrally and tightest over the inferolateral tissue. It encircles the orbit as an extension of the orbital rim. periosteum of the roof and the floor of the orbit.2 Ghavami et al.17 further clarified that the The orbital septum acts as a barrier of the orbital orbicularis-retaining ligament is a circumferential, contents, and the orbital fat can be found posterior periorbital structure and that the orbicularis to it. It extends from the arcus marginalis, where retaining ligament of the superior orbit arises 2 to 3 the periosteum and periorbita fuse, toward the mm above the orbital rim in the mid orbit. tarsus.3 In the upper eyelid the septum inserts at the levator, approximately 2 to 3 mm above the superior Anterior and Posterior Lamellae edge of the tarsus. In the lower eyelid, the septum The eyelid is divided into two lamellae (Fig. 3).13 inserts to the inferior edge of the tarsus.19 The The anterior lamella consists of skin and the septum attaches medially to the lower end of the orbicularis oculi muscle, and the posterior lamella anterior lacrimal crest, called the lacrimal tubercle. It consists of the tarsal plate and conjunctiva.15 continues from the lower to upper eyelid by passing under the medial orbicularis muscle.3 Putterman19 Tarsus noted that the septum is difficult to trace laterally The tarsal plates act as the skeleton of the eyelids, because it blends with the lateral canthal tendon providing semirigid support.18 The tarsus is and the lateral horn of the levator. The septum also composed of dense regular connective tissue and takes the shape of an arch under the supraorbital contains the Meibomian glands.4 The superior tarsus notch and around the supratrochlear and is 10 to 12 mm at its greatest vertical dimension, infratrochlear nerves and vessels. Weakness in the and the inferior tarsus is 3 to 5 mm.18 The upper orbital septum contributes to herniation of the and lower tarsal plates are similar in length (29 mm) orbital fat. and thickness (1 mm).2 The Meibomian glands Reid et al.20 described a distinct fibrous are modified holocrine sebaceous glands and are anatomic layer, which extends from the orbital oriented vertically in parallel rows through the septum to cover the tarsus. They named the fibrous tarsus. The upper lid contains 25 meibomian glands, structure the septal extension. They described the and the lower lid contains 20.13 preaponeurotic fat layer covered by the septal extension, which extends to cover the tarsus along Conjunctiva its anterior border to the ciliary margin. The septal The palpebral conjunctiva lines the inner surface extension was found between the orbicularis of the eyelids and is covered by a non-keratinized oculi and the levator aponeurosis, distinct from epithelium. Holocrine glands known as goblet the levator tissue. Fibrous connections extending cells secrete mucous and are located throughout from the levator aponeurosis penetrate the septal the conjunctiva. The goblet cells are mainly extension and the orbicularis muscle, connecting the concentrated in the conjunctival fornices and at the levator-dermal link to the septal extension. Tension caruncle. The palpebral conjunctiva is continuous placed on the orbital septum leads to referred with the conjunctival fornices and merges with tension on the septal extension and secondary the bulbar conjunctiva overlying the globe. The lagophthalmos. The authors stated that the findings

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Figure 3. Lower eyelid anatomy. (Reprinted with permission from Kersten.13)

might help avoid relapse and complications The levator muscle palpebrae originates associated with aesthetic and functional upper under the lesser wing of the sphenoid just anterior eyelid surgery. to the optic foramen.3 It extends anteriorly for 40 to 45 mm and becomes tendinous in front of Upper Eyelid Retractors and Müller Muscle Whitnall ligament (Fig. 4). Whitnall ligament The upper and lower eyelids are analogous is a transverse band of fibrous condensation that structures with their main difference being their attaches superiorly to the widening levator. It is respective retractors. In the upper eyelid, the levator the condensed fascial sheath of the levator muscle palpebrae superioris and its aponeurosis comprise a approximately 18 to 20 mm above the superior distinct entity that evolved from the superior rectus border of the tarsus. Medially, it attaches to the muscle.20 The lower eyelid retractor is a fascial connective tissue around the trochlea and superior extension of the inferior rectus, which divides to oblique tendon. Laterally, it attaches to the inner encircle the inferior oblique muscle, called the aspect of the lateral orbital wall, approximately capsulopalpebral fascia. 10 mm superior to the lateral orbital tubercle. It

5 SRPS • Volume 11 • Issue R2 • 2010 functions to convert the anterior-posterior pulling structure in eyelid anatomy. It is a crucial surgical force of the levator to a superior-inferior direction, landmark. The levator aponeurosis lies just posterior which raises and lowers the eyelid.21−23 The levator to the preaponeurotic fat, and the septum lies aponeurosis joins the orbital septum above the just anteriorly. In the upper eyelid, two fat pads superior border of the tarsus and sends fibrous are found: the nasal and middle fat pads (Fig. 5). strands between the orbicularis oculi muscle septa The nasal fat pad lies beneath the trochlea. The to the skin to make the lid crease.22 The normal lower eyelid has three fat pads. The nasal fat pad is excursion of the levator muscle is 15 mm.3 separated posteriorly from the central fat pad by the Müller muscle is a smooth, sympathetically inferior oblique muscle. The central and lateral fat innervated muscle in the upper eyelid. It originates pads are connected in deeper layers but anteriorly from the undersurface of the levator muscle 8 to 10 are divided into two pads by a dense septal mm above the superior tarsal border and attaches partition.22 The nasal fat pads are distinctly whiter to the superior edge of the tarsus.22 It functions to in color in both the upper and lower eyelids when provide 2 mm of lid retraction, and its interruption compared with the yellow color of the more lateral in Horner syndrome causes mild ptosis.24 fat pads. Kakizaki et al.25 found that the levator aponeurosis has doubly stratified layers that include Medial Canthus smooth muscle. The authors suggested that the The medial canthus provides a support point for the levator aponeurosis regulates tension in the anterior eyelids, helps provide its normal angular shape, and lamella of the upper eyelid as the Müller muscle assists the lacrimal pump apparatus.27 It is rigidly regulates the tension of the posterior lamella of fixed to the orbital wall. the upper eyelid.26 The structures lead to ordered McCord et al.22 illustrated the structure of movement in the upper eyelid. the medial canthus and reported that medially, the pretarsal orbicularis produces two heads that pass Lower Eyelid Retractors superficial and deep to the canaliculi. The anterior, In the lower eyelid, the retractors originate from more superficial, pretarsal orbicularis muscle forms the capsulopalpebral head of the inferior rectus the anterior crus of the medial canthal tendon that muscle. The capsulopalpebral fascia is analogous to inserts into the frontal process of the maxillary the levator in the lower eyelid. The capsulopalpebral bone. The posterior, deeper, pretarsal orbicularis head splits around the inferior oblique muscle inserts into the posterior lacrimal crest. The muscle and fuses again to form Lockwood ligament is known as Horner muscle. The deep pretarsal (similar to Whitnall ligament in the upper lid). orbicularis inserts on the posterior lacrimal crest The inferior tarsal muscle is a sympathetically and the lacrimal fascia. The deep preseptal fibers innervated muscle analogous to Müller muscle of insert mainly on the lacrimal fascia, and this is the upper lid. It originates on the posterior surface known as Jones muscle. The preseptal muscle forms of capsulopalpebral fascia. The inferior tarsal muscle, the horizontal raphe laterally, and medially, it inserts capsulopalpebral fascia, and orbital septum insert at into the anterior crus of the medial canthal tendon. a fusion point into the anterior and inferior surface and base of the tarsus.22 The capsulopalpebral Lateral Canthus fascia sends anterior projections that penetrate The lateral canthal tendon resembles the medial through the orbicularis to the skin to create a canthal tendon in that it supports the lids by transverse crease.3 supplying a tendinous attachment of pretarsal orbicularis oculi muscle and ligamentous Preaponeurotic Fat attachment of the tarsal plates to the periosteum The preaponeurotic fat serves as an important of the lateral orbital tubercle. It also allows

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Figure 4. Anterior view of the levator palpebrae superioris shows the relationship to the tarsal plate and Whitnall ligament.

Figure 5. Fat compartments and lacrimal gland in the upper and lower eyelids.

7 SRPS • Volume 11 • Issue R2 • 2010 movement of the canthal angle by its posterior nasal artery), a branch of the facial artery (angular fibrous attachments to the check ligament of the artery), and the superficial temporal artery.33,34 lateral rectus muscle. In contrast to the medial The lateral region of the upper eyelid also receives canthus, the lateral canthus is mobile, possessing further blood supply from the branches of the up to 6 mm of vertical movement and 2 mm of superficial temporal artery and the lacrimal artery.34 lateral movement.28,29 The lateral canthal tendon is Erdogmus and Govsa33 described the a fibrous structure that joins the upper and lower connection of the vascular supply and its location: tarsal plates to Whitnall tubercle inside the orbital “The dissection showed that the main rim, deep to the septum. Whitnall tubercle is an blood supplies of the upper and lower area that is not easily found intraoperatively and lids were provided by the arterial arcades; must be estimated clinically. It forms a prominence the marginal, peripheral, superficial, approximately 5 mm posterior to the lateral orbital and the deep ones. The marginal and rim.30 Rosenstein et al.31 described the lateral peripheral arcades consisted of the canthal tendon: anastomosis of medial and lateral “Superiorly, it is in continuity palpebral arteries. The marginal arcade with the lateral horn of the levator coursed just anterior to the lower aponeurosis. Inferiorly, it receives margin of the tarsal plate and gave fibrous contributions from Lockwood’s off small perforating branches that suspensory ligament and then curves ascended tortuously on both sides of the posteriorly to attach to Whitnall’s orbicularis oculi muscle and the tarsal tubercle. Anteriorly, the lateral extensions plate. These branches extend to the skin, of the preseptal and pretarsal orbicularis the muscle and the tarsal plate. The oculi muscles coalesce. Posteriorly, perforating branches running over the contributions from the check ligaments orbicularis oculi traversed obliquely, in of the lateral rectus muscle complete the contrast to the perforating vessels, with a formation of the lateral canthal tendon.” descending diameter and became part of The lateral canthus is located approximately 2 mm the vascular plexus and lower palpebrae higher than the medial canthus. The measurement in all cases. The peripheral arcade coursed is the same for both sexes and does not change with along the upper border of the tarsal plate. increasing age.28,32 It was positioned along the surface of the Muller muscle at the superior border Vascular Supply of the Eyelids of the tarsus. The peripheral arcade gave The eyelids receive their vascular supply from the off perforating branches that descended facial system, which is made from the branches off on both sides of the tarsal plate. The the internal and external carotid arteries. Off of the descending branches running over the internal carotid artery comes the ophthalmic artery, tarsal plate connected with the ascending which branches into the supraorbital, supratrochlear, branches arising from the marginal dorsal nasal, and lacrimal arteries. The external arcade, whereas the descending branches carotid artery contributes the facial artery (angular coursing under the tarsal plate fanned artery) and superficial temporal artery (transverse out fine vessels and formed a vascular facial artery, median temporal artery, and frontal network with the ascending branches and parietal branches). The arterial network of the arising from the marginal arcade.” upper eyelid is composed of anastomoses between The authors observed arterial arcades near the the collateral branches of the ophthalmic artery orbital rim and perforating vessels running on the (supraorbital artery, supratrochlear artery, and dorsal superficial and deep surfaces of the orbicularis oculi

8 SRPS • Volume 11 • Issue R2 • 2010 muscle, rather than intramuscular vessels, which or baseline secretion is produced by approximately suggests that the orbicularis oculi muscle. Their 50 small accessory glands of the Krause and observation indicated that the orbicularis oculi Wolfring glands, mucin-secreting goblet cells of the muscle is not a tissue with a large vascular conjunctiva, and oil-secreting meibomian glands network but is instead supplied by the surrounding and the glands of Zeiss at the eyelid margin. The vascular network. main lacrimal gland is actually a reflex secretor and The venous system for the eyelids was acts in response to physical and emotional triggers 22,28,35 described by McCord et al.,22 who reported that (i.e., from emotional or foreign body stimulus). the anterior facial vein is the main superficial The main lacrimal gland is divided into two venous structure. It follows approximately the same parts by the lateral horn of the levator aponeurosis course as that of the facial artery but is superficial and is found superotemporally in the orbit. The and more lateral to it. The facial vein is called upper or orbital lobe conforms to the space between the angular vein near the medial canthus; it then the orbital wall and the globe, extending from the becomes the supratrochlear vein and forms deep lateral border of the levator aponeurosis on which 22 anastomosis superomedially in the orbit with the it rests, down to the frontozygomatic suture. The superior ophthalmic vein via the supraorbital vein. lower or palpebral lobe is located under the levator The angular vein lies temporal to the angular artery aponeurosis in the subaponeurotic space. This inferior lobe is mobile and often can be prolapsed over the insertion of the medial canthal tendon. 35 Laterally, the supraorbital vein runs below the into view in the conjunctival sac. orbicularis oculi muscle on the frontalis muscle to communicate with the frontal branches of the superficial temporal vein. Medially, the supraorbital vein runs horizontally beneath the orbicularis and does not surface to join the frontal vein until it communicates with the superior ophthalmic vein of the orbit. A confluence of angular, supraorbital, and supratrochlear veins forms the superior ophthalmic vein. The superior ophthalmic vein acquires venous drainage from the globe and travels to the cavernous sinus. Because of the direct passage to the cavernous sinus, infection of the facial area can cause a superficial sepsis to spread to the cavernous sinus.

Lymphatics of Eyelids Lymphatic vessels are found in the eyelids and parallel the course of the veins. The medial lymphatics drain to the submandibular lymph nodes. The lateral lymph vessels drain into the preauricular lymph nodes (Fig. 6).2

Lacrimal System Under ordinary conditions, a tear film is Figure 6. Lymphatic drainage of the upper and lower continuously produced. It protects the cornea and eyelids with drainage to the submandibular and preauricular lymph nodes. provides some refractive power for the eye. Basic

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The vascular supply to the lacrimal gland is the movement of the lids during blinking. via the lacrimal branch of the ophthalmic artery. The superficial and deep heads of the pretarsal It receives its innervation by way of cranial nerves orbicularis muscle close the ampullae and shorten V and VII and from sympathetics of the superior the canaliculi. The preseptal orbicularis creates a cervical ganglion.22 The secondary and accessory negative pressure in the tear sac as the lacrimal lacrimal glands are responsible for tearing under diaphragm produces alternating negative and ordinary circumstances, providing baseline tear positive pressures to pull the tears into the sac and secretion.22,35 out of the nose. The excretory system is made up of the upper and lower puncta, canaliculi, the tear sac, and the EYELID RECONSTRUCTION nasolacrimal duct. They work in conjunction with Techniques for eyelid laceration repair or eyelid pretarsal orbicularis oculi, which drives the tears defects after tumor removal range from allowing from the tear meniscus in the conjunctival cul-de- wounds to heal via secondary intention to the use sac down to the inferior meatus of the nose. of complex flaps and grafts. Those without loss of Jones35 described its structure. The author tissue should undergo minimal débridement and be reported that the canaliculi are approximately 10 closed primarily.3 When repairing eyelid lacerations mm long, consisting of a vertical portion 2 mm long or defects, one must take great care to address and a horizontal portion 8 mm long. The vertical proper alignment of the lamellae. Structural repair component of each canaliculus begins with the of the anterior lamella affords a skin covering and punctum, which lies in the apex of the lacrimal blood supply to the eyelid. The posterior lamella papilla. It is approximately 0.3 mm in diameter and provides semirigid support to the eyelid and a is surrounded by a ring of connective and elastic nonabrasive mucosal surface for normal blinking, tissue and a constrictor muscle. It is unique in that which helps keep the ocular surface moist to protect it is the only part of the passages with walls rigid the cornea from drying. Functional restoration of enough to produce capillary attraction. The lumen the upper eyelid acts to protect the cornea, and that widens to form the ampulla, which is 2 to 3 mm of the lower eyelid allows it to oppose the globe and at its longest diameter. The ampulla, in turn, gives furnish stability, aiding in the normal flow of tears.15 rise to the horizontal section, which is ≥0.5 mm in In addition to proper alignment of the wound diameter. In 90% of cases, both canaliculi join to edges, the suture knots should be positioned away form a single common duct, which opens into the from the globe to prevent corneal abrasions from tear sac just posterior and superior to the center of the suture ends. its lateral wall. Granulation or healing via secondary intention Jones35 noted that the tear sac and is an option in the repair of certain defects. The nasolacrimal duct are anatomically a single defects tend to be small and/or superficial and to structure. The upper end is the fundus, which involve such concave surfaces as the medial canthus extends 3 to 5 mm above the level of the medial or upper nasal side wall.36−39 commissure. The combined length of the tear sac Full-thickness eyelid defects ≤25% of eyelid and nasolacrimal duct is approximately 30 mm. The length can be transformed into a pentagonal upper 12 mm of the nasolacrimal duct lies in the excision and directly closed in younger patients with nasolacrimal canal and is known as the interosseous less eyelid laxity. In older patients with more eyelid part. The meatal portion of the duct usually opens laxity, defects up to 40% of the length of the eyelid 5 mm below the vault of the anterior end of the margin can be closed directly in the same manner. inferior meatus. One must ensure that the skin excision involved in a The lacrimal pump begins in the conjunctival pentagonal excision does not extend beyond the lid sac, where a tear strip is forced medially by crease, if possible. If necessary, the anterior lamella

10 SRPS • Volume 11 • Issue R2 • 2010 can be excised as a pentagon and the posterior eyelid margin. The suture is then tied lamella can be excised as a rectangle to avoid and buried deep to the orbicularis oculi extending the skin incision across the lid crease.15 muscle everting the wound edges at The full-thickness defect is directly closed with the eyelid margin. Simple interrupted the use of the buried vertical mattress technique, 6-0 Vicryl sutures are performed along as first described by Burroughs et al.40 The buried the anterior aspect of the tarsus to vertical mattress technique uses a single 6-0 or 7-0 approximate the remainder of the tarsus. polyglactin 910 suture pass, which is begun and Another simple interrupted 6-0 Vicryl completed in the tarsus with the knot tied deep suture is used to align the lash line. It is within the eyelid tissue. crucial to align the lash line for a good Ahmad et al.15 described the buried vertical cosmetic outcome. The skin is closed mattress suture in detail: using simple, interrupted 6-0 nylon “The buried vertical mattress suture is sutures.” performed using a 6-0 Vicryl suture The orbicularis muscle can be closed as a separate on an S-29 needle (Ethicon, Inc., layer. The septum should not be closed because Somerville, NJ) in a ‘far-far-near-near- closure of the septum can lead to eyelid retraction near-near-far-far’ pattern” (Fig. 7).15 “The and lagophthalmos, which can lead to significant suture is first passed through the tarsus corneal morbidity. at one of the wound edges far from the Burroughs et al.40 reported that in 90 patients eyelid margin and out of the tarsus at the undergoing the buried vertical mattress technique, eyelid margin far from the wound edge. no cases of wound dehiscence and only five cases of The suture is then passed back through minimal notch formation occurred within follow- the same tarsus at the eyelid margin near up ranging from 3 to 12 months. the wound edge and out of the tarsus at the wound edge near the eyelid margin. Free Tissue Grafts The suture is then passed through the Free tissue grafts should be coordinated to match tarsus of the opposite wound edge, near both cosmetically and functionally. They should the eyelid margin and out of the tarsus at have little or no shrinkage or absorption and the eyelid margin near the wound edge. be associated with a minimal rate of infection The suture is then passed back through or rejection. Typically, autogenous tissue grafts the same tarsus at the eyelid margin far are better at meeting the requirements than are from the wound edge and out of the homologous tissue grafts or alloplastic materials. tarsus at the wound edge far from the

Figure 7. Buried vertical mattress technique. A, Buried vertical mattress suture. B, Anterior tarsal sutures. C, Lash line suture. (Reprinted with permission from Ahmad et al.15)

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Skin are difficult to handle. One must take care to Full-thickness skin grafts contain both an epidermal avoid compromising the donor fornix.3 Mucous and a dermal component. Preferred donor sites membrane grafts in an anophthalmic socket for full-thickness skin grafts used in eyelid contract rapidly. A conformer is therefore to be reconstruction have traditionally included the upper kept in the socket at all times for many weeks to eyelid, retroauricular or preauricular areas, and the prevent socket contracture. Skin cannot be used to supraclavicular region, with the best match being replace conjunctiva because the hairs on skin and from the contralateral eyelid.22,41,42 The inner arm the squamous layer of epidermis are highly irritating and groin are also possible donor sites, but they and potentially damaging to the cornea.3,43 should not be considered first because they do not Oral or buccal mucosa is the tissue of choice provide as suitable a match.22 For those patients for many plastic surgeons in need of a mucous who have undergone previous facial surgery (i.e., membrane graft. It is the most readily available of blepharoplasty or rhytidectomy) or for whom mucous membranes that can be grafted in place large skin grafts are needed, Custer and Harvey41 of posterior lamellae or eyelid margin resurfacing, described using the skin of the inner arm as an but it tends to contract to approximately 50% of alternative. A large amount of suitable skin might pre-graft volume.3,43 It can be cut fairly thin and is be obtained from the arm for grafting purposes. pliable. The graft donor site typically is the inner In their study, 52 procedures were performed on surface of the lower lip, but additional grafts can be 42 patients. Partial graft necrosis occurred in two taken from the inner cheek or upper lip if needed. patients, and mild asymptomatic graft contracture Because mucosal grafts tend to contract, they must developed in four. Steroid injections were be prepared slightly larger than the size of the administered to two patients with more marked proposed graft site. One must take care to avoid the graft contracture. Chronic graft shrinkage occurred vermillion margin of the lips, the gum, and Stenson in three cases and involved the repair of ichthyosis- duct inside the cheek when obtaining the graft.22 related cicatricial ectropion, and abnormal hairs The harvesting site is outlined with methylene blue appeared in four grafts. and subsequently incised with a number 15 Bard- A split-thickness skin graft is composed of Parker blade (BD, Franklin Lakes, NJ). The graft is epidermis only, and the standard donor site is the removed with sharp and blunt scissor dissection and anterior thigh. The split-thickness grafts from the then thinned with scissors. The graft is then placed thigh generally have deficient texture, color match, in an antibiotic solution until needed to replace the and a tendency to become pigmented. The graft is eyelid defect. Alternatively, a mucotome can be used obtained by a power-driven dermatome. The main to harvest oral mucosa at preset thicknesses varying application in ophthalmic plastic and reconstructive between 0.2 and 0.5 mm. surgery is for lining anophthalmic sockets and Bowen Jones and Nunes44 followed patients orbital cavities. Only in severe burn cases should with oral mucosal grafts to the orbit for more this method be a viable choice.22 than 3.5 years. Fourteen of the study population were anophthalmic and suffered from contracted Conjunctiva socket. Three patients had eyes but were in need The conjunctiva provides a smooth moist surface of of additional conjunctiva. In those patients with contact for the cornea. A similar material is needed eyes who were short of conjunctiva, the defect and when replacing conjunctiva to prevent corneal fornices were covered with oral mucosa and a soft irritation. Defects of the conjunctiva that cannot be curved-shell conformer was fitted to maintain repaired by advancement require a free graft. the depth of the fornices for 2 weeks. Satisfactory Free conjunctival grafts from the same or functional results were obtained. The authors opposite eye undergo significant contraction and concluded that the use of the soft shell to cover the

12 SRPS • Volume 11 • Issue R2 • 2010 globe and stretch the graft was essential to maintain authors noted that the reconstructed area can be the full extent of the fornices for several weeks. very large provided that the underlying bed is not They reported using palatal mucosa and nasal ischemic and the adjacent host conjunctiva remains septal mucosa for lining eyelids with less resulting normal. Amniotic membrane grafts have several contraction, but less material was available for advantages over oral mucosa. They are readily harvesting and the grafts were less pliable. available, can be trimmed to the required sizes, Ang and Tan45 described the use of autologous and entail no donor site morbidity. They also have serum-free cultivated conjunctival sheets in a therapeutic effects, such as promoting epithelial 10-year-old patient with extensive recurrent viral healing and reducing inflammation and pain. papillomata involving the superior and inferior Solomon et al.51 reported that the therapeutic tarsal, forniceal, and bulbar conjunctiva. The effect of the amniotic membrane involves patient underwent surgical excision of all diseased synergistic actions that suppress fibrosis, reduce areas and double freeze-thaw cryotherapy. The inflammation, and promote epithelialization. The conjunctival equivalents were used to reconstruct amniotic membrane suppresses transforming the ocular surface and conjunctival fornices. Almost growth factor-β signaling and prevents complete epithelialization was achieved by 5 differentiation of normal human corneal and days postoperatively. The transplanted epithelium limbal fibroblasts. It also suppresses the expression remained intact, and good cosmetic and functional of certain inflammatory cytokines that originate results were achieved. Despite the extensive surgery, from the ocular surface epithelia. The inhibition of no significant cicatricial complications, such as inflammation is a major factor in the prevention forniceal shortening, symblepharon formation, or of further fibrovascular proliferation and scar ocular motility restriction, occurred. Twelve months formation in the conjunctiva. Additionally, postoperatively, the eye remained disease-free with amniotic membrane transplants maintain a no recurrence of the viral papilloma. normal conjunctival epithelium with goblet cell The amniotic membrane is anatomically differentiation in vivo. In that regard, it is the innermost layer of the placenta and consists superior to buccal or nasal mucous membrane of a thick basement membrane and an avascular grafts, the epithelia of which are dissimilar from stroma. It commonly is used to replace damaged that of the conjunctiva. mucosal surfaces and has been effectively and 46−51 extensively used for reconstructing corneal and Tarsal Plate 52−55 conjunctival surfaces damaged by a variety of For cases of eyelid reconstruction in which the 51,56 insults and in different ocular surface disorders. posterior lamella has been lost, it is critical to use 51 Solomon et al. showed that amniotic membrane a material that simulates the tarsal-conjunctival transplant maintained a deep fornix and scar-free complex in thickness, surface quality, and resilience. environment with complete or partial success in 14 A wide variety of materials have been used, of 17 eyes. In that study, preserved human amniotic including autogenous, homologous, and synthetic membrane was obtained from Bio-Tissue, Inc. grafts. Autogenous grafts that have been used (Miami, FL). After thawing, the membrane was include hard palate, ear cartilage, temporalis fascia, trimmed to correspond with the conjunctival defect, fascia lata, nasal septal cartilage, tarsus, dermis, including the bulbar surface of the fornix and the and periosteum.57−62 Homologous donor sclera deeper portion of the palpebral aspect of the fornix. and synthetic polytetrafluoroethylene grafts have The membrane was then secured to the recessed also been used.63−65 Some materials do not lend a conjunctival edge. Alternatively, the membrane permanent solution, and late problems can arise. can be stabilized with tissue glue such as Tisseel Hard palate grafts and free tarsal grafts are tissue sealant (Baxter Corp., Mississauga, ON). The commonly used as posterior lamella alternatives in

13 SRPS • Volume 11 • Issue R2 • 2010 eyelid reconstruction. They each provide a mucosal incisive foramina. After the required graft size was surface.66−73 A free tarsal graft is a suitable material marked, two parallel incisions were made between in that it provides flexibility, rigidity, and shape. A the median raphe and the gingival mucosa using hard palate graft also provides rigidity, flexibility, a number 15 Bard-Parker blade. An edge of the and thickness. The hard palate graft is also readily graft was lifted, and dissection was continued in the available and is not associated with any morbidity to submucosal plane. Hemostasis was achieved using the contralateral eyelid.66 The dense concentration pressure, minimal cautery, or an absorbable gelatin of collagen fibers in the lamina propria of the sponge soaked in thrombin. A surgical stent was hard palate provides this tissue with stability and used in some cases. The harvested hard palate graft firmness, but at the same time, it has enough was carefully thinned by removing fatty submucosa flexibility to allow it to maintain its contour and with scissors. act as replacement for the tarsus with excellent Leibovitch et al.66 explained that the hard eyelid appearance and function, unlike ear or nasal palate grafts were preferred in cases with insufficient cartilage.57 However, harvesting the hard palate height of the contralateral tarsal plate to enable graft requires a second surgical site that is not harvesting of adequate free tarsal graft with sterile and that must heal by secondary intention. preservation of 4 mm of residual tarsus, to avoid Donor site morbidity and patient discomfort both morbidity to the contralateral eye, and also per the discourage the use of hard palate grafts.74 patient’s preference. The complications for the hard Leibovitch et al.66 retrospectively evaluated palate group included ocular irritation or discomfort 15 patients who were treated with autogenous in three patients, corneal edema or transient hard palate grafts and 16 who were treated with keratopathy in two, partial graft dehiscence in two, autogenous free tarsal grafts. The authors described upper lid retraction in two, and necrosis of the the free tarsus and hard palpate graft harvesting. For overlying skin flap in one. Donor site complications free tarsal graft harvesting, the authors described included only one case of excessive bleeding from the following technique: the hard palate site in the recovery room, which “Local anesthetic was injected beneath required packing. No significant complications the pretarsal upper eyelid skin before occurred in the patients treated with free tarsal eversion of the eyelid using a Desmarres plate grafts. The donor upper lid complications were retractor for subconjunctival injection of two cases of mild upper lid retraction and central additional anesthetic above the superior peaking from a fibrous band. tarsal margin. The tarsus was incised 4 The presence of keratinized epithelium often to 5 mm above the lid margin, parallel discourages the use of hard palate grafts in the to the eyelid margin, with the length of upper lid because of the possible adverse effects on the horizontal incision up to 16 mm, the cornea. The authors found this side effect to be depending on the available upper eyelid temporary in all cases, resolving after several weeks tarsus. This was followed by 2 vertical to a non-keratinzed type, possibly in correlation incisions at each end of the horizontal with the gradual metaplasia of the epithelium. incision, towards the upper border of the An ear cartilage graft furnishes rigid support tarsus. The graft was then dissected from similar to that of the tarsus and has the ability to the loosely attached levator aponeurosis, epithelialize over a period of weeks. Ear cartilage Müller’s muscle, and conjunctiva.” is also resistant to contraction and is thus an ideal In the study by Leibovitch et al.,66 hard palate material to act as a spacer.22 It lacks the malleability harvesting involved local anesthetic injection into needed to conform to the curved surface of the eye the hard palate mucosa and mucoperiosteum, but remains a valuable material for repairing tarsus. including the area around the greater palatine and It can be thinned, rendering it more malleable when

14 SRPS • Volume 11 • Issue R2 • 2010 using a mucotome. McCord et al.75 described the for the cartilage strip to go in, with technique for harvesting autogenous ear cartilage. its upper edge as close as possible to The authors described skin hooks used to expose the lid margin. The auricular cartilage the posterior surface of the ear. They marked a strip is then inserted into the tunnel. curvilinear line parallel to the edge of the helix, The tension of the lower lid is properly keeping 4 mm from the edge of the helix. They adjusted, then one end of the strip is incised the skin and continued dissection down fixed to the medial canthal ligament with to the ear cartilage, which they then marked. The nonabsorbable suture and the other is authors incised the cartilage with a scalpel and used fixed to the periosteum at the level of the scissors to complete the full-thickness incision and insertion of the lateral canthal ligament, to cut the graft off at its base. ascertaining that the lacrimal canaliculi Hashikawa et al.76 described the use of ear is not ligated. There is no need to fix the cartilage as a support for the lower lid instead of cartilage to the tarsus. Thus, the total a spacer. The authors reasoned that the long and lower lid is supported by the plane of the wide plane of the auricular cartilage can enable cartilage strip. Finally, the two incisions the lower lid to make contact naturally and closely made at the medial and the lateral with the globe. Ear cartilage is generally sutured to canthal regions are simply closed.” the eyelid remnants on either side of the defect, if Because the procedure is simple and conducive any, otherwise to the lateral orbital rim periosteum. to restoring a stable and long-lasting lower lid Hashikawa et al. did not fix the grafted cartilage to support, the authors claimed that it is widely the tarsal plate but to the medial canthal ligament applicable to various deformities of the lower lid. and lateral orbital rim without resting on the bony Although the grafted cartilage was slightly visible rim. The procedure was applied to various lower in some cases, none required removal. lid deformities, including anophthalmic orbits, facial paralyses, reconstructed lids, and deformities Two of the 34 cases required secondary secondary to trauma, maxillectomy, infection, burns, operations during the early postoperative period and neurofibromatosis. The authors described the because of detachment of the grafted cartilage from technique used in the study: the point of fixation. This was considered the only “The auricular cartilage strip is harvested complication of the technique; otherwise, there from the anterior side of the ear. From was good lid position during a follow-up period an incision made along the ridge of of as long as 15 years. Warping of the cartilage did the antihelix and its superior crus, the not occur in any of the cases. A disadvantage of subcutaneous plane is dissected, the this procedure is that the lower lid becomes fixed perichondrium is incised, and then a 4.5 postoperatively, and patients might experience × 1-cm strip of the auricular cartilage is partial disturbance in the visual field at the extreme harvested. The donor site is subsequently down-gaze. Therefore, the authors recommend the simply closed layer by layer. procedure for patients with anophthalmic orbit or “Small skin incisions are made at the severe deformity. Patients with poor vision in the medial and lateral canthal regions. A eye undergoing eyelid repair might not be bothered submuscular or a subcutaneous tunnel by the possible complication of the down-gaze (depending on whether the orbicularis disturbance and might therefore also be suitable oculi muscle is lost at previous surgery candidates for the procedure. or trauma) is bluntly dissected from the Scuderi et al.77 published the results of their medial canthal ligament to the lateral 10-year experience with the nasal chondromucosal orbital rim and made wide enough flap for large upper eyelid full-thickness defects.

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Fifteen patients underwent reconstruction of at or can be left to heal spontaneously, and the skin is least three-fourths of the eyelid. The procedure closed with fine nylon.77 78 was derived from a description by Micali et al. of The procedure modified by Scuderi et al.77 a full-thickness mucosal-chondrocutaneous flap resulted in a viable flap in every patient, without harvested from the lateral side of the nose, including total or partial necrosis. Static parameters were part of the triangular and sesamoid cartilages. within normal ranges: levator function was 8 to 18 Scuderi et al. modified the method by using an mm (mean, 13 mm), and eyelid length was 25 to ipsilateral axial chondromucosal flap to recreate the 30 mm (mean, 29.2 mm). Patients were generally posterior lamella. They initially used a local skin flap pleased with the results. Complications included for cutaneous coverage and later changed to using lagophthalmos in one case, orbital emphysema in a skin graft because of the bulkiness of the flap. one, and corneal abrasions in three. Scuderi et al. described the surgical technique as follows: Acellular human dermis (AlloDerm; LifeCell Corporation, Branchburg, NJ), is a cadaveric dermal “After the skin is incised for 2.5 cm along graft that has been enzymatically processed to the border between the lateral nasal wall remove all cellular material to leave only an acellular and the cheek from the inner canthus to and immunologically inert collagen matrix. The the ala nasi, the periosteum is dissected dermal framework promotes fibroblast immigration, from lateral to medial, up to and beyond 57,74 neovascularization, and collagen deposition. In the midline of the nose. Dissection is postoperative animal studies, the matrix is replaced extended superiorly to the inner canthus 79 74 by host cells. Li et al. compared 35 patients and glabella and inferiorly to the lower undergoing AlloDerm grafting with 25 patients margin of the nasal bones. Then, the undergoing hard palate grafting of the lower eyelid subcutaneous tissue is dissected, always after postoperative cicatricial changes. The lower from lateral to medial, onto a line beyond eyelid heights were measured. No statistically the midline of the nose, where it joins significant difference was found between the the subperiosteal plane. The subcutaneous AlloDerm and hard palate groups, although a trend dissection is extended superiorly to the was observed that hard palate grafts resulted in glabellar area and inferiorly to or beyond both better elevation and a lower failure rate. the lower margin of the upper lateral Female patients in both groups were found to cartilages. Distally, the flap is harvested experience significantly greater eyelid elevation including the cranial portion of the than male patients. upper lateral cartilage, depending on 57 the size of the defect to repair, and the Taban et al. evaluated the long-term corresponding nasal mucosa. The flap efficacy of a thick AlloDerm graft in lower eyelid is then transposed to reconstruct the reconstruction compared with previous results for posterior lamella of the missing eyelid, thin AlloDerm and hard palate grafts. The results flap mucosa is sutured to the conjunctival showed similar rates of success and final eyelid margin (separating it from the fornix if height position. necessary), and the levator muscle stump An alternative material that can be used in is inserted into the cartilaginous portion place of tarsus is a product known as Enduragen, of the flap. This simulates insertion of the which is a porcine acellular dermal collagen matrix levator muscle into the tarsal plate.” manufactured by Tissue Science Laboratories With this technique, a skin graft is used for the (Aldershot, United Kingdom). McCord et al.80 anterior lamella. The nasal lining donor defect is described the first experiences with Enduragen repaired with direct closure using absorbable sutures as a spacer graft in 69 patients and 129 eyelids

16 SRPS • Volume 11 • Issue R2 • 2010 for both reconstructive and aesthetic procedures forearm in six patients and from the leg in one as a substitute for autogenous ear cartilage and patient to replace the tarsal-conjunctival complex. fascia. In eight procedures, a spacer was placed in No complications occurred at any of the donor sites the upper lid. One hundred four procedures were or the eyelid area. No graft or flap suffered vascular performed for spacers in the lower lid and 17 for failure. Cosmetic and functional results were lateral canthal reinforcement. In the upper eyelid, judged to be good to outstanding by both patients Enduragen typically was used as a spacer graft and physicians. The authors reported that the between the levator-Müller muscle and tarsal plate reconstructed eyelids had congruous thinness and for upper lid advancement procedures used to treat that the fornices were adequately deep. The venous Graves lagophthalmos or overcorrected ptosis wall was found to be useful in that it is thin and repairs. All upper lid procedures were accomplished permits reconstruction of the entire height of the using an anterior transcutaneous approach. After upper eyelid (approximately 15 mm) when using a release of the levator attachment to the tarsal vein with a 5-mm diameter. The elastic properties, plate, an Enduragen spacer graft, of varying height smoothness, and concavity of the venous graft depending on needs (generally 3−5 mm), was then allow it to conform to the globe without inducing secured to the superior edge of the tarsal plate a chronic inflammatory reaction on the bulbar and the distal fibers of the levator aponeurosis conjunctiva or on the cornea. Autogenous dermis using absorbable sutures. In the lower eyelid, the can also be used as a replacement for tarsus and is procedures were performed either to insert spacer discussed below. material in the lower lid in patients with prominent eyes or to counteract scarring in retracted lids. Composite Grafts Either an anterior approach through a subciliary Composite grafts provide multiple tissue incision or a posterior approach including a requirements for eyelid reconstruction in one stage. cantholysis and transconjunctival incision was Composite grafting is a simple, safe, less invasive, used. Thirteen eyelid complications occurred in the and time-saving method for eyelid repair. series presented by McCord et al., with a resulting Korn et al.82 reported their experience with complication rate of 10%. Nine cases required autologous dermis fat grafts as a posterior lamellar surgical revision. Four cases of infection occurred, spacer graft in repair of eyelid malpositions. The use and all were successfully treated with oral and of dermis fat as a composite graft in anophthalmic topical antibiotics. Many of the cases that needed orbits has been well described.83,84 The authors revision were extreme cases that had undergone argued that several features make autologous multiple eyelid procedures before the operation in dermis fat a suitable spacer graft, including the the series by McCord et al. In those cases, extreme ability to supply both posterior lamella on the scar contractures, previously placed grafts, and other dermis face, volume replacement with fat, no risk problems were encountered. The authors noted that of a transmissible agent, and low incidence of Enduragen is slightly more rigid than other tissue tissue rejection. Eleven patients with lower eyelid products; therefore, all edges and corners should malpositions from various causes were treated with be trimmed and tapered before closure. Enduragen dermis fat grafting to the lower eyelid. The source of is described as having superior uniformity and dermis fat was the hip, inferior and posterior to the predictability of thickness, structural integrity, ease superior iliac crest. After marking an ellipse of skin, of use (it does not require soaking), and the epithelium can be removed with either sharp better durability. dissection or with a diamond burr. The dermis with Barbera et al.81 described using a venous wall the needed fat is then excised, and the composite graft to reconstruct the posterior lamellae. The graft is sutured into the eyelid defect with the walls of propulsive veins were harvested from the dermis side toward the globe. The donor site is then

17 SRPS • Volume 11 • Issue R2 • 2010 closed primarily. After 1 year of follow-up, all (average follow-up duration, 2.5 years after surgery) 11 patients reported marked cosmetic without development of any complications. improvement and high satisfaction after the Yildirim et al.87 used composite sandwich reconstructive surgery. grafts containing skin-cartilage-skin for the The main concerns regarding the use of dermis reconstruction of full-thickness defects of the eyelid fat grafting are surface keratinization and growth margin. Composite grafts were removed from the of hairs leading to ocular surface irritation and upper third of the auricular helix. Thirteen patients complications.85 Korn et al.82 performed mechanical were followed monthly for up to 6 months. Graft débridement of the epithelium and found that loss resulted in three patients who had marginal step necessary to prevent graft complications. necrosis of the outer skin layer of the composite With that approach, the authors did not note any graft. All of the marginal losses were successfully postoperative hair growth, surface keratinization, or treated with daily dressings, without the need for any major complications. Furthermore, the authors additional surgery. No corneal irritation or injury noted that meticulous end-to-end approximation from the use of helical skin for reconstruction of of the dermis side of the graft with the conjunctival conjunctiva at the eyelid margin was observed. edge allows for uniform migration of the The authors stated that an advantage of using conjunctival epithelial cells over the dermal graft this composite graft technique is that the helical surface. Finally, the authors placed the graft deep in cartilage is thinner than that of the nasal septum the fornix, where corneal apposition is minimal. and is therefore more similar to tarsus. Helical Lee et al.86 treated 13 patients with sunken cartilage also has a better curvature than does septal and/or multiply folded upper eyelids using fascia-fat cartilage for the globe. composite grafts from the mons pubis, temporal, and preauricular areas. The technique was used Reconstructive Flaps in patients who had undergone Oriental upper A wound or surgical defect that cannot be closed blepharoplasty, which often results in excessive fat primarily might require a flap for successful removal and can be associated with injury to the reconstruction. A flap maintains its own blood orbital septum. Adhesions of the skin to underlying supply from a pedicle or base attachment from tissues down to the septum can develop. To remedy adjacent tissue, so it is useful for reconstructing sites such deformities, local tissue transfer can be used with poor vascularity that cannot sustain a skin to return a more desirable volume to the eyelids graft.22 This feature also leads to less contraction and can solve the adhesion problem. The authors and a more cosmetically appealing result than those argue that dermis fat grafts might be too heavy, achieved with grafts. might affect upper eyelid motion, and might also produce a visible mass. By contrast, the fascia-fat Upper Eyelid composite has a rich vascular fascial component; Direct Closure it is therefore expected to achieve vascularity Most upper eyelid defects are caused by the removal earlier and to survive better than free fat alone. In of tumors, trauma, or congenital abnormalities. As addition, it is lighter than the dermis-fat composite, discussed earlier, direct closure of a full-thickness provides a closer anatomic match to the damaged eyelid defect that is ≤25% of the eyelid length can orbital fat and septum, and is abundant throughout be successfully accomplished with a pentagonal the body. All 13 patients were satisfied with the excision approach in a younger patient with less appearance of the final results. Deformities resulting eyelid laxity. Older patients have increased lid laxity; from volume depletion and adhesion disappeared thus, defects up to 40% of the length of the eyelid immediately after the operation. Six-month results margin can be closed directly. For direct closure, the were maintained throughout the follow-up period buried vertical mattress technique15,40 is preferred to

18 SRPS • Volume 11 • Issue R2 • 2010 the classically taught three-suture technique. defect, as described by Tenzel.92,93 An inferior arching semicircular line is marked from the Canthotomy and Cantholysis lateral canthus extending temporally (Fig. 8). The If direct eyelid closure causes excessive tension diameter of the flap is approximately 20 mm. The on the eyelid, further mobilization of tissue is flap is incised with a number 15 Bard-Parker blade, needed and performing a lateral canthotomy and and a Bovie cutting needle (Bovie Medical Corp., cantholysis is a suitable solution. The lateral canthal Clearwater, FL) can be used to incise through area is injected with lidocaine with epinephrine muscle and to achieve hemostasis.75 A lateral to achieve both anesthesia and hemostasis. A canthotomy is made beneath the semicircular skin number 15 Bard-Parker blade is used to make a incision, and dissection is carried out to the lateral horizontal incision for 5 mm, starting at the lateral orbital rim. A superior cantholysis is performed as canthus.75,88,89 The incision is continued down to the described above, and the lateral portion of the upper orbital rim. The superior ramus of the lateral canthal lid is advanced medially to be attached to the lateral tendon should then be identified. The superior and orbital rim. The flap is then undermined and rotated inferior rami are more easily palpated with scissor inward. The edge of the flap should be sutured to tips than visualized.90 With Westcott scissors the medial edge of the defect with a buried vertical pointed superoposteriorly toward the lateral orbital mattress technique, as described above. Lateral rim, the superior arm of the lateral canthal tendon fixation is obtained by suturing the edge of the flap can be detached from the orbital rim, causing to the periosteum at the lateral orbital rim with significant mobilization of the upper eyelid.89 fixation to the inferior ramus of the lateral Holds and Anderson91 described the use of canthal tendon.75 combined medial canthotomy and cantholysis as a single-stage reconstructive technique for use in Cutler-Beard Flap (Bridge Flap) the reconstruction of the upper or lower eyelid. The Cutler-Beard flap is a lower eyelid That technique sacrifices one lacrimal canaliculus advancement flap that uses a full-thickness and can provide up to 20% of the horizontal eyelid rectangular segment from the lower eyelid to length for closure. The authors recommended that repair large or total defects of the upper eyelid.94 the patient be under general anesthesia for this It is a two-stage procedure used for reconstruction procedure. It involves transection of one lacrimal of defects involving more than one-half of the canaliculus, lysis of one crus of the medial canthal eyelid. The defect of the upper lid is fashioned tendon, and lateral advancement of the medial in a rectangular manner in preparation for a eyelid stump. Adequate reconstructive results were rectangular flap from the lower eyelid.95 The first achieved by using this technique to correct 29 eyelid step involves marking the lower eyelid 1 to 2 mm defects (21 upper eyelids and eight lower eyelids) below the inferior border of tarsal plate. A full- during a 12-year period. Eleven of the patients thickness horizontal incision is then made along underwent simultaneous lateral canthotomy and the distal border of the lower tarsus. Vertical cantholysis. Complications included anterior incisions are made next, completing a rectangular displacement of the medial portion of the eyelid, flap (Fig. 9). The flap is then advanced beneath epiphora, notching of the medial portion of the the remaining, undisturbed lower eyelid margin eyelid, medial ectropion, and blepharoptosis. bridge and is inset into the upper eyelid defect. The skin and orbicularis of the flap are split from Tenzel Rotational Flap the palpebral conjunctiva. The conjunctiva is then Central upper eyelid defects involving sutured to the remaining upper eyelid conjunctiva. approximately 40% of the lid margin can be closed The capsulopalpebral fascia just anterior to the with a semicircular flap, which is rotated into the conjunctiva is sutured to the remaining levator

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Figure 8. (Above) Tenzel flap for upper eyelid reconstruction. An inferior arching semicircular line is marked and incised from the lateral canthus, extending temporally. A lateral canthotomy is made, and a superior cantholysis is performed. The flap is rotated inward and sutured to the medial edge of the defect.

Figure 9. (Left) Classic Cutler-Beard bridge flap technique. A horizontal incision is made along the distal border of the lower tarsus. A full-thickness inferior eyelid flap is created. The remaining lower lid margin forms a bridge. After 4 to 8 weeks, the flap is cut. The pedicle slides back and is sutured to the distal border of the bridge.

20 SRPS • Volume 11 • Issue R2 • 2010 complex.96 The myocutaneous flap is advanced and tissue, but orbital septum is left intact. A hard sutured to the skin of the upper eyelid defect. Four palate mucoperiosteal graft is harvested for to 8 weeks later, the second stage occurs, during posterior lamella reconstruction. The hard palate which the flap is divided and the margin of the graft is positioned in the defect and sutured to upper lid is reconstructed.97 The pedicle slides back the remaining tarsus or canthal tendon stumps and is sutured to the distal border of the bridge.95 and conjunctiva. The myocutaneous flap is then To gain more rigid support of the reconstructed lid, advanced vertically to the defect and sutured to the some authors98,99 recommend recreating the upper inferior edge of the mucoperiosteal graft. The eight lid tarsus by using an inlay graft of ear cartilage, patients in the study by Demir et al. experienced fascia lata, or eye bank sclera. This graft is sutured no major complications during follow-up periods medially and laterally to remaining tarsus and of 6 months to 4 years. The flap was viable in every superiorly to the cut edge of the patient, without total or partial necrosis, and no levator aponeurosis.75 patient required surgical revision. The authors Hollomon and Carter96 described found that the technique allows for immediate replacement of upper eyelid tarsus with Achilles visual rehabilitation, provides functional orbicularis tendon as part of the Cutler-Beard procedure. muscle to preserve blinking and eyelid closure, and The Achilles tendon is composed of collagen fibril permits formation of natural eyelid surfaces bundles with supportive cells in a dense connective and contours. tissue, similar to tarsus. It is readily available from Irvine and McNab100 described a technique most tissue banks. The technique was successful for large upper eyelid marginal defects with 3 to in four patients. The total follow-up ranged from 4 mm of residual upper lid tarsus. The residual 6 months to 4 years. Of the four patients, none upper tarsus travels on a conjunctival pedicle experienced infection, dehiscence, or necrosis. after releasing the levator aponeurosis and Müller No cases of secondary ptosis, eyelid retraction, or muscle. The tarsus is moved to fill the posterior eyelid malposition occurred, and no case required lamella defect in a way similar to that of mobilizing a second procedure. The authors explained that a Hughes flap (Fig. 10). Lagophthalmos often was the main advantage of using this graft is its present to a minor degree of 1 to 2 mm, but patients unlimited quantity, providing sufficient length for were asymptomatic. The main late complication reconstructing large areas. An additional benefit occurring in two patients was lanugo hairs from is that there is no second surgical site, reducing the anterior lamella causing corneal irritation and complications and healing time. Achilles tendon intermittent punctate epithelial keratopathy. The was found to be more pliable and mobile than conditions were successfully managed with topical cartilage, yet it maintained its stability over time. lubricants. After the complication occurred in the The disadvantages are cost, waste of excess unused first four patients, the technique was modified by tissue, and rare possibility of disease transmission suturing the anterior lamella in a recessed position present in all allografts. of 1 to 2 mm to avoid the complication of lanugo Demir et al.97 reported a single-stage hairs causing corneal irritation. A full-thickness procedure for reconstructing large full-thickness skin graft can be used in the event of insufficient upper eyelid defects using an orbicularis oculi anterior lamella. advancement flap. The skin and muscle of the Hsuan and Selva101 described a modified limbs are totally mobilized, leaving the base of the Cutler-Beard flap involving a free tarsal graft with pedicle intact with submuscular tissue attachments. a skin-only advancement flap from the lower eyelid, A triangular V-Y advancement myocutaneous which is divided at 2 weeks. In four cases, the free flap is created, based on the submuscular plane. tarsal graft was harvested from the contralateral The flap includes skin, muscle, and submuscular upper eyelid. The authors stated that using skin

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Figure 10. With an upper lid defect that includes 3 to 4 mm of residual tarsus, the upper tarsus is mobilized on a conjunctival pedicle. Advancement of the tarsoconjunctival flap is shown. The tarsus is sutured in an advanced position, forming a new posterior lamella lid margin. alone in the advancement flap spares dissection eyelid bridge are trimmed to expose all lamellae. of the orbicularis, resulting in less disruption to The lateral and medial edges of the cheek incisions the lower lid tissues. They suggested that the time are undermined, and, if necessary, a portion of the required for the skin to stretch is less than that for a stretched flap ends is excised. The conjunctiva and comparable myocutaneous flap, which is supported lower eyelid retractors are sutured to the inferior by their results showing the flap was divided at 2 border of the lower tarsus with a running 6-0 fast- weeks. The skin-only flap carries a sufficient blood absorbing plain gut suture. The authors described supply, apparent during flap division at 2 weeks, performing the procedure in only two patients who which showed bleeding from the reconstructed were reported to have achieved excellent functional tarsal margin and indicated good vascularity. and cosmetic results, although a follow-up duration Another advantage of this method is eye occlusion was not specified for the first patient described. The for only 2 weeks compared with the traditional 4 to second patient subsequently underwent a frontalis 8 weeks. Only one patient developed mild ectropion sling procedure to correct residual ptosis 8 months and was noted to be the youngest patient needing postoperatively. the greatest vertical displacement to cover the upper Another less common technique is a lid defect. pentagonal composite graft from the contralateral Dutton and Fowler102 presented a modification upper eyelid. Up to 30% of the contralateral of the Cutler-Beard technique, which is valuable in upper eyelid can be harvested and transferred to cases in which the upper eyelid margin is spared. the affected eyelid. The technique should be a The technique is helpful for patients with cicatricial last resort measure to avoid complications in the upper eyelid scarring and retraction of non-marginal normal eye. One should consider this method if tumor resection. A full-thickness horizontal incision the contralateral eye is blind or has poor visual is cut just above the tarsus of the upper lid (in cases potential. A reconstructive ladder for upper eyelid of cicatricial retraction), or the non-marginal lesion defects is shown (Fig. 11).13 is excised, conserving the upper lid margin. The remainder of the surgery consists of the traditional Lower Eyelid Cutler-Beard technique. After 2 to 3 weeks, the flap Direct Closure gains adequate blood supply from above. After 3 to Lower eyelid defects involving 25% or less of the 4 weeks, the flap is divided. The epithelium and scar eyelid length in a young patient can be closed in tissue along the inferior border of the lower eyelid a fashion similar to closure of the upper eyelid, bridge and along the superior border of the upper with a direct end-to-end closure. In older patients

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Figure 11. Reconstructive ladder for upper eyelid defect. A, Primary closure with or without lateral canthotomy or superior cantholysis. B, Semicircular flap.C , Adjacent tarsoconjunctival flap and full-thickness skin graft.D , Free tarsoconjunctival graft and skin flap.E , Full-thickness lower eyelid advancement flap (Cutler-Beard flap).F , Lower eyelid switch flap or median forehead flap.Reproduced ( with permission from Kersten.13)

23 SRPS • Volume 11 • Issue R2 • 2010 with additional lid laxity, a defect consisting of Tenzel Rotational Flap up to 40% of the lower eyelid margin can also be Lower eyelid defects involving 40% to 60% of the closed directly. As revealed earlier; a pentagonal lid margin can be closed with a lateral, semicircular excision closure with the buried vertical mattress miniflap rotated into the lid defect.75,103 Similar technique15,40 is preferred over the classically taught to the technique used in creating a pentagonal three-suture technique. configuration for direct closure of a lid defect, the tissue inferior to the tarsal defect is excised in a Lateral Canthotomy and Inferior Cantholysis triangular shape. A superior arching line is drawn If direct closure causes excessive tension on the on the skin beginning from the lateral canthus wound edges, a lateral canthotomy and inferior extending temporally to the lateral extension of cantholysis can notably mobilize the lateral portion the brow line (Fig. 13). The diameter of the flap of the defect. As described earlier, a number 15 drawn is approximately 20 mm.75 The outline is Bard-Parker blade is used to make an approximately incised with a blade, and a lateral canthotomy 5-mm horizontal incision in the skin at the lateral incision is made below the flap with subsequent 75,88,89 canthus. The incision is continued down to the dissection down to the lateral orbital rim. An orbital rim. The inferior ramus of the lateral canthal inferior cantholysis is then performed. The flap is tendon should then be identified with scissor tips. undermined and rotated nasally. Using Westcott scissors pointed toward the lateral Lateral lid support must be re-established orbital rim, the inferior arm of the lateral canthal to prevent lateral drooping of the eyelid. This is tendon is cut from the orbital rim (Fig. 12). The accomplished by suturing the dermis of the flap lower lid should easily pull away from the lateral tissue to the inner periosteum of the superior inner canthus. The lateral margin of the wound can then 75 75 aspect of the lateral orbital rim. be mobilized nasally to close the lid margin defect. The Tenzel flap can also be supplemented with periosteum or ear cartilage for slightly larger defects to create a support for the lateral eyelid. A periosteal flap is created by elevating a strip from the lateral orbital rim and keeping it hinged off the orbital rim. The flap is stretched across and attached to the inside of the advanced Tenzel flap. Alternatively, an ear cartilage graft can be used to support the lateral portion deficient of tarsus.75,103

Hughes Flap Larger defects that involve more than 50% (depending on lid laxity) of the lower lid margin are ideally closed with a Hughes flap.69 In 1937, Hughes104 presented a method for lower eyelid reconstruction that makes use of the upper eyelid as the donor site. See also Hughes105 (1945) and Rohrich and Zbar106 (1999). A tarsoconjunctival flap was created from the ipsilateral upper eyelid, and it was advanced inferiorly into the lower eyelid Figure 12. With the scissors pointed inferoposteriorly toward the lateral orbital rim, the inferior arm of the lateral defect to replace the absent posterior lamella. canthal tendon is cut. Hughes undermined cheek skin to elevate it, replacing absent lower lid skin without tension. The

24 SRPS • Volume 11 • Issue R2 • 2010 undermined cheek skin was then brought upward Modified Hughes Flap and sutured onto the anterior portion of the lower Years after his original description104 was published, half of the upper lid tarsal plate to rebuild the Hughes108 presented a modified Hughes flap in anterior lamella. response to criticisms regarding postoperative 107 Macomber et al. later altered the Hughes outcomes. Cies and Bartlett109 reported methods flap by using a full-thickness skin graft harvested to avoid postoperative complications with the from either the postauricular, supraclavicular, or Hughes flap. They argued to leave the inferior contralateral upper lid skin as an alternative to portion of the upper eyelid tarsal plate in situ by elevating cheek skin. The graft was sewn onto placing the incision above the lid margin, and they the advanced tarsal plate. The vascular supply recommended removing Müller muscle from the for the graft came from the tarsoconjunctival flap at the time of original dissection. The authors flap. Macomber et al. also recommended eyelash stated that the maneuvers preserved upper eyelid transplantation only in the young or aesthetically support and decreased postoperative upper eyelid minded patient after several weeks using a single retraction and entropion. Cies and Bartlett109 row of hair follicles from the eyebrow. After 6 and Pollock et al.110 additionally explained that weeks, the lid was divided. preservation of at least 4 mm of tarsus vertically from the eyelid margin is necessary to avoid postoperative eyelid contour complications. McCord et al.75 described the modified Hughes flap in detail. Per the authors, the lower extent of the lower eyelid wound is fashioned into a rectangular shape. The horizontal length of the defect is measured to determine the width of the upper lid flap. A three-sided advancement flap is marked on the conjunctiva of the upper eyelid. The horizontal margin of the flap must be 4 mm away from the lid margin. The outlined flap is incised through conjunctiva and tarsus to a level between tarsus and levator aponeurosis. The dissection is continued superiorly between Müller muscle and the levator aponeurosis. The medial and lateral edges of the tarsal flap are sutured to the edges of the lower lid tarsus. The previous upper lid superior tarsal border becomes the lower lid tarsal margin. In cases in which lower lid tarsus at the lateral margin of the defect is not available, the tarsal flap from the upper lid can be anchored to the periosteum using lateral canthal fixation. The inferior border of the flap is sutured to the remaining conjunctiva. Figure 13. Tenzel flap in lower eyelid reconstruction. A full-thickness skin graft is placed over the tarso- After a superior arching line is drawn and incised from conjunctival flap, and the superior edge of the skin the lateral canthus extending temporally, a lateral graft is sutured 1 to 2 mm higher than the future canthotomy incision is created and inferior cantholysis lower lid margin. performed. The flap is then undermined, rotated nasally, and sutured. Various authors divided the Hughes flap after 6 to 8 weeks109 or even after 2 to 4 weeks.75,111,112

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Additionally, successful division after 1 week was of ischemia. reported.113 McNab et al.111 conducted a prospective Maloof et al.116 described use of the Hughes randomized study comparing division of the flap combined with oblique medial and lateral pedicle of modified Hughes flaps at 2 and 4 weeks. periosteal flaps in eight patients. The use of medial Statistical analyses showed no significant difference and lateral periosteal flaps was noted to be the key between the two groups for upper and lower eyelid element in the procedure, facilitating the use of the position at 3 months of follow-up or for other Hughes tarsoconjunctival flap to correct maximal eyelid complications. In all cases, vascularization of defects of the lower eyelid in cases in which both the reconstructed lower eyelid was excellent in both medial and lateral canthal tendons were absent. The the 2- and 4-week groups. authors named the procedure the maximal Hughes Bartley and Messenger114,115 reported the procedure. Here is their description of the creation of results of eight cases of premature traumatic the flaps: dehiscence of a Hughes flap. Each case had been “The periosteal flaps were elevated from caused by accidental trauma that occurred between the inferomedial and inferolateral orbital 1 and 11 days postoperatively in seven of the eight margins with the base of the flap located patients. One patient was unable to identify the at the desired position of the medial exact day on which the flap separated. In four and lateral canthal tendons. The medial patients, the entire flap was involved. The eyelids periosteal flap was elevated from the were allowed to heal without immediate surgical anterior aspect of the inferomedial orbital intervention. In four patients whose dehiscence rim, overlying the frontal process of the did not involve the entire pedicle, the residual maxilla and passing inferolaterally along tarsoconjunctival flap was divided after 16 to 36 the orbital rim. Care was taken to ensure days. Final cosmetic and functional outcomes were that the flap remained at least 4 mm acceptable for the majority of the patients in the wide along its entire length. Once above series. The findings suggest that elective division the level of the medial canthal tendon, of the conjunctival pedicle in routine cases can the margins of the flap followed an conceivably be performed sooner after primary angled path from the anterior aspect of reconstructive procedures than previously thought. the frontal process of the maxilla to the Leibovitch and Selva113 reported the outcomes rim of the orbit above the nasolacrimal of early division of 29 eyelids of 29 patients 1 week sac, where the flap was reflected into the after undergoing lower eyelid reconstructive surgery orbital base. The flap was constructed with a modified Hughes flap. The follow-up period in this fashion to reduce the chance of ranged from 6 to 23 months. No cases of flap medial ectropion of the lower eyelid. The ischemia, necrosis, or retraction of the lower eyelid average length of this medial periosteal occurred. Lower eyelid complications occurred in flap was long, approximating 20 mm, to two patients with margin erythema. In one of the take into account the curvature at the two patients, margin hypertrophy required excision proximal end of the flap. To produce a and cautery. Upper eyelid complications included horizontal attachment, the periosteal three cases of lash ptosis. One patient had lateral flap was then folded on itself, giving a upper eyelid retraction of 2 mm requiring an total length of approximately 15 mm. anterior approach levator recession 3 months after The lateral periosteal flap was created surgery. In two patients, biopsies were obtained in the same fashion, by elevating an from the central and distal tarsal components of the oblique strip of periosteum from the flap at the time of division. The biopsies showed lateral orbital rim over the zygoma and viable vascularized tissue with no evidence passing inferomedially along the orbital

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rim. The periosteum was elevated above artery.118 The advantages with the use of nasolabial the former site of the lateral canthal flaps were the inconspicuous donor scar concealed tendon and reflected into the base of the in the nasolabial fold, the reliable vascularity of the orbit. Unlike the medial flap, the lateral flap, and use of a non-hair-baring area. flap did not need to follow an angled course and was not folded on itself. In Mustarde Rotational Cheek Flap all cases, the lateral periosteal flap was The Mustarde flap is a full-thickness rotational thicker than the medial flap. The tarsus cheek flap that can be used for complete lower was anchored medially and laterally to eyelid reconstruction in one operation.43,119,120 It is the periosteal flaps using interrupted most valuable for correcting vertically deep defects, 5-0 polyglactin sutures. The conjunctiva particularly those in which the vertical dimension was sutured to the inferior border of the is greater than the horizontal dimension, and the tarsal plate and inferior margin of the more nasal defects.22,75 A large, nasal, superiorly periosteal flaps using a continuous 7-0 based triangle is outlined with the medial edge on polyglactin suture. The anterior lamella the nasolabial fold (Fig. 14). A semicircular flap is of the lower eyelid was then mobilized then made, beginning at the lateral canthus and and sutured to the upper border of the continuing laterally down to the area anterior to the tarsoconjunctival flap. Cases in which auricular tragus. The superior edge should extend skin was deficient, an orbicularis muscle at least to the height of the brow or above. The advancement flap was mobilized and medial triangle is excised, but its size will depend a full-thickness skin graft was used on the amount of tissue needed to rotate the flap. to replace the anterior lamella. The The semicircular flap is then undermined. Before tarsoconjunctival flap was not divided for the undermined tissue is rotated, a chondromucosal at least 8 weeks.”116 graft or autogenous ear cartilage graft is obtained The average follow-up duration in that study was 13 for posterior lamellae reconstruction and is sutured months (range, 7−22 months). All flaps and grafts inferiorly to the conjunctival mucosa in the inferior remained viable, and no patient experienced corneal fornix. Alternatively, a tarsoconjunctival graft, hard complications or lagophthalmos. All patients had a palate graft, or synthetic material such as AlloDerm cosmetically acceptable appearance with excellent can be used. The cheek flap is then rotated nasally to eyelid contour. In two patients who underwent skin fill the nasal triangular defect. The medial canthus muscle advancements, late lower eyelid retraction is recreated by placing a 5-0 Vicryl suture through developed. Medial ectropion developed in one the dermis of the cheek flap and anchoring it to the patient at 4 months postoperatively. posterior ramus of the medial canthal tendon or to Tei and Larsen117 illustrated the use of a the periosteum of the medial orbital rim. The graft Hughes flap with a nasolabial flap to reconstruct the used for the posterior lamellae is then sutured to lower eyelid and to cover a large accompanying skin the posterior margin of the cheek flap at the new lid defect in one case. The defect measured 38 mm in margin. Running 5-0 plain catgut suture is placed width and 30 mm in height and was reconstructed at the mucosal-epithelial border. The lateral canthus with the use of a subcutaneously based nasolabial is replaced by suturing the dermis of the rotational flap. The tarsoconjunctival flap was divided 3 weeks flap to the superior, inner aspect of the lateral postoperatively. Three months postoperatively, the orbital rim with lateral canthal fixation. The skin patient had neither ectropion nor entropion. The is then closed. The lateral edge of the flap can be vascular supply for the flap was derived from the closed with a V-to-Y configuration or a triangular infraorbital artery and the anastomoses between the excision of redundant skin. To end with, the eyelids lateral nasal artery and branches of the infraorbital are sutured together with a tarsorrhaphy stitch that

27 SRPS • Volume 11 • Issue R2 • 2010 provides added upward tension on the flap and eyelid defect (Fig. 15).122 The flap consists of upper everts the mucosa skin interface. The tarsorrhaphy eyelid skin and orbicularis muscle. Tripier121 stated and skin sutures can be removed after 5 days.75 that for a successful flap, the number of facial nerve branches severed needed to be minimized and it was desirable to maintain the continuity of the orbicularis muscle fibers.123 He wrote that defects of one-half or even two-thirds of the lower eyelid could be reconstructed by using this technique. Adaptations of this flap have since been described.123−127 In his original manuscript, Tripier121 also described a second variation of the flap that was used to reconstruct upper eyelid defects with a myocutaneous flap based on prefrontal orbicularis oculi muscle fibers positioned superior to the eyebrow. That technique is no longer commonly used.121−123 Elliot and Britto123 described a third variation of the Tripier flap for reconstruction of marginal defects of the upper eyelid. The authors reported the design of a “bucket-handle flap” immediately inferior to the eyebrow on the upper preseptal fibers of orbicularis oculi. The flap is designed identically to the flap used by Tripier to reconstruct the lower eyelid but uses the tissues more superior and closer to the lower margin of the eyebrow. Bickle and Bennett122 presented a fourth Tripier flap variation for reconstruction of a medial defect on the lower eyelid. A medially based myocutaneous flap (including superficial fibers of the orbicularis oculi muscle) was designed from Figure 14. Mustarde rotational cheek flap.Top , Shaded area the medial upper eyelid. The flap was intentionally shows inferior eyelid defect. Middle, Nasal chondromucosal made longer than necessary because, on rotation, graft is secured to the lateral orbital rim. The rotated flap is it loses length. The lower planned incision line was anchored to the external lateral orbital rim. Bottom, Defect placed over the pretarsal crease. An incision was is closed. made from the defect on the lower eyelid extending across the medial canthus and onto the upper eyelid; the incision was then continued laterally Tripier Flap along the pretarsal crease and curved upward and 121 In 1889, Tripier described the original Tripier flap then medially to complete the flap. The flap was for cases in which the posterior lamella is preserved elevated and transposed into the defect on the but anterior lamellae lower eyelid restoration is medial aspect of the lower eyelid and then sutured required. It consisted of dissecting and elevating into place. A standing cone (dog ear) occurred at a bipedicled flap from the upper eyelid that was the flap base in the medial canthus, but it could not then transposed inferiorly into a lateral lower be excised at the time of flap placement because

28 SRPS • Volume 11 • Issue R2 • 2010 doing so would compromise the vascular supply the lateral canthus while raising the flap. The flap to the flap. At 5 months’ follow-up, the lacrimal is then islanded once the vessel is identified, and system was functional, and no eyelid malposition the subcutaneous fat is preserved over the feeding had occurred. The authors stated that the residual vessel. The flap can be transferred to the defect dog ear would probably resolve on its own, although either through a subcutaneous tunnel or by in some cases, if excessive, the dog ear might need opening the bridge of skin. Follow-up at 1 year to be injected with triamcinolone acetonide (10 in the two cases reported showed stable results mg/mL) or excised. Other potential problems cited without ectropion. by the authors were medial canthal blunting, mild pincushioning, and mild medial eyelid ectropion. Modified Hewes Procedure Levin and Leone128 incorporate the pedicles of The modified Hewes procedure is useful for the Tripier flap into the wound. The incision for flap repair of lower eyelid defects not involving the elevation in the upper eyelid crease is lengthened entire lid margin, in particular those involving the medially and laterally to meet the ends of the lower temporal half of the lower eyelid. Hewes et al.129 eyelid defect. The donor site in the upper eyelid is described a transposition flap of tarsoconjunctiva. primarily closed. The flap is positioned at the lateral canthal angle Vuppalapati and Niranjan125 described a and brought into the lower eyelid defect. A full- modification of the Tripier myocutaneous flap, thickness skin graft or flap is then placed over it. converting it into a perforator islanded flap. The upper eyelid is first everted, and a rectangular The feeding vessel for the flap was a branch of block encompassing the superior tarsal border and the zygomatico-orbital artery arising from the the conjunctiva above the superior tarsal border, superficial temporal artery or transverse facial artery. all based at the lateral canthal angle, is marked. Raising the flap was similar to raising a unipedicled With this design, the peripheral arcade at the Tripier flap with a layer of orbicularis oculi muscle. superior tarsal edge is included and provides a The authors stated that the essential step with this vascular supply for the flap (Fig. 16). The flap is method is to identify the feeding vessel entering then dissected into the canthal angle, ensuring the the flap from deeper layers of orbicularis oculi near arcade is preserved as it enters the base of the flap.

Figure 15. Tripier flap for repair of a lower eyelid defect.

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The flap is transposed into the lower eyelid defect Other Combined Techniques and secured to the tarsus and conjunctiva with Zinkernagel et al.130 described repair of a large lower absorbable sutures. The flap is then covered with eyelid full-thickness defect using an autogenous a full-thickness skin graft or a musculocutaneous free tarsal graft for the posterior lamellae and a transposition flap from the same upper lid based at skin rotation flap from the ipsilateral upper eyelid 75 the lateral canthal angle. A reconstructive ladder for the anterior lamellae. In all four of the cases 13 for lower eyelid defects is shown (Fig. 17). presented, the skin flap provided adequate vascular support. Follow-up of 10 to 20 months showed good outcomes achieved by all patients. The authors noted that with the Hughes flap or Cutler-Beard techniques for eyelid reconstruction, a two-step approach with occlusion of the eye for at least 1 week is required, but reconstruction with a free tarsal graft is a one-stage procedure that does not necessitate eye occlusion. Moesen and Paridaens131 presented a one-step technique to repair lower lid marginal full-thickness defects (Fig. 18).132 The posterior lamella is reconstructed by advancing residual lower lid tarsus on a conjunctival pedicle, as described by Irvine and McNab100 for the upper eyelid. The anterior lamella is reconstructed by orbicularis muscle advancement and a free skin graft. The authors studied five patients with lower eyelid marginal defects ranging from 8 to 9 mm in height and 12 to 22 mm in length after tumor excision. All tumors were excised with 2-mm tarsal margins to allow a residual vertical tarsus of 2 mm, which is required for the reconstruction technique. To avoid retraction of the reconstructed lower eyelid, the lower eyelid retractors are released from the conjunctival pedicle before advancement of the tarsoconjunctival flap. After a mean follow-up duration of 10 months, the outcomes were graded as good in one case and excellent in four. Paridaens and van den Bosch132 described a one-stage “sandwich technique” for reconstruction of full-thickness lower eyelid defects in 12 patients and a full-thickness upper eyelid defect in one. The sandwich technique consists of an orbicularis Figure 16. Modified Hewes procedure.Dashed lines represent the flap site, which includes part of the superior oculi muscle advancement flap that is covered peripheral arcade. The upper eyelid tarsoconjunctival flap with a free tarsoconjunctival graft posteriorly and is mobilized and transposed into the lower eyelid defect. a free skin graft anteriorly. It allows for one-stage An upper eyelid musculocutaneous flap is transposed to reconstruction of relatively shallow lower eyelid cover the tarsoconjunctival flap. defects with a horizontal size of up to 70% of

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Figure 17. Reconstructive ladder for lower eyelid defect. A, Primary closure with or without lateral canthotomy or inferior cantholysis. B, Semicircular flap.C , Adjacent tarsoconjunctival flap and full-thickness skin graft.D , Free tarsoconjunctival graft and skin flap.E , Tarsoconjunctival flap from upper eyelid and skin graft (Hughes procedure). F, Composite graft with cheek advancement flap (Mustarde flap).Reproduced ( with permission from Kersten.13)

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

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Figure 18. Various steps of the one-stage sandwich technique for eyelid reconstruction are shown. a, Shallow lower eyelid defect after tumor excision. b, Width of the graft was 2 mm less than the horizontal defect size to ensure adequate horizontal tension. The horizontal width of the defect was measured with calipers. c, With straight Stevens scissors, the orbicularis oculi muscle was dissected from the skin anteriorly and from the orbital septum posteriorly to the orbital rim. d, Two vertical cuts were then made in the muscle to liberate it sufficiently to fill the eyelid defect without vertical traction. e, Contralateral or ipsilateral upper eyelid was everted, and a free tarsoconjunctival graft was harvested. f, Graft was sutured to the margins of the tarsal plate in the defect. g, Orbicularis oculi muscle flap was sutured to the margins of the orbicularis oculi muscle surrounding the defect. h, Free skin graft was harvested from the ipsilateral or contralateral upper eyelid. i, After careful removal of any remaining muscle fibers or subcutaneous tissue, the graft was sutured into the skin defect. (Reprinted with permission from Paridaens and van den Bosch.132)

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Medial Canthal Defects drawn-together brows is the super thinned inferior Defects of the medial canthus resulting from pedicled glabellar flap described by Emson and tumor excision are commonly encountered. They Benlier.136 With that technique, the glabellar are second in frequency to lower eyelid defects. flap is raised, as classically described.137,138 Once Proper repair of the defects is essential to restore the forehead wound superior to the eyebrow is functionality to the eyelids and to achieve an closed, the frontalis muscle and subcutaneous fat aesthetic result to eyelid reconstructive surgery. If are removed from the flap, leaving the axial blood not appropriately addressed, the defects can lead vessels. In their series of eight patients, Emson to life-long symptoms of tearing, foreign body and Benlier found that satisfactory cosmesis was sensation, and poor cosmesis. Appropriateness achieved in all, and the normal inter-brow distance of the repair techniques depends on the type, was maintained. size, and depth of the defect and the health of the surrounding tissues. Most importantly, a combination of techniques might be necessary to achieve the most desirable surgical outcome.

Glabellar Flaps Glabellar flaps are commonly used to repair medial canthal defects. When properly created, the flaps can be effective. Turgut et al.134 noted that a traditional glabellar flap entails creating an inverted V in the glabellar region, which is then undermined and rotated to close the medial canthal defect. Closure of the resultant wound converts the inverted V to an inverted Y (Fig. 19). The size of the flaps depends on the size of the defects and can be enough to cover a full range of medial canthal defects. Glabellar flaps offer advantages to other flaps in the region. They are relatively simple and can cover deep defects. They have sufficient blood supply from the subdermal plexus and the supratrochlear vessels.134 One disadvantage to this technique is that it tends to draw the eyebrows closer together. Meadows and Manners135 proposed a simple modification. With the modified technique, the glabellar flap is raised and rotated to cover the defect, as described for the classic technique. The redundant skin that results from transposing the flap is then cut away and used to help close the resultant Y-shaped wound, maintaining the normal Figure 19. Glabellar V-Y flap. Illustration on the top depicts the spacing of the eyebrows (Fig. 20). medial canthal defect with an inverted V originating from the Another modification of the traditional apex of the defect. Incision and rotation of the flap into the glabellar flap that helps to avoid the “bulky” defect result in an inverted Y as depicted in the illustration on the bottom. appearance in the medial canthal region and the

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A combination approach of glabellar and nasolabial V-Y flaps has been described to be particularly successful for large medial canthal defects.140 Yildirim et al.140 described a series of 23 patients who underwent combined glabellar and nasolabial V-Y flaps. In the reported series, the average defect size was 28 mm × 30 mm. Because of the size of the defect, it was thought that closure with a single flap, either glabellar or nasolabial, would lead to significant deformity. The vertical dimension of the glabellar flap was planned to be approximately three times the breadth of the defect at its narrowest part, whereas the nasolabial flap was planned to be two times the longitudinal diameter of the defect. The flaps were raised and advanced into the defect and were interdigitated and sutured with 5-0 nylon. The forehead and nasolabial wounds were closed in usual fashion as an inverted V and an inverted Y. Sutures were removed on postoperative day 6. The authors reported that no patients suffered ectropion, lymphedema, or lid lag during a minimum follow-up duration of 6 months.

Rhomboid Flap Another flap involving the glabellar tissue is the rhomboid flap (Fig. 21). Essentially, the flap is Figure 20. Modified glabellar flap. Note the additional horizontal incision where excess glabellar tissue was accomplished by conceptualizing the medial canthal incused, allowing the brows to rest in a more defect as a rhombus with its long axis being vertical. natural position. Medial to the defect, half of the rhombus, again along the vertical axis, can be drawn. By dividing that half along its horizontal axis, the resulting Nasolabial and Melolabial Flaps rectangular flap can be advanced to fill the medial Similar to glabellar flaps, tissue from the nasolabial canthal defect.141 As with the traditional glabellar region can be used as flaps in the same classically flaps, “bunching” might be seen medially and described V-Y configuration. The inverted V is narrowing of the inter-brow distance can occur. created with the apex inferiorly oriented into the nasolabial tissue. The flaps are harvested from the Medial Myocutaneous Flaps nasolabial fold lateral to the nasolabial crease. That First described in 1983 by Goldstein142 and later region has a rich blood supply from the perforating re-described by Jelks et al.,143 a myocutaneous flap branches of the facial artery. Because of the rich is a versatile flap for medial canthal reconstruction. vascularity, the flap can be based inferiorly or Initially, the defect is carefully measured and an superiorly. This particular area contains the most appropriately sized flap is fashioned from the upper redundant skin on the face and allows for sizeable eyelid. The flap containing skin and orbicularis flaps and relatively easy closure. The scar often can is raised lateral to medial, carefully leaving 139 be hidden in or parallel to the nasolabial crease. the vascular supply intact, which includes the

35 SRPS • Volume 11 • Issue R2 • 2010 supratrochlear, infratrochlear, and medial a full thickness skin graft can be used to cover the palpebral vessels (Fig. 22). Its attachment to the remaining area. Because this is a sliding cutaneous medial fat pad is kept intact, and the area acts as flap, it is not useful in cases of deep medial its pedicle, allowing rotation of the flap to cover a canthal defects.146 variety of different medial defects. As described by Jelks et al., the flap is sutured in place in layered Medial Pedicled Orbicularis Oculi Flap fashion with deep 5-0 Vicryl sutures and 6-0 nylon The medial pedicled orbicularis oculi flap, as sutures to approximate the skin. The donor site is described by Tezel et al.144 in 2002, combines closed primarily.143,144 concepts from the bipalpebral sliding flap and the myocutaneous flap. The lower edge of the flap Skin Grafts is the lid crease. The width of the flap created Full-thickness skin grafts are useful for correcting depends on the size of the defect. The flap is then medial canthal defects that are relatively superficial. elevated lateral to medial and includes both skin The skin can be harvested from the upper eyelid, and orbicularis. The medial portion of the flap is retroauricular, supraclavicular, and inner arm de-epithelialized, and the flap is tunneled to the areas.22,41,42 Dryden and Wulc145 described using contralateral side, allowing the de-epithelialized preauricular skin, which can provide a better color portion of the flap to be buried under the tunnel match, as opposed to the traditional retroauricular while the myocutaneous flap is inset to the area of grafts. Although grafts are very useful, skin the defect. The flap is sutured in place in a layered color and thickness match can be cosmetically fashion, and the donor site is closed primarily challenging. Nevertheless, skin grafts are commonly (Fig. 23).144,147 used to cover medial canthal defects. They are simple, effective, and conform well to the concave Mid Forehead Flaps surface of the medial canthus. They should be Mid forehead flaps, including the median and avoided when vascular compromise of the recipient paramedian flaps and their many variations, are bed is suspected, such as in smokers or after useful in midfacial reconstruction, including radiation damage. reconstruction of medial canthal defects. Forehead skin flaps are consistently useful for reconstruction Bipalpebral Sliding Flaps of the periorbital region in that they have a rich Adenis and Serra146 described a technique that uses network of vascular structure and low donor site a combination of flaps from the upper and lower morbidity, are thin and pliable, and are compatible eyelids to correct medial canthal defects. Upper with the color of the facial skin.148 Per Baker,139 eyelid incisions are made 2 mm above the cilia the median forehead flap was originally described and 2 mm below the brow. The lower lid incisions in the Indian medical treatise in approximately are made 2 mm below the cilia, and the inferior 700 bce and has evolved greatly over time. Baker incision is created in a curvilinear fashion starting reported that in the 1930s, Kazanjian described at the lower edge of the defect and continuing the procedure in detail. The technique presented to the inner portion of the cheek (approximately by Kazanjian used a midline forehead flap that was 10−20 mm below the superior incision). The flaps created with a hairline incision that continued to a are undermined at the level of the orbicularis point immediately above the nasofrontal angle and muscle and are slid into place, covering the medial derived its blood supply from the supratrochlear defect. With a small defect, the two flaps can be and supraorbital arteries. In the 1960s, Millard149 approximated to each other, completely covering described a modification of the median forehead the defect. With larger defects, the individual flaps flap called theseagull flap with which lateral can be tacked down to the underlying tissue and extensions were used to cover the nasal alae. The

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Figure 21. Rhomboid flap. Note the creation of a rectangular flap that can be used to fill the medial canthal defect.

Figure 22. Medial myocutaneous flap. Note the Figure 23. Medial pedicled orbicularis oculi flap. The pentagonal attachment of the myocutaneous flap with the section represents the portion of the graft that has been de- medial fat pad. epithelialized and will reside tunneled beneath the nasal tissue.

37 SRPS • Volume 11 • Issue R2 • 2010 flap incision extended below the orbital rim to as is a majority of the subcutaneous fat. The flap is gain additional flap length. According to Baker, sutured at the recipient site with vertical mattress Labat re-designed the median forehead flap to be sutures, and the forehead donor site is closed centered around a unilateral supratrochlear artery in layers.139 and Millard and Menick then modified the flap A frontal hairline flap, as described by by shifting the entire vertical axis to a paramedian Karşdağ et al.,152 can be used in a single-stage position and showed that the flap would survive alternative to closing a medial canthus defect with without the central glabellar skin. The modification an accompanying dorsal nasal defect. In 10 patients allowed for a narrower flap with greater freedom of who were status post surgical tumor resection, tissue movement. Baker reported that in the 1980s, Karşdağ et al. fashioned an elliptically shaped Burget and Menick extended the paramedian flap frontal island flap at the level of the frontal hairline. below the bony orbital rim, which allowed the flap The flap was vascularized by the supraorbital and to exclude hair-bearing scalp tissue. supratrochlear arteries. The lateral points of the Baker139 described, in great detail, the pedicle were in alignment with the vertical lines paramedian forehead flap based on a single crossing the medial canthus and pupillary midline, supratrochlear artery. A Doppler probe often is respectively. Dissection of the pedicle was confined used to assist in locating the supratrochlear artery, between the lines, and a subcutaneous tunnel was although Baker noted that it is not necessary. formed between the defect and the flap recipient The vertical axis of the supratrochlear artery is area. The island flap was transposed to the recipient located approximately 2 cm lateral to the midline, area through the subcutaneous tunnel. The hairline corresponding to the medial border of the brow, incision was sutured intracuticularly. No major and the width of the flap is designed to be 1.5 cm vascular damage was observed during dissection, and not flared. In recent Doppler studies of healthy and arterial insufficiency was not reported. Venous volunteers, the supratrochlear vascular pedicle was insufficiency and trapdoor deformity occurred in found, at most, to be 3 mm lateral (more common two patients and healed spontaneously. They authors in men) or medial (more common in women) to stated that the venous insufficiency might have the medial canthus.150 Kelley et al.151 showed that occurred secondary to the kinking of the pedicle or within the paranasal and medial canthal region, the inadequately narrow tunnel. an anastomotic connection exists between the A pericranial flap composed of periosteum supratrochlear, infraorbital, and branches of the and subgaleal fascia is a very versatile flap facial arteries and branches from the contralateral used extensively in craniofacial surgery. Its side, producing a rich vascular arcade. This use for repairing medial canthus defects is relationship allows a median forehead flap to be fairly new. Leatherbarrow et al.153 conducted a narrowly based at the level of the medial canthus. retrospective review of consecutive cases requiring The upper border of the flap typically is the reconstruction of medial canthal defects involving frontal hairline unless the patient has a receding loss of periosteum or bone by a median forehead hairline or frontal balding. It is crucial to carefully pericranial flap and full-thickness skin grafting. The measure the size of the defect and correlate it to authors described two different techniques of flap the size of the flap that is raised. Once measured harvest. One is an open technique that includes and marked, an incision is created and the flap is a midline forehead incision, and the other is an elevated from the underlying periosteum. To close endoscopic technique that includes two incisions the donor site, it is necessary to undermine the behind the hairline. wound in a subfacial plane from one temporalis With the open technique, a vertical midline muscle to the other. Galea and frontalis muscles are incision of approximately 3 to 4 cm is made, completely removed from the distal tip of the flap, extending superiorly from the glabella with a

38 SRPS • Volume 11 • Issue R2 • 2010 remaining short bridge of skin and deeper tissue used in posttraumatic and tumor ablation cases. between the inferior aspect of the incision and the In their report of two patients, the skin located 2 superior aspect of the medial canthal defect, under mm medial to the canthus was incised vertically to which the flap can later be tunneled. The tissues are avoid the lacrimal apparatus and to provide direct dissected down to the pericranium, and the desired access to the medial canthal tendon. The periosteum dimensions of the flap are outlined with a surgical corresponding to the opposite medial canthal marker. The flap is then cut from the pericranium tendon attachment point was elevated, and two with a number 15 Bard-Parker blade, keeping a holes were created 3 to 4 mm apart with a Kirchner length:width ratio of approximately 4:1. The pedicle wire. One of the free ends of two 3-0 polypropylene is based on the opposite side of the medial canthal sutures was passed through each hole within a No. defect. A subcutaneous dissection of the superior 14 Angiocath (Dogsan, Istanbul, Turkey). Both aspect of the medial canthal defect is performed sutures were extracted by using forceps inserted in with Stevens scissors, and the flap is then rotated the ipsilateral nasal ostium. The free ends of the inferiorly into the defect so that the deep periosteal sutures were tied outside the nostril. The needles surface lies on the deep aspect of the defect. It is were then passed through the canthal tendon. then sutured in place with interrupted with 7-0 While tying the suture ends, the tendon was Vicryl sutures.153 repositioned to its original bony attachment With the endoscopic technique, two vertical point with simultaneous tightening of the tied paramedian 1-cm incisions are made behind the knot inside the nostril. Follow-up of the patients hairline. A straight 4-mm endoscope is inserted was not discussed. into one of the scalp incisions for visualization, and a plane is created between the pericranium and Secondary Intention the frontal bone with a Freer periosteal elevator. Secondary intention healing is a method that An additional plane is then created between the is commonly used as a means of reconstruction. pericranium and the galea with endoscopic scissors. However, it has been less commonly used in the The superior and lateral borders of the flap are cut periocular region for fear of poor functional or with the endoscopic scissors. The remainder of the cosmetic results. Several studies showed some technique is the same as the open technique.153 success with secondary intention healing of eyelid The average length of follow-up was defects, including healing in the medial and lateral 13 months for the 21 cases described by canthal regions.158−160 Leatherbarrow et al.153 Ten cases required additional In 2002, Shankar et al.158 retrospectively oculoplastic procedures, including local periosteal studied results of the “laissez-faire” technique with flaps and mucous membrane grafts. Two patients which the eyelid defects were allowed to heal by (10%) experienced complete flap failure, one of secondary intention. Twenty-four patients with which was caused by infection. Five patients (24%) 25 periocular defects after tumor removal were experienced partial (<50%) skin graft necrosis. Two followed, with initial skin defects ranging from patients (10%) required additional surgery. 6 mm × 7 mm to 15 mm × 32 mm. Five patients had medial canthal involvement, and one had Medial Canthal Tendon Fixation lateral canthal involvement. Twenty-three of the 25 Transnasal wiring has commonly been used to healed defects were rated “good” or “very good” by repair medial canthus dystopia. With the technique an independent observer, and only one required a of transnasal wiring, a stainless steel wire is second procedure. passed through the nasal bridge to the opposite Lowry et al.159 presented a similar study in nasal bone.154−156 Turgut et al.157 described the 1997, and the results were nearly the same. In that unitransnasal canthopexy technique, which can be series, 83% of the 59 patients achieved satisfactory

39 SRPS • Volume 11 • Issue R2 • 2010 functional and cosmetic results and only two its position and shape. Any tissue rearrangement required secondary repair. Zitelli160 divided the around the lateral canthus should not exert undue regions of the face into three groups—NEET, tension on the lateral canthus. Even minor changes NOCH, and FAIR—and reported the results of are noticeable and could lead to poor cosmetic secondary intention healing. The NEET areas are results. Inadequate support to the lateral canthus the concave areas of the face, including the nose, can lead to blepharophimosis, rounding of the eye, ear, and temple, and they tend to heal with lateral canthal angle, slanting of the lateral canthal excellent cosmetic results. The NOCH areas are angle, ectropion, inferior scleral show, and exposure. the convex surfaces, including the nose, oral lips, Numerous approaches can be used to repair defects cheeks, chin, and helix of the ear, and they produce in the lateral canthal region, including primary noticeable scars. The FAIR areas are the flat closure, skin grafting, and regional advancement surfaces, including the forehead, antihelix, eye lid, flaps. Although a majority of lateral canthal defects and remainder of the nose, lips, and cheek, and they can be repaired by techniques previously described achieve intermediate results. for the upper and lower eyelid reconstruction Ceilley et al.161 described the use of secondary sections, in cases of larger or more complex intention healing to delay skin grafting, either full defects, the following flaps have been described as thickness or split thickness. The authors postulated being useful. that partial healing of deep wound defects by secondary intention will produce a wound that is Bilobed Flap much smaller and of more normal contour than In 2007, Mehta and Olver162 described achieving the original wound and is therefore more amenable great success by using a bilobed flap for to skin grafting. They warned, however, that areas reconstructing the lateral canthal area. The flaps requiring constant protection (i.e., the central used in that study originated in the zygomatic or eyelid) might require immediate grafting or flap lateral cheek region. This advancement flap consists reconstruction to avoid exposure keratopathy. of two lobes with one common base that can be Appropriate repair of medial canthal defects mobilized and rotated into place to cover the defect. is crucial to ensure proper functioning of the eyelid The first lobe is slightly smaller than the defect, and lacrimal system and creation of an aesthetically and the second lobe usually is one-half the width acceptable result. A number of approaches to this of the first lobe. The design allows the defect from type of repair are described in the literature and the second flap to be closed primarily. To avoid skin have been proven to be effective. In choosing the tension, the flap should be based superiorly in a most suitable repair, a variety of factors should be design with which the second flap is elevated from considered, including the size and depth of the the preauricular region horizontally and the first defect and involvement of the lacrimal system. flap is elevated in a vertical orientation. By elevating Additionally, it must be recognized that all the the second flap from the preauricular region with a techniques described above do not exist in isolation. horizontal orientation, the closure line can be placed A combination of two or more techniques often is parallel to the crow’s feet.162 needed in closing medial canthal defects. The approach provides excellent color and texture matches. Additionally, ectropion is not Lateral Canthal Defects commonly encountered because the flap is based Proper repair of the lateral canthal region is an superiorly. However, the length of the scar is important issue in facial aesthetics. Improper considered a disadvantage. Additionally, in male repair can lead to cosmetic deformity or functional patients, the second lobe of the flap might contain failure caused by eyelid malposition. The crucial some hair-bearing skin. issue in the reconstruction of the lateral canthus is

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Superior Auricular Artery Island Flap Hematoma Kilinc et al.163 described using a superior auricular As with any surgery, hematoma formation is a artery (SAA) island flap for repairing periorbital potential complication. Meticulous hemostasis defects, including lateral canthal defects. The flap with bipolar cautery can minimize the risk. tends to have perfect color, thickness, and texture Likewise, preoperative planning regarding the matches with the facial skin. Kilinc et al. described discontinuation of anti-coagulation medications is three types of flaps based on the pedicle. A type 1 prudent. Hematomas can lead to suboptimal results, flap is a superficial temporal vessel pedicled SAA including failure of grafts and excessive scarring. island flap. Type 2 SAA flaps are based on the frontal branch of the superior temporal artery. Type Eyelid Malpositions 3 is an SAA flap based on the parietal branch of Entropion the superior temporal artery. The authors reported Shortening of the posterior lamellae causes a that the flaps they used ranged in size from 3 cm× cicatricial entropion, with the lid margin turning 6 cm to 8 cm × 6 cm. In their study of 14 patients, in and the lashes rubbing over the cornea. This aesthetically and functionally successful results were can lead to significant ocular surface problems, achieved with minimal donor site morbidity. including corneal abrasion and ulceration. Mauriello164 emphasized the importance of Treatments of cicatricial entropion include tarsal adequate fixation of the reconstructed eyelid to fracture with rotation of the eyelid margin and the periosteum to avoid eyelid malposition. With posterior lamellar grafts. small defects, direct closure usually is effective and Entropion can also result from horizontal the cut edge of the tarsus can be directly anchored laxity, disinsertion of the inferior lid retractors, to the orbital rim periosteum. For large defects, and overriding of the preseptal orbicularis over the periosteal flaps can be used. A periosteal flap is pretarsal orbicularis. Correction of such entropions raised as a rectangular strip from the outer aspect of should include correction of all components the lateral orbital rim at the level of the pupil. The contributing to the occurrence of that hinged flap can be reflected medially and sutured to specific entropion. the free edge of the tarsus with 5-0 Vicryl sutures. The periosteal flap should be covered with a sliding Ectropion or advancement flap with its own blood supply.164 Shortening of the anterior lamellae leads to Tenzel semicircular flaps have been described to cicatricial ectropion, especially if horizontal lid be helpful in the lateral canthal region and were laxity is present. This will cause corneal dryness discussed earlier.75,92,93,103 Any tissues mobilized from exposure and will also lead to epiphora from around the lateral canthus should be anchored to both the increased reflex tearing and from the the lateral orbital rim, periosteum, temporalis fascia, punctum not opposing the globe. The treatment or other solid deep tissue to ensure that no undue of ectropion is by horizontal tightening and by tension is transmitted to any component of the increasing the anterior lamellae, either by skin grafts lateral canthus. or recruiting skin from the cheek.

Complications of Eyelid Reconstruction Eyelid Retraction and Lagophthalmos Reconstruction of the eyelid requires great Lagophthalmos, or incomplete eyelid closure, can attention to detail. Many pre- and postoperative occur secondary to cicatricial eyelid retraction considerations must be taken into account. Even or can be paralytic. Lagophthalmos can result well-planned surgical intervention for eyelid in exposure keratopathy and requires prompt reconstruction can result in complications. attention. Acutely, copious lubrication of the ocular surface by means of eye drops and ointments or

41 SRPS • Volume 11 • Issue R2 • 2010 a moisture chamber can help protect the cornea. acceptable result but also to ensure proper drainage Surgical intervention might be required as a of tears. If the lateral or medial canthal tendons definitive solution. The surgical approach depends are not adequately fixated at the lateral and medial on the cause of the lagophthalmos. If retraction orbital rims, the eyelid will not have appropriate occurs because of limited anterior lamellae (skin tension to allow the orbicularis muscles to exert and orbicularis), repair is best accomplished with a pressure along the canaliculi and tear sac, which is full-thickness skin graft or adjacent advancement crucial for the active drainage of tears. Additionally, flap. Middle lamellar shortening can lead to eyelid without proper tension on the eyelid, ectropion can retraction and inferior scleral show and can be result, as discussed above. treated with spacer grafts, such as tarsoconjunctival grafts, AlloDerm, ear cartilage, or hard palate grafts. Blepharoptosis Blepharoptosis occurring after eyelid reconstruction Notching and Contour Deformities can be caused by the initial trauma or tumor or by When reconstructing the eyelids, care must be the surgical repair itself. A ptotic eyelid, in addition taken to avoid creation of irregularities along to being a cosmetic concern, might interfere with the eyelid margin and to maintain the normal the central visual axis. The complication becomes curvilinear contour of the upper and lower eyelids. even more serious in pediatric patients when the Failure to accomplish this can lead to a cosmetically development of amblyopia is a possibility. displeasing result and loss of the normal eyelid The normal anatomy of the eyelid must function regarding protection of the cornea and be carefully considered when attempting eyelid facilitation of a functional tear drainage system. reconstruction. The preaponeurotic fat serves as A notching defect can occur when the eyelid one of the most important surgical landmarks in margin is not adequately everted during its repair. eyelid reconstruction. Just posterior to the fat lies Contraction of the wound during healing leads to the levator aponeurosis, which can easily be severed. a notch in the normally smooth and continuous Additionally, extensive tissue swelling can lead eyelid margin. Notching is also common if wound to dehiscence of the levator aponeurosis from its dehiscence occurs. Such dehiscences can occur attachment to the tarsus. from excessive wound tension or from infections. Repair of ptosis after eyelid reconstruction It is a common complication if the closure of the should be delayed at least 6 months and sometimes wound does not include the tarsus in the margin or longer if serial examinations reveal improvement anterior surface sutures. By disrupting the normal in eyelid position. Surgical repair is aimed at lash line, eyelashes can be turned inward, leading to reattaching or advancing the levator aponeurosis localized trichiasis. Patients encounter foreign body along the tarsus. If reattachment is not possible, or sensation and corneal irritation leading to epiphora, if the levator function is poor, a brow suspension abrasion, infection, and possible perforation of the procedure might be necessary. globe. Additionally, the notch formed can lead to inappropriate coverage of the cornea, leading to Epiphora corneal exposure and associated complications that Excessive tearing and increased tear lake cause are discussed later in this section. Removal of the distorted vision by disrupting the normal eyelid notch is typically achieved by a simple wedge tear-cornea interface. Irritation and maceration resection and marginal eyelid repair. Additionally, of the periocular skin occur because of the manual epilation of the in-turned eyelashes can help prolonged wetness. temporize the situation. Commonly, medial canthal defects result in Maintaining the normal curvilinear contour injury to the canalicular system, disturbing the of the eyelid is essential not only for a cosmetically normal drainage of tears. Repair should include

42 SRPS • Volume 11 • Issue R2 • 2010 monocanalicular silicone tube intubation of the the distribution of the tear film. Both the physical lacrimal system. In the elderly with dry eyes, a coverage of the cornea and the maintenance of an single canalicular injury might not need repair appropriate tear film are necessary to protect the because the other canalicular system might be delicate anterior surface of the eye, which is only enough to drain the decreased tear production. 0.5 mm thick. When this coverage is hindered Eyelid malposition can also lead to poor secondary to eyelid malpositions, consequences tear drainage and epiphora. As discussed earlier, can be dire. Exposure of the cornea leads to a ectropion causes the puncta to lose contact with breakdown of the epithelial cells, allowing a portal the lacrimal tear lake, leading to ineffective tear of entry for infectious pathogens. This can lead drainage. Likewise, if an eyelid is not adequately to infectious keratitis, resulting in significant tight, proper tear pump function cannot morbidity, including partial or complete loss be maintained. of vision. Irritation of the cornea, caused by either Even in the absence of corneal infection, direct contact with an irritant (e.g., eyelashes) corneal exposure and irritation can lead to or dryness, causes a reflex production of tears. vascularization and scarring of the cornea, causing Large reconstructions often involve damage to visual loss. Prolonged exposure of the cornea, cranial nerve VII, impeding orbicularis function even when mild, can eventually lead to corneal and hindering lid closure. A significant paralytic decompensation. Patients present with irritation, lagophthalmos can result. Corneal dryness results pain, photophobia, and decreased vision years in excessive reflex tearing. Medical management after periocular or facial surgery. These signs and is aimed at decreasing the corneal irritation symptoms can occur without overt signs of eyelid and includes copious lubrication by means of malposition as a result of chronic inflammation of ophthalmic tear drops, gels, and ointments. Surgical the ocular surface. options include insertion of a gold weight in the It is crucial for surgeons performing upper eyelid, horizontal tightening of the lower periocular and facial surgical procedures to realize eyelid, and tarsorrhaphy. that even mild eyelid malpositions can lead to Reflex tearing resulting from entropion chronic inflammation of the ocular surface. Such and trichiasis is common and problematic. The inflammation can cause decreased tear production. lashes cause corneal abrasions. Repair is aimed at The patients’ advancing age also contributes to addressing the underlying entropion or removing further decrease in tear production. The ocular the eyelashes by manual epilation or cryotherapy. surface might withstand the initial injury caused by eyelid malpositions but will eventually Exposure Keratopathy decompensate. It is prudent that surgeons keep in One of the most devastating complications of mind the health of the ocular surface years after any eyelid surgery is exposure keratopathy. As periocular procedures. We will not be doing the described in the Anatomy section, the upper and patients or ourselves any favors if years after a lower eyelids serve the important functions of reconstructive or cosmetic procedure, the patient covering and protecting the cornea and facilitating ends up with visual loss or dysfunction.

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REFERENCES 306–318. 1. McCord CD Jr, Codner MA. Eyelid & Periorbital Surgery. St. Louis: Quality Medical Publishing; 2008. 16. Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anatomy of the ligamentous attachments of the lower lid 2. Cibis GW. Fundamentals and principles of ophthalmology: and lateral canthus. Plast Reconstr Surg 2002;110:873–884. Section 2. In, Purdy EP (ed): American Academy of Ophthalmology Basic and Clinical Science Course. San 17. Ghavami A, Pessa JE, Janis J, Khosla R, Reece EM, Rohrich Francisco: American Academy of Ophthalmology; 2006: RJ. The orbicularis retaining ligament of the medial orbit: 21–29. Closing the circle. Plast Reconstr Surg 2008;121:994–1001.

3. Thornton JF, Kenkel JM. Eyelid Reconstruction. Dallas: 18. Wesley RE, McCord CD Jr, Jones NA. Height of the tarsus Selected Readings in Plastic Surgery, Inc.; 2005. of the lower eyelid. Am J Ophthalmol 1980;90:102–105.

4. Rootman, J. Diseases of the Orbit: A Multidisciplinary 19. Putterman AM. Cosmetic Oculoplastic Surgery: Eyelid, Approach. 2nd ed. Philadelphia: Lippincott Williams & Forehead, and Facial Techniques. 3rd ed. Philadelphia: W.B. Wilkins; 2003:23–26. Saunders; 1999.

5. Kikkawa DO, Lemke BN. Orbital and eyelid anatomy. In, 20. Reid RR, Said HK, Yu M, Haines GK III, Few JW. Revisiting Dortzbach RK (ed): Ophthalmic Plastic Surgery: Prevention upper eyelid anatomy: Introduction of the septal extension. and Management of Complications. New York: Raven Press; Plast Reconstr Surg 2006;117:65–66. 1994:1–29. 21. Doxanas MT, Anderson RL. Eyebrows, eyelids, and 6. Han MH, Kwon ST. A statistical study of upper eyelids of anterior orbit. In, Doxanas MT, Anderson RL (ed): Clinical Korean young women. Korean J Plast Surg 1992;19:930–935. Orbital Anatomy. Baltimore: Williams & Wilkins; 1984:57–88.

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8. Hawes MJ, Dortzbach RK. The microscopic anatomy of the 23. Whitnall SE. Anatomy of the Human Orbit and Accessory lower eyelid retractors. Arch Ophthalmol 1982;100: Organs of Vision. 2nd ed. London: Oxford University Press; 1313–1318. 1932.

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10. Kakizaki H, Jinsong Z, Zako M, Nakano T, Asamoto K, 25. Kakizaki H, Zako M, Nakano T, Asamoto K, Miyaishi O, Miyaishi O, Iwaki M. Microscopic anatomy of Asian lower Iwaki M. The levator aponeurosis consists of two layers eyelids. Ophthal Plast Reconstr Surg 2006;22:430–433. that include smooth muscle. Ophthal Plast Reconstr Surg 2005;21:379–382. 11. Narayanan K, Barnes EA. Epiphora with eyelid laxity. Orbit 2005;24:201–203. 26. Matsuo K. Stretching of the Mueller muscle results in involuntary contraction of the levator muscle. Ophthal Plast 12. Becker BB. Tricompartment model of the lacrimal pump Reconstr Surg 2002;18:5–10. mechanism. Ophthalmology 1992;99:1139–1145. 27. Kelly CP, Cohen AJ, Yavuzer R, Moreira-Gonzalez A, 13. Kersten R. Orbits, eyelids, and lacrimal system: Section Jackson IT. Medial canthopexy: A proven technique. Ophthal 7. In, Purdy EP (ed): American Academy of Ophthalmology Plast Reconstr Surg 2004;20:337–341. Basic and Clinical Science Course. San Francisco: American Academy of Ophthalmology; 2006:139. 28. Fagien S. Putterman’s Cosmetic Oculoplastic Surgery. 4th ed. Philadelphia: Saunders Elsevier; 2008:48–52. 14. Wulc AE, Dryden RM, Khatchaturian T. Where is the gray line? Arch Ophthalmol 1987;105:1092–1098. 29. Gioia VM, Linberg JV, McCormick SA. The anatomy of the lateral canthal tendon. Arch Ophthalmol 1987;105:529–532. 15. Ahmad J, Mathes DW, Itani KM. Reconstruction of the eyelids after Mohs surgery. Semin Plast Surg 2008;22: 30. Azizzadeh B, Murphy MR, Johnson CM. Master

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Techniques in Facial Rejuvenation. Philadelphia: Saunders 46. Tsubota K, Satake Y, Ohyama M, Toda I, Takano Y, Ono Elsevier; 2007:22. M, Shinozaki N, Shimazaki J. Surgical reconstruction of the ocular surface in advanced ocular cicatricial pemphigoid 31. Rosenstein T, Talebzadeh N, Pogrel MA. Anatomy of the and Stevens-Johnson syndrome. Am J Ophthalmol lateral canthal tendon. Oral Surg Oral Med Oral Pathol Oral 1996;122:38–52. Radiol Endod 2000;89:24–28. 47. Lee SH, Tseng SC. Amniotic membrane transplantation 32. van den Bosch WA, Leenders I, Mulder P. Topographic for persistent epithelial defects with ulceration. Am J anatomy of the eyelids, and the effects of sex and age.Br Ophthalmol 1997;123:303–312. J Ophthalmol 1999;83:347–352. 48. Shimazaki J, Yang HY, Tsubota K. Amniotic membrane 33. Erdogmus S, Govsa F. The arterial anatomy of the eyelid: transplantation for ocular surface reconstruction in Importance for reconstructive and aesthetic surgery. J Plast patients with chemical and thermal burns. Ophthalmology Reconstr Aesthet Surg 2007;60:241–245. 1997;104:2068–2076.

34. Lopez R, Lauwers F, Paoli JF, Boutault F, Guitard J. The 49. Tseng SC, Prabhasawat P, Barton K, Gray T, Meller D. vascular system of the upper eyelid: Anatomical study and Amniotic membrane transplantation with or without limbal clinical interest. Surg Radiol Anat 2008;30:265–269. allografts for corneal surface reconstruction in patients with limbal stem cell deficiency.Arch Ophthalmol 1998;116: 35. Jones LT. An anatomical approach to problems of 431–441. the eyelids and lacrimal apparatus. Arch Ophthalmol 1961;66:111–124. 50. Pires RT, Tseng SC, Prabhasawat P, Puangsricharern V, Maskin SL, Kim JC, Tan DT. Amniotic membrane 36. Brown DJ, Jaffe JE, Henson JK. Advanced laceration transplantation for symptomatic bullous keratopathy. Arch management. Emerg Med Clin North Am 2007;25:83–99. Ophthalmol 1999;117:1291–1297. 37. Renner G, Kang T. Periorbital reconstruction: Brows and 51. Solomon A, Espana EM, Tseng SC. Amniotic membrane eyelids. Facial Plast Surg Clin North Am 2005;13:253–265. transplantation for reconstruction of the conjunctival 38. Chandler DB, Gausas RE. Lower eyelid reconstruction. fornices. Ophthalmology 2003;110:93–100. Otolaryngol Clin North Am 2005;38:1033–1042. 52. Prabhasawat P, Barton K, Burkett G, Tseng SC. 39. Rafii AA, Enepekides DJ. Upper and lower eyelid Comparison of conjunctival autografts, amniotic membrane reconstruction: The year in review. Curr Opin Otolaryngol grafts, and primary closure for pterygium excision. Head Neck Surg 2006;14:227–233. Ophthalmology 1997;104:974–985.

40. Burroughs JR, Soparkar CN, Patrinely JR. The buried 53. Tseng SC, Prabhasawat P, Lee SH. Amniotic membrane vertical mattress: A simplified technique for eyelid margin transplantation for conjunctival surface reconstruction. Am J repair. Ophthal Plast Reconstr Surg 2003;19:323–324. Ophthalmol 1997;124:765–774.

41. Custer PL. Harvey H. The arm as a skin graft donor 54. Prabhasawat P, Tseng SC. Impression cytology study of site in eyelid reconstruction. Ophthal Plast Reconstr Surg epithelial phenotype of ocular surface reconstructed by 2001;17:427–430. preserved human amniotic membrane. Arch Ophthalmol 1997;115:1360–1367. 42. Kaufman AJ. Periorbital reconstruction with adjacent- tissue skin grafts. Dermatol Surg 2005;31:1704–1706. 55. Paridaens D, Beekhuis H, van den Bosch W, Remeyer L, Melles G. Amniotic membrane transplantation in the 43. Mustardé JC. Repair and Reconstruction in the Orbital management of conjunctival malignant melanoma and Region: A Practical Guide. Edinburgh: Livingstone; 1966. primary acquired melanosis with atypia. Br J Ophthalmol 2001;85:658–661. 44. Bowen Jones EJ, Nunes E. The outcome of oral mucosal grafts to the orbit: A three-and-a-half-year study. Br J Plast 56. Puangsricharern V, Tseng SC. Cytologic evidence Surg 2002;55:100–104. of corneal diseases with limbal stem cell deficiency. Ophthalmology 1995;102:1476–1485. 45. Ang LP, Tan DT. Autologous cultivated conjunctival transplantation for recurrent viral papillomata. Am J 57. Taban M, Douglas R, Li T, Goldberg RA, Shorr N. Efficacy Ophthalmol 2005;140:136–138. of “thick” acellular human dermis (AlloDerm) for lower

45 SRPS • Volume 11 • Issue R2 • 2010 eyelid reconstruction: Comparison with hard palate and thin 72. Kersten RC, Kulwin DR, Levartovsky S, Tiradellis H, Tse AlloDerm grafts. Arch Facial Plast Surg 2005;7:38–44. DT. Management of lower-lid retraction with hard-palate mucosa grafting. Arch Ophthalmol 1990;108:1339–1343. 58. van der Meulen JC. The use of mucosa-lined flaps in eyelid reconstruction: A new approach. Plast Reconstr Surg 73. Cohen MS, Shorr N. Eyelid reconstruction with 1982;70:139–146. hard palate mucosa grafts. Ophthal Plast Reconstr Surg 1992;8:183–195. 59. Marks MW, Argenta LC, Friedman RJ, Hall JD. Conchal cartilage and composite grafts for correction of lower lid 74. Li TG, Shorr N, Goldberg RA. Comparison of the efficacy retraction. Plast Reconstr Surg 1989;83:629–635. of hard palate grafts with acellular human dermis grafts in lower eyelid surgery. Plast Reconstr Surg 2005;116:873–878. 60. Holt JE, Holt GR, Van Kirk M. Use of temporalis fascia in eyelid reconstruction. Ophthalmology 1984;91:89–93. 75. McCord CD, Tanenbaum M, Nunery WR. Oculoplastic Surgery. 3rd ed. New York: Raven; 1995. 61. Matsumoto K, Nakanishi H, Urano Y, Kubo Y, Nagae H. Lower eyelid reconstruction with a cheek flap supported by 76. Hashikawa K, Tahara S, Nakahara M, Sanno T, Hanagaki fascia lata. Plast Reconstr Surg 1999;103:1650–1654. H, Tsuji Y, Terashi H. Total lower lid support with auricular cartilage graft. Plast Reconstr Surg 2005;115:880–884. 62. Obear MF, Smith B. Tarsal grafting to elevate the lower lid margin. Am J Ophthalmol 1965;59:1088–1090. 77. Scuderi N, Ribuffo D, Chiummariello S. Total and subtotal upper eyelid reconstruction with the nasal 63. Doxanas MT, Dryden RM. The use of sclera in the chondromucosal flap: A 10-year experience.Plast Reconstr treatment of dysthyroid eyelid retraction. Ophthalmology Surg 2005;115:1259–1265. 1981;88:887–894. 78. Micali G, Scuderi N, Moschella F, Soma PF. I tumori delle 64. Karesh JW, Fabrega MA, Rodrigues MM, Glaros DS. palpebre. In, Micali G, Scuderi N, Moschella F, Soma PF (ed): Polytetrafluoroethylene as an interpositional graft material Aspetti Clinici e Terapeutici. vol 2. Milan: Bold/Ad; 1990. for the correction of lower eyelid retraction. Ophthalmology 1989;96:419–423. 79. Sheridan RL, Choucair RJ. Acellular allogenic dermis does 65. Karesh JW. Polytetrafluoroethylene as a graft material not hinder initial engraftment in burn wound resurfacing in ophthalmic plastic and reconstructive surgery: An and reconstruction. J Burn Care Rehabil 1997;18:496–499. experimental and clinical study. Ophthal Plast Reconstr Surg 80. McCord C, Nahai FR, Codner MA, Nahai F, Hester TR. 1987;3:179–185. Use of porcine acellular dermal matrix (Enduragen) grafts 66. Leibovitch I, Malhotra R, Selva D. Hard palate and free in eyelids: A review of 69 patients and 129 eyelids. Plast tarsal grafts as posterior lamella substitutes in upper lid Reconstr Surg 2008;122:1206–1213. surgery. Ophthalmology 2006;113:489–496. 81. Barbera C, Manzoni R, Dodaro L, Ferraro M, Pella P. 67. Stephenson CM, Brown BZ. The use of tarsus as a free Reconstruction of the tarsus-conjunctival layer using a autogenous graft in eyelid surgery. Ophthal Plast Reconstr venous wall graft. Ophthal Plast Reconstr Surg 2008;24: Surg 1985;1:43–50. 352–356.

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47 SRPS • Volume 11 • Issue R2 • 2010 reconstruction. Am J Ophthalmol 2002;134:627–630. thickness lower eyelid reconstruction. Ophthal Plast Reconstr Surg 2007;23:228–231. 116. Maloof A, Ng S, Leatherbarrow B. The maximal Hughes procedure. Ophthal Plast Reconstr Surg 2001;17:96–102. 131. Moesen I, Paridaens D. A technique for the reconstruction of lower eyelid marginal defects. Br 117. Tei TM, Larsen J. Use of the subcutaneously based J Ophthalmol 2007;91:1695–1697. nasolabial flap in lower eyelid reconstruction.Br J Plast Surg 2003;56:420–423. 132. Paridaens D, van den Bosch WA. Orbicularis muscle advancement flap combined with free posterior and 118. Nakajima H, Imanishi N, Aiso S. Facial artery in the anterior lamellar grafts: A 1-stage sandwich technique for upper lip and nose: Anatomy and a clinical application. Plast eyelid reconstruction. Ophthalmology 2008;115:189–194. Reconstr Surg 2002;109:855–861. 133. deSousa JL, Leibovitch I, Malhotra R, O’Donnell B, 119. Mustardé JC. Major reconstruction of the eyelids: Sullivan T, Selva D. Techniques and outcomes of total Functional and aesthetic considerations. Clin Plast Surg upper and lower eyelid reconstruction. Arch Ophthalmol 1981;8:227–236. 2007;125:1601–1609.

120. Belmahi A, Oufkir A, Bron T, Ouezzani S. Reconstruction 134. Turgut G, Ozcan A, Yeşiloğlu N, Baş L. A new glabellar of cheek skin defects by the “Yin-Yang” rotation of the flap modification for the reconstruction of medial canthal Mustardé flap and the temporoparietal scalp.J Plast Reconstr and nasal dorsal defect: “Flap in flap” technique.J Craniofac Aesthet Surg 2009;62:506–509. Surg 2009;20:198–200. 121. Tripier L. Lambeau musculo-cutané en forme de pont: 135. Meadows AE, Manners RM. A simple modification of Appliqué à la restauration des paupières [in French]. Gazette the glabellar flap in medial canthal reconstruction.Ophthal des Hôpitaux de Paris 1889;62:1124–1125. Plast Reconstr Surg 2003;19:313–315. 122. Bickle K, Bennett RG. Tripier flap for medial lower eyelid 136. Emsen IM, Benlier E. The use of the superthinned reconstruction. Dermatol Surg 2008;34:1545–1548. inferior pedicled glabbelar flap in reconstruction of small to 123. Elliot D, Britto JA. Tripier’s innervated myocutaneous large medial canthal defect. J Craniofac Surg 2008;19: flap 1889.Br J Plast Surg 2004;57:543–549. 500–504.

124. Labbé D, Bénateau H, Rigot-Jolivet M. Homage to 137. Onishi K, Maruyama Y, Okada E, Ogino A. Medial Leon Tripier: Description of the first musculocutaneous flap canthal reconstruction with glabeller combined Rintala and current indications [in French]. Ann Chir Plast Esthet flaps.Plast Reconstr Surg 2007;119:537–541. 2000;45:17–23. 138. Bertelmann E, Rieck P, Guthoff R. Medial canthal 125. Vuppalapati G, Niranjan N. Islanded Tripier flap: reconstruction by a modified glabellar flap.Ophthalmologica Another useful variant. Br J Plast Surg 2005;58:882–884. 2006;220:368–371.

126. Gubisch W, Bromba M. Tripier bridge flap technique for 139. Baker SR. Local Flaps in Facial Reconstruction. 2nd ed. lower eyelid reconstruction [in German]. Handchir Mikrochir Edinburgh: Elsevier Mosby; 2007. Plast Chir 1999;31:416–420. 140. Yildirim S, Aköz T, Akan M, Cakir B. The use of combined 127. Siegel RJ. Severe ectropion: Repair with modified nasolabial V-Y advancement and glabellar flaps for large Tripier flap.Plast Reconstr Surg 1987;80:21–28. medial canthal defects. Dermatol Surg 2001;27:215–218.

128. Levin ML, Leone CR Jr. Bipedicle myocutaneous flap 141. Chiarelli A, Forcignanò R, Boatto D, Zuliani F, Bisazza repair of cicatricial ectropion. Ophthal Plast Reconstr Surg S. Reconstruction of the inner canthus region with a 1990;6:119–121. forehead muscle flap: A report on three cases.Br J Plast Surg 2001;54:248–252. 129. Hewes EH, Sullivan JH, Beard C. Lower eyelid reconstruction by tarsal transposition. Am J Ophthalmol 142. Goldstein MH. “Orbiting the orbicularis”: Restoration 1976;81:512–514. of muscle-ring continuity with myocutaneous flaps.Plast Reconstr Surg 1983;72:294–301. 130. Zinkernagel MS, Catalano E, Ammann-Rauch D. Free tarsal graft combined with skin transposition flap for full- 143. Jelks GW, Glat PM, Jelks EB, Longaker MT. Medial

48 SRPS • Volume 11 • Issue R2 • 2010 canthal reconstruction using a medially based upper eyelid 154. Markowitz BL, Manson PN, Sargent L, Vander Kolk CA, myocutaneous flap.Plast Reconstr Surg 2002;110:1636–1643. Yaremchuk M, Glassman D, Crawley WA. Management of the medial canthal ligament in nasoethmoidal orbital fractures: 144. Tezel E, Sönmez A, Numanoğlu A. Medial pedicled The importance of the central fragment in classification and orbicularis oculi flap for medial canthal resurfacing.Ann treatment. Plast Reconstr Surg 1991;87:843−853. Plast Surg 2001;47:213. 155. Yaremchuk MJ. Changing concepts in the 145. Dryden RM, Wulc AE. The preauricular skin graft in management of secondary orbital deformities. Clin Plast eyelid reconstruction. Arch Ophthalmol 1985;103: Surg 1992;19:113−124. 1579–1581. 156. Fink SC, Gocken DJ, Oh AK, Hardesty RA. Transnasal 146. Adenis JP, Serra F. Bipalpebral sliding flap in the canthoplasty. J Craniomaxillofac Trauma 1997;3:43−48. repair of inner or outer canthal defects. Br J Ophthalmol 1986;70:135–137. 157. Turgut G, Ozkaya O, Soydan AT, Baş L. A new technique for medial canthal tendon fixation.J Craniofac Surg 147. Tezel E, Sönmez A, Numanoğlu A. Medial pedicled 2008;19:1154–1158. orbicularis oculi flap.Ann Plast Surg 2002;49:599–603. 158. Shankar J, Nair RG, Sullivan SC. Management of peri- 148. Kilinc H, Bilen BT. Supraorbital artery island flap for ocular skin tumours by laissez-faire technique: Analysis of periorbital defects. J Craniofac Surg 2007;18:1114–1119. functional and cosmetic results. Eye 2002;16:50–53.

149. Millard DR Jr. Total reconstructive rhinoplasty and a 159. Lowry JC, Bartley GB, Garrity JA. The role of second- missing link. Plast Reconstr Surg 1966;37:167–183. intention healing in periocular reconstruction. Ophthal Plast Reconstr Surg 1997;13:174–188. 150. Ugur MB, Savranlar A, Uzun L, Küçüker H, Cinar F. A reliable surface landmark for localizing the supratrochlear 160. Zitelli JA. Secondary intention healing: An alternative artery: Medial canthus. Otolaryngol Head Neck Surg to surgical repair. Clin Dermatol 1984;2:92–106. 2008;138:162–165. 161. Ceilley RI, Bumsted RM, Panje WR. Delayed skin 151. Kelly CP, Yavuzer R, Keskin M, Bradford M, Govila L, grafting. J Dermatol Surg Oncol 1983;9:288–293. Jackson IT. Functional anastomotic relationship between supratrochlear and facial arteries: An anatomical study. Plast 162. Mehta JS, Olver JM. Infraglabellar transnasal bilobed Reconstr Surg 2008;121:458–465. flap in the reconstruction of medial canthal defects.Arch Ophthalmol 2006;124:111–115. 152. Karşdağ S, Sacak B, Bayraktaroglu S, Ozcan A, Urgulu K, Bas L. A novel approach for the reconstruction of medial 163. Kilinc H, Bilen BT, Ulusoy MG, Aslan S, Arslan A, Sensoz canthal and nasal dorsal defects: Frontal hairline island flap. O. A comparative study on superior auricular artery island J Craniofac Surg 2008;19:1653–1657. flaps with various pedicles for repair of periorbital defects. J Craniofac Surg 2007;18:406–414. 153. Leatherbarrow B, Watson A, Wilcsek G. Use of the pericranial flap in medial canthal reconstruction: Another 164. Mauriello JA. Unfavorable Results of Eyelid and Lacrimal application of this versatile flap.Ophthal Plast Reconstr Surg Surgery: Prevention and Management. Boston: Butterworth- 2006;22:414–419. Heinemann; 2000.

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Li TG, Shorr N, Goldberg RA. Comparison of the efficacy of RECOMMENDED READING Ahmad J, Mathes DW, Itani KM. Reconstruction of the hard palate grafts with acellular human dermis grafts in eyelids after Mohs surgery. Semin Plast Surg 2008;22: lower eyelid surgery. Plast Reconstr Surg 2005;116:873–878. 306–318. McCord CD, Codner MA, Hester TR. Eyelid Surgery: Principles Burroughs JR, Soparkar CN, Patrinely JR. The buried vertical and Techniques. Philadelphia: Lippincott-Raven; 1995. mattress: A simplified technique for eyelid margin repair. Ophthal Plast Reconstr Surg 2003;19:323–324. Moesen I, Paridaens D. A technique for the reconstruction of lower eyelid marginal defects. Br J Ophthalmol deSousa JL, Leibovitch I, Malhotra R, O’Donnell B, Sullivan T, 2007;91:1695–1697. Selva D. Techniques and outcomes of total upper and lower eyelid reconstruction. Arch Ophthalmol 2007;125: Paridaens D, van den Bosch WA. Orbicularis muscle 1601–1609. advancement flap combined with free posterior and anterior lamellar grafts: A 1-stage sandwich technique for Erdogmus S, Govsa F. The arterial anatomy of the eyelid: eyelid reconstruction. Ophthalmology 2008;115:189–194. Importance for reconstructive and aesthetic surgery. J Plast Reconstr Aesthet Surg 2007;60:241–245. Putterman AM. Cosmetic Oculoplastic Surgery: Eyelid, Forehead, and Facial Techniques. 3rd ed. Philadelphia: W.B. Fagien S. Putterman’s Cosmetic Oculoplastic Surgery. 4th ed. Saunders; 1999. Philadelphia: Saunders Elsevier; 2008:48–52. Scuderi N, Ribuffo D, Chiummariello S. Total and subtotal Hashikawa K, Tahara S, Nakahara M, Sanno T, Hanagaki upper eyelid reconstruction with the nasal chondromucosal H, Tsuji Y, Terashi H. Total lower lid support with auricular flap: A 10-year experience.Plast Reconstr Surg cartilage graft. Plast Reconstr Surg 2005;115:880–884. 2005;115:1259–1265.

Korn BS, Kikkawa DO, Cohen SR, Hartstein M, Annunziata Taban M, Douglas R, Li T, Goldberg RA, Shorr N. Efficacy of CC. Treatment of lower eyelid malposition with dermis fat “thick” acellular human dermis (AlloDerm) for lower eyelid grafting. Ophthalmology 2008;115:744–751. reconstruction: Comparison with hard palate and thin AlloDerm grafts. Arch Facial Plast Surg 2005;7:38–44. Leatherbarrow B, Watson A, Wilcsek G. Use of the pericranial flap in medial canthal reconstruction: Another application Zinkernagel MS, Catalano E, Ammann-Rauch D. Free tarsal of this versatile flap.Ophthal Plast Reconstr Surg 2006;22: graft combined with skin transposition flap for full-thickness 414–419. lower eyelid reconstruction. Ophthal Plast Reconstr Surg 2007;23:228–231. Leibovitch I, Malhotra R, Selva D. Hard palate and free tarsal grafts as posterior lamella substitutes in upper lid surgery. Ophthalmology 2006;113:489–496.

50 We thank the Aesthetic Surgery Journal and Plastic and Reconstructive Surgery for their support.

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Aesthetic Surgery Journal (ASJ) is a peer-reviewed international journal focusing on scientifi c developments and clinical techniques in aesthetic surgery. An offi cial publication of the 2200-member American Society for Aesthetic Plastic Surgery (ASAPS), ASJ is also the offi cial English-language journal of twelve major international societies of plastic, aesthetic, and reconstructive surgery representing South America, Central America, Europe, Asia, and the Middle East, and the offi cial journal of The Rhinoplasty Society. Submit your manuscript! www.aestheticsurgeryjournal.com

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This is your life. Whether you’re performing a routine cosmetic procedure or a difficult burn repair, having the right tool for unexpected complications is critical.

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for their support of plastic surgery education as a Platinum Education Partner.