Guidelines for reconstruction of the eyelids and canthal regions

Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 1420e1433

REVIEW

Guidelines for reconstruction of the eyelids and canthal regions Irene M.J. Mathijssen*, Jacques C. van der Meulen Department of Plastic and Reconstructive Surgery, Erasmus MC, Room Hs-509, P.O. Box 2040, 3000 DR Rotterdam, the Netherlands Received 5 March 2009; accepted 18 May 2009

KEYWORDS Upper eyelid; Lower eyelid; Canthus; Periorbit; Reconstruction

Summary A large number of reports are available on the options for reconstructing specific defects of the eyelids or (peri) orbital area, which may complicate decision making in choosing the most optimal technique for a particular defect. Based on more than 40 years’ experience in reconstruction of eyelids and periorbital defects, combined with an extensive literature review, general principles on reconstruction are presented and illustrated. Surgical techniques are outlined with respect to anatomical layer, depth, size and location of the defect. Adherence to specific principles for eyelid and canthal reconstruction will lead to predictable, stable and functionally good results. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

A defect of the eyelids and/or canthal regions can have various causes, being congenital, traumatic or following oncologic resection. These defects involve impairment of function and appearance and have a serious impact on the patient’s quality of life. Choosing the type of reconstruction is independent of the cause. A vast number of papers on eyelid reconstruction have been published, describing various reconstructive options (Table 1). Many of these options are merely variations of a limited number of basic principles. Articles were selected from Pubmed and the presented technique classified by indication, composition and type of flap, and donor site. This article aims to provide * Corresponding author. Tel.: þ31 107033827; fax: þ31 107032693. E-mail address: [email protected] (I.M.J. Mathijssen).

guidelines and specific tips and tricks (Table 2) to decide on the most ideal reconstruction, taking into account both the functional and aesthetic aspects.

General principles of reconstruction Defects of the eyelids and canthal areas should ideally be reconstructed with matching tissues with respect to composition, size, colour and pliability, leaving minimal donor-site morbidity and inconspicuous scars. Reconstruction for congenital defects with exposed cornea is within the first weeks of life and within a few hours for traumatic cases. Reconstruction following oncologic surgery is done once the surgical margins are free of tumour. Mohs’ surgery can be indicated within the orbital region, being especially

1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.05.035

Guidelines for reconstruction of the eyelids and canthal regions

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Table 1 Overview of literature. Papers are divided by anatomical site of the defect that is described and year of publication. The presented flaps are listed by their tissue composition, donorsite and type of flap Author, year of publication

Composition of flap

Medial canthal region defect MF Chiarelli, 2001 33 SC Ng, 2001 34 Yildirim, 2001 35 SC Jelks, 2002 36 Tezel, 2002 37 Meadows, 2003 38 Stagno, 2004 39 Behroozan, 2005 40 Bertelmann, 2006 41 Leatherbarrow, 2006 Mehta, 2006 43 Onishi, 2007 44

Emsen, 2008

MC MC MC MC MC

42

45

MC PC SC SC MC CSC

Medial part lower eyelid defect Hughes, 1937 46 TCj Gorney, 1969 47 FT Hewes, 1976 48 FT TCj MC Leone, 1979 49 Van der Meulen, 1982 Goldstein, 1983 13 Anderson, 1988 50 Van der Meulen, 1991

7

51

Donorsite

Type of flap; pedicle

Forehead Nasal bridge Glabella þ Nasolabial region Upper eyelid Upper eyelid Glabella Upper eyelid Mediocranial part upper eyelid Glabella Forehead Infraglabella Glabella Supraglabella/ Supraeyebrow Glabella

Transposition; caudal Rhomboid; cranial V-Y advancement; subcutaneous Transposition; medial Transposition; medial Transposition; caudal Transposition; medial Rotation; lateral

Upper Upper Lower Lower Upper

Transposition; cranial Island; medial Transposition; caudal Transposition: lateral Transposition; medial

eyelid eyelid eyelid/cheek eyelid eyelid

MC MC SC FT TCj MC

Lower eyelid Lower eyelid Nasolabial Upper eyelid Lower eyelid Lower eyelid

Van der Meulen, 1996

31

C

Lower eyelid

Van der Meulen, 1996

31

C

Upper eyelid

MC þ TCj island CSC

Upper eyelid Medial cheek

CC 1st MC 2nd TCj M

Helical rim Upper eyelid

Porfiris, 1999 Ito, 2001 11

52

Pascone, 2005 Atik, 2007 54 Moesen, 2007

53

55

Lower eyelid Lower eyelid

Medial part lower eyelid with medial canthal region defect MC Lower eyelid Anderson, 1979 22 extended temporally or with cheek flap CM Lateral nasal wall Scuderi, 1993 56 Chiarelli, 2001 33 MF Forehead Leatherbarrow, 2006 42 PC Forehead

Specifics

Rhomboid; caudal Transposition; caudal Rotation; caudal Transposition; caudal Advancement; cranial Transposition; caudal

Transposition; lateral Transposition; medial Transposition; cranial Transposition; medial Transposition; caudal Advancement; caudal, lateral and medial Transposition; various pedicles Transposition; various pedicles Transposition; medial V-Y advancement, subcutaneously Island; reversed flow Transposition; lateral Separation of flap Advancement; caudal Advancement; lateral and medial

þMC flap SC flap as pedicle þLat. cantholysis Free TCj graft þ Skin graft þMucosa graft

þHard palate graft

þConchal graft Marginal defects only þSkin graft

Advancement; lateral

þGraft/flap inner lamella

Island; cranial Transposition; caudal Transposition; caudal

þNasolabial flap

(continued on next page)

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I.M.J. Mathijssen, J.C. van der Meulen

Table 1 (continued) Author, year of publication

Composition of flap

Lateral canthal region defect M Naugle, 1995 57 Atik, 2007

54

Basxterzi, 2007

1st MC 2nd SC

58

Lateral part lower eyelid Denonvillier, 1854 59 Hughes, 1937 46 Gorney, 1969 47 Hewes, 1976 48 Leone, 1977 60 Putterman, 1977 61 Anderson, 1979

22

Jackson, 1981 62 Van der Meulen, 1982 Goldstein, 1983 13 Van der Meulen, 1984 Anderson, 1988 Papp, 1990 63

MC

7

4

50

FT MC MC SC FT FT

57

Naugle, 1995

C TCj FT TCj TCj SC

Type of flap; pedicle

Specifics

Upper þ lower eyelid þ temporally Upper eyelid

Advancement; lateral þ medial Transposition; lateral Separation of flap Island; lateral

þSkin graft

Forehead Temporal area Upper eyelid Upper eyelid Upper eyelid Upper eyelid Lower eyelid þ temporally Lower eyelid

Transposition; Transposition; Island; lateral Transposition: Transposition; Transposition;

Upper eyelid Upper eyelid Upper eyelid Upper eyelid þ temporally Upper eyelid Upper eyelid

Transposition; Transposition; Transposition; Transposition;

Van der Meulen, 1996

31

C

Lower eyelid þ temporally Lower eyelid

Van der Meulen, 1996

31

C

Upper eyelid

MC þ TCj island CSC

Upper eyelid

SC CC 1st MC 2nd SC

Nasolabial fold Helical rim Upper eyelid

52

Porfiris, 1999 Ito, 2001

M

Donorsite

10

Tan, 2007 64 Pascone, 2005 Atik, 2007 54 Basxterzi, 2007

53

58

Lateral cheek

Forehead

Lateral part lower eyelid with lateral canthal region defect Rubino, 2006 65 MC Nasolabial fold

Central part lower eyelid defect Esser, 1919 66 FT Hughes, 1937 46 Gorney, 1969 47 Tenzel, 1975 67 Hewes, 1976

48

Doxanas, 1986 Papp, 1990

68

63

Van der Meulen, 1991

51

Upper eyelid

TCj FT FT MC FT TCj M

Upper eyelid Upper eyelid Lower eyelid Extension temporally Lower eyelid/cheek Upper eyelid Lower eyelid

FT

Upper þ Lower eyelid

TCj MC

Lower eyelid Lower eyelid

lateral cranial lateral lateral lateral

Advancement; medial lateral lateral medial lateral

Transposition; lateral Transposition; craniomedial Advancement; lateral þ medial Transposition; various pedicles Transposition; various pedicles Transposition; lateral V-Y advancement, subcutaneously Island; cranial Island; reversed flow Transposition; lateral Separation of flap Island; lateral

þConchal graft þHard palate graft

þMC flap SC flap as pedicle þTemporal skin flap

þGraft/flap inner lamella þMucosa graft

þSkin-þConchal graft

þHard palate graft

þConchal graft þHard palate graft

Transposition þ V-Y advancement of subcutaneous pedicle; medial Transposition; lateral or medial Transposition; cranial Island; lateral Transposition; lateral Transposition; caudal Transposition; caudal Transposition: lateral Advancement; lateral and medial Transposition; craniomedial Transposition; caudal Advancement; caudal, lateral and medial

þMC flap SC flap as pedicle þLat. cantholysis þLat. cantholysis þHughes flap

Guidelines for reconstruction of the eyelids and canthal regions

1423

Table 1 (continued ) Author, year of publication Moschella, 1992

69

57

Naugle, 1995

Composition of flap

Donorsite

Type of flap; pedicle

Specifics

MC (3)

Lower eyelid

þCM graft

M

Lower eyelid

Advancement; subcutaneous Advancement; lateral þ medial Transposition; various pedicles Transposition; various pedicles Transposition; lateral

Van der Meulen, 1996

31

C

Lower eyelid

Van der Meulen, 1996

31

C

Upper eyelid Upper eyelid

Pascone, 2005 53 Porfiris, 2006 71 DeSousa, 2007 72

MC þ TCj island CM MC CC MC T

Upper eyelid Nasolabial region Helical rim Upper eyelid Lower eyelid

Transposition; cranial Transposition; cranial Island; reversed flow Island; lateral Advancement; lateral or medial

Total lower eyelid defect Landolt, 1885 73

C

Upper eyelid

MC

Upper eyelid

Esser, 1918 27 Hughes, 1937 46 Gorney, 1969 47

FT TCj FT

Cheek Upper eyelid Upper eyelid

Lipshutz, 1972 75 Mustarde ´, 1972 76

FT MC

Cheek Upper eyelid

28

MC FT

Cheek Cheek

MC

Upper eyelid

MC SC FT

Lower eyelid Nasolabial Upper eyelid

CM MC MC(P)MC MMC F FT

Lateral nasal wall Nasolabial region Lateral nasal wall Nasolabial region Temporoparietal Cheek

Advancement; lateral and medial Advancement; lateral and medial Rotation; caudal Transposition; cranial Island; lateral and medial Rotation; caudal Transposition; lateral and medial Rotation, caudal Rotation þ Z-plasty, caudal Transposition; lateral and medial Transposition; medial Transposition; cranial Transposition; medial and lateral Island; cranial Cranial Island; cranial Free flap Transposition; caudal Rotation; caudal

Forehead Upper eyelid

Transposition; caudal Transposition; lateral

Boutros, 2005 30 Miyawaki, 2005 82

MF MC þ TCj island FT FC

Cheek þ Neck Forearm

Rotation; caudal Free

Pascone, 2005 53 Vayvada, 2006 83 Kilinc, 2007 5 Ueda, 2007 84

CC MC MC SC

Helical rim Paranasal Retroauricular Forearm

Island; reverse flow Transposition; cranial Island; reverse flow Free

M

Lower eyelid

Advancement; caudal Shallow defects only

52

Porfiris, 1999 Tei, 2003

70

Tripier, 1889

74

McGregor, 1973

Van der Meulen, 1982 Goldstein, 1983

13

Anderson, 1987

77

Scuderi, 1993

56

Porfiris, 1997 78 Sasaki, 1998 79 Ellis, 1992 80 Matsumoto, 1999

81

Chiarelli, 2001 33 Porfiris, 1999 52

Paridaens, 2007

85

7

þSkin-þTarsal graft

Flap folded at rim Chondral graft for partial defect tarsus No lining No lining

þMC flap SC flap as pedicles þNasal CM graft þNasal CM graft þNasal CM graft

þMucosa graft

þSkin graft þFascia þ Mucosa graft

þFascia sling Pre-expanded þ Mucosa-lined Chondral graft May include concha Fixation with PL tendon þ Chondral graft þCM graft þSkin graft (continued on next page)

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I.M.J. Mathijssen, J.C. van der Meulen

Table 1 (continued) Author, year of publication

Composition of flap

Medial part upper eyelid defect C Landolt, 1885 73 Hueston, 1961 86 FT Mustarde FT ´, 1966 87 Putterman, 1978 88 C Van der Meulen, 1982 Boynton, 1985 89 Kersten, 1986 90 Jordan, 1989 91 Van der Meulen, 1996 Van der Meulen, 1996 Hayashi, 2007

7

31

31

92

Donorsite

Type of flap; pedicle

Medial canthal area Lower eyelid Lower eyelid Upper eyelid

Rotation: caudal Transposition; medial Transposition; medial Transposition; laterocranial Transposition; medial Rotation; cranial Transposition; cranial Transposition; lateral Advancement, cranial Transposition; various pedicles Transposition; various pedicles Rotation; medial

MC MC TCj T TCj C

Lower eyelid Temporally Upper eyelid Upper eyelid Upper eyelid Lower eyelid

C

Upper eyelid

MC

Upper eyelid

Medial part upper eyelid with medial canthal region defect Anderson, 1979 22 MC Upper eyelid extended temporally MF Forehead Chiarelli, 2001 33 Leatherbarrow, 2006 42 PC Forehead Lateral part upper eyelid defect Landolt, 1885 73 C Hueston, 1961 86 FT Mustarde FT ´, 1966 87 Putterman, 1977 61 SC Putterman, 1978 Anderson, 1979

88

22

Kersten, 1986 90 Naugle, 1995 57

C

Lateral canthal area Lower eyelid Lower eyelid Upper eyelid þ temporally Upper eyelid

MC

Upper eyelid

T M

Van der Meulen, 1996

31

C

Upper eyelid Upper eyelid þ temporally Lower eyelid

Van der Meulen, 1996

31

C

Upper eyelid

CSC

Upper eyelid þ temporally Upper eyelid Upper eyelid Upper eyelid

Ito, 2001

10

Azuma, 2006 93 Hayashi, 2007 92 Demir, 2008 94

OS þ MC MC MC

Central part upper eyelid defect FT Esser, 1919 66 Cutler, 1955

95

Hueston, 1961

86

Mustarde ´, 1966 Tenzel, 1975

87

67

Putterman, 1978

88

Upper eyelid

1st FT 2nd FT

Lower eyelid

FT

Lower eyelid

FT MC C

Upper eyelid Extension temporally Upper eyelid

Lower eyelid

Advancement; lateral

Specifics

þFT upper eyelid graft þMucosa graft

þMC flap þMC flap

þGraft/flap inner lamella

Transposition; caudal Transposition; caudal Advancement: lateral Transposition; lateral Transposition; lateral Transposition; lateral Transposition; mediocranial Advancement; lateral Transposition; medial Advancement; lateral þ medial Transposition; various pedicles Transposition; various pedicles V-Y advancement, subcutaneously Reversed; caudal Rotation; lateral Advancement; subcutaneous Transposition; lateral or medial Advancement; caudal Division of flap Transposition; lateral or medial Transposition; lateral or medial Transposition; lateral Transposition; cranial Transposition; medio-/laterocranial

þTCj-margin graft þGraft/flap inner lamella þMC flap þSkin-þConchal graft

þHard palate graft þConchal graft þHard palate graft

No tarsus in flap

þLat. cantholysis þTCj-margin graft

Guidelines for reconstruction of the eyelids and canthal regions

1425

Table 1 (continued ) Author, year of publication

Composition of flap

Donorsite

Type of flap; pedicle

Specifics

TCj

Upper þ Lower eyelid

þSkin graft

TCj TCj C

Upper eyelid Lower eyelid Lower eyelid

C

Upper eyelid

FT

Upper eyelid

MC

Upper eyelid

Advancement; cranial þ caudal Advancement, cranial Advancement; caudal Transposition; various pedicles Transposition; various pedicles V-Y advancement; cranial Island; lateral

Dutton, 2007 99 Hayashi, 2007 92

FT MC

Lower eyelid Upper eyelid

Advancement; caudal Rotation; medial or lateral

Total upper eyelid defect Tripier, 1889 74

MC

Upper eyelid or supra-eyebrow Lower eyelid

Advancement; lateral and medial Advancement; caudal Division of flap Transposition; lateral Division of flap Rotation þ Z-plasty, cranial Transposition; lateral and medial Advancement; cranial þ caudal Island; cranial Advancement; caudal Advancement; lateral þ medial Transposition; caudal Transposition; caudal Transposition; lateral and medial Advancement; caudal Transposition; cranial Transposition; caudal Transposition; lateral and medial Reversed; caudal Island: reverse flow Free Advancement; caudal Shallow defects only Island; cranial

Leone, 1983

96

Jordan, 1989 91 Mauriello, 1994 97 Van der Meulen, 1996 Van der Meulen, 1996

31

98

Okada, 1997 Porfiris, 2006

Cutler, 1955

31

71

95

Mustarde ´, 1966/1968 McGregor, 1973

100,101

28

7

1st FT 2nd 1st FT 2nd FT

Lower eyelid þ Cheek Cheek

MC

Lower eyelid

TCj

Upper þ Lower eyelid

Scuderi, 1993 56 Mauriello, 1994 97 Naugle, 1995 57

CM TCj M

Lateral nasal wall Lower eyelid Brow area

Breier, 1997 102 Tse, 1997 103 Patrinely, 1999 104

MF G or PC MC

Temporal muscle Forehead Upper eyelid

Holloman, 2005 105 Scuderi, 2005 106 Fujiwara, 2006 107

FT CM MC MC

Lower eyelid Lateral nasal wall Supra-eyebrow Upper eyelid

Ohshiro, 2006 108 Kilinc, 2007 5 Ueda, 2007 84 Paridaens, 2007 85

OS þ MC MC SC M

Upper eyelid Retroauricular Forearm Lower eyelid

SC

Nasolabial fold

Van der Meulen, 1982 Leone, 1983

Tan, 2007

64

96

Lateral upper and lateral lower eyelid defect Basxterzi, 2007 58 SC Forehead C ¸o SC Forehead ˜log˘lu, 2007 109

Island; lateral Bilobed island; lateral

Total upper and partial lower eyelid defect Landolt, 1885 73 C C

Transposition: caudal Advancement; lateral

Tse, 1997

103

G or PC

Forehead Lower eyelid þ Temporal area Forehead

Transposition; caudal

þMC flap þSkin graft

Flap folded at rim Chondral graft

No tarsus in flap þCM graft

þMucosa graft þSkin graft þNasolabial flap þSkin graft þSkin-þTarsal graft

þTarsal graft þTCj þ Skin graft þAchilles tendon þHard palate graft

þConchal graft þBuccal mucosa graft Fixation with PL tendon þTCj graft þSkin graft

þHard palate graft þMC or mucosal graft

þTarsal graft (continued on next page)

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I.M.J. Mathijssen, J.C. van der Meulen

Table 1 (continued) Author, year of publication

Composition of flap

Total lower and partial upper eyelid defect MF Chiarelli, 2001 33 Boboridis, 2005 110 TCj MC MC Total upper and lower eyelid defect Yap, 1997 111 SC Thai, 1999 112 1st SC Cj

Donorsite

Type of flap; pedicle

Specifics

Forehead Upper eyelid Upper eyelid Supra-eyebrow

Transposition; caudal Advancement; cranial Advancement; cranial Transposition; caudal

With midface lift

Dorsum hand Dorsum foot Upper and lower eyelid

Free Free Advancement; cranial and caudal

2nd Lalonde, 2005

113

1st MC

Upper þ Lower eyelid

2nd DeSousa, 2007

72

M

DeSousa, 2007

72

1st MC 2nd

DeSousa, 2007

72

DeSousa, 2007

72

DeSousa, 2007

72

MC (upper) P (lower) MC (upper) FT (lower) TCj (upper) FT (lower) 1st FC 2nd

Rubino, 2007

114

Upper and lower eyelid Forehead midline

Forehead Forehead Upperbrow Cheek Upper eyelid Cheek Anterolateral thigh

Advancement; cranial þ caudal Division in lower and upper eyelid Advancement; cranial and caudal Transposition; caudal Divison in lower and upper eyelid Island; lateral Transposition; caudal Transposition; lateral V-Y transposition; lateral Advancement Transposition; lateral Free Division in lower and upper eyelid

þChondral graft

Division in lower and upper eyelid þHard palate graft þBuccal grafts inside þTarsal þ Hard palate graft þSeptal CM graft

þTarsal graft þHard palate graft þHard palate graft þHard palate graft

C Z cutis; Cj Z conjunctival; CC Z chondrocutaneous; CM Z chondromucosal; CSC Z cutanosubcutaneous; FT Z full thickness; G Z galeal; M Z muscular; MC Z myocutaneous; MC(P)MC Z mucochondro(periosteo)myocutaneous; MF Z myofascial; MMC Z mucomyocutaneous; F Z fascial; FC Z fasciocutaneous; PL Z palmaris longus; T Z tarsal; TCj Z tarsoconjunctival; TMC Z tarsomyocutaneous; OS Z orbital septum; P Z periosteal; PC Z pericranial (periosteum þ subgaleal fascia); SC Z subcutanocutaneous.

Table 2

Tips and tricks based on 40 years of experience

Avoid secondary healing. Reconstruct the defect whenever primary closure causes distortion. Always supply inner lining of a flap, preferably buccal mucosa. Insertion of a cartilage graft in the lower eyelid for support is not indicated: dynamic restoration with innervated orbicularis muscle flap or static reconstruction with a tendon sling are superior. Avoid pedicled tarsoconjunctival flaps (Hughes flap) from the upper eyelid to the lower eyelid or vice versa. Pedicled (myo)cutaneous flaps from the upper eyelid can be designed in a way that secondary inset of the pedicle(s) can be avoided. Keep the pedicles situated above the level of the canthal ligaments to further suspend the lower eyelid. Avoid medial canthotomy; lateral canthotomy should only be performed on the lower limb of the canthal ligament. Add a Z-plasty to the medial side of the cheek flap to allow higher inset at the medial canthal area. A Z-plasty at the most lateral part of a temporal flap allows further medialization of the flap. The lower eyelid can safely be used as donor site for reconstruction of a defect of the upper eyelid. Reconstruction of the medial canthal area is best performed with a skin graft. With exposed bone a cutaneous flap from the upper eyelid is preferred. Reinsertion of the medial canthal ligament or fixation of the medial part of the reconstructed lower eyelid is best achieved with the use of a bone anchor.

Guidelines for reconstruction of the eyelids and canthal regions

1427

Figure 1 A. A basal cell carcinoma was primary treated with radiation therapy, resulting in a painful and dry eye, and a defect at the lateral canthal area. Damage to the skin precludes the use of a local flap. B. Reconstruction of the lower eyelid with a pedicled superficial temporal artery fascia flap, covered with a skin graft. C. Result after 3 months.

valuable in the medial canthal area and for tumour recurrences.1,2 We consider radiation therapy to be contraindicated as the primary treatment in the periorbital area (Figure 1A). Leaving a defect to heal through secondary intention (the so-called laissez faire technique) is never indicated in the periorbital area, as contour deformity or contracture was repeatedly encountered (Figure 2). This method only works well for concave surfaces, such as the forehead or the malar prominence. Primary closure leads to the most optimal result and is usually feasible for defects up to one-third of the length of the eyelid. It is essential that no functional deficit or distortion is caused. Partial-thickness defects of the lid involving only the superficial layer that has a well-vascularised wound bed can virtually always be closed with a skin graft. Full-thickness lid defects larger than one-third of the length require reconstruction. During World War I, reconstruction was performed with the use of local, pedicled flaps. A common complication, however, was postoperative shrinking of the flaps. This problem was dealt with the addition of an inner lining to the flap by Esser.3 Pedicled flaps are preferably taken locally within the periorbital region. If these are at risk due to excessive burns or radiation, one should consider delayed creation of these flaps. Distant flaps are indicated when local flaps are not available and can be taken from the glabella, forehead (Figure 3), nasolabial groove (Figure 4), lateral wall of the nose, cheek (Figure 5), supra-brow area, temporal region of the scalp, periostal scalp flaps (Figure 6), various scalp flaps

based on the superficial temporal artery (Figure 1), retroauricular temporal flap4,5 or submental artery flap.6 Flaps with a mismatching skin colour can be taken without skin or de-epithelialised and covered with a skin graft of a similar colour as the original skin. The thickness of these flaps that affects pliability may be a major disadvantage of these flaps. Therefore, a second stage is incorporated in which the flap is thinned while leaving the pedicle intact. Only at the third stage the pedicle is cut with the inset of the flap. One can also use a distant flap as a nursing flap: the muscular or fascial flap is only used to vascularise the affected area. After 2e3 weeks, the flap is raised and sutured back into place if needed, leaving a thin layer of vascularised tissue on which a skin graft can be applied. The most complex reconstruction involves a free flap. The use of free flaps in the orbital region is usually reserved for very extensive defects and often aims at coverage only. The use of a free flap to reconstruct eyelids is only seldom

Figure 2 Secondary healing of the medial canthal defect following Mohs’ surgery for a basal cell carcinoma, resulted in a contracture with detachment of the lower eyelid off the eyeball.

1428

Figure 3 A. Result following multiple resections of basal cell carcinomas and radiotherapy, with loss of the eye due to perforation of a corneal ulcer. Both the superior and inferior fornices were completely lost and patient was unable to wear his ocular prosthesis. A paramedian forehead flap was used to reconstruct both eyelids. In the 2nd procedure the flap was divided in an upper and lower eyelid and in the 3rd procedure the pedicle was divided. B. Result one week after 3rd procedure.

indicated in which case the (fascial) radial artery flap or the superficial temporal artery fascia flap is best suited.

Reconstruction related to anatomical structures Skin Reconstruction with a skin graft alone can be applied when the defect is limited to the outer lamella and when the wound bed is well vascularised. Usually, previous irradiation or third-degree burn will preclude the use of a graft. A full-thickness graft is most appropriate as the amount of contraction is more limited compared to a split-skin graft. The superior donor site for a full-thickness skin graft is the upper eyelid. The next best option is pre- and post-auricular skin, followed by supraclavicular skin and skin of the inner side of the upper arm. Generally, the donor site can be closed primarily or covered with a split-skin graft.

Conjunctiva and tarsal plate Loss of conjunctiva, with or without tarsus, is best matched with the insertion of a buccal mucosa graft.7 Again, vascularisation of the wound bed is mandatory. Grafts can also be taken from the hard palate.8e10 Histologically, the hardpalate graft, including periosteum, is almost similar to that of the tarsal plate and more rigid compared to buccal mucosa and therefore considered to be the optimal choice

I.M.J. Mathijssen, J.C. van der Meulen

Figure 4 A. Patient after treatment of a very aggressive form of Morbus Wegener with a near perforation of the cornea. B. The lower eyelid was reconstructed using a cranially based paranasal flap after which the corneal ulceration settled down.

by some.10,11 However, we do not prefer the use of the hard-palate graft because the benefit of a double-layered mucoperiosteal graft versus a mucosal graft is unproven and creates significantly more inconvenience to the patient for some weeks. In addition, long-term experience has shown that stability is virtually guaranteed by the formation of scar tissue between the buccal graft and outer layer.12 With the inset of a graft, prevention of corneal damage caused by sutures is essential. We prefer to use vicryl rapid 6/0 as a running suture with inverted knots. Numerous techniques are described in which tarsoconjunctival defects are reconstructed with tarsoconjunctival grafts or flaps or chondromucosal grafts. Generally, however, the partial or total resected tarsal plate itself does not require a substitute.7,8,13,14 This statement is best illustrated in facial nerve paralysis with drooping of the lower eyelid, illustrating that the orbicularis oculi muscle tone is the primary source of support and not the tarsal plate. Histology of the tarsal plate shows connective tissue with abundant collagen fibres,11 without a cartilaginous component. Insertion of a cartilage graft can even cause distortion due to warping of the cartilage or sagging of the eyelid due to the weight. The key is to insert the mucosal graft with tension and assure that the reconstructed eyelid is firmly attached to the medial and lateral orbital walls, which in most cases will prevent an ectropion. Another option that we prefer to avoid is a pedicled (tarso)conjunctival flap, usually from the opposing eyelid. A defect is created at the donor site while there is never an excess of conjunctiva. If performed in less experienced hands, a retracted eyelid may result. Furthermore, vision is

Guidelines for reconstruction of the eyelids and canthal regions

1429

Figure 5 A. Coloboma of the medial half of the lower eyelid in a patient with a bilateral nasomaxillary cleft. B. The myocutaneous flap of the lower eyelid was extended into the temporal area and a Z-plasty further enhanced its advancement medially. A paraglabellar flap was turned downwards. C. Result 2 years postoperatively.

blocked for at least 2 weeks. Given the availability of more elegant options we feel that the indications for these Hughes-type flaps are limited.

If the lower eyelid remains positioned too low, one may insert a tendon (e.g., palmaris longus tendon) or fascial strip while fixing its edges at the medial and lateral canthus that serves as a hammock.16

Orbicularis oculi muscle Canthal ligaments The orbicularis oculi muscle closes the eye and supports the lower eyelid. When a significant part of the orbicularis oculi muscle in the upper eyelid is lost, function can be near normal. In contrast, a similar major defect in the lower eyelid requires reconstruction to prevent ectropion. This is performed with a flap that may include the orbicularis oculi muscle. With electromyographic studies, Lowry et al. have shown that the orbicularis oculi muscle transferred as a bipedicled flap to the lower eyelid remains active.15

When either the medial and/or the lateral canthal ligaments are lost, re-fixation of the lid into the original position of the canthal ligaments is essential to maintain an adequate position. Various techniques for fixation into the bone are possible, such as a drill hole in the lateral orbital wall through which a suture is taken, the insertion of a bone anchor17 or a periosteal flap.18,19 Inadequate fixation will cause rounding of the lateral corner of the eye. Inappropriate positioning of the medial canthus leads to

Figure 6 A. 27 years after enucleation and radiotherapy, and with multiple reconstructions afterwards, the superior sulcus of the socket was too shallow to retain the prosthesis. B. A pericranial flap was developed and turned downwards. The flap was covered with a skin graft from the contralateral upper eyelid for outer lining. C. Three months after surgery.

1430 telecanthus or distorted drainage of the tears if the lachrymal system is intact otherwise. Focus should be on proper alignment of the medial part of the lower eyelid to the eyeball through deep positioning.

Musculus levator palpebrae The most natural and symmetric opening of the upper eyelid is achieved with the re-insertion of the remnant of the levator palpebrae muscle. If no levator palpebrae muscle is present, a part of the frontal muscle is used as a substitute. The current technique involves dissection of the frontal muscle directly through an incision just above the eyebrow or through an upper blepharoplasty incision. The caudal edge of the muscle is taken just below the eyebrow. The frontal muscle is detached from the periosteum of the frontal bone along an area that is about 1.5e2-cm wide.20 The muscle is cut at the medial and lateral border, in a cranial direction. The caudal edge of the strip is sutured to the reconstructed eyelid. In case of incomplete closure of the eye, the patients should use teardrops during the day and ointment during the night, with or without an hourglass. However, with time, a synergism between opening and closure forces usually develops, due to the fact that the orbicularis oculi muscle also pulls on the frontal muscle.

Reconstruction related to defect depth, size and location Full-thickness defect £one-third of eyelid length When both the outer and the inner lamellae are missing and the remaining length of the upper or lower eyelid measures at least two-thirds of its original length and the canthi are spared, primary closure is the best option. A local myocutaneous transposition flap, particularly for defects of the upper eyelid, can be helpful in reducing the tension. These flaps can usually be designed in a V-Y or rhomboid pattern within the lines of minimal tension, which is usually oblique to the eyelid rim. Some authors advocate the release of the medial or lateral canthal ligament to enable primary closure.21,22 If used for closure of a defect of just the lower or upper eyelid, sufficient mobilisation is achieved by releasing only the inferior or superior part of the lateral canthal ligament, respectively, thereby preventing distortion of the lateral canthus.22e24

Full-thickness defect >one-third to half of eyelid length In the elderly, even defects of up to 50% can be closed primarily due to laxity of the tissues. If not, a defect of this size requires a (myo) cutaneous flap, lined with a mucosal graft. The flap of choice can be either a local transposition or advancement flap from within the eyelid itself since a fair amount of tissue is still at hand. For lateral defects, the temporal area can be used as the donor site. The remaining part of the eyelid between the lateral canthus and the defect may be moved medially in continuity with the temporal flap to align the eyelashes and re-arrange the defect completely

I.M.J. Mathijssen, J.C. van der Meulen lateral, which is closed with a flap and a mucosal graft. An alternative is a unipedicled (island) myocutaneous flap from the opposing ipsilateral eyelid. If the defect involves the medial part of the lid margin, a medial advancement of the lateral part in continuity with a temporal extension can be performed for eyelid reconstruction. Callahan described the use of a full-thickness composite graft of the contralateral upper eyelid.25 Given the unreliable results of this technique, we strongly advise against it.

Full-thickness defect >half and
Complete upper or lower eyelid loss With an intact upper eyelid and blepharochalazis, a bipedicled myocutaneous flap can be taken to reconstruct the lower eyelid, covered with a mucosal graft on the back. Keeping the muscular pedicles situated above the canthi prevents an ectropion. The donor site rarely requires a skin graft for closure. This technique is often used as a twostage procedure with further inset of the pedicles, although, with experience, a similar result can be achieved in one stage. Another valuable option is the cheek flap, originally described by Esser.27 To further facilitate the advancement of the cheek flap with tensionless inset of the flap, McGregor added a Z-plasty laterally.28 Van der Meulen further modified the cheek flap by incorporating an unequal Z-plasty medially, allowing an upward positioning of the flap and fixing in the medial canthal area.29 Careful planning of the cheek flap is essential, as has been well illustrated in the paper by Boutros and Zide.30 The second option for reconstruction of the lower eyelid is, for instance, the nasolabial flap. The upper eyelid can be totally reconstructed with a bipedicled cutaneous flap from the lower eyelid.7,31 Keeping the orbicularis oculi muscle intact prevents ectropion, while the donor site is closed with a skin graft. In addition, a myocutaneous flap from just below or above the eyebrow can be used, with a skin graft on the donor site.31 A more extended technique involves transposition of the lateral two-thirds of the lower eyelid, in continuity with the cheek flap. The lower eyelid with its medial pedicle is inserted into the upper lid defect, and the cheek flap is used for replacement of the lower eyelid donor defect. A second procedure is required for pedicle division and adjustment of the flap. We feel that the disturbance of the

Guidelines for reconstruction of the eyelids and canthal regions lower eyelid anatomy with this method is not justified whenever other options are available.

Complete upper and lower eyelid loss A large amount of tissue is required for replacing both upper and lower eyelid. This mostly involves patients with severe burns or extensive tumours that were resected. A staged repair can be undertaken with distant flaps, such as the superficial temporal artery fascial flap. This pedicled flap (or free flap when taken from the contralateral side) is thin and well vascularised. It can be covered with the required grafts on both sides and inset on the medial side of the orbit. If the pedicle allows it, the flap is divided in an upper and lower part. If not, the division of the flap in performed at a second procedure. This reconstruction is static, but may create a sufficient socket for wearing an ocular prosthesis. A similar procedure can be performed with a different flap, for instance, the forehead flap. These thick flaps need thinning in a second stage, keeping the pedicle intact. The pedicle is divided at the third stage. DeSousa et al. reported on the outcome of reconstruction of total upper and lower eyelids in six patients.32 A major drawback of the various techniques was the residual rigidity of the eyelids. Eyelid movement was only noticed when some orbicularis oculi muscle was preserved. Epiphora was also a common feature in all patients.

Inner canthal area The vast majority of defects situated at the medial canthus can be closed with a full-thickness skin graft from an upper eyelid, because this area requires thin skin that is adherent to the bone. A prerequisite for the graft to take is the presence of intact, vascularised periosteum. Otherwise, one should choose a uni-pedicled cutaneous flap from either the ipsilateral or contralateral upper eyelid. Should the medial canthal ligament need re-fixation to the nasal bone, the use of a micro mitek bone anchor is preferred.17 Using the same bone anchor, one can also attach the flap to the inner canthal area, preventing loss of contour at this site.

Outer canthal area Usually a local transposition flap from the temporal region is sufficient. Again, a superiorly based flap is preferred because this will lower the risk of an ectropion and more skin is available within this area. Reinsertion of the lateral canthal structure can also be done with the insertion of a bone anchor.

Conflict of interest statement None.

Role of the funding source No funding was received.

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95. Cutler NL, Beard C. A method for partial and total upper lid reconstruction. Am J Ophthalmol 1955;39:1e7. 96. Leone Jr CR. Tarsal-conjunctival advancements flaps for upper eyelid reconstruction. Arch Ophthalmol 1983;101: 945e8. 97. Mauriello Jr JA, Antonacci R. Single tarsoconjunctival flap (lower eyelid) for upper eyelid reconstruction (‘reversed’ modified Hughes procedure). Ophthalmic Surg 1994;25:374e8. 98. Okada E, Iwahira Y, Maruyama Y. The V-Y advancement myotarsocutaneous flap for upper eyelid reconstruction. Plast Reconstr Surg 1997;100:996e8. 99. Dutton JJ, Fowler AM. Double-bridged flap procedure for nonmarginal, full thickness, upper eyelid reconstruction. Ophthal Plast Reconstr Surg 2007;23:459e62. 100. Mustarde ´ JC. Two-stage reconstruction of the upper lid. Trans Ophthalmol Soc UK 1966;86:197. 101. Mustarde ´ JC. Reconstruction of the upper lid and the use of nasal mucosal grafts. Br J Plast Surg 1968;21:367e77. 102. Breier F, Meissl G, Diem E. Functional reconstruction of the upper eyelid after excision of squamous cell carcinoma in xeroderma pigmentosum. Plast Reconstr Surg 1997;99: 1730e3. 103. Tse DT, Goodwin WJ, Johnson T, et al. Use of galeal of pericranial flaps for reconstruction of orbital and eyelid defects. Arch Ophthalmol 1997;115:932e7. 104. Patrinely JR, O’Neal K, Kersten RC, et al. Total upper eyelid reconstruction with mucosalized tarsal graft and overlying bipedicle flap. Arch Ophthalmol 1999;117:1655e61. 105. Holloman EL, Carter KD. Modification of the Cutler-Beard procedure using donor Achilles tendon for upper eyelid reconstruction. Ophthal Plast Reconstr Surg 2005;21:267e70. 106. Scuderi N, Ribuffo D, Chiummariello S. Total and subtotal upper eyelid reconstruction with the nasal chondromucosal flap: a 10-year experience. Plast Reconstr Surg 2005;115: 1259e65. 107. Fujiwara M. Upper eyelid reconstruction with a hard palate mucosa-lined bipedicled myocutaneous flap. J Craniofac Surg 2006;17:1011e5. 108. Ohshiro T, Tsuchida Y, Harashina T, et al. Reconstruction of the levator palpebrae function and conjunctiva using an inferiorly based orbital septal flap for subtotal full-thickness defects of the upper eyelid. Ann Plast Surg 2006;56:336e9. 109. C ¸o ¸er U, Oruc ¸ M, et al. Axial bilobed superficial ˜log˘lu H, Koc temporal artery island flap (tulip flap): reconstruction of combined defects of the lateral canthus including the lower and upper eyelids. Plast Reconstr Surg 2007;119:2080e7. 110. Boboridis KG, Dimitrakos SA, Georgiadis NS, et al. Combination of periocular myocutaneous flaps for one-stage reconstruction of extensive defects of the eyelid. Scand J Plast Reconstr Surg Hand Surg 2005;39:100e3. 111. Yap LH, Earley MJ. The free ‘V’: a bipennate free flap for double eyelid resurfacing based on the second dorsal metacarpal artery. Br J Plast Surg 1997;50:280e3. 112. Thai KN, Billmire DA, Yakuboff KP. Total eyelid reconstruction with free dorsalis pedis flap after deep facial burn. Plast Reconstr Surg 1999;104:1048e51. 113. Lalonde DH, Osei-Tutu KB. Functional reconstruction of unilateral, subtotal, full-thickness upper and lower eyelid defects with a single hard palate graft covered with advancement orbicularis myocutaneous flaps. Plast Reconstr Surg 2005;115:1696e700. 114. Rubino C, Farace F, Puddu A, et al. Total upper and lower eyelid replacement following thermal burn using an ALTflapea case report. J Plast Reconstr Aesth Surg 2008;61: 578e81.