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Reconstruction of the Medial Eyelid
RECONSTRUCTION O F T H E MEDIAL EYELID C H A R L E S R. L E O N E , J R . , M.D.,
AND S T A N L E Y I. H A N D , J R . ,
M.D.
San Antonio, Texas
When a full-thickness lower eyelid de fect cannot be closed with a canthotomy and cantholysis, a temporal rotational flap1,2 or eyelid sharing procedure 3 from the upper eyelid is usually considered. This is particularly true in the medial one third of the eyelid where there is little stretch of the medial canthal tissue. We describe herein a method of repairing medial defects of the lower eyelid by using a free tarsal-conjunctival graft and a nasal-based skin-muscle pedicle flap. M A T E R I A L AND M E T H O D S
This procedure was usually done under local anesthesia using 2% lidocaine with hyaluronidase and epinephrine 1:100,000. The tumor was examined with the oper ating microscope and a clear 1.5-mm mar gin was drawn around the tumor (Fig. 1). The punctum or canaliculus were re moved if necessary and externalization of the canaliculus was attempted only if a small portion of the punctum or canalicu lus had been resected. The specimen was sent to the pathologist for a frozen section examination, and when free margins were reported, reconstruction was begun. The upper eyelid was everted over a Desmarres retractor and a free tarsalconjunctival graft 4 mm wide and corre sponding in length to the size of the defect was removed. The graft was taken from the midportion of the tarsus, leaving at least 3 mm of tarsal support for the From the Oculoplastic Service, Division of Oph thalmology University of Texas Medical School, and Wilford Hall, United States Air Force Medical Cen ter, Lackland Air Force Base, Texas. Reprint requests to Charles R. Leone, Jr., M. D., 311 Camden St., 504 Madison Square Bldg., San Antonio, TX 78215.
eyelid margin. The tarsal defect was left unsutured. If the canaliculus was resected, the graft was sutured to the lower arm of the canthal tendon with a double arm suture of 4-0 Dacron. Otherwise, it was sutured to the tarsus of the remaining eyelid with 6-0 chromic catgut with the superior edge level with the eyelid margin. The graft was also sutured to the conjunctiva in the inferior cul de sac as well. The sutures were placed in such a way that the knots were tied on the anterior surface to avoid rubbing against the cornea. If the graft was too tight against the globe it was trimmed to avoid a postoperative sag. The skin beyond the medial aspect of the defect formed the base of the pedicle flap that rotated into the defect. An out line of the flap was drawn and was slight ly larger than the defect it would fill. The flap including orbicularis was cut, lifted from its bed, and rotated upward to cover the tarsal-conjunctival graft and the re mainder of the defect. The skin was su tured to the tarsal-conjunctival graft with 6-0 silk to create the new eyelid margin, and the lateral aspect of the flap was sutured to the lateral eyelid segment. A full-thickness postauricular graft was placed in the defect created by the trans fer of the pedicle flap to the eyelid mar gin. A pattern of the defect was made with sterile paper, then traced in the postauric ular area. The skin was injected with 2% lidocaine with epinephrine 1:100,000 and the area outlined was cut with a No. 15 Bard-Parker blade. The graft was re moved from its bed by sharp dissection, leaving as much subcutaneous tissue as possible. The graft was placed in saline
AMERICAN JOURNAL OF OPHTHALMOLOGY 87:797-801, 1979
797
798
AMERICAN JOURNAL OF OPHTHALMOLOGY
JUNE, 1979
VOL. 87, NO. 6
RECONSTRUCTION OF THE MEDIAL EYELID
while the closure of the defect was done with a continuous suture of 4-0 Prolene. Small stab incisions were made in the graft to allow for drainage. The graft was made to fit the defect with only a slight redundancy present. The graft was placed with 6-0 silk with the ends of the suture left long. At the superior edge where the graft was joined to the pedicle graft, su ture bites were taken in the subcutaneous tissue to secure both edges to the deeper layer. A cotton roll soaked in neomycin sulfate (Neosporin drops) was placed over the graft and the silk sutures were tied over the stent as a pressure bandage. Antibiotic ointment was placed over the eyelid area and a wet loose dressing was applied. The sutures were removed in seven days. CASE REPORTS Case 1—A 49-year-old woman had a 6-mm recur rent basal cell carcinoma just lateral to the punctum in the right lower eyelid (Fig. 2). Using frozen section control, a 9-mm resection was carried out sparing the punctum. We used a free tarsalconjunctival graft from the ipsilateral upper eyelid to fill the defect in addition to using a nasal-based skin-muscle pedicle flap. The secondary defect was repaired with a full thickness skin graft. Postoperatively, the patient has a cosmetically satisfactory appearance with a normal upward contour of the medial aspect of the lower eyelid. Case 2—A 42-year-old man had a 15-mm resection of the medial aspect of his left lower eyelid includ ing the punctum and canaliculus for basal cell carcinoma (Fig. 3). A 10-mm tarsal-conjunctival graft was taken from the ipsilateral upper eyelid to fill the defect. Because of tension on the suture line between the graft and eyelid, it was necessary to do a
799
small canthotomy and cantholysis at the lateral canthus. A nasal-based skin-muscle pedicle flap was brought from below to cover the tarsal-conjunctival graft, and the secondary defect was repaired with a full-thickness skin graft. One year postoperatively, he has a cosmetically satisfactory result with only occasional epiphora. DISCUSSION
Defects of the medial aspect of the lower eyelid are difficult to repair as com pared to the lateral canthal and temporal areas because of a lack of available tissue in the medial canthus. If a temporal rota tional flap1,2 is used to repair a moderately large defect, normal eyelid must be rotat ed nasally leaving an area laterally of unsupported tissue against the globe. This occasionally requires additional re construction or mucous membrane cover ing of the lateral eyelid area. A modified Hughes 3 procedure may be done but this requires occluding the fissure for several weeks until the upper eyelid can be re leased. Confining the reconstruction to the local area is preferable, and does not violate the lateral canthal area to any great extent. Thus, the risk of a cosmetic defor mity in the uninvolved area can be avoid ed. However, a small canthotomy and cantholysis does not usually distort the lateral canthus, and as in Case 2, is some times necessary to relieve tension on wound edges. The punctum and canaliculus may be removed to get tumor-free edges. If the distal aspect of the canaliculus is intact, we attempt to externalize it by leaving a
Fig. 1 (Leone and Hand). A, The tumor is outlined and removed with a clear margin of at least 1.5 mm. B, The upper eyelid is everted and a free tarsal-conjunctival graft 4-mm wide and similar in length to the defect in the lower eyelid is removed leaving at least 3 mm of tarsus at the eyelid margin. This defect is left unsutured. C, The graft is sutured in place with interrupted sutures of 6-0 chromic catgut. If the graft is not fairly tight against the globe it should be trimmed. D, The skin and orbicularis below the defect form a pedicle flap slightly larger than the defect and is based in the medial canthal area. E, The skin and tarsal-conjunctival grafts are joined with interrupted sutures of 6-0 silk to form the new eyelid margin. Some undermining may be necessary to obliterate tractions lines. F, An ellipse of full thickness postauricular skin is removed and the donor site is closed with a continuous 4-0 prolene suture. G, In the defect created by the transfer of the skin pedicle flap, the full thickness postauricular graft is placed and sutured with interrupted 6-0 silk. Stab incisions are made in the graft for drainage. H, This is the immediate postoperative appearance.
800
AMERICAN JOURNAL OF OPHTHALMOLOGY
JUNE, 1979
m
Fig. 2 (Leone and Hand). Top left, Recurrent basal cell carcinoma lateral to the punctum in the right lower eyelid. Top right, Postoperative ap pearance one week after surgery shows the heal ing grafts. Bottom left, Postoperative appearance six months after surgery shows a satisfactory cosmetic result and restoration of the normal contour to the medial eyelid.
Fig. 3 (Leone and Hand). Left, Basal cell carcinoma occupying the medial aspect of left lower eyelid. Right, Postoperative appearance one year later after a 15-mm resection of the medial aspect of the left lower eyelid.
VOL. 87, NO. 6
RECONSTRUCTION O F T H E MEDIAL EYELID
silicone tube within the orifice for four to six weeks while it is healing. However, if only a small portion of the proximal canaliculus is left, and if the upper canaliculus is functioning, no attempt is made to externalize it because it may interferre with the placement of the tarsal-conjunctival graft. Because a newly reconstructed eyelid needs support, a tarsal-conjunctival graft is the ideal material. This is placed in the defect to simulate the tarsus that has been removed, and if there is no medial eyelid remaining, it is sutured to the remnant of the medial canthal tendon to retain the upward curvature of the lower eyelid and close apposition to the globe. The pedicle skin-muscle graft is necessary to nourish the free tarsal-conjunctival graft, and can be fitted in the area with a minimum of traction lines. Orbicularis is a necessary part of the pedicle flap because it is vas cular and increases the blood supply brought to the tarsal-conjunctival graft. In the secondary defect, a postauricular skin graft is preferred to upper eyelid skin because the shrinkage factor is less. The
801
advantage to this procedure is that the lat eral canthus is left undisturbed and the visual axis is left open while confining the repair strictly to the medial canthal and nasal areas. SUMMARY
We used a free tarsal-conjunctival graft from the upper eyelid and a nasal-based pedicle skin-muscle flap for reconstruc tion of the medial aspect of the lower eyelid. This had the advantage of con fining the reconstruction to the local area and eliminated the need for a temporal flap or an eyelid sharing procedure that necessitates occluding the fissure for sev eral weeks. REFERENCES 1. Mustarde, J. C : Repair and Reconstruction in the Orbital Region. Baltimore, Williams and Wilkins Co., 1966, pp. 116-147. 2. Tenzel, R. R.: Reconstruction of the central one-half of an eyelid. Arch. Ophthalmol., 93:125, 1975. 3. Smith, B.: Eyelid reconstruction. In Soil, D. B., (ed.): Management of complications in ophthalmic plastic surgery. Birmingham, Aesculapius, 1976, pp. 226-228.
AND S T A N L E Y I. H A N D , J R . ,
M.D.
San Antonio, Texas
When a full-thickness lower eyelid de fect cannot be closed with a canthotomy and cantholysis, a temporal rotational flap1,2 or eyelid sharing procedure 3 from the upper eyelid is usually considered. This is particularly true in the medial one third of the eyelid where there is little stretch of the medial canthal tissue. We describe herein a method of repairing medial defects of the lower eyelid by using a free tarsal-conjunctival graft and a nasal-based skin-muscle pedicle flap. M A T E R I A L AND M E T H O D S
This procedure was usually done under local anesthesia using 2% lidocaine with hyaluronidase and epinephrine 1:100,000. The tumor was examined with the oper ating microscope and a clear 1.5-mm mar gin was drawn around the tumor (Fig. 1). The punctum or canaliculus were re moved if necessary and externalization of the canaliculus was attempted only if a small portion of the punctum or canalicu lus had been resected. The specimen was sent to the pathologist for a frozen section examination, and when free margins were reported, reconstruction was begun. The upper eyelid was everted over a Desmarres retractor and a free tarsalconjunctival graft 4 mm wide and corre sponding in length to the size of the defect was removed. The graft was taken from the midportion of the tarsus, leaving at least 3 mm of tarsal support for the From the Oculoplastic Service, Division of Oph thalmology University of Texas Medical School, and Wilford Hall, United States Air Force Medical Cen ter, Lackland Air Force Base, Texas. Reprint requests to Charles R. Leone, Jr., M. D., 311 Camden St., 504 Madison Square Bldg., San Antonio, TX 78215.
eyelid margin. The tarsal defect was left unsutured. If the canaliculus was resected, the graft was sutured to the lower arm of the canthal tendon with a double arm suture of 4-0 Dacron. Otherwise, it was sutured to the tarsus of the remaining eyelid with 6-0 chromic catgut with the superior edge level with the eyelid margin. The graft was also sutured to the conjunctiva in the inferior cul de sac as well. The sutures were placed in such a way that the knots were tied on the anterior surface to avoid rubbing against the cornea. If the graft was too tight against the globe it was trimmed to avoid a postoperative sag. The skin beyond the medial aspect of the defect formed the base of the pedicle flap that rotated into the defect. An out line of the flap was drawn and was slight ly larger than the defect it would fill. The flap including orbicularis was cut, lifted from its bed, and rotated upward to cover the tarsal-conjunctival graft and the re mainder of the defect. The skin was su tured to the tarsal-conjunctival graft with 6-0 silk to create the new eyelid margin, and the lateral aspect of the flap was sutured to the lateral eyelid segment. A full-thickness postauricular graft was placed in the defect created by the trans fer of the pedicle flap to the eyelid mar gin. A pattern of the defect was made with sterile paper, then traced in the postauric ular area. The skin was injected with 2% lidocaine with epinephrine 1:100,000 and the area outlined was cut with a No. 15 Bard-Parker blade. The graft was re moved from its bed by sharp dissection, leaving as much subcutaneous tissue as possible. The graft was placed in saline
AMERICAN JOURNAL OF OPHTHALMOLOGY 87:797-801, 1979
797
798
AMERICAN JOURNAL OF OPHTHALMOLOGY
JUNE, 1979
VOL. 87, NO. 6
RECONSTRUCTION OF THE MEDIAL EYELID
while the closure of the defect was done with a continuous suture of 4-0 Prolene. Small stab incisions were made in the graft to allow for drainage. The graft was made to fit the defect with only a slight redundancy present. The graft was placed with 6-0 silk with the ends of the suture left long. At the superior edge where the graft was joined to the pedicle graft, su ture bites were taken in the subcutaneous tissue to secure both edges to the deeper layer. A cotton roll soaked in neomycin sulfate (Neosporin drops) was placed over the graft and the silk sutures were tied over the stent as a pressure bandage. Antibiotic ointment was placed over the eyelid area and a wet loose dressing was applied. The sutures were removed in seven days. CASE REPORTS Case 1—A 49-year-old woman had a 6-mm recur rent basal cell carcinoma just lateral to the punctum in the right lower eyelid (Fig. 2). Using frozen section control, a 9-mm resection was carried out sparing the punctum. We used a free tarsalconjunctival graft from the ipsilateral upper eyelid to fill the defect in addition to using a nasal-based skin-muscle pedicle flap. The secondary defect was repaired with a full thickness skin graft. Postoperatively, the patient has a cosmetically satisfactory appearance with a normal upward contour of the medial aspect of the lower eyelid. Case 2—A 42-year-old man had a 15-mm resection of the medial aspect of his left lower eyelid includ ing the punctum and canaliculus for basal cell carcinoma (Fig. 3). A 10-mm tarsal-conjunctival graft was taken from the ipsilateral upper eyelid to fill the defect. Because of tension on the suture line between the graft and eyelid, it was necessary to do a
799
small canthotomy and cantholysis at the lateral canthus. A nasal-based skin-muscle pedicle flap was brought from below to cover the tarsal-conjunctival graft, and the secondary defect was repaired with a full-thickness skin graft. One year postoperatively, he has a cosmetically satisfactory result with only occasional epiphora. DISCUSSION
Defects of the medial aspect of the lower eyelid are difficult to repair as com pared to the lateral canthal and temporal areas because of a lack of available tissue in the medial canthus. If a temporal rota tional flap1,2 is used to repair a moderately large defect, normal eyelid must be rotat ed nasally leaving an area laterally of unsupported tissue against the globe. This occasionally requires additional re construction or mucous membrane cover ing of the lateral eyelid area. A modified Hughes 3 procedure may be done but this requires occluding the fissure for several weeks until the upper eyelid can be re leased. Confining the reconstruction to the local area is preferable, and does not violate the lateral canthal area to any great extent. Thus, the risk of a cosmetic defor mity in the uninvolved area can be avoid ed. However, a small canthotomy and cantholysis does not usually distort the lateral canthus, and as in Case 2, is some times necessary to relieve tension on wound edges. The punctum and canaliculus may be removed to get tumor-free edges. If the distal aspect of the canaliculus is intact, we attempt to externalize it by leaving a
Fig. 1 (Leone and Hand). A, The tumor is outlined and removed with a clear margin of at least 1.5 mm. B, The upper eyelid is everted and a free tarsal-conjunctival graft 4-mm wide and similar in length to the defect in the lower eyelid is removed leaving at least 3 mm of tarsus at the eyelid margin. This defect is left unsutured. C, The graft is sutured in place with interrupted sutures of 6-0 chromic catgut. If the graft is not fairly tight against the globe it should be trimmed. D, The skin and orbicularis below the defect form a pedicle flap slightly larger than the defect and is based in the medial canthal area. E, The skin and tarsal-conjunctival grafts are joined with interrupted sutures of 6-0 silk to form the new eyelid margin. Some undermining may be necessary to obliterate tractions lines. F, An ellipse of full thickness postauricular skin is removed and the donor site is closed with a continuous 4-0 prolene suture. G, In the defect created by the transfer of the skin pedicle flap, the full thickness postauricular graft is placed and sutured with interrupted 6-0 silk. Stab incisions are made in the graft for drainage. H, This is the immediate postoperative appearance.
800
AMERICAN JOURNAL OF OPHTHALMOLOGY
JUNE, 1979
m
Fig. 2 (Leone and Hand). Top left, Recurrent basal cell carcinoma lateral to the punctum in the right lower eyelid. Top right, Postoperative ap pearance one week after surgery shows the heal ing grafts. Bottom left, Postoperative appearance six months after surgery shows a satisfactory cosmetic result and restoration of the normal contour to the medial eyelid.
Fig. 3 (Leone and Hand). Left, Basal cell carcinoma occupying the medial aspect of left lower eyelid. Right, Postoperative appearance one year later after a 15-mm resection of the medial aspect of the left lower eyelid.
VOL. 87, NO. 6
RECONSTRUCTION O F T H E MEDIAL EYELID
silicone tube within the orifice for four to six weeks while it is healing. However, if only a small portion of the proximal canaliculus is left, and if the upper canaliculus is functioning, no attempt is made to externalize it because it may interferre with the placement of the tarsal-conjunctival graft. Because a newly reconstructed eyelid needs support, a tarsal-conjunctival graft is the ideal material. This is placed in the defect to simulate the tarsus that has been removed, and if there is no medial eyelid remaining, it is sutured to the remnant of the medial canthal tendon to retain the upward curvature of the lower eyelid and close apposition to the globe. The pedicle skin-muscle graft is necessary to nourish the free tarsal-conjunctival graft, and can be fitted in the area with a minimum of traction lines. Orbicularis is a necessary part of the pedicle flap because it is vas cular and increases the blood supply brought to the tarsal-conjunctival graft. In the secondary defect, a postauricular skin graft is preferred to upper eyelid skin because the shrinkage factor is less. The
801
advantage to this procedure is that the lat eral canthus is left undisturbed and the visual axis is left open while confining the repair strictly to the medial canthal and nasal areas. SUMMARY
We used a free tarsal-conjunctival graft from the upper eyelid and a nasal-based pedicle skin-muscle flap for reconstruc tion of the medial aspect of the lower eyelid. This had the advantage of con fining the reconstruction to the local area and eliminated the need for a temporal flap or an eyelid sharing procedure that necessitates occluding the fissure for sev eral weeks. REFERENCES 1. Mustarde, J. C : Repair and Reconstruction in the Orbital Region. Baltimore, Williams and Wilkins Co., 1966, pp. 116-147. 2. Tenzel, R. R.: Reconstruction of the central one-half of an eyelid. Arch. Ophthalmol., 93:125, 1975. 3. Smith, B.: Eyelid reconstruction. In Soil, D. B., (ed.): Management of complications in ophthalmic plastic surgery. Birmingham, Aesculapius, 1976, pp. 226-228.