The reconstruction of an eyelid following the excision of a lesion can be difficult. The surgeon may address small lesions with direct closure. However, the closure of more significant lesions frequently warrants the use of flaps, free tissue grafts or both.
Nevertheless, reconstructing a lower lid defect is a comparatively simple process. Defects in the upper lid are less common and more difficult to correct. The reason behind this is the constant movement of the eyelid and its function of protecting the cornea.
Why is Reconstruction Needed?
The objective of eyelid reconstruction is to re-create a stable margin for the eyelid, provide sufficient eye protection, minimize vertical tension on the eyelid, restore good aesthetic appearance and provide a smooth posterior surface.
Defects that are full thickness are reconstructed in layers, namely tarsal plate and conjunctiva, orbicularis oculi muscle and skin.
Generally, an eyelid defect is considered to be small if it forms around 30% or less of the eyelid. A defect is classified as medium-sized if it involves nearly 30 to 50% of the eyelid while a large defect is 50% or more of the lid.
A significantly small defect or a larger defect in an older patient can usually be repaired via direct closure which is sewn in layers if the defect is full-thickness.
Defects that are larger and require only a small quantity of surplus tissue can frequently be closed directly with the use of adjacent tissue from the lateral canthus. In case the patient requires more tissue, the surgeon can perform a semicircular rotational flap procedure.
Lateral Canthotomy and Cantholysis
A lateral canthotomy and cantholysis release eyelid at the outer corner where it connects to the orbital rim. This procedure can offer an additional 25 t0 30% of horizontal length for defect closure depending on the age and tissue laxity of the patient.
This procedure works well on both upper and lower eyelids. In a canthotomy procedure, the upper and lower eyelids are divided with scissors at the lateral canthus.
Semicircular Rotational Flap
A semicircular rotational flap, also known as a Tenzel procedure, can be employed when there is a requirement for additional tissue or when the defect is nearly 50%.
This procedure enables the surgeon to take adjacent temporal tissue and rotate it at the lateral side to create sufficient laxity to achieve defect closure. The flap’s diameter should be around two times the diameter of the defect. In lower eyelid repair, the semicircle begins at the lateral corner of the eyelid and curves superiorly and temporally towards the eyebrow while avoiding the brow hairs.
A lower eyelid lesion that involves over 50% of the eyelid needs reconstruction in layers. This will require re-creating the posterior and an anterior lamella. Many procedures are available for such reconstruction. However, a majority of these repairs are frequently achieved with graft or flap reconstruction.