Lower Eyelid Reconstruction

Anatomy and Physiology

Understanding the structural complexity of the anterior and posterior lamella of the eyelid is crucial for effective eyelid reconstruction. The anterior lamella comprises the skin and orbicularis oculi muscle, while the posterior lamella includes the conjunctiva and tarsus. In eyelid reconstruction, it is vital to address both lamellae.

Free skin grafts or free tarsoconjunctival grafts can replace defects in either anterior or posterior lamella, provided they are attached to vascularized tissue. Therefore, anterior or posterior lamella grafts can be performed only when the opposite lamella remains healthy and vascularized. Dual anterior and posterior lamellar grafts are rarely performed due to the significant risk of vascular compromise.[3]

Indications

The most common malignancy affecting the eyelid is basal cell carcinoma (BCC), which often occurs on the lower eyelid. Surgical excision with clear margins is critical, typically performed using frozen section control or Mohs micrographic surgery. Reconstruction of the lower eyelid is frequently required following such procedures, necessitating the expertise of ophthalmic plastic surgery. In addition to cancer, traumatic injuries, and congenital defects may also necessitate reconstruction. Various techniques are available, customized to the size of the defect and patient-specific factors.[4][5][6][7]

Contraindications

Lower eyelid reconstruction may be contraindicated in patients who cannot tolerate the procedure. A thorough preoperative assessment is essential. Contraindications may include the following:

• Severe systemic medical conditions
• Anesthesia intolerance
• Active infection
• Severe eyelid or periocular scarring
• Poor wound healing
• Inadequate tissue vascularization

Equipment

Lower eyelid surgery requires standard oculoplastic surgical instruments, specialized sutures, and tools for skin graft preparation. In addition, access to frozen section pathology or Mohs micrographic equipment may be beneficial, especially in cancer cases, to ensure clear margins during tumor excision.[8]

Personnel

Working with a Mohs surgeon to excise a carcinoma is often beneficial, as their expertise ensures the removal of cancerous tissue with clear margins. Following tumor excision, reconstruction should be performed by an experienced oculoplastic surgeon who specializes in eyelid anatomy and functional restoration.

In addition to the surgeons, an anesthesiologist or nurse anesthetist is needed to manage anesthesia and ensure patient safety and comfort during the procedure. Surgical assistants may also be required to assist with instrumentation, tissue handling, and suturing. 

A pathologist may be present to review tissue samples, particularly in cancer cases requiring frozen section analysis. Postoperative care personnel, such as nursing staff, must monitor recovery and assist with wound care, ensuring optimal healing and minimizing complications.

Preparation

Preoperative imaging, such as magnetic resonance imaging (MRI) or computed tomography (CT) scans, may be necessary to assess the extent of deeper invasion in more extensive malignancies. Patient counseling is essential to explain the surgical steps, associated risks, and postoperative expectations.

Technique or Treatment

Small full-thickness eyelid defects, typically involving up to 25% of the lid's width, can often be directly closed by precisely suturing the free edges. Direct closure typically involves 2-layer closure: The tarsus is repaired in one layer, while the skin is closed in the second. The lid margin is generally closed with a horizontal mattress technique to provide proper wound edge eversion, which promotes healing without leaving a notch. In patients with highly lax eyelids, direct closure may be feasible for larger defects, accommodating up to 30% of the lid's width.

For defects between 25% and 50% of the lid's width, lateral canthotomy and inferior cantholysis may be performed to provide additional laxity, enabling direct closure. This approach allows the lateral lower lid to stretch further medially, facilitating defect closure. Periosteal flaps can be utilized as necessary to support the posterior lamella. 

For medium-sized defects involving 33% to 66% of the eyelid width, a Tenzel semicircular musculocutaneous rotation flap can be utilized. This flap originates at the lateral canthus and extends upward and laterally in a semicircular pattern to recruit anterior lamellar tissue. The flap is then rotated into position to cover the eyelid defect. While this technique addresses the anterior lamella defect (skin and muscle), it does not resolve the posterior lamella defect (conjunctiva and tarsus). A periosteal flap may be performed concurrently to provide posterior labella support and facilitate the closure of larger defects.

For large defects, a tarsoconjunctival flap, also known as the Hughes procedure, may be performed to address defects involving up to 100% of the lower eyelid. This technique utilizes a flap from the superior eyelid, comprising a portion of the tarsus and conjunctiva, which is brought down and sutured into the lower eyelid defect to replace the posterior lamella. Approximately 4 mm of the inferior tarsus is preserved to maintain upper eyelid stability.

Local flaps may be used to replace the anterior lamella if sufficient skin laxity is present.; otherwise, a full-thickness skin graft, often harvested from the upper lid, can be used. Following flap placement, the upper and lower eyelids are temporarily closed, rendering the patient unable to see from the affected eye. A second-stage procedure usually performed 4 to 6 weeks later, separates the lids and reforms the eyelid margins. Alternatively, a Mustarde cheek rotation flap, similar to but larger than a Tenzel flap, can be used to reconstruct extensive lower eyelid defects for larger lamella replacements.

Proper lower eyelid height and support are essential to prevent postoperative ectropion and retraction. Temporary tarsorrhaphy, which connects the upper and lower eyelids, or a Frost suture tarsorrhaphy, which connects the eyelid margins to the brow, can provide additional elevated support. If significant eyelid laxity is noted pre- or postoperatively, an ectropion repair with a lateral tarsal strip procedure may be necessary. This is particularly important during a first or second-stage Hughes procedure.

A tarsal strip may also be necessary for lower eyelid skin-only defects, such as those resulting from skin cancer excision that does not involve the posterior lamella, especially if the lower eyelid exhibits laxity. Cicatricial changes during healing can predispose the lower lid to cicatricial ectropion, warranting proactive measures to maintain eyelid position and function.

A mid-face lift can be performed to repair large defects of the lower eyelids and significant anterior lamella defects. This technique requires posterior lamella support, typically provided by a Hughes tarsoconjunctival flap from the upper eyelid or a hard palate graft to preserve eye closure functionality. The mid-face life then provides the anterior lamella, restoring structure and function.[9][10][11][12][13][14]

Complications

Complications may include partial or complete graft or flap failure, scar tissue formation, dehiscence, infection or retraction, ectropion, recurrence, irregular eyelid margins causing foreign body sensation, dry eyes, and the potential need for additional surgeries to optimize eyelid structure and function. Long-term surveillance is necessary to monitor for malignancy recurrence or cicatricial changes requiring revision.[15][16]

Clinical Significance

Customizing reconstruction is necessary to provide each patient with the most appropriate surgical approach. Factors such as eyelid laxity significantly influence the choice of procedures and their potential benefits. Other critical considerations include the patient's age and the status of the contralateral eye. 

Avoiding vision obstruction is paramount in pediatric or monocular patients to prevent developmental or functional impairments. For example, a Hughes flap may be avoided in young children to reduce the risk of deprivation amblyopia, especially during the amblyogenic age. Similarly, in monocular patients, blocking vision in the functional eye for 4 to 6 weeks with a Hughes flap may not be advisable due to the risk of severe visual limitations.

Lastly, as with any cancer treatment, ongoing surveillance is crucial to monitor for carcinoma recurrence and address any potential complications promptly.[17] Regular follow-up also allows for early detection of secondary issues, such as cicatricial changes or functional impairments, which may require timely intervention to optimize patient outcomes.

Enhancing Healthcare Team Outcomes

Maintaining an interprofessional team approach is crucial for the follow-up care of these patients. This team includes dermatologists, oncologists, radiologists, oculoplastic surgeons, and nursing staff, all working collaboratively. Close surveillance is essential, and all team members should be actively involved in regular follow-ups to monitor for recurrence and address any long-term complications.

Nursing, Allied Health, and Interprofessional Team Interventions

Nurses are critical in pre- and postoperative care, monitoring for signs of infection, graft rejection, or ectropion. Allied health professionals can assist with postoperative rehabilitation, including eyelid massage and scar management.

Nursing, Allied Health, and Interprofessional Team Monitoring

Routine monitoring involves tracking the healing surgical site, assessing functional outcomes, and ensuring adherence to follow-up schedules. Coordination with social workers or patient advocates can help address barriers to care.