Lisa M. DiFrancesco, M.D., Mark A. Codner, M.D., and Clinton D. McCord, M.D.

Transcription

1 CME Upper Eyelid Reconstruction Lisa M. DiFrancesco, M.D., Mark A. Codner, M.D., and Clinton D. McCord, M.D. Atlanta, Ga. Learning Objectives: After studying this article, the participant should be able to: 1. Understand upper eyelid anatomy and function. 2. Analyze upper eyelid defects. 3. Understand an algorithm of upper eyelid reconstruction. 4. Have a basic understanding of techniques for upper eyelid reconstruction. There are several options available for upper eyelid reconstruction that depend on the extent of involvement of the anterior and posterior lamella. Knowledge of the anatomy will ensure that in addition to the creation of an aesthetically acceptable eyelid reconstruction, a functional upper lid will be restored. The purpose of this article is to outline the anatomy of the eyelid, to analyze the components of eyelid defects, and to provide options for lid reconstruction. (Plast. Reconstr. Surg. 114: 98e, 2004.) Any reconstructive procedure attempts to optimally restore form and function. Specifically, the eyelid is critical in protection of the eye and preservation of vision. To ensure an optimal outcome, it is necessary to understand the specialized anatomic structures and function of the orbit, eyelid, and globe. Once basic anatomy and function are understood, analysis of eyelid defects can be simplified when broken down into separate components. The workhorses of reconstruction, such as skin and muscle flaps, are described, as well as their techniques. Even the most complex eyelid problems can be addressed. This article will outline the various techniques available for eyelid reconstruction. ANATOMY Superficial skin anatomy includes the brow, upper eyelid, lower eyelid, and midface. The upper eyelid rests 2 mm below the superior limbus on forward gaze, whereas the lower eyelid is positioned at the inferior limbus. The supratarsal crease in the Occidental eyelid is generally 8 mm from the lid margin in men and 10 mm in women. The upper eyelid crease is formed by the dermal insertion of the levator aponeurosis to the orbital septum. In the Asian eyelid, this distance is only 2 to 3 mm from the lid margin as a result of fusion of the levator aponeurosis extensions with the orbital septum. The pretarsal space is the area superior to the eyelid margin where the skin is adherent to the tarsal plate. The orbital sulcus is defined by the space between the superior orbital rim and the upper eyelid crease. Loss of the orbital sulcus is seen with relaxation of the upper septum or herniation of the preaponeurotic orbital fat pads (Fig. 1). The eyelid is divided into two main layers. The anterior lamella consists of skin and muscle, and the posterior lamella is formed by the tarsal plate and conjunctiva. The medial and lateral canthi are important support structures in normal eyelid function and bony fixation. They represent the confluence of the orbicularis muscle, tarsal plate, eyelid retractors, orbital septum, and cheek ligaments. At the medial canthus this complex anatomic interplay provides the mechanism for the lacrimal pump. The lateral canthus inserts posterior on the lateral orbital rim, pulling the eyelid against the globe. The lateral canthus allows for bony stabilization of the eyelid during eyelid movement. Analysis of an acquired defect should include evaluation of the anterior lamella, posterior lamella, and medial and lateral canthi to facilitate reconstruction. The eyelid skin is the thinnest in the body, particularly on the medial aspect of the upper eyelid. At the eyelid margin the tarsal plates are From Paces Plastic Surgery. Received for publication January 15, 2003; revised April 24, DOI: /01.PRS e

2 Vol. 114, No. 7 / UPPER EYELID RECONSTRUCTION 99e FIG. 1. Anatomy of the preaponeurotic space demonstrating the structures encountered during eyelid reconstruction. tightly adherent to the skin. The tarsal plate is a fibrous structure that provides the skeletal support for the eyelid. In the upper eyelid, it measures 25 mm in length, is 1 mm thick, and has a maximal central height of 10 mm. The tarsal plate is centralized over the midpupillary line in childhood and migrates laterally with aging. Along with the conjunctiva, the tarsal plates form the posterior lamella. The orbicularis muscle is divided into pretarsal, preseptal, and orbital components. The pretarsal and preseptal orbicularis are each divided into a deep layer and a superficial layer, both medially and laterally. The medial canthal tendon is composed of superficial pretarsal and preseptal fibers. The deep pretarsal and preseptal fibers intersect posterior to the lacrimal sac and function as the lacrimal pump. The deep pretarsal and deep preseptal orbicularis insert on Whitnall s tubercle laterally within the orbital rim. Riolan s muscle represents a strip of pretarsal muscle and forms the gray line of the eyelid, which is important for alignment of full-thickness defects. 1 The orbital septum is posterior to the orbicularis muscle and forms the anterior barrier to the orbital contents. In the upper lid, the septum inserts on the levator aponeurosis approximately 10 mm above the eyelid margin just superior to the tarsal plate. The orbital septum attaches to the orbital rim at the arcus marginalis. The preaponeurotic fat pads (postseptal) are anterior extensions of orbital fat and are divided into nasal and medial compartments. The trochlea divides the nasal and medial fat pads. The lacrimal gland is located lateral to the fat pads. The eyelid retractor muscles include the levator palpebrae superioris and Müller s muscle, which are responsible for eyelid elevation. The levator palpebrae superioris originates along the lesser wing of the sphenoid and is innervated by cranial nerve III. The levator muscle extends anteriorly approximately 40 mm to Whitnall s ligament. Whitnall s ligament attaches superiorly to the levator muscle and changes the direction of levator muscle pull to a superior-inferior direction. The levator muscle extends inferiorly and transitions into a dense aponeurosis approximately 10 mm inferior to Whitnall s ligament. The levator aponeurosis inserts on the anterior surface of the tarsal plate. Müller s muscle is a smooth muscle that is innervated by the sympathetic nervous system. It originates at the level of Whitnall s ligament posterior to the levator aponeurosis and inserts on the superior tarsal plate. 2 The medial canthus represents a fixed-point fulcrum that is necessary for eyelid function. The medial canthus is a complex structure that consists of an anterior and posterior reflection of the medial canthal tendon that envelops the lacrimal sac. The tendons insert on the anterior and posterior lacrimal crest, respectively. The lateral canthal tendon is approximately 5 mm to 7 mm in length and provides dynamic support by connecting the tarsal plates to Whitnall s tubercle along the lateral orbital rim. The lateral canthus also consists of anterior

3 100e PLASTIC AND RECONSTRUCTIVE SURGERY, December 2004 and posterior fibrous attachments of the tarsal plate and fibers of the pretarsal orbicularis. 1 Eisler s fat pad can be found anterior to the lateral canthal tendon and is a useful anatomic landmark (Fig. 2). The arterial supply to the upper eyelid is primarily from branches of the ophthalmic artery that form two main arcades. The peripheral arcade is located between Müller s muscle and the levator aponeurosis on the upper border of the tarsus; the marginal arcade is in the pretarsal space 2 to 3 mm above the eyelid margin (Fig. 3). The superior palpebral vein courses parallel to the eyelid margin with an anastomosis between the angular vein and the supraorbital vein. The lymphatic drainage of the upper eyelid is to the preauricular nodes, whereas the lymphatic drainage of the lateral canthus is to the submandibular nodes. Evaluation of the appropriate lymphatic basin is important for treatment of cancers such as squamous cell carcinoma, melanoma, and sebaceous carcinoma. Sensory innervation of the upper eyelid is divided between the supratrochlear nerve medially and a combination of the supraorbital nerve and the lacrimal nerve laterally. The facial nerve cranial nerve VII supplies the motor innervation to the eyelid through the zygomatic and buccal branches. 2 Recent data collected by the authors, however, suggest that the buccal branches have a more significant contribution to motor function. RECONSTRUCTION Understanding the complex anatomy of the upper eyelid enables the surgeon to accurately analyze upper eyelid defects. The division of the eyelid into its component structures facilitates the approach to reconstruction. DIRECT REPAIR Benign lesions or biopsy defects often create small defects amenable to direct repair. This is possible with defects of up to 30 percent of the eyelid in younger patients and up to 40 percent of the eyelid in patients with eyelid skin laxity. Full-thickness incisions should be made perpendicular to the eyelid margin and extend to the superior tarsal margin to prevent notching (Figs. 4 and 5). Superior to the tarsal plate the incision is connected to a horizontal suture line hidden in the eyelid crease. Tension on the upper eyelid closure can result in mechanical ptosis; a lateral cantholysis may be performed to reduce closure under tension. It is critical that the eyelid margin, gray line, and lash line are approximated exactly to prevent eyelid inversion, which can cause corneal irritation. Next, the repair is completed in layers. The conjunctival sutures are placed with the knot buried away from the conjunctival surface. Finally, the anterior lamella is repaired. Any remaining excess tissue may be removed by two Burrow s triangles. Postoperative care consists of ophthalmic antibiotic ointment and suture removal at 7 days. 3 SKIN GRAFT A full-thickness graft can adequately reconstruct small superficial anterior lamellar defects. The skin graft may also be used as a vertically shortened eyelid with a split level with FIG. 2. Cross-section anatomy of the eyelid and orbit demonstrating the posterior insertion of the medial and lateral canthus.

4 Vol. 114, No. 7 / UPPER EYELID RECONSTRUCTION 101e FIG. 3. Arterial supply to the upper lid. a posterior lamellar graft. 2 Upper eyelid skin is the best donor site because of the match in color and thickness. Excess skin from the contralateral upper lid can be used but may only be available in limited quantities. Alternative harvest sites for skin include the supraclavicular skin, preauricular skin, and the lateral cervical skin. An elliptical incision is made in the eyelid, and using iris scissors, the skin is separated from the muscle. The donor site is closed primarily. The skin graft is inset and a bolster dressing is placed. The medial eyelid skin is avoided as a donor site to prevent lagophthalmos. There are limited indications for a splitthickness skin graft; an example would be burns or other eyelid trauma involving extensive loss of upper and lower eyelid skin. When designing a split-thickness skin graft, 50 to 70 percent overcorrection should be incorporated to allow for secondary contraction. In the upper lid, separate grafts are placed in the pretarsal area and the orbital sulcus, with the suture line hidden in the eyelid crease. 1 POSTERIOR LAMELLA Sliding Tarsoconjunctival Flap The sliding tarsoconjunctival flap (tarsal extension flap) is a transposition flap based on small adjacent conjunctival defects involving the medial or lateral upper eyelid. 3 The upper lid is everted over a Desmarres retractor. An incision is made in the adjacent conjunctiva 4 mm superior to the eyelid margin to avoid potential margin eversion. The incision is extended parallel to the lid margin with the flap length in a 1:1 ratio with the defect. Finally, the incision is carried superiorly to the edge of the tarsal plate. The blood supply is from the superior peripheral arcade, which is included in the base of the flap. Westcott scissors are used to dissect the tarsal flap from the levator aponeurosis and Müller s muscle of the remaining eyelid, and the flap is transposed into position (Fig. 6). Suture fixation secures the flap to the periosteum of the orbital rim. The tarsal plate is aligned with 6-0 silk. The conjunctiva is repaired with 6-0 plain catgut inverted sutures. The remaining anterior lamellar defect is repaired with a skin/muscle flap or a full-thickness skin graft. The transposition graft provides a highly vascularized bed for the skin graft. The eye is sutured closed and a bolster dressing is left in place for 1 week postoperatively. Free Tarsoconjunctival Flap If the ipsilateral eyelid skin is not available for reconstruction, then the contralateral upper eyelid can be used as a free tarsoconjunctival flap. An incision is made 4 mm from the lid margin to preserve the integrity of the eyelid with length equal to the defect length. Parallel vertical incisions are made and extended to the superior margin of the tarsal plate. The

5 102e PLASTIC AND RECONSTRUCTIVE SURGERY, December 2004 FIG. 4. Upper lid marginal tumors require full-thickness skin parallel excision of the lid and tarsal plate to avoid postoperative notching. FIG. 5.(Left) Outline of upper lid resection. (Right) Parallel full-thickness excision through tarsal plate. flap is dissected free from the levator aponeurosis and Müller s muscle, and the donor site is left to reepithelialize. The free graft is inset with 6-0 plain catgut sutures. 2 Other Autologous Options Oral mucosal grafts from the upper lip, lower lip, or buccal mucosa may be used as a conjunctival lining. Although oral mucosa does

6 Vol. 114, No. 7 / UPPER EYELID RECONSTRUCTION FIG. 6. Sliding tarsoconjunctival flap. The upper border of the tarsal plate is used to reconstruct posterior lamellar defects based on the lateral superior arcade. not have sufficient integrity for tarsal replacement, the smooth, nonkeratinizied epithelium is important to avoid irritation to the cornea during blinking after reconstruction of central upper eyelid defects. Ear cartilage should not be exposed directly to the cornea because of the risk of abrasion and irritation. ANTERIOR LAMELLA Semicircular Rotation Flap Tenzel and Stewart described the semicircular rotation flap for defects of 40 to 60 percent 103e of the eyelid. 4,5 The tarsal edges of the defect must be parallel for reconstruction. The flap is designed as a superiorly based musculocutaneous flap starting at the lateral canthus and extending in a semicircle with a diameter of at least 3 cm (Fig. 7). The plane of dissection is deep to the orbicularis muscle. Once the flap is dissected, a selective lateral canthotomy is performed on the upper lateral canthal tendon, preserving the anterior tendon. The flap is advanced into the defect and the tarsal plate is reapproximated first with 7-0 silk. The lateral canthus is reconstructed with a lateral canthoplasty, with the skin/muscle flap sutured to the periosteum at the point the flap overlaps the orbital rim with 4-0 Prolene. The anterior and posterior components of the lateral canthus require reconstruction by suturing the tarsal plate to the inner aspect of the orbital rim and the skin/muscle flap to the anterior aspect of the orbital rim. The conjunctiva is closed with inverted 6-0 plain catgut sutures, and the skin/ muscle flap is closed with 6-0 nylon. The donor site is closed, and removal of a Burrow s triangle may be necessary for a residual dog-ear. The Tenzel flap lateralizes the defect to create a continuous eyelash line for eye protection. Bridge Flap The Cutler-Beard 6 or bridge flap 7 is a fullthickness lower lid bridge flap designed for broad, shallow upper eyelid defects, including FIG. 7. The semicircular rotation or Tenzel flap is used for defects of 40 to 60 percent of the upper eyelid. Lateral canthotomy is required to rotate the flap and lateral remaining lid margin.

7 104e PLASTIC AND RECONSTRUCTIVE SURGERY, December 2004 total eyelid reconstruction (Fig. 8). An incision is made 5 mm inferior to the lower eyelid margin to preserve lid margin vascularity. The width of the flap corresponds to the eyelid defect. Vertical incisions are made inferiorly to the fornix and the inferior orbital rim for the skin/muscle flap. The flap is maximally mobilized for superior placement. Relaxing incisions in the capsulopalpebral fascia are made to allow passage of the flap under the eyelid margin bridge to the upper eyelid. The conjunctival layer is sutured with inverted 6-0 plain catgut sutures. Because the flap lacks tarsal support, the ear cartilage graft is harvested from the flat scaphoid donor site rather then the conchal cartilage. The cartilage is placed anterior to the conjunctiva to avoid corneal irritation and sutured with 7-0 silk along the lateral and medial borders (Figs. 9 and 10). The superior edge of the cartilage graft is sutured to the levator aponeurosis to maintain lid function. Finally, the skin/muscle flap is sutured with 7-0 silk to the cutaneous border of the defect. Division of the flap traditionally occurs at 6 weeks. The flap is transected 2 mm below the optimal position for the upper eyelid. A 1- to 2-mm section of skin and muscle is resected, leaving a conjunctival border that is rotated anteriorly and secured to the skin. This prevents corneal irritation from exposure to the keratinized skin. The donor site is repaired by insetting the residual skin bridge with deepithelialization. The edges are reapproximated and the conjunctival surface is allowed to reepithelialize. Lateral canthoplasty of the lower lid is required to avoid lower lid malposition or ectropion at the donor site. PEDICLED LOWER LID SHARING Originally described by Mustardé, 8 broad, shallow, full-thickness defects of the upper lid margin may be addressed with a pedicled flap from the lower eyelid (Fig. 11). The flap is based in the central portion of the lower lid and is the only flap that allows for primary lower lid closure. A full-thickness, 5-mm vertical incision is then made at the lateral limbus. Because a selective lateral canthotomy of the inferior tendon is made, the blood supply is preserved from the medial inferior marginal arcade. The inferior incision is then made parallel to the lid margin below the marginal artery until adequate mobilization is achieved to reach the upper lid defect. The flap is rotated FIG. 8. The bridge flap or Cutler-Beard flap is used for total upper lid reconstruction. The flap is a biplanar flap passed under the lower lid margin.

8 Vol. 114, No. 7 / UPPER EYELID RECONSTRUCTION 105e FIG. 9.Left, total upper eyelid defect following resection of squamous cell cancer. Right, outline of Cutler-Beard flap inferior to lower lid marginal blood supply. FIG. 10. Left, ear cartilage is used in the biplanar flap for tarsal plate replacement. Right, final result after division of flap. FIG. 11. Lid sharing or Mustardé lid flap utilizes a two-stage transposition of the lower lid margin, including lashes. superiorly and the lateral lower lid tarsal plate is sutured to the medial upper eyelid tarsal plate. Care must be taken to align the grey line and the lash line. Traditional flap division occurs in 6 weeks, although earlier flap division can be performed successfully. An angled incision is made and the remainder of the flap is rotated into the upper eyelid defect. The lateral margin of the defect gray line and lash line is aligned with the flap. The donor site is repaired by allowing lateral advancement of the lower lid margin and reapproximation of the lid margin. If there is concern for excess tension or lower lid malposition, a lateral canthotomy and canthoplasty should be performed.

9 106e PLASTIC AND RECONSTRUCTIVE SURGERY, December 2004 Periorbital Donor Sites The periorbital donor sites are an option for large-volume tissue loss or when adequate eyelid tissue is not available. The surrounding periorbital skin, however, is of a different quality and thickness. Temporal Forehead Flap The temporal forehead flap was first described by Fricke 9 (Fig. 12). The temporal forehead is used as a transposition flap for fullthickness eyelid defects. The scar can be hidden in the brow margin. This is a skin/ muscle flap, and conjunctival reconstruction might be necessary in conjunction with this flap. Forehead Flap The forehead flap first described by Kazanjian and Roopenian 10 can also be used for large defects in upper eyelid reconstruction. The blood supply is based on the supratrochlear or supraorbital artery and the flap is elevated in the subgaleal plane (Fig. 13). Generally, 2 weeks are required before division of the flap. The forehead flap is generally a last resort, as it requires a two-stage procedure and is a very thick flap when used for lid reconstruction. Glabellar Flap Medial canthal defects can be reconstructed from redundant glabellar tissue. 1 An inverted V-shaped incision is made and the skin flap is rotated into the defect. The donor site is closed primarily. The broad base of this flap allows it to be safely thinned to contour the defect. Quilting sutures must be used to help the flap conform to the local tissue architecture at the defect site. The glabellar flap generally requires a second procedure to thin and inset the flap. COMPLICATIONS As with any surgical procedure, the best way to handle a complication is with prevention. During surgery appropriate lubrication and corneal protectors should be used to avoid corneal irritation. The patient should be closely followed postoperatively to avoid the adverse sequelae of early complications. Complaints of dry eyes are evaluated with fluorescein and a slit-lamp examination. If a corneal abrasion occurs, liberal use of lubrication and temporary closure of the eye with an eye pad will alleviate the discomfort and prevent further injury. Hematoma is another early complication that requires prompt diagnosis and evacuation. Chemosis or postoperative swelling can be deterred with a Frost stitch or temporary tarsorrhaphy. Skin graft failure is avoided with the use of a bolster dressing and temporary tarsorrhaphy. The bolster dressing will also help to prevent skin graft contracture. If skin graft or flap failure should occur, the wound is débrided and treated with ointment to prevent desiccation. Late postoperative complications are often the result of anatomic problems that subsequently create functional problems with the new eyelid. It is best to wait 3 months before surgical revision, but it is often necessary to treat them earlier. Lid notching, lid malposition, flap failure, and lagophthalmos require surgical correction. Lid notching is best corrected with direct excision. Malposition, fail- FIG. 12. Temporal forehead flap or Fricke flap is a transposition flap from above the eyebrow used for total upper lid reconstruction.

10 Vol. 114, No. 7 / UPPER EYELID RECONSTRUCTION 107e FIG. 13. A forehead flap can be used for total upper lid reconstruction combined with a mucosal graft for lining against the cornea. ure, or lagophthalmos requires additional tissue recruitment for correction. In addition, corneal irritation from trichiasis seen with opposite lid flaps can be eliminated with excision or cryotherapy. CONCLUSIONS Upper eyelid reconstruction can be challenging to a surgeon, given the specialized anatomy and function of the eyelid. Successful aesthetic and functional reconstruction begins with analysis of a complex defect and division into its separate components. Next, an algorithmic approach is used to determine the optimal reconstruction. Finally, meticulous surgical technique and avoidance of complications will result in an optimal reconstruction. Mark A. Codner, M.D Downwood Circle, Suite 640 Atlanta, Ga macodner@aol.com REFERENCES 1. Codner, M. A. Reconstruction of the eyelids and orbit. In B. Achauer (Ed.), Plastic Surgery: Indications, Operations, and Outcomes, Vol. 3. St. Louis: Mosby, Pp McCord, C. D. Eyelid Surgery. Philadelphia: Lippincott- Raven, Pp McCord, C. D., and Wesley, R. Reconstruction of upper eyelid and medial canthus. In C. D. McCord and M. Tannenbaum (Eds.), Oculoplastic Surgery. New York: Raven, Pp Tenzel, R. R. Reconstruction of the central one half of an eyelid. Arch. Ophthalmol. 93: 125, Tenzel, R. R., and Stewart, W. B. Eyelid reconstruction by semi-circular flap technique. Trans. Am. Soc. Ophthalmol. Otolaryngol. 85: 1164, Culter, N., and Beard, C. A method for partial and total upper lid reconstruction. Am. J. Ophthalmol. 39: 1, Smith, B., and Obear, M. F. Bridge flap technique for reconstruction of large upper lid defects. Plast. Reconstr. Surg. 38: 45, Mustardé, J. C. Eyelid reconstruction. Orbit 1: 33, Fricke, J. C. G. Die Bildung neuer Augenlider (Blepharoplastik) nach Zerstorungen und dadurch hervorgebrachten Auswartswendungen derselben. Hamburg: Perthes and Bessler, Kazanjian, V. H., and Roopenian, A. Median forehead flaps in the repair of defects of the nose and surrounding areas. Trans. Am. Acad. Ophthalmol. Otolaryngol. 60: 557, 1956.