PARPADO SUPERIOR.pdf

L SECTION Upper Eyelid Reconstr uction F ull-thickness...

L SECTION Upper Eyelid Reconstr uction F ull-thickness de ects o the upper eyelid may result rom mechanical or thermal trauma, rom the surgical excision o eyelid tumors, or rom congenital colobomas. In the recon- the size and location o the de ect; involvement o deep eyelid structures, such as the levator aponeurosis or can- thal ligaments; the availability o adjacent or distant tissue struction o such de ects, it is essential not only to reestablish or repair; and the skills o the surgeon. Care ul evaluation the anatomic integrity o the lid but also to restore its physi- o the de ect and essential unctional components o the ologic unction. T e surgeon must pay special attention to the eyelid must precede any attempt at repair. Basic techniques individual layers o the eyelid to ensure appropriate mobility are illustrated below, but the appropriate application o and protection o the globe. these procedures, in combination when necessary, will Small ull-thickness marginal de ects o 25% to 30% may determine the nal unctional and cosmetic result. be closed by direct layered closure, depending on the lax- When possible, replacement o eyelid tissue should be ity o the eyelid. In older individuals, when suf cient eye- obtained rom adjacent portions o the same or opposite lid laxity permits, de ects o 40% or more may be repaired ipsilateral eyelid. Several techniques allow such trans er o by this technique. T e unctional and cosmetic results are normal eyelid tissue, including the skin, orbicularis muscle, superior to any other procedure, and when it is per ormed tarsus, and conjunctiva. When these options are not pos- properly, direct layered closure leaves an intact lid margin sible, adjacent aps rom the temple, cheek, or orehead with a ull lash line. may have to be used. T ese provide both skin and mus- In more complicated reconstructive procedures, the cle, although unctionally they are less suitable or eyelids. anterior lamella o the upper lid must be covered with thin When local aps cannot be developed easily, ree skin skin, which is loose enough to allow complete eyelid clo- gra ts are a good alternative. sure, yet thin and exible enough to old easily when the Internal stability with tarsal replacement can be lid is opened. A circum erential muscle layer is necessary achieved by using eye bank scleral gra ts, autogenous auric- or closure to prevent lagophthalmos and corneal expo- ular or nasal cartilage gra ts, or preserved ascia or carti- sure. Vertical retraction, either with the levator muscle or a lage. Mucous membrane is usually readily available rom suitable substitute, is necessary to elevate the lid above the the oral cavity except in situations in which oral mucosa visual axis. Internal support by replacement o the tarsus or is diseased, such as in cicatricial mucous membrane pem- other rm tissue provides marginal stability and intimate phigoid. In some cases, vaginal mucosa may also be used. corneal contact in all positions o gaze. Reconstruction o Free tarsoconjunctival gra ts rom the contralateral upper the canthal ligaments is less important here than in the eyelid provide a superior source o tissue, containing both lower eyelid because the e ects o gravity enhance eyelid normal tarsus and conjunctiva. Canthal ligaments can be position rather than oppose it. A mucous membrane lining reconstructed with ascial aps or gra ts or with perios- on the posterior eyelid sur ace is critical to prevent corneal teum rom the lateral orbital rims. abrasion. Meticulous detail is paid to reconstruction o the eyelid margin to exclude keratinized epithelium and pre- SUGGESTED FURTHER READING vent notching and trichiasis. Direct Layered Closure of Marginal Defects Many procedures are available or the partial or complete Grover AK, Chaudhuri Z, Malik S, et al. Congenital eyelid colobomas in 51 patients. J Pediatr Ophthalmol Strabismus. 2009;46:151– 159. reconstruction o the upper eyelid. T e choice depends enzel RR. Lid reconstruction. In: Smith BC, Delia Rocca RC, Nesi FA, upon numerous actors, and requently a combination o Lisman RD, eds. Ophthalmic Pla stic and Reconstructive Surgery. Vol techniques is necessary or adequate repair. In traumatic 1. St. Louis, MO: Mosby-Year Book; 1987. injuries, especially ollowing thermal or chemical burns, Lateral Semicircular Rotational Flap tissue vascularity may be compromised. In such situations, Anderson RI, Edwards JJ. Reconstruction by myocutaneous eyelid aps. ree gra ts may not take as readily; there ore, the use o a Arch Ophthalmol. 1979;97:2358– 2362. vascularized ap may be more appropriate. T e same is enzel RR, Stewart WB. Eyelid reconstruction by semicircular ap tech- true or heavily irradiated tissues. T e development o local nique. Trans Am Soc Ophthalmol Otol. 1978;85:1164– 1169. aps or eyelid reconstruction requires some degree o tis- Horizontal Tarsoconjunctival Transposition Flap sue laxity, which may not readily be available in younger Bergin DJ, McCord CD. Reconstruction o the upper eyelid: major de ects. In: Hornblass A, ed. Oculopla stic, Orbital and Reconstructive Surgery. individuals or in those with cicatrizing skin diseases. Baltimore, MD: Williams & Wilkins; 1988. No hard and ast rules or the reconstruction o speci c Leone CR Jr. arsal-conjunctival advancement aps or upper eyelid de ects can be given. T e surgical approach is dictated by reconstruction. Arch Ophthalmol. 1983;101:945– 948. 172  SECTION L ▼ Upper Eyelid Reconstruction 173 enzel RR. Lid reconstruction. In: Smith BC, Delia Rocca RC, Nesi FA, Holloman EL, Carter KD. Modi cation o the Cutler-Beard procedure Lisman RD, eds. Ophthalmic Pla stic and Reconstructive Surgery. Vol using donor Achilles tendon or upper eyelid reconstruction. Ophthal 1. St. Louis, MO: Mosby-Year Book; 1987. Pla st Reconstr Surg. 2005;21:267– 270. Hsuan J, Selva D. Early division o a modi ed Cutler-Beard ap with a ree Free Tarsoconjunctival Graft tarsal gra t. Eye 2004;18:714– 717. Lisman RD, Smith BC. Eyelid surgery or thyroid ophthalmopathy. In: Smith Kadoi C, Hayasaka S, Kato , Nagaki Y, et al. T e Cutler-Beard bridge ap BC, Delia Rocca RC, Nesi FA, Lisman RD, eds. Ophthalmic Plastic and technique with use o donor sclera or upper eyelid reconstruction. Reconstructive Surgery. Vol 1. St. Louis, MO: Mosby-Year Book; 1987. Ophthalmologica. 2000;214:140– 142. Obear M, Smith BC. arsal gra ting to elevate the lower lid margin. Am Sa HS, Woo KI, Kim YD. Reverse modi ed Hughes procedure or J Ophthalmol. 1965;59:1088– 1090. upper eyelid reconstruction. Ophthal Pla st Reconstr Surg. 2010;26: Shaw GY, Khan J. T e management o ectropion using the tarsoconjuncti- 155– 160. val composite gra t. Arch Otolaryngol Head Neck Surg. 1996;122:51– 55. Smith B, Obear MF. Bridge ap technique or reconstruction o large Lower Eyelid Bridged Advancement Flap (Cutler-Beard Procedure) upper lid de ects. Pla st Reconstr Surg. 1966;38:45– 48. Baylis HI, Perman KI, Fett DR, Sutcli e R. Autogenous auricular carti- Wesley RE, McCord CD. ransplantation o eyebank sclera in the Cut- lage gra ting or lower eyelid retraction. Ophthal Pla st Reconstr Surg. ler-Beard method o upper eyelid reconstruction. Ophthalmology. 1985;1:23– 27. 1980;87:1022– 1028. Baylis HI, Rosen N, Neuhaus RW. Obtaining auricular cartilage or recon- Double Bridged Flap Upper Eyelid Reconstruction structive surgery. Am J Ophthalmol. 1981;93:709–712. Dutton JJ, Fowler AM. Double-bridged ap procedure or non-marginal, Cutler N, Beard C. A method or partial and total upper lid reconstruc- ull-thickness, upper eyelid reconstruction. Ophthal Pla st Reconstr tion. Am J Ophthalmol. 1955;39:1– 7. Surg. 2007;23:459– 462 Fischer , Noever G, Langer M, Kammer E. Experience in upper eye- lid reconstruction with the Cutler-Beard technique. Ann Pla st Surg. 2001;47:338– 342.  56 Direct Layered Closure of Marginal Eyelid Defects INDICATIONS: Reconstruction o small to medium eyelid de ects involving the ull-thickness lid margin where the wound can be approximated without excessive tension. FIG. 56.1. Create or reshape the upper eyelid defect to FIG. 56.4. Close the vertical edges of the tarsal plates form a pentagon, with vertical sides perpendicular to the with three interrupted 6-0 Vicryl sutures passed through lid margin, extending the full length of the tarsus and two-thirds thickness to avoid abrading the cornea. connecting arms meeting near the superior conjunctival fornix. FIG. 56.5. Place a second 6-0 silk vertical mattress suture across the lid margin through the lash line and tie the FIG. 56.2. Pass a vertical mattress suture of 6-0 silk through marginal sutures to slightly evert the wound edge. Leave the tarsal plates across the defect at the lid margin. Place the marginal sutures long. the deep bite of the suture at the same depth from the margin on both sides of the wound and the super cial bite through FIG. 56.6. Close the orbicularis muscle layer with 6-0 Vicryl the edge of the wound only. sutures and the skin with interrupted 6-0 silk stitches. Incorporate the long marginal suture ends to keep them away FIG. 56.3. Pull the wound edges together gently. If the from the cornea. wound does not close without excessive tension, pull the lid medially to put the lateral canthal ligament on stretch, and FIG. 56.7. If there is upward traction on the repaired lid, or with scissors perform a lateral canthotomy to the orbital in cases of traumatic laceration, pass a reverse-Frost traction rim. Divide the superior crus of the canthal ligament to allow suture through the lid margin and over a silicone bolster, closure of the defect. and tape it to the cheek below to put the lid on stretch. POSTOPERATIVE CARE: Apply antibiotic ointment to notching also results rom not extending the pentagonal the sutures three to our times daily or 7 days. Remove de ect to the upper border o the tarsal plate so the tar- the Frost suture a ter 3 to 4 days and the skin sutures a ter sus buckles on closure. 1 week. T e marginal sutures are le t in place or 7 to 10 Ptosis—It is usual or the lid to be tight and somewhat days. ptotic ollowing larger direct closures o the de ect. T is typically resolves as the lid stretches over several weeks POTENTIALCOMPLICATIONS: to months. Eyelid notching—T e primary cause is nonpentago- nal, pie-shaped sides to the de ect to be closed. Eyelid 174  CHAPTER 56 ▼ Direct Layered Closure of Marginal Eyelid Defects 175 FIG. 56.1 FIG. 56.5 FIG. 56.2 FIG. 56.6 FIG. 56.3 FIG. 56.7 FIG. 56.4  57 Lateral Semicircular Rotation Flap ( enzel) INDICA IONS: Reconstruction o 30% to 50% upper eyelid de ects that cannot be closed directly. FIG. 57.1. Prepare the upper eyelid defect by excising the FIG. 57.5. T e ap may be left bare of mucosa if less than lesion or freshening the wound edges to form a pentagonal one-third of the lid is involved. If more than one-third of shape. Make the vertical cuts from the lid margin to the upper the lid is to be reconstructed, evert the ap and mobilize border of the tarsus. Extend these to converge at a point close the conjunctiva to cover the orbicularis muscle. If this is not to the superior fornix. possible, a mucous membrane graft can be placed over the bare portion of the ap. FIG. 57.2. Mark a semicircular line beginning at the lateral canthal angle and arching downward and laterally to follow FIG. 57.6. Advance the lid and ap medially into the defect the curve of the opened upper eyelid margin. Continue the and repair the eyelid margin as described for Direct Layere curve upward to end at a point 2 to 3 cm lateral to the canthal Closure, 56.2 through 56.6 (pp. 214–215). angle, below the lateral extent of the eyebrow. FIG. 57.7. Anchor the orbicularis muscle of the lateral FIG. 57.3. Pull the lids medially to straighten the lateral portion of the ap to periosteum at the lateral orbital canthal ligament, and cut the ligament along the marked rim and to the inferior crus of the canthal ligament with line from the canthal angle to the orbital rim. With a scalpel interrupted 5-0 Vicryl sutures to reconstruct the canthal blade, cut through the skin along the remainder of the marked angle support. If a dog-ear is present at the lateral extent of line. Open the orbicularis muscle with scissors. Dissect beneath the ap incision, remove a small triangle of skin and muscle the skin–muscle ap and upward along the lateral rim. from the lateral side of the wound corner. FIG. 57.4. Elevate the ap to expose the lateral canthal FIG. 57.8. Close the ap wound with deep interrupted 6-0 ligament. With scissors, cut through the superior crus to Vicryl sutures and close the skin with stitches of 6-0 Vicryl mobilize the lateral eyelid. or prolene. POS OPERA IVE CARE: Place a f rm dressing over the Ptosis—Some degree o ptosis is expected with this pro- wound or 24 hours. Apply antibiotic ointment to the cedure but usually resolves within several weeks or suture lines three to our times daily or 7 days. Remove months. Added care should be taken to mobilize enough the skin stitches a ter 5 to 7 days, except or the mattress ap to close the de ect without excessive tension on the eyelid margin sutures, which are le t in place or 7 to 10 upper eyelid. days. Wound dehiscence—T is results rom too much tension on the marginal wound. Deep 5-0 Vicryl sutures are PO EN IALCOMPLICA IONS: used to anchor the orbicularis muscle o the temporal Poor eyelid margin contour—T e lateral canthal incision ap to the periosteum o the lateral orbital rim to relieve line should ollow the downward curve o the opened tension on the wound. eyelid margin. Angulation o the margin results rom Rounded lateral eyelid contour—T is may be caused by extending the lateral cut horizontally instead o in a ailure to ref x the lid to the lateral ligament. downward curve. 176  CHAPTER 57 ▼ Lateral Semicircular Rotation Flap (Tenzel) 177 FIG. 57.1 FIG. 57.5 FIG. 57.2 FIG. 57.6 FIG. 57.3 FIG. 57.7 FIG. 57.4 FIG. 57.8  58 Horizontal Tarsoconjunctival Transposition Flap INDICATIONS: Reconstruction o 40% to 50% o upper eyelid de ects when there is insuf cient laxity o adjacent tissue to mobilize myocutaneous aps. FIG. 58.1. Place a 4-0 silk suture through the marginal Be certain not to pass the suture onto the conjunctival surface. eyelid tarsus adjacent to the defect. Evert the remaining lid Place a mattress suture across the lid margin to align the tarsal over a Desmarres retractor to expose the tarsal surface. surfaces as for Direct Layered Closure, Fig. 56.2 (p. 215). FIG. 58.2. Make a horizontal cut through the conjunctiva FIG. 58.6. Suture the other free edge of the tarsal ap to and the tarsus 3 to 4 mm from and parallel to the eyelid the opposite side of the eyelid defect or to the remnant of margin. Continue the cut along the lid for a distance equal to the lateral canthal ligament with 6-0 Vicryl sutures. the horizontal width of the defect when the wound is closed under mild tension. FIG. 58.7. Advance the cut edge of the levator aponeurosis downward and suture it to the upper border of the tarsus with FIG. 58.3. At the end of the horizontal incision, extend the 1-2 interrupted 6-0 prolene stitches. If it cannot be advanced cut vertically to the superior border of the tarsus. With ne without retracting the eyelid, allow the aponeurosis to retract scissors, separate the tarsoconjunctival ap from the underlying and suture it to the conjunctiva above the tarsus with interrupted levator aponeurosis. 6-0 plain stitches. If performed under local anesthetic, ask the patient to look up to con rm appropriate height of the lid margin. FIG. 58.4. Cut Müller’s muscle from the upper border of the tarsus. Continue the dissection between the conjunctiva FIG. 58.8. Repair the anterior lamella with a sliding or and Müller’s muscle to the superior fornix. Extend the vertical rotational myocutaneous ap or with a skin graft. Recess cut in the conjunctiva to the fornix to complete the ap. the skin edge 1 mm behind the distal edge of the tarsal ap and suture it with a running 7-0 chromic stitch. Tie the long FIG. 58.5. Transpose the tarsoconjunctival ap hori- marginal mattress suture ends to the skin with an interrupted zontally into the defect and suture the tarsal edge to the stitch. Place a Frost suture to hold the eyelid closed and apply remaining eyelid with interrupted 6-0 Vicryl stitches. a rm dressing to hold the lid at. POSTOPERATIVE CARE: Remove the Frost suture a ter the lid margin. At least 3 to 4 mm o marginal tarsus 5 days. Apply antibiotic ointment to the skin edges until should be le t to support the lid. the skin sutures dissolve. Remove any nonabsorbable skin Eyelid retraction—Care must be taken to reconstruct the stitches a ter 7 to 10 days. lateral canthal ligament to prevent upward retraction o the lid. T e levator aponeurosis must not be advanced POTENTIALCOMPLICATIONS: to the tarsal ap under tension. Marginal entropion—Instability o the donor portion o the eyelid may result rom cutting the ap too close to 178  CHAPTER 58 ▼ Horizontal Tarsoconjunctival Transposition Flap 179 FIG. 58.1 FIG. 58.5 FIG. 58.2 FIG. 58.6 FIG. 58.3 FIG. 58.7 FIG. 58.4 FIG. 58.8  59 Free Tarsoconjunctival Gra t INDICATIONS: Reconstruction of the upper or lower eyelid where the defect is of shallow to moderate depth, where replacement of up to two-thirds of the posterior tarsoconjunctival lamella is required, and where the ipsilateral or con- tralateral upper eyelid is available for donor tissue. FIG. 59.1. Place a 4-0 silk suture across the marginal FIG. 59.5. Advance the levator aponeurosis downward and tarsus o the donor upper eyelid, and evert the lid over a suture it to the upper border o the tarsal gra t with several Desmarres retractor. Make a horizontal incision through the 6-0 prolene stitches. tarsus 3 to 4 mm from the lid margin and equal to the small- est length of the recipient defect when the margins are pulled FIG. 59.6. Mark a subciliary incision line rom the lateral together on slight tension. edge o the de ect to the lateral canthal angle and continue downward as a lateral semicircular ap. Cut the skin along FIG. 59.2. At each end o the incision, extend the cuts vertically the marked line with a scalpel blade. to the upper border o the tarsus. With ne scissors, dissect sharply to separate the tarsus from the levator aponeurosis. FIG. 59.7. Cut through the orbicularis muscle layer with scissors and dissect a skin–muscle ap of the underlying FIG. 59.3. Make a second horizontal cut near the upper bor- temporalis ascia and the periosteum. If necessary, excise a der o the tarsus to excise a rectangular block with adherent Burow’s triangle at the inferotemporal corner of the defect to conjunctiva. It is not necessary to close the donor wound. prevent it from buckling. FIG. 59.4. Insert the donor tarsoconjunctival gra t into the FIG. 59.8. Advance the ap medially to cover the de ect recipient de ect with the mucosal side toward the globe, and the gra t. T in the muscle slightly from the portion of and the cut ends o the meibomian glands toward the lid the ap over the tarsoconjunctival graft. Recess the ap 1 mm margin. Suture the edges of the graft to the remnants of proximal to the graft margin and suture it with a running the tarsus at the medial and lateral ends of the defect with 7-0 chromic stitch. Close the orbicularis muscle with deep interrupted 6-0 Vicryl sutures. Place the sutures through interrupted 6-0 Vicryl stitches and the skin with 6-0 Vicryl or three-fourths thickness of the tarsus only. Pass a 6-0 silk suture prolene. across the margin of the tarsus to align the edges. POSTOPERATIVE CARE: Apply a dressing to the eyelids Eyelid retraction—T is may be seen when the defect for 24 hours. Place antibiotic ointment on the suture lines extends up to the orbital rim, and the levator aponeu- and beneath the donor eyelid three to four times daily for rosis is advanced downward to the graft. In such cases, 7 days. Remove all skin sutures after 7 days. Reinforce the the conjunctiva at the superior edge of the defect should temporal wound with Steri-Strips for an additional 3 days be advanced into the defect and sutured to the tarsal if necessary. graft. T e aponeurosis is then advanced appropriately and sutured directly to the conjunctiva with 6-0 chro- POTENTIALCOMPLICATIONS: mic stitches. Corneal abrasion—T is results from placing the tarsal Ptosis—Some degree of ptosis is normal following recon- graft sutures through the conjunctival surface. ake care struction because of horizontal tension. T is usually to place these through partial-thickness tarsus only. resolves over several weeks to months. 180  CHAP ER 59 ▼ Free arsoconjunctival Graft 181 FIG. 59.1 FIG. 59.5 FIG. 59.2 FIG. 59.6 FIG. 59.3 FIG. 59.7 FIG. 59.4 FIG. 59.8  60 Lower Eyelid Single Bridged Advancement Flap (Cutler-Beard) INDICATIONS: Reconstruction o 60% to 100% horizontal upper eyelid de ects. FIG. 60.1. Trim the upper eyelid defect into an approximate FIG. 60.5. Separate the skin–muscle ap from the orbital rectangular shape. Mark a horizontal line along the lower septum and advance it beneath the marginal bridge eyelid 4 mm from the margin at the inferior tarsal border, and and into the defect to cover the graft. Approximate the equal in width to the upper lid defect, or slightly less if there orbicularis muscle and skin layers with 6-0 Vicryl sutures. If is signi cant laxity. Place a lid plate beneath the lower lid and necessary, cut two triangular Burow’s triangles from the base of cut through all layers along the marked line centrally with a the ap along the lower eyelid to reduce tension and allow for scalpel blade. With scissors, complete the incision medially and upward advancement. laterally, taking care not to injure the palpebral arteries. FIG. 60.6. Separate the ap after 2 to 3 weeks. Retract the FIG. 60.2. Make the vertical cuts from the ends of the hori- lower eyelid marginal bridge downward, and pass a grooved zontal incision through full thickness of the eyelid for a director beneath the ap. With a scalpel blade, cut across the ap distance of about 15 mm to the inferior fornix. Using scis- 2 mm below the desired position of the new upper lid margin. sors, dissect the conjunctiva from Müller’s muscle and the capsulopalpebral fascia to the inferior fornix. FIG. 60.7. Trim 2 mm of skin and muscle from the new upper eyelid margin, leaving a ap of conjunctiva FIG. 60.3. Pass the conjunctival ap beneath the lower posteriorly. Roll the conjunctiva over the lid margin and eyelid marginal bridge and suture it to the conjunctival suture it to the skin edge with a running 7-0 chromic stitch. remnant of the upper eyelid defect with a running suture of 6-0 plain gut. FIG. 60.8. Excise the epithelium and scar tissue from the inferior border of the lower lid bridge to expose all FIG. 60.4. Fashion a piece of autogenous auricular cartilage lamellae. Undermine the lateral and medial edges of the cheek or donor sclera to t the defect. Suture the graft medially and incisions. If necessary, excise a portion of the stretched lower laterally to the tarsal remnants or to the canthal ligaments with lid ap. Suture the conjunctiva and lower lid retractors to the 6-0 Vicryl stitches. Advance the edge of the levator aponeurosis inferior border of the tarsus with a running 6-0 chromic suture. downward and attach it to the upper edge of the graft with a Close the muscle layer with 6-0 Vicryl sutures and the skin with running 6-0 Vicryl stitch. 6-0 fast-absorbing plain gut sutures. POSTOPERATIVE CARE: Apply antibiotic ointment to correct with time. I not, secondary trimming o the the suture lines three to our times daily or 7 days a ter margin can be per ormed later. both the primary procedure and secondary takedown. Eyelid retraction—T is is caused by separating the ap too high during the second stage o reconstruction. Su - POTENTIALCOMPLICATIONS: f cient lid length must be allowed or complete eyelid Corneal abrasion—T is results rom keratinized epithe- closure. lium or f ne skin cilia at the new eyelid margin. T e Persistent edema—It is usual or the reconstructed eyelid conjunctiva should be rolled over the skin edge during to have edema or several months ollowing separation. the second stage o reconstruction to provide a smooth T is usually resolves with time. mucous membrane margin. Upper eyelid ptosis—T is is not uncommon ollowing separation and is pre erable to lid retraction. It may 182  CHAPTER 60 ▼ Lower Eyelid Single Bridged Advancement Flap (Cutler-Beard) 183 FIG. 60.1 FIG. 60.5 FIG. 60.2 FIG. 60.6 FIG. 60.3 FIG. 60.7 FIG. 60.4 FIG. 60.8  61 Lower Eyelid Double Bridged Advancement Flap INDICATIONS: Reconstruction o an upper eyelid de ect or contracted scarring when the marginal eyelid and lash line can be preserved. FIG. 61.1. Prepare the lower lid ap as for Lower Eyelid eyelid to reduce tension and allow for adequate upward Single Bridged Flap Fig. 60.1 and 60.2, pp. 228–229. advancement. FIG. 61.2. If the midportion of the upper lid is contracted, FIG. 61.5. Separate the ap after 2 to 3 weeks. Retract the place a lid plate beneath the eyelid and make a horizontal lower and upper eyelid marginal bridges with Desmarres retrac- full-thickness incision from the skin to conjunctiva across tors, and pass a grooved director beneath the ap. With a scalpel the lid from medial to lateral at the upper border of the blade, cut across the ap in the middle of the palpebral ssure. tarsus. FIG. 61.6. Excise the epithelium and scar tissue from the FIG. 61.3. Pass the full-thickness lower lid ap beneath the inferior border of the lower lid bridge and the superior lower and upper marginal bridges and suture the conjunc- border of the upper lid bridge to expose all layers. If tival layers with 6-0 plain gut. necessary, excise a small portion of the stretched lower and upper lid aps. Repair both the lower and upper eyelids by FIG. 61.4. Approximate the orbicularis muscle and skin reapproximating the conjunctiva with a running 6-0 plain gut layers with 6-0 Vicryl sutures. If necessary, cut two triangular suture. Close the muscle with 6-0 Vicryl sutures and the skin Burow’s triangles from the base of the ap along the lower with 6-0 fast-absorbing plain gut. POSTOPERATIVE CARE: Apply antibiotic ointment to Lower eyelid retraction—T is is caused by separating the the suture lines three to our times daily or 7 days a ter f ap too low during the second stage o reconstruction. both the primary procedure and secondary takedown. It is best not to trim too much o the f aps and, i neces- sary, per orm secondary reduction o eyelid length. POTENTIALCOMPLICATIONS: Persistent edema—It is usual or the reconstructed eye- Upper eyelid ptosis—T is is expected ollowing separa- lids to have edema or several months ollowing separa- tion and will usually require a secondary ptosis repair. tion. T is usually resolves with time. 184  CHAPTER 61 ▼ Lower Eyelid Double Bridged Advancement Flap 185 FIG. 61.1 FIG. 61.4 FIG. 61.2 FIG. 61.5 FIG. 61.3 FIG. 61.6  M SECTION Lower Eyelid Reconstruction T he surgical and anatomic principles described or reconstruction o the upper eyelid apply equally to the lower eyelid. Separate reconstruction o anterior and posterior SUGGESTED FURTHER READING Lateral Semicircular Rotation Flap with Periosteal Fixation Hawes MJ. Free autogenous gra ts in eyelid reconstruction. Ophthal Surg. 1987;18:37– 41. lamellae with appropriate tissue is essential. Attention to the Leone CR Jr. Periosteal f ap or lower eyelid reconstruction. Am J Oph- vertical suspension o the lower eyelid by replacing internal thalmol. 1992;114:513– 514. stability and canthal ligament support is critical and is even Levine MR, Buckman G. Semicircular f ap revisited. Arch Ophthalmol. more important than in the upper lid. T e e ects o gravity 1986;104:915– 917. act to distort eyelid position, and even minimal amounts o enzel RR, Steward WB. Eyelid reconstruction by semicircular f ap tech- nique. Ophthalmology. 1978;85:1164– 1169. vertical tension or laxity can result in retraction, scleral show, or rank ectropion. Upper to Lower Eyelid Tarsoconjunctival Advancement Flap T e technique o direct closure or marginal de ects (Hughes Procedure) Bartley GB, Messenger MM. T e dehiscent Hughes f ap: outcomes and requires the same meticulous attention to the eyelid mar- implications. Trans Am Ophthalmol Soc. 2002;100:61– 65. gin as described or the upper lid. Because excessive hori- Ceis WA, Bartlett RE. Modi cation o the Mustarde and Hughes zontal tension is less critical here, somewhat larger de ects methods o reconstruction o the lower lid. Ann Ophthalmol. 1975;7: can be closed primarily. With de ects over 30% to 40%, a 1497– 1502. lateral canthotomy and cantholysis may be required. For Hawes MJ, Grove AS Jr, Hink EM. Comparison o ree tarsoconjunctival gra ts and Hughes tarsoconjunctival gra ts or lower eyelid recon- larger segments, a semicircular temporal f ap ( enzel f ap) struction. Ophthal Pla st Reconstr Surg. 2011;27:219– 223. may allow closure o de ects up to 60% o the horizontal lid Hughes WL. Reconstruction o the lid. Am J Ophthalmol. 1945;28:1203. length. In such cases, it is important to reestablish canthal Hughes WL. otal lower lid reconstruction: technical details. Trans Am support with a ascial or periosteal f ap. Ophthalmol Soc. 1976;74:321– 329. For very large de ects o 80% to 100% o the lower eye- Leibovitch I. Modi ed Hughes f ap: division at 7 days. Ophthalmology. 2004;111:2164– 2167. lid, the tarsoconjunctival advancement f ap rom upper to Leone CR Jr. arsal-conjunctival advancement f aps or upper eyelid lower lid (Hughes f ap), combined with a ree skin gra t or reconstruction. Arch Ophthalmol. 1983;101:945– 948. myocutaneous f ap, yields excellent unctional and cos- McNab AA. Early division o the conjunctival pedicle in modi ed Hughes metic results. However, this is a two-stage procedure that repair o the lower eyelid. Ophthalmic Surg La sers. 1996;27:422– 424. requires the visual axis to be occluded or 2 to 3 weeks, Free Tarsoconjunctival Graft thus making it inappropriate or monocular patients or or Glatt HJ. arsoconjunctival f ap supplementation: an approach to the young children in the amblyopia-prone age group. reconstruction o large lower eyelid de ects. Ophthal Pla st Reconstr As with the upper eyelid, complex lower eyelid recon- Surg. 1997;13:90– 97. structive procedures usually require a combination o tech- Leone CR Jr, Van Gemert JV. Lower lid reconstruction using tarsocon- junctival gra ts and bipedicle skin-muscle f ap. Arch Ophthalmol. niques, which may simultaneously include advancement 1989;107:758– 760. f aps, ree gra ts, and direct closure. Complete operations Oestreicher JH, Pang NK, Liao W. reatment o lower eyelid retraction are not described below, but rather individual components by retractor release and posterior lamellar gra ting: an analysis o 659 are described that can be combined as necessary to achieve eyelids in 400 patients. Ophthal Pla st Reconstr Surg. 2008;24:207–212. any reconstruction. Final repair strategy must be le t to the Stephenson CM, Brown BZ. T e use o tarsus as a ree autogenous gra t in eyelid surgery. Ophthal Pla st Reconstr Surg. 1985;1:43–50. ingenuity and skill o the surgeon based on unctional need and anatomic resources. 187