Lower lid reconstruction

LOWER LID
RECONSTRUCTION

PROF.DR.M.V.S.PRAKASH
PROF.DR.ASHOK KUMAR
ASST .DR.GEETHA
ASST.DR.UMA MAHESWARI
ASST.DR.SUJATHA
ASST.DR.MAHALAKSHMI
DR.VISHNUPRIYA

INTRODUCTION

 Lowerlid reconstruction technique will depend on the
size,
location,
configuration &
depth of the defect

 Superficial defects: only anterior lamella needs to be repaired
 Full thickness defects: needs reconstruction of both lamellae

INDICATIONS BURNS

TRAUMA TUMORS

CONGENITAL
DEFECTS

AIMS

 TO RE ESTABLISH FUNCTIONAL EYELID
 ADEQUATE PROTECTION OF EYE
 COSMESIS

 smooth inner lid lining to maintain lubrication & avoid corneal
irritation

 skeletal support to provide adequate lid rigidity
 stable lidmargin to keep eyelashes away from cornea
 proper fixation of MCT & LCT for lid stability &orientation
 adequate muscle to provide tone & power for closure

 Small defects( upto 30%) DIRECT CLOSURE WITH
DIRECT CLOSURE CANTHOTOMY

DIRECT CLOSURE WITH TENZEL’S FLAP

 FOR MODERTE DEFECTS( UPTO 50%)
POSTERIOR LAMELLA : HUGHE’S TARSOCONJUNCTIVAL FLAP

ANTERIOR LAMELLA : CHEEK SKIN ADVANCEMENT
SKIN GRAFT
TRIPIER’S FLAP

 FOR LARGE DEFECTS( UPTO 100%)

POSTERIOR LAMELLA:
HUGHE’S TARSOCONJUNCTIVAL FLAP
NASAL CARTILAGE
HARD PALATE

ANTERIOR LAMELLA:

MUSTARDE’S CHEEK ROTATION FLAP
NASOLABIAL FLAP
LATERAL TEMPORAL FLAP(FRICKLE’S)
MEDIAN FOREHEAD FLAPS

DIRECT CLOSURE

 IF DEFECT IS </= 25%
 EVEN FOR 50% DEFECTS IN LAX LIDS

PROCEDURE

 5- 0 vicryl suture is passed through the most superior
aspect of tarsus anterior to conjunctiva

 Suture tied with a single knot & lid approximation
checked

 If approximation is good,untie the suture & ends are
clamped to head drape

 5-0 vicryl sutures placed in tarsus inferiorly &
orbicularis

 6-0 silk passed through lidmargin along the line of
meibomian glands and lash line in a vertical
mattress fashion and cut leaving the ends long &
the ends are incorporated into skin sutures

 Skin closed with 6-0 silk

LATERAL CANTHOTOMY &
CANTHOLYSIS

 4-5 mm horizontal skin incision made at the lateral canthus
 Incision deepened to periosteum of lateral orbital margin

 Inferior cantholysis is done by cutting the tissue b/w
conjunctiva and skin close to periosteum

 Lower lid will give once the lower crus of lateral canthal
tendon is severed

 Anchor muscle layer to periosteum after closing the primary
defect

 Wound closed with simple interrupted 6-0 silk

TENZEL SEMICIRCULAR ROTATION
FLAP

 For defects upto 50% where some tarsus remain on either side
of the defect

 A semicircular incision is made at the lateral canthus curving
superiorly to a level just below the eyebrow & temporally 2 cm
away

 Flap undermined till temporalis fascia

 Lateral canthotomy & inferior cantholysis done ;eyelid defect
closed

 Lateral canthus suspended with a deep suture to periosteum
of lateral orbital margin to prevent flap retraction

 Any residual ‘dog ear’ is cut & sutured

 Inferior forniceal conjunctiva is mobilized & sutured to the flap
edge with 8-0 vicryl

HUGHES FLAP

 upper tarsoconjunctival pedicle flap for
larger lid defects

 Staged procedure
 Upper lid everted & marking made over

tarsal conjunctiva 3.5 mm below the lid
margin
 Tarsus & conj dissected free from levator
aponeurosis uptil superior fornix
 Tarso conjunctival flap mobilized into the
lowerlid defect
 Flap conjunctiva is sutured wit LL
conjunctiva &UL tarsus sutured with LL tarsus
( partial thickness)

 myocutaneous flap from cheek advanced to
cover the anterior surface of the flap

 3- 10 weeks later, flap is cut open just above the
desired level of new lower lid border

 upper lid everted & the residual flap is excised

MUSTARDE CHEEK ROTATION FLAP

 For defects > 75%
 A deep inverted triangle is excised below the defect to

allow adequate flap rotation

 The outline of the flap should rise in a curve toward the tail
of the eyebrow& hairline and reach down just infront of ear
as far as lobule

 Skin incised and blunt dissection done long subcutaneous
plane

 Posterior lamellar tarsal substitute is usually harvested from
nasal cartilage/ hard palate

 Deep aspect of flap is sutured to periosteum of lateral
orbital margin

 Skin sutured to posterior lamellar graft wit 7 -0 vicryl
 Wound closed with drain

TRIPIER FLAP

 Myocutaneos bipedicular flap taken from
upperlid to reconstruct lowerlid
For extensive anterior lamellar defects
2 staged

FRICKE FLAP

 HARVESTED FROM ABOVE BROW
 BASED LATERALLY
 TWO STAGED

McGregor flap

 Used for large lid defects

 After the V excision of the full thickness of LL,the
flap as outlined is raised

 Once orbicularis is reached,the plane of
elevation becomes deep to muscle,the muscle
being advanced as a part of flap

 In the process of flap elevation,lateral
cantholysis is performed

 Flap advnced medially & the defect is closed

TAKE HOME POINTS

 Eyelid defects can be reconstructed using various techniques based
on their site,size & depth

 Choosing the technique also depends on the patients’parameters
like age , status of other eye

 The lost structure should be replaced with the same or a similar
structure from neighbouring areas

 A good graft should be well vascularized, sutured with minimal
tension

 The ultimate aim is to restore an anatomically & physiologically
stable eyelid

REFERENCES

 OCULOPLASTIC SURGERY- BRAIN LEATHERBARROW
 COLLIN’S MANUAL OF OCULOPLASTIC SURGERY
 KANSKI CLINICAL OPHTHALMOLOGY
 KHURANA’S ANATOMY & PHYSIOLOGY OF EYE
 PEYMAN’S PRINCIPLE & PRACTICE OF OPHTHALMOLOGY