Abstract
Purpose:
The reconstruction of large (>50%) upper eyelid margin defects can be technically challenging, with multiple approaches described in the literature. We sought to review the recent literature for new techniques or modifications to existing techniques.
Methods:
We conducted a Pubmed search for technique papers on the reconstruction of large upper eyelid defects published within the past ten years with a minimum of four patients.
Results:
We identified ten articles, and divided them into techniques that use a bridging flap from the lower eyelid and those that do not. The number of upper eyelids repaired in each article ranged from four to 17. Most techniques could be considered either a modification of the Cutler-Beard technique or a novel anterior lamella flap laid over a graft for the posterior lamella. Postoperative complications included upper or lower eyelid cicatricial retraction, trichiasis, or entropion, and lagophthalmos.
Conclusions:
Surgeons continue to innovate for this challenging reconstructive surgery. Overall, the trend was to use a graft, most commonly tarsoconjunctiva from the contralateral upper lid, to replace the posterior lamella, and a skin flap, from the lower eyelid or from the adjacent periorbital area, to replace the anterior lamella. Bridging techniques utilized the skin; the skin, orbicularis, and conjunctiva; or a tarsoconjunctival flap from the lower eyelid. Non-bridging techniques generally used a tarsoconjunctival or substitute graft for the posterior lamella, and a skin flap for the anterior lamella.
Keywords: Upper eyelid reconstruction, eyelid tumor, surgical techniques, upper eyelid graft, tarsoconjunctival upper eyelid flap
Introduction
Upper eyelid defects that involve more than 50% of the width of the horizontal eyelid margin pose significant reconstructive challenges. Replacing lost bi-lamellar anatomy, maintaining proper eyelid position, movement and closure, while protecting the underlying globe, are functional prerequisites for any reconstructive option. Cosmesis is also critical to achieving a good outcome involving this aesthetically important structure. These requirements make upper eyelid reconstruction potentially more complex than that of the lower eyelid, which has less dynamic movement and covers less of the globe.
Numerous procedures have been developed to address the complexities of upper eyelid reconstruction. Defects less than 50% of the width of the eyelid pose less of a technical challenge than defects greater than 50% width, and the techniques of repair are generally agreed upon.1,2 Upper eyelid reconstruction requires the careful reestablishment of multiple anatomic layers: the anterior lamella, formed by skin and orbicularis muscle; the posterior lamella, consisting of tarsus and conjunctiva; and potentially other elements such as the levator aponeurosis.
Each tissue layer has its own function. When reconstructing each lamella, one must abide by basic flap and graft principles. Grafts require a vascularized recipient site for successful uptake, while flaps require adequate blood supply to survive. Therefore, multiple reconstructive combinations are possible: a graft can be used with an overlying or underlying flap, or two flaps may be used, but due to a lack of blood supply to a graft, stacked simultaneous grafts are generally not used to reconstruct each lamellae. The number of techniques, and modifications to those techniques, that have been developed to repair large upper eyelid defects is a testament to the difficulty in achieving a satisfactory result.
In general, reconstruction techniques can be categorized as bridging, in which a flap is brought up from the ipsilateral lower eyelid, or non-bridging. Bridging techniques occlude the visual axis until a second stage procedure is performed where the bridge flap between the two eyelids is divided. The classic Cutler-Beard procedure3 has been described in many instructional texts as the standard option for large, full-thickness upper eyelid defects. While the Cutler-Beard is a work-horse procedure, it can result in inadequate stability of the upper and lower eyelid leading to entropion, as well as upper eyelid retraction.4
Other described techniques include the reverse Hughes procedure, Mustarde lid switch flap, as well as non-bridging procedures that generally use tarsoconjunctival substitutes as a graft to replace the posterior lamella, and a skin flap to replace the anterior lamella.1 These procedures also have potential downsides with cases of reported post-reconstruction ectropion, lid retraction, flap or graft necrosis, and corneal abrasion.2 One study compared outcomes of upper eyelid reconstruction across different techniques and reported complications in 56% of 126 eyelids, with 23% requiring an adjunctive surgery.5
The relatively low incidence of patients with large palpebral defects with easily matched phenotypes, causes, and confounders has led to a dearth of properly powered studies comparing these reconstructive options. Thus, evidence-based approaches to these complex reconstructive problems are lacking. Nevertheless, surgeons around the world have sought to improve upon existing techniques and innovate new methods for reconstruction of large upper eyelid defects.
In this report, we review the literature from the past ten years, focusing on innovations in the reconstruction of large upper eyelid defects, including both novel approaches and modifications to previously described techniques.
Methods:
The authors conducted a PubMed database search for upper eyelid reconstruction techniques using a combination of medical subject headings (MeSH) and keywords that would be most effective at capturing a wide variety of techniques.a The search was limited to English language articles published in the ten years preceding May 1, 2020. There were 1291 results, which were screened for relevance to reconstructive advancements of full-thickness palpebral defects greater than 50% of the upper eyelid margin. We excluded articles with fewer than four patients. Ten studies met all inclusion criteria for assessment and review.
Results
Bridging Techniques (Table 1)
Table 1.
Bridging Techniques.
Author/Year | Anterior Lamella | Posterior Lamella | # of Upper Eyelids | Defect Size (% of horizontal length of eyelid) | Outcomes | Complications |
---|---|---|---|---|---|---|
Rajak et al.4 (2019) | Skin flap from lower eyelid “over-the-top” of the lower eyelid margin | Tarsconjunctival graft | 4 | 75–90% | 3/4 patients achieved good functional and cosmetic outcomes; revision surgery for upper lid notch (1) |
|
Mandal et al.6 (2016) | Skin-muscle flap from lower eyelid | Auricular cartilage graft on top of lower eyelid conjunctival flap | 16 | >70% | 16/16 good functional and cosmetic outcomes | None reported |
Bengoa-González et al.8 (2019) | Skin-muscle flap from lower eyelid | Tarsoconjunctival graft and lower eyelid conjunctival flap | 10 | >60% | 10/10 good functional and cosmetic outcomes |
|
Sa et al.9 (2010) | Orbicularis muscle flap plus upper eyelid skin flap or graft | Tarsoconjunctival flap from lower eyelid | 17 | >80% | 17/17 satisfactory functional and cosmetic outcomes; 5 patients required secondary procedures due to post-operative complications |
|
Vahdani et al.10((2018) | Myocutaneous advancement flap from upper eyelid or orbicularis muscle flap and skin graft | Acellular dermal allograft alone, with lower eyelid tarsoconjunctival flap, or with a tarsconjunctival graft | 9 | 30–90% | 7/10 good functional and cosmetic outcome; 3/10 required revision surgery |
|
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Rajak et al.described a variation to the Cutler-Beard technique (CBT) in their retrospective review of four patients (age range 49–90, 1:3 male to female ratio) with 75–90% full-thickness upper eyelid defects following tumor excision.4 Their technique used a 4–5 mm tarsoconjunctival graft from the contralateral upper eyelid to reconstruct the posterior lamella, and an ipsilateral lower eyelid skin flap raised “over-the-top” of the lower eyelid margin to reconstruct the anterior lamella (Figure 1A). The lower lid skin flap is sutured into position over the upper lid tarsoconjunctival graft, then separated at 2–4 weeks, at which time a temporary Frost suture is placed on the lower eyelid. This novel modification minimizes disruption to the lower eyelid anatomy by only recruiting skin for the flap, rather than all of the layers of the lower eyelid as in the traditional CBT.
Notable postoperative complications included one patient with flap dehiscence requiring debridement and lid notch requiring reconstruction at 18 months follow-up, and one patient with severe pain until flap separation, suggestive of corneal abrasion. They note that a bandage contact lens can be placed during the first-stage procedure in order to prevent lower eyelid lashes from abrading the cornea. Three of the four patients achieved good cosmetic and functional outcomes at 24-month follow-up.
Mandal et al. reported a case series of 16 patients (age range 60–86, 3:5 male to female ratio) with full-thickness defects comprising 70–100% of the upper eyelid secondary to tumor removal.6 They used an auricular cartilage graft as a tarsal substitute to supplement the traditional lower lid advancement flap of the CBT (Figure 1B). The auricular cartilage is inset between the anterior and posterior lamella of the Cutler-Beard flap. The cartilage provides stability to the posterior lamella, thereby avoiding entropion and retraction that can result from the CBT. There were no major postoperative complications or need for secondary procedures within the follow-up time ranging from 6–24 months. Although the technique has been described before,7 and reported on in the context of a comparison with other techniques,5 the authors report that theirs is the first series to report outcomes specifically with first stage placement of auricular cartilage in the CBT.
Bengoa-Gonzalez et al. conducted an interventional retrospective review of ten cases (age range 64–86, 1:1 male to female ratio) requiring reconstruction following removal of upper eyelid tumors resulting in >60% full-thickness defects.8 Like Mandal, they modify the CBT, in this case, by using a tarsoconjunctival graft from the contralateral lid. They attach the conjunctiva of the lower lid to the inferior border of the tarsoconjunctival graft, and then place a lower eyelid myocutaneous flap over the tarsoconjunctival graft (Figure 1C). The authors suggest that placement of the graft in this fashion ensures vascularization and reduces traction, and thus decreases the likelihood of graft necrosis. No serious complications were reported. Follow-up time ranged from 24–60 months, and all patients reported a satisfactory aesthetic result with the exception of minimal retraction of the upper eyelid in 50% of cases.
Sa et al. conducted a retrospective case series of 17 patients (age range 40–81, 1:7 male to female ratio) with full-thickness upper eyelid defects involving 80% or more of the upper lid margin following tumor excision.9 The authors described two novel modifications to the reverse modified Hughes procedure. First, they mobilize and advance orbicularis oculi muscle superior to the defect to cover the tarsoconjunctival flap. They posit that mobilization reduces scarring, enhances eyelid mobility, and preserves orbicularis functionality in the upper lid. Second, they use adjacent residual skin as an advancement flap to cover the orbicularis flap, as opposed to the traditional skin graft (Figure 1D). Post-operative complications included epithelial keratopathy (23.5%), lagophthalmos (17.6%), upper eyelid entropion (11.7%), granuloma formation (11.7%), and lower eyelid entropion (5.9%). Five patients required secondary procedures. Ultimately, functional and aesthetic outcomes were determined to be satisfactory for all patients within the follow-up period of 6–84 months.
Vahdani et al. conducted a retrospective review of a consecutive series of 14 eyelids in 10 patients (age range 64–86, 2:3 male to female ratio). These patients had full thickness defects of the upper lid (n=9), lower lid (n=5), or both, ranging from 60–90% of the eyelid, secondary to trauma or tumor resection.10 The authors use acellular dermal allograft (ADA) as a posterior lamella substitute in situations where donor tissue was unavailable or a transconjunctival flap or graft was not sufficient to cover the entirety of the defect (Figure 1E). For posterior lamella reconstruction, they used ADA alone or as a supplement to a tarsoconjuctival flap (reverse modified Hughes flap) or graft. For anterior lamella reconstruction, they used a myocutaneous flap if there was sufficient adjacent tissue, or if not, then an orbicularis oculi muscle flap and full-thickness skin graft. The ADA was placed directly against the ocular surface, rather than inset over a conjunctival flap.
The authors reported one patient with upper lid retraction and one patient with upper lid entropion, each of whom required an additional surgery. The lack of a mucosalized surface behind the ADA can potentially cause keratopathy, however the authors did not note any instances of this complication in their series. There was no implant rejection reported. Overall, patients without complications (7/10) had good functional and cosmetic outcomes Follow-up time ranged from 33–164 months.
Non-bridging Techniques (Table 2)
Table 2.
Non-Bridging Techniques
Author/Year | Anterior Lamella | Posterior Lamella | # of Upper Eyelids | Defect Size (% of horizontal length of eyelid) | Outcomes | Complications |
---|---|---|---|---|---|---|
Toft11 (2016) | Myocutaneous pedicle flap for primary defect and skin graft for secondary defect | Tarsoconjunctival graft | 8 | >50% | 8/8 good functional outcomes 6/8 satisfactory cosmetic outcomes Two patients had imperfect lid margins after reconstruction |
|
Yazici et al.14 (2019) | Lateral bilobed skin flap | Tarsoconjunctival graft | 5 | 18.5–25 mm | 2/5 satisfactory functional and cosmetic outcomes |
|
Ito et al.15 (2019) | Upper eyelid advancement flap | Auricular cartilage graft | 4 | 30–80% | 4/4 good functional and cosmetic outcomes; Revisional blepharoplasty required in 2 patients | None Reported |
Cheng et al.16 (2015) | Lateral rotational flap through “subcutaneous tunnel” | Hard palate graft | 4 | >75% | 4/4 satisfactory functional and cosmetic results | None reported |
Pushker et al.17 (2016) | Lower eyelid rotational flap | Lower eyelid rotational flap | 5 | 10–25 mm | 10/10 good functional outcomes (evaluated with TBUT and Schirmer’s test) 8/10 patients “good-excellent” cosmesis; 2/10 graded “adequate” cosmesis |
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Toft conducted a retrospective case series of eight patients (age range 52–94, 1:3 male to female ratio) with full-thickness eyelid defects comprising >50% of the eyelid margin secondary to tumor removal.11 Toft describes a novel single-stage technique that uses a tarsoconjunctival graft from the contralateral lid to reconstruct the posterior lamella and a laterally based myocutaneous flap from the remaining upper lid for reconstruction of the anterior lamella (Figure 2A). The secondary skin defect is then covered with a skin graft. Use of a long myocutaneous flap with a single pedicle illustrates a new modification to the previously described bipedicle technique.12–13
Complications included corneal erosion in one patient, and eye pain in two patients, lasting three weeks and three months, respectively. Both patients required contact lenses post-operatively to ease eye discomfort. Cosmetically, two patients had imperfect lid margins after reconstruction. Overall, the author reported acceptable functional outcomes in all patients. Follow-up time ranged from 1–23 months.
Yazici et al. conducted a review of five patients (age range 42–87, 2:3 male to female ratio) who underwent upper eyelid reconstruction with a bilobed flap.14 All patients had upper eyelid defects measuring 60–80% of the eyelid margin following tumor removal. The authors proposed a technique which utilized a tarsoconjunctival graft for posterior lamella reconstruction, and the novel use of a bilobed flap, recruited from the lateral and inferolateral periorbital area, for anterior lamellar reconstruction (Figure 2B).
There were four complications reported in three patients, including superficial-epidermal necrosis on the distal ends of the flap, pin-cushion deformity, superficial keratopathy, and lanugo hair on the flap touching the cornea, which was managed with use of therapeutic contact lenses. The remaining two patients had satisfactory cosmetic and functional results. The follow-up time ranged from 4–102 months.
Ito et al. conducted a retrospective review of four consecutive patients (age range 62–88) with full-thickness defects ranging from 30–80% of the upper lid secondary to tumor removal.15 The authors reported an innovative single-stage procedure utilizing excess skin of the upper eyelid as an advancement flap to reconstruct the anterior lamella, combined with an auricular cartilage graft with perichondral lining to reconstruct the posterior lamella (Figure 2C). This technique achieves reconstruction in one stage. A bandage contact lens was placed for two weeks after surgery, after which the conjunctiva re-epithelialized. Satisfactory cosmetic outcomes were achieved in all patients, with no major complications. The follow-up time ranged from 7–75 months.
Cheng et al. conducted an observational study that analyzed data of 22 eyelids in 21 patients (age range 3–69, 4:1 male to female ratio). These patients had full thickness defects encompassing >75% of the upper lid (n=5), lower lid (n=18), or both (n=1).16 Defects were secondary to trauma or malignancy. The authors developed a novel one-step procedure utilizing a temporally based orbicularis oculi myocutaneous flap designed along the lateral canthal “crow’s feet” lines (Figure 2D). The flap is rotated and tunneled subcutaneously to the defect site to reconstruct the anterior lamella. They used a hard palate mucosal graft for reconstruction of the posterior lamella. According to the authors, the use of the “subcutaneous tunnel” avoids “dog-earring” of the pedicle common in traditional procedures. In addition, the procedure utilizes a rich blood supply in the lateral peri-orbital region, reducing graft necrosis and optimizing aesthetic results. There were no reported complications and they reported that all patients had satisfactory functional and cosmetic results. The follow-up time ranged from 3–12 months.
Pushker et al. conducted a prospective interventional study of ten patients (age range 10–70, 1:1 male to female ratio with full-thickness defects of the upper (n=5) and lower (n=5) lids, ranging from 50–66% of the eyelid margin secondary to trauma or tumor excision.17 In their procedure, they rotate the lateral lower lid margin and lateral canthus to the upper eyelid (Figure 2E). The addition of the lateral canthus and eyelid margin into the lateral flap creates a more functional upper lid with additional retained vascular supply.
Complications included loss of lashes (n=2), eyelid margin notching (n=3), lateral eyelid ectropion (n=3), and misdirected lashes (n=2). Functional outcome was assessed by measuring tear film break-up time (TBUT) and Schirmer’s test in both eyes. At three-month follow-up, TBUT and Schirmer’s were performed and no significant difference was found between the operated and contralateral eye. Patient-reported cosmetic outcomes included 80% “good-excellent” and 20% “adequate.”
Discussion
The repair of large, full-thickness defects of the upper lid has remained a challenging area of periocular reconstruction. The complex anatomy and dynamic functions of the upper lid, combined with the relative paucity of similar specialized tissue to this region, makes reconstruction technically difficult and can be associated with functional complications or cosmetic dissatisfaction. One study that compared outcomes of periorbital reconstruction based on their anatomical zone—the upper eyelid, medial canthus, lateral canthus, or lower eyelid—reported that 72% of the patients that required revision surgery were from defects that were greater than 50% of the upper eyelid.18 While the foundations that govern large upper lid reconstruction have been generally agreed upon, surgeons have continued to modify traditional techniques in order to reduce complications and overall surgical burden. The aim of this article was to review novel techniques, and modifications to well-described procedures, for reconstruction of large upper lid defects that have been published over the past 10 years.
Bridging Modifications
In 1955, Cutler and Beard introduced a technique to repair full-thickness upper eyelid defects comprising >70% of the eyelid width.3 The classic Cutler-Beard technique (CBT) has since become a staple in upper lid reconstruction and is frequently used by surgeons when dealing with large defects. This two-stage procedure involves the creation of an advancement flap 4 mm inferior to the lower lid margin, which is composed of full thickness lower eyelid inferior to the tarsal plate. The flap is then placed under the lower lid margin and advanced to fill the upper lid defect, and divided 4–8 weeks later. Disadvantages of this technique include prolonged occlusion of the eye, insufficient posterior lamellar support due to lack of tarsus, and disruption to the lower eyelid; all of which can potentially lead to complications such as lid retraction and malposition.2
The reviewed modifications to this technique utilize tarsal substitutes.4,6,8 These modifications were intended to provide additional stability to the reconstructed lid as compared to the traditional CBT. These modifications are not without limitations and drawbacks. The “over-the-top” modification proposed by Rajak et al. takes a skin flap from the lower lid and places it over the lower lid margin in order to reconstruct the anterior lamella, while the posterior lamella is reconstructed with a tarsconjunctival graft.4 To avoid skin flap dehiscence from the tension created by the opposing pull of the upper and lower lid retractor muscles, they suggest quilting sutures through the skin flap. They also suggest that a bandage contact lens may be indicated until the second stage procedure, in order to prevent lower eyelid lashes from abrading the cornea. As their flap is only composed of skin, there is a concern for a lack of vascular supply, as well as lack of orbicularis muscle tone, each of which may contribute to cicatricial retraction of the upper lid.
Bengoa-Gonzalez et al. minimized the potential for necrosis and corneal abrasion through their use of a transconjunctival graft as an adjunct to the CBT.8 While a tarsoconjunctival graft had been used with a skin flap from the lower eyelid19 or placed at the second stage of the CBT,20 Bengoa-Gonzalez et al. report that they are the first to report a case series where the tarsoconjunctival graft is placed superior to a lower lid conjunctival flap, in a CBT modification. Although auricular cartilage has been used as a tarsal substitute for years,7,21 Mandal et al. report that they are the first to investigate its use when sandwiched between the layers of the Cutler-Beard flap in a series.6 They reported no complications in their series of 16 patients.
Two reconstructive options that did not come up in our literature search were a modification to a Cutler-Beard flap, described by Lee and Nunery in 201222, and a lid switch flap, described by Mustarde in 1970.23 In the former, a grey line incision is made on the lower lid to separate the anterior from the posterior lamella, and the lash line is excised from the anterior lamella. A tarsoconjunctival flap is fashioned by dissecting in the suborbicularis plane, and releasing the inferior retractors from the tarsus and conjunctiva. The tarsoconjunctival flap is advanced and sutured into the upper eyelid defect site. The anterior lamella of the upper eyelid is then filled in using redundant lower eyelid or upper eyelid skin or a skin graft. The resulting lower eyelid defect can be repaired with a Tenzel semicircular flap. The bridging flap is divided 6–8 weeks later. The advantage of this technique is that it uses the full height of the lower eyelid tarsus as a flap, as compared to the Cutler-Beard technique, which uses none of the lower eyelid tarsus, or the reverse modified Hughes flap, which uses half of the lower eyelid tarsus. This modification thereby substitutes an upper lid defect with a lower lid defect, which is the same premise as the lid switch flap.
The lid switch flap is a two-stage procedure that uses a lower lid full-thickness flap based on a medial or lateral pedicle.23 The lower lid, full-thickness flap is rotated in a circular fashion to cover the upper lid defect, and then separated 2–4 weeks later. Its purported advantages over the Cutler-Beard technique are that the full-thickness flap creates a more stable lid and allows for incorporation of an intact eyelid margin that includes the eyelashes.23 The main disadvantages of this procedure are the potential for corneal irritation due to transposition of the flap from the lower to upper lid, as well as the need to repair the lower lid donor site.2
The reverse modified Hughes technique is another two-stage reconstruction procedure that is analogous to the modified Hughes procedure for full-thickness lower eyelid defects.2 The technique, introduced in 1994, employs a tarsoconjunctival flap from the lower lid to reconstruct the posterior lamella, and a posterior auricular skin graft to reconstruct the anterior lamella.24 When compared to the Cutler-Beard procedure, this may be a technically simpler technique. It allows for the provision of tarsal support via the lower lid flap, with less disruption to the lower lid anatomy.24 However, the lack of orbicularis oculi muscle and paucity of lower lid tarsal tissue are downsides to this option.1
Sa et al. sought to address these problems via novel modifications to the technique. They mobilized superior upper lid orbicularis muscle over the advanced tarsoconjunctival flap and used residual upper lid skin to cover the orbicularis. These modifications, specifically mobilization of the orbicularis, allowed for enhanced lid mobility and additional vascularity to the affected area.24
This technique cannot be employed for patients with large vertical defects, although the same group explored using ADA as a tarsoconjunctival substitute in their case series from 2018.10 They used ADA alone, with a reverse modified Hughes flap, or with a tarsoconjunctival graft for posterior lamella reconstruction, and a myocutaneous flap or orbicularis muscle flap plus skin graft for anterior lamella reconstruction. They did not line the ADA with mucosa, and reported no ocular surface problems. Two patients underwent a secondary surgery for upper lid entropion and retraction, respectively.
Non-Bridging Modifications
Non-bridging techniques have the advantages of being completed in one stage and not occluding the eye. They generally use a graft to reconstruct the posterior lamella and a skin flap for the anterior lamella. In the techniques reviewed here, grafts were taken from the ear, hard palate, and contralateral upper eyelid tarsoconjuctiva. Although a tarsonjunctival graft replaces like-for-like, the amount that can be harvested is limited, and may not be sufficient for complete upper eyelid defects, without the use of an adjoining periosteal flap or other supplemental (e.g. ADA) material. Other posterior lamella graft sites that have been utilized in other sources include nasal cartilage and mucosa, buccal mucosa and distant veins.1
Grafts, regardless of source, require a vascularized anterior lamella for viability. In large, full-thickness defects often there is little remaining upper lid tissue, thus techniques require locoregional, vascularized flaps from the adjacent tissue that simulate the thin, pliable, tissue of the normal upper eyelid. Previously described techniques include the unipedicled (Fricke) flap, bipedicled flaps, paramedian forehead flaps, the Tessier nasojugal flap, an islandized superficial temporal artery flap, and the lower to upper eyelid transposition flap.2 These flaps can be bulky and may result in the need for pedicle division or thinning of the mobilized tissue. In addition, the tissue composing these flaps rarely meet the unique functionality required of the upper lid. Lastly, lanugo hairs can pose a risk of corneal irritation and result in aesthetic outcomes that are unfavorable.
Over the past decade, a variety of new approaches to non-bridging techniques have been proposed. Toft described a technique that used a superiorly-based, sub-brow myocutaneous pedicle flap to repair the anterior lamella in conjunction with a tarsoconjunctival graft for posterior lamellar reconstruction.15 The donor defect was repaired with a full-thickness skin graft. The long myocutaneous flap is a modification of the bipedicle flap,1 but since it has a single pedicle, it is at greater risk for distal flap necrosis.
Yazici et al. described the use of a superiorly based lateral periorbital bilobed flap for creation of an anterior lamella and a tarsoconjunctival graft for posterior lamellar reconstruction.14 This flap has a wide pedicle, which increases vascularity, and allows for a large area of skin to be transferred to the upper lid without lower lid distortion. Pincushion deformity can compromise functional and aesthetic results. To avoid this, the authors recommend sizing the flap lobes slightly smaller than the defect sites and utilizing a thin flap, except at its base.
There have been a variety of approaches that describe the use of novel anterior lamellar flaps in conjunction with well-described posterior lamella grafts to create an innovative overall approach. Ito et al. described the use of an advancement flap using excess skin of the upper lid in conjunction with an auricular graft with perichondrium.15 They use a bandage contact lens for two weeks after surgery, and reported no problems with ocular surface irritation. The main limitation is that the patient must have adequate excess skin adjacent to the defect for the creation of the advancement flap, and therefore is only recommended for small to medium defects of the upper lid.
Cheng et al.16 used a temporal myocutaneous flap for anterior lamellar reconstruction and a palatal mucosal graft for posterior lamellar reconstruction. This technique is an evolution of an approach reported by Putterman, in which a composite contralateral eyelid graft is paired with a temporal semicircular, vascularized flap.25 The myocutaneous flap, based on an orbicularis pedicle, is rotated 120°–180° through a “subcutaneous tunnel” to reach the defect site. It would seem that the vascular supply to the flap is tenuous, given its degree of rotation, distance travelled, and narrow pedicle. Yet the authors report excellent results and no serious complications.
Finally, Pushker et al. describe a lateral rotation flap that includes both the eyelid margin and lateral canthus in addition to the full-thickness lower lid advancement flap.17 One major drawback to this procedure is that it cannot be used for defects involving the medial canthus or those over 2/3 of the eyelid width, as available tissue from the lower lid that can be rotated is limited.9 In addition, the vector of pull required to bring the lateral aspect of the lower eyelid margin into continuity with the residual upper eyelid margin seems extreme.
Conclusion
Surgeons have been innovating both bridging and non-bridging techniques: in this review there were an equal number of articles in each category. Overall, tarsoconjunctival grafts are a popular posterior lamella substitute, as half of the articles reviewed used this. Harvesting a tarsconjunctival graft introduces risk to the unaffected contralateral upper eyelid, although donor site morbidity was not a commonly reported complication. For the anterior lamella, four out of the ten articles used a skin flap from the lower eyelid, which can be thought of as a Cutler-Beard modification, and six out of the ten used a skin flap from the periocular area. In general then, the trend among these articles is to use a graft to replace the posterior lamella and a flap for the anterior lamella.
Among the bridging techniques discussed, to reconstruct the posterior lamella, the surgeon may use a tarsoconjunctival flap (reverse modified Hughes) from the lower eyelid by itself or supplemented by ADA, or a conjunctival flap from the lower eyelid supplemented with a tarsal substitute (auricular cartilage, tarsconjunctival graft). The anterior lamella can then be reconstructed with a skin flap from the upper or lower eyelid or a skin graft over an orbicularis oculi muscle flap. A risk with any bridging technique, which, by definition, recruits tissue from the lower eyelid, is cicatricial retraction of the lower eyelid, particularly because there is not a surfeit of lower lid skin typically.
Among the non-bridging techniques discussed, the posterior lamella can be reconstructed with a tarsoconjunctival, auricular, or hard palate graft, and the anterior lamella can be reconstructed with a laterally or superiorly based flap. Any tarsal substitute, and particularly firmer ones, such as hard palate, auricular cartilage or ADA, carries the risk of abrading the cornea, as it can erode through a mucosal or conjunctival layer placed posterior to it. Donor sclera, though not utilized in the articles reviewed here, is another option that may reduce the risk of erosion through conjunctiva thanks to its more pliable consistency.
The cornea can also be abraded by skin or lanugo hair from a skin flap or graft, due to the fact that the normal lid margin architecture is absent with any of these reconstructive techniques (except with the lid switch flap, not discussed here). A mucous membrane graft or other revision that recesses the anterior lamella from the new lid margin may be indicated to alleviate this problem. In fact, the surgeon and patient should be prepared for revision surgery no matter what reconstructive technique is utilized, given the drastic anatomical changes that are inherent to a structure as dynamic as the upper eyelid.
The diversity of techniques demonstrates the creativity and ingenuity that these reconstructions call from the surgeon, as each patient’s characteristics, such as laxity of skin, whether the canthus or opposing eyelid is involved, the amount of residual anterior or posterior lamella, will all help to determine the technique chosen by the surgeon. Despite these advancements, the incidence of complications and revision surgeries remain relatively high. The mechanisms for postoperative complications are related to the altered anatomy of the substitute eyelid tissue: increased eyelid rigidity inherent with grafts or flaps, which can result in ptosis; graft contraction, which can result in entropion or retraction; and decreased eyelid protractor function, which can lead to lid retraction and lagophthalmos.5
Advances in non-bridging and bridging techniques are ongoing. Our study is limited due to the relative rarity of large upper eyelid defects. The largest case series in this review dealt with 17 upper eyelids. We only sought to review articles from the past ten years, and those that described a new technique or modification that was used on at least four patients. The scarcity of data makes significant analysis of each technique, and head-to-head comparison, unfeasible at this time. Future controlled, prospective studies, while challenging given the relative infrequency and variability of these types of defects, are needed to develop evidence-based recommendations for particular interventions.
Acknowledgments
Disclosure Statement:
Dr. Vinay Aakalu: In accordance with Taylor & Francis policy and my ethical obligation as a researcher, I am reporting that I am consultant to Horizon Pharmaceuticals. I have also received Grant Funding from the following:
Unrestricted Grant, Research to Prevent Blindness, NY,NY
P30 EY001792 National Eye Institute, National Institutes of health
I have disclosed those interests fully to Taylor & Francis, and I have in place an approved plan for managing any potential conflicts arising from this involvement.
Footnotes
Presentations: The content of this manuscript has not been presented or published elsewhere in any medium.
a
((“Eyelids/surgery”[Mesh]) AND “Reconstructive Surgical Procedures/methods” [Majr]) OR (upper eyelid reconstruction)
Bibliography
- 1.Fin A, De Biasio F, Lanzetta P, Mura S, Tarantini A, Parodi PC. Posterior lamellar reconstruction: a comprehensive review of the literature. Orbit. 2019;38(1):51–66. 10.1080/01676830.2018.1474236. [DOI] [PubMed] [Google Scholar]
- 2.Morley AM, deSousa JL, Selva D, Malhotra R. Techniques of upper eyelid reconstruction. Surv Ophthalmol. 2010;55(3):256–271. 10.1016/j.survophthal.2009.10.004.. [DOI] [PubMed] [Google Scholar]
- 3.Cutler ML, Beard C. A method for partial and total upper lid reconstruction. Am J Ophthalmol. 1955;39:1—7. 10.1016/0002-9394(55)92646-5.. [DOI] [PubMed] [Google Scholar]
- 4.Rajak SN, Malhotra R, Selva D. The ‘over-the-top’ modified Cutler-Beard procedure for complete upper eyelid defect reconstruction. Orbit. 2019;38(2):133–136. 10.1080/01676830.2018.1444061. [DOI] [PubMed] [Google Scholar]
- 5.Poh EW, O’Donnell BA, McNab AA, et al. Outcomes of upper eyelid reconstruction. Ophthalmology. 2014;121(2):612–3.e1. 10.1016/j.ophtha.2013.10.010. [DOI] [PubMed] [Google Scholar]
- 6.Mandal SK, Fleming JC, Reddy SG, Fowler BT. Total Upper Eyelid Reconstruction with Modified Cutler-Beard Procedure Using Autogenous Auricular Cartilage. J Clin Diagn Res. 2016;10(8):NC01–NC4. 10.7860/JCDR/2016/20303.8239. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Carroll RP. Entropion following the Cutler-Beard procedure. Ophthalmology. 1983September1;90(9):1052–5. 10.1016/s0161-6420(83)80046-3. [DOI] [PubMed] [Google Scholar]
- 8.Bengoa-González Á, Laslău BM, Martín-Clavijo A, Mencía-Gutiérrez E, Lago-Llinás MD. Reconstruction of Upper Eyelid Defects Secondary to Malignant Tumors with a Newly Modified Cutler-Beard Technique with Tarsoconjunctival Graft. J Ophthalmol. 2019;2019:6838415. 10.1155/2019/6838415. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Sa HS, Woo KI, Kim YD. Reverse modified Hughes procedure for upper eyelid reconstruction. Ophthalmic Plast Reconstr Surg. 2010;26(3):155–160. 10.1097/IOP.0b013e3181b8e5fd. [DOI] [PubMed] [Google Scholar]
- 10.Vahdani K, Siapno DL, Lee JH, Woo KI, Kim YD. Long-Term Outcomes of Acellular Dermal Allograft as a Tarsal Substitute in the Reconstruction of Extensive Eyelid Defects. J Craniofac Surg. 2018;29(5):1327–1331. 10.1097/SCS.0000000000004464. [DOI] [PubMed] [Google Scholar]
- 11.Toft PB. Reconstruction of large upper eyelid defects with a free tarsal plate graft and a myocutaneous pedicle flap plus a free skin graft. Orbit. 2016;35(1):1–5. 10.3109/01676830.2015.1078372. [DOI] [PubMed] [Google Scholar]
- 12.Patrinely JR, O’Neal KD, Kersten RC, Soparkar CN. Total upper eyelid reconstruction with mucosalized tarsal graft and overlying bipedicle flap. Arch Ophthalmol. 1999;117(12):1655–1661. 10.1001/archopht.117.12.1655. [DOI] [PubMed] [Google Scholar]
- 13.Moschella F, Cordova A. Upper eyelid reconstruction with mucosa-lined bipedicled myocutaneous flaps. Br J Plast Surg 1995; 48:294–299. 10.1016/0007-1226(95)90067-5. [DOI] [PubMed] [Google Scholar]
- 14.Yazici B, Ozturker C, Cetin Efe A. Reconstruction of Large Upper Eyelid Defects With Bilobed Flap and Tarsoconjunctival Graft. Ophthalmic Plast Reconstr Surg. 2019;10.1097. 10.1097/IOP.0000000000001557. [DOI] [PubMed] [Google Scholar]
- 15.Ito R, Maeda T, Yamamoto Y, et al. Advancement Flap Using Excess Skin for Upper Eyelid Full-Thickness Defects. J Craniofac Surg. 2019;30(8):2614–2616. 10.1097/SCS.0000000000005944. [DOI] [PubMed] [Google Scholar]
- 16.Cheng JX, Zuo L, Huang XY, Cui JZ, Wu S, Du YY. Extensive full-thickness eyelid reconstruction with rotation flaps through “subcutaneous tunnel” and palatal mucosal grafts. Int J Ophthalmol. 2015;8(4):794–799. 10.3980/j.issn.2222-3959.2015.04.27. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Pushker N, Batra J, Meel R, Bajaj MS, Chawla B, Ghose S. Lateral eyelid rotation flap: a novel technique for reconstruction of full thickness eyelid defect. Int Ophthalmol. 2015;35(6):793–799. 10.1007/s10792-015-0047-9. [DOI] [PubMed] [Google Scholar]
- 18.Saito A, Saito N, Furukawa H, et al. Reconstruction of periorbital defects following malignant tumour excision: a report of 50 cases. J Plast Reconstr Aesthet Surg. 2012;65(5):665–670. 10.1016/j.bjps.2011.09.012. [DOI] [PubMed] [Google Scholar]
- 19.Hsuan J, Selva D. Early division of a modified Cutler-Beard flap with a free tarsal graft. Eye (Lond). 2004;18(7):714–717. 10.1038/sj.eye.6701321. [DOI] [PubMed] [Google Scholar]
- 20.Yoon MK, McCulley TJ. Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure. Ophthalmic Plast Reconstr Surg. 2013;29(3):227–230. 10.1097/IOP.0b013e3182831c84. [DOI] [PubMed] [Google Scholar]
- 21.Graue-Morena Gerardo. Adding Stability to the Upper Lid: a Modified Cutler Beard Flat Technique. American Academy of Ophthalmology. https://www.aao.org/annual-meeting-video/adding-stability-to-upper-lid-modified-cutlerbeard. Updated December 13 2011. AccessedMay 5, 2020. [Google Scholar]
- 22.Lee HB, Nunery WR. Reconstruction of the upper lid. In: Yen MT, ed. Surgery of the eyelid lacrimal system, and orbit. New York: Oxford University Press; 2012:51–62. [Google Scholar]
- 23.Mustarde JC. Repair and reconstruction in the orbital region. 2nd ed. Churchill Livingston, Edinburgh: 1980; 130–151. [Google Scholar]
- 24.Hayek B, Hatef E, Nguyen M, Ho V, Hsu A, Esmaeli B. Acellular dermal graft (AlloDerm) for upper eyelid reconstruction after cancer removal. Ophthalmic Plast Reconstr Surg. 2009;25(6):426–429. 10.1097/IOP.0b013e3181b78989. [DOI] [PubMed] [Google Scholar]
- 25.Putterman AM. Combined viable composite graft and temporal semicircular skin flap procedure. American journal of ophthalmology. 1984September1;98(3):349–54. 10.1016/0002-9394(84)90327-1. [DOI] [PubMed] [Google Scholar]