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EYELID RECONSTRUCTION

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SUMMARY

  • Eyelid reconstruction lies at the crossroads of multiple surgical specialties, and presents distinct challenges for the periocular surgeon.

  • The unique multilaminate composition of the eyelids, freely mobile yet bound by fixed bipolar attachments, is vulnerable to tensional forces that require diligent management to preserve their unique anatomic and functional relationships.

image Beginner Pearls

  • Preoperative evaluation and collaboration with ophthalmic and oculoplastic specialists when indicated is essential for optimal outcomes.

  • Knowledge of and familiarity with the management of tension are essential to periocular surgery.

  • Tension on the lid margin should be assessed pre-, post-, and intraoperatively to ensure the lid remains in optimal position snug against the globe.

image Expert Pearls

  • Keeping tension parallel to the lid margin is the cornerstone of periocular repairs, and is often balanced with placing incisions along relaxed skin tension lines.

  • Transposition flaps and rotation flaps are useful for many periocular defects.

  • Primary repair of full-thickness lid defects is fundamental to more advanced reconstructive techniques.

image Don’t Forget!

  • Reconstruction of larger full-thickness lid defects involves a progressive approach with a combination of techniques to repair the anterior and posterior lamella.

  • Suspension sutures should be used routinely to support periocular repairs and avoid ectropion, even when the canthal support has not been disrupted by tumor extirpation.

image Pitfalls and Cautions

  • Full-thickness skin grafts must be appropriately sized with the defect on full stretch to avoid excessive wound contraction and ectropion.

  • Complications include bleeding, infection, hematoma, chemosis, epiphora, dry eye, suture granuloma, trichiasis, lid notching, scleral show, asymmetry, ectropion, and webbing.

  • Even mild ectropion can cause significant epiphora and discomfort and may require a slit-lamp examination to evaluate for corneal abrasion.

image Patient Education Points

  • Select patients undergoing extensive surgery around the eye may have a preoperative ocular examination and consultation with an oculoplastic surgeon to ensure a smooth transition of care if needed.

  • Both ectropion and webbing tend to occur 2 to 4 weeks postoperatively during maximal wound contraction. Correction usually requires flap revision and canthopexy procedures.

image Billing Pearls

  • Excisions and repairs on the eyelid rely on the standard code series; keep in mind that placement of suspension sutures in a linear repair is likely sufficient to elevate a layered closure to complex status.

INTRODUCTION

Eyelid reconstruction lies at the crossroads of multiple surgical specialties, and presents distinct challenges for the periocular surgeon. The unique multilaminate composition of the eyelids, freely mobile yet bound by fixed bipolar attachments, is vulnerable to tensional forces that require diligent management to preserve their unique anatomic and functional relationships. The eyelids not only protect the globe and provide a tear film necessary for visual perception, but also hold great aesthetic significance. An understanding of anatomy, principles, and fundamental techniques of periocular surgery is a prerequisite for addressing methods of managing tension on the eyelids.

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