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SUMMARY
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DON’T FORGET
First and foremost, either the anterior or the posterior lamella must have its own blood supply.
There must be maximal horizontal stabilization with minimal vertical tension, proper canthal fixation, and an epithelialized internal surface.
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CLINICAL PEARLS
The amount of tissue laxity is a key factor in deciding which reconstructive method is most appropriate.
The precise identification of both the transverse edge of the levator aponeurosis and the facial nerve course are important to provide a properly functioning eyelid.
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PATIENT EDUCATION POINTS
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The eyelid consists of an anterior lamella (skin and orbicularis) and a posterior lamella (tarsal plate and conjunctiva). Thorough knowledge of these bilamellar tissues is the key to successfully reconstructing the eyelid and periocular region. Fundamental principles of eyelid reconstruction must be taken into consideration to achieve optimum functional and cosmetic outcomes. First and foremost, either the anterior or the posterior lamella must have its own blood supply. Two free grafts without independent blood supplies are very unlikely to survive.
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Furthermore, there must be maximal horizontal stabilization with minimal vertical tension, proper canthal fixation, and an epithelialized internal surface.1 Lastly, the precise identification of both the transverse edge of the levator aponeurosis and the facial nerve course are essential to ensure proper opening and closing of the reconstructed eyelid. Proper alignment and function of the eyelid are necessary to prevent ocular exposure and protect the globe.
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Anterior Lamella Deficit, Lid Margin Intact
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Anterior lamella defects without lid margin involvement are generally closed if distortion is not induced. The closure should be directed along a primarily horizontal tension line rather than a vertical plane to minimize lid margin distortion. Horizontal undermining and subsequent closure necessitate a vertical incision. The defect is closed with deep, interrupted 5-0 Vicryl sutures and interrupted, superficial 6-0 plain gut or 7-0 nylon sutures. Care should be taken to avoid horizontal lid distortion. If there is insufficient anterior lamella remaining, a full-thickness pentagonal wedge that includes the anterior lamella defect may be required. The wedge is excised with a #15 blade (the lid may be secured in a chalazion clamp to protect the globe) or Wescott scissors. The tarsal borders must be sharp and perpendicular to the lid margin. This resulting full-thickness defect is then closed primarily as outlined on the following page.
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A full-thickness skin graft may be used to repair defects that are too large for primary closure. Split-thickness skin grafts are generally ...