Upper eyelid reconstruction

1. Upper Eyelid Reconstruction
Dr. Suiyibangbe
M.Ch 2nd year
Plastic and reconstructive Surgery

2. Anatomy
Eyelid is traditionally described as a bilaminar
structure.
Anterior lamella-skin and orbicularis muscle.
Posterior lamella-tarsal plate, medial and
lateral canthal tendons, capsulapalpebral
fascia, lid retractors and conjunctiva.

3. Skin
Thinnest in the body, measuruing about
0.3mm in some areas.
Surgical incisions within the skin of the eyelid
generally heal with almost imperceptible
scarring.

4. Orbocularis oculi muscles
They lie behind the skin.
Originated from the medial canthus and the
bone of medial orbit and inserted at hte
lateral canthus and lateral orbital rim.
Divided into palpebral & orbital regions
Palpebral region subdivided into pretarsal &
preseptal parts.
Responsible for lid closure

5. Orbital Septum
Fascial membrane which separates the eyelid
structures from the deep orbital structures
Barrier that helps prevent the spread of
hemorrhages, infection, inflammation.

6. Orbital Septum
 Upper lid: OS inserts
into the levator
aponeurosis 2-5mm
above the superior
portion of the tarsus.
 Lower lid: OS inserts
into the lower edge of
the tarsus

7. Tarsal plate
Thin elongated plates of connective tissue
Contribute to form and support the eyelids
Closely related to the LPS, medial, lateral canthal
structures
Superior tarsus 8-10mm tapering to the sides.
Inferior tarsus 4 mm
The tarsal palte are attached by the medial and
lateral canthal liagament
The meibomian glands are approximately 20 in
each lid within the substance opening in a row of
tiny dots corresponding to the Grey line –
mucocutaneous junction

8. Levator palpebral superioris
 Striated muscle (CN III)
 Origin: lesser wing of
sphenoid anterior to
the optic foramen
becomes aponeurotic 5-
7mm above the
superior border of the
tarsus and 10-14mm
below the whitnall’s
ligament.

9. Muller’s muscle
 Smooth muscle
(sympathetic)
 Posterior surface of the
levator muscle & inserts
at superior tarsal border
 Horner’s syndrome

10. Conjunctiva
• Mucosal layer adjacent to the surface of the
eye.
• Palpebral portion lines inner surface of eyelid.
• Bulbar portion lines sclera

11. Canthal tendons

12. Lacrimal System

13. Blood supply

14. Nerve supply
Upper eyelid- lacrimal, supraorbital,
supratrochlear, infratrochlear nerve.
Lower eyelid- infraorbital and infratrochlear
nerve

15. Lymphatic drainage
Medial halves of the eyelid drain into the
submandibular nodes.
Lateral halves into the preauricular nodes

16. Indication
To re-establish functional eyelid
Adequate protection of the eyeball
Reasonable cosmesis

17. Requirements
Smooth mucous membrane internal lining to
maintain lubrication of the ocular surface and
avoid corneal irritation.
Skeletal support to provide adequate lid rigidity
and shape.
Proper fixation of the medial & lateral canthal
attachments of the lids for eyelid stability &
orientation
Adequate muscle to provide tone & power for
closure.
Adequate levator action to lift the upper lid
above the visual axis.

18. In the reconstruction of both anterior &
posterior lamellae, at least one must have its
own blood supply
Techniques would depend on the size,
location, configuration, & depth of the defect
Superficial defect: only anterior lamella needs
to be repaired
Full thickness defect: needs reconstruction of
both layers

19. Anterior lamella
– Flaps - advancement, transposition, or
rotational musculocutaneous flaps
– Full thickness skin grafts

20. Posterior lamella:
– Tarsal conjunctival transposition, advancement
or rotational flap
– Free autogenous composite tarsal grafts
– Tarsal substitute grafts - sclera, nasal septal
chondromucosa, hard palate mucosa

21. Defects up to 25-50% can be close directly +/-
Canthal release
• Lateral Canthotomy • Inferior Cantholysis

22. Upper Eyelid Reconstruction
Direct Closure +/- lateral cantholysis
Tenzel Flap
Sliding Tarsoconjunctival Flap.
Posterior Lamellar Graft with local
myocutaneous flap
Cutler-Beard (Bridge) Flap

25. Direct Closure

26. Direct closure (20-30%)
• Advantages
• Lash continuity
• Disadvantages
• Ptosis possible with
tight closure

27. Tenzel or semicircular flap
(anterior lamella defect of upto 60%)
• Advantages
• Reconstructing of large
anterior lamella defects
• Disadvantages
• No lash restoration
• Requires posterior
lamella coverage

28. Tenzel Flap

29. Sliding tarsocunjunctival flap
(medial or lateral posterior lamilla defect)
• Advantages
• One step procedure.
• Composite flap (tarsal
and conjunctiva)
• Disadvantages
• No lash restoration
• Requires anterior
lamella coverage

30. Sliding Tarsoconjunctival Flap

31. Reverse Hughes
-Note: Another type of flap
good for up to 70% of
margin is the upper lid
advancement
tarsoconjunctival flap with
a skin graft.

32. Fricke flap (Temporl)
• Advantages
• Large anterior lamella
reconstruction.
• Disadvantages
• Two stages procedure
• Donar skin very thick
• Risk of frontal branch
lesion

33. Temporal Forehead Flap (Fricke Flap)

34. Posterior Lamellar Graft with Local
Myocutaneous Flap
Good for patients with skin laxity
Posterior lamella defect
– Conjunctival advancement.
– Supplement with ear cartilage
Anterior lamella
– Myocutaneous flap for blood supply

35. Posterior Lamellar Graft with
Local Myocutaneous Flap

36. Cutler-Beard (Bridge) Flap
Used for 60% to entire lid defects
Borrows skin, muscle and conjunctiva from
lower eyelid
Autogenous cartilage to provide support
Requires 2nd stage procedure

37. Cutler-Beard (Bridge) Flap

38. • Advantages
• Total eyelid reconstruction
• Disadvantages
• Two stage
• No lash restoration
• Risk of lower lid ectropion
• Need for tarsal replacement

39. Cutler-Beard (Bridge) Flap – 2nd
Stage Procedure

40. Pedicle Flap From Lower Lid
(Mustarde Lid Switch)

41. Mustarde flap
(broad shallow full thickness marginal defect of 30-60)
• Advantages
• Lash continuity
• Disadvantages
• Two stage
• May need tenzel flap to
close donar site

42. Lateral Canthal Reconstruction

43. Lateral Canthal Reconstruction

44. Split finger flap
reconstruction of medial canthus

46. Conclusion
Thorough understanding of eyelid anatomy
Understand basic techniques of repair
Challenging problem do to complex nature of
eyelid anatomy
Careful attention to detail with delicate
surgical technique required

47. Thank you