Author Affiliations: Lions Eye Institute, Perth, Australia (Dr deSousa); Corneoplastic Unit, Queen Victoria Hospital, East Grinstead, England (Dr deSousa and Mr Malhotra); Oculoplastic and Orbital Unit, Department of Ophthalmology, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel (Dr Leibovitch); Department of Ophthalmology, Royal North Shore Hospital, Sydney, Australia (Dr O’Donnell); Orbital, Plastic, and Lacrimal Clinic, Department of Ophthalmology, Royal Brisbane and Women's Hospital, Brisbane, Australia (Prof Sullivan); and Oculoplastic and Orbital Division, Department of Ophthalmology and Visual Sciences, University of Adelaide and South Australian Institute of Ophthalmology, Adelaide, Australia (Prof Selva).
To describe techniques used for reconstruction of the eyelids following total loss of the upper and lower eyelids and to describe visual and functional outcomes.
Multicenter, retrospective, interventional case series of all of the patients requiring unilateral reconstruction of both the upper and lower eyelids.
Six cases were identified, 1 following trauma and 5 following tumor excision (4 with basal cell carcinoma and 1 with melanoma). The median age was 69 years (range, 18-90 years). Primary repair using preserved tissue was carried out in the case of traumatic avulsion. Following tumor excision, bilamellar repair was performed using composite grafts for the posterior lamella and skin-muscle flaps for the anterior lamella. Graft necrosis occurred in 3 cases (50%). In all of the cases, the reconstructed eyelids were stiff and immobile. Lagophthalmos (6 cases [100%]), ptosis (3 cases [50%]), lower eyelid retraction (3 cases [50%]), and ectropion (2 cases [33%]) were common. Useful vision was retained in all of the cases.
Total eyelid defects are rare and often unanticipated. Adequate corneal protection can be achieved using lamellar repair principles and local tissues; however, poor vascularity demands careful planning, with vascularized flaps favored over free grafts. Reconstructed eyelids have poor function in the setting of total upper and lower eyelid loss, and revision surgery is often required to improve eyelid structure and function.
We use the term total eyelid defect to describe the unilateral loss of the full thickness of the upper and lower eyelids, including the tarsi and overlying anterior lamellar tissue from medial to lateral canthus. Loss of the upper and lower eyelids with preservation of a seeing eye is a rare event that may result from burns, trauma, or periocular tumor excision.
This type of defect presents a reconstructive challenge owing to both its size and the fact that reconstructive techniques relying on neighboring tissue are often not possible.1 Furthermore, the peripheral and marginal eyelid vascular arcades may have also been lost, compromising the vascularity of reconstructed eyelids. With a preserved globe and vision, adequate corneal protection is the prime goal; however, for functional repair, the eyelids also need to be sufficiently mobile to open and clear the visual axis.
For reconstruction of these defects, Mustardé2 suggested mobilizing conjunctival flaps from the remaining forniceal conjunctiva and securing these over the cornea. A midline forehead flap is then used for the anterior lamella. Division of the new eyelids may be performed several weeks later, but there is a tendency for the eyelids to be very thick, stiff, and immobile.
While reviewing the literature, we found 7 cases of total eyelid defects, 4 following trauma,3- 5 2 following burns,6,7 and 1 following periocular tumor excision.8 The remaining conjunctiva was used to provide corneal coverage in 4 cases,3,4,6 whereas nasal chondromucosa and buccal mucosa were used for the posterior lamella in another.7 Anterior lamellar repair was described with pedicled tissue flaps,3,4 sandwich flaps containing pedicled muscle under free skin grafts,7 and free flaps.6
Lesser defects of both eyelids after tumor excision have been repaired with composite grafting for the posterior lamellar and anterior lamellar flaps.9- 13 Results have been variable, with the best function and cosmesis seen when some eyelid tissues were preserved, particularly the tarsus and the pretarsal and preseptal orbicularis.10,12
The aims of this study are to describe methods of reconstruction that may be used to deal with these difficult cases and to examine the structural and functional outcomes. This is the largest reported series of the management of total eyelid defects of which we are aware.
This is a retrospective multicenter review including cases treated during the last 15 years. Four specialist oculoplastic centers were included. Local institutional review board approval was obtained. Cases of total eyelid reconstruction were collected from clinical databases, and patient records were reviewed. Collected data included patient demographics, previous surgery, visual acuity, defect size, technique of repair, complications, further surgery, and final visual outcome.
Six cases requiring total upper and lower eyelid reconstruction were identified and are summarized in Table 1. There were 3 male and 3 female patients; the median age was 69 years (range, 18-90 years). Follow-up ranged from 9 to 153 months.
The cause of tissue loss was traumatic avulsion in 1 case and tumor excision in 5 cases (4 with recurrent basal cell carcinoma [BCC] and 1 with melanoma in situ). All of the patients had useful vision in both eyes prior to trauma or tumor excision. Two cases with recurrent eyelid BCC had lagophthalmos preoperatively, otherwise the eyelid function and ocular surface were normal before surgery. The case with traumatic avulsion sustained significant periorbital fractures without evidence of globe injury. In the periocular malignancy cases, there was no clinical or radiologic evidence of orbital involvement.
Margin-controlled excision was performed in all of the tumor cases, Mohs micrographic excision in 4 and modified en-face frozen-section margin-controlled excision in 1.14 Total eyelid defects were not anticipated prior to tumor excision; however, patients were aware of the potential for incomplete Mohs excision and advisability of orbital exenteration in the event of orbital extension.
The defects involved the full thickness of the upper and lower eyelids including pretarsal and preseptal orbicularis in 5 cases, whereas 1 case had a thin sliver of upper tarsus and upper preseptal orbicularis preserved. The medial and lateral canthal tendons and canaliculi were lost in all of the cases, with the defect including the lacrimal sac in 3 cases. The inferior fornix was lost in 2 cases, the remainder had residual inferior fornix, and all of the cases had some preserved superior forniceal conjunctiva.
Reconstruction was performed within 24 hours of injury or tumor excision. In the trauma case, primary repair was carried out using the avulsed tissues. In the cases of reconstruction following tumor repair, lamellar repair was planned in all and the methods used are summarized in Table 2. A single anterior lamellar flap was used with planned division postoperatively in 1 case, whereas the remaining 4 cases had separately reconstructed upper and lower eyelids. Free composite grafts of tarsoconjunctiva, hard palate mucosa, or nasal chondromucosa were used for posterior lamellar reconstruction. These were secured to residual medial and lateral canthal structures where present and to a reflected periosteal flap in 1 case with complete loss of the lateral canthal tendon. For the anterior lamella, skin flaps or skin grafts with an interposed orbicularis flap were used.
An 18-year-old man (Figure 1) sustained a partial facial degloving injury in a motor vehicle crash. The left upper and lower eyelids were avulsed, including the canthal tendons and lacrimal canaliculi, sac, and gland, with the defect extending to involve the cheek laterally to the hairline (Figure 1A). The avulsed tissues remained attached on a narrow inferolateral pedicle. Fractures of the orbital floor, medial and lateral walls, and zygoma were present. The globe was intact clinically, although vision and extraocular movements could not be assessed.
Case 1 with traumatic avulsion. A, Total eyelid and partial cheek avulsion from projectile trauma. B, Orbital reconstruction using bone grafts and miniplate fixation. C, Immediate postoperative result. D, Reconstructed eyelid 9 months postoperatively on attempted eyelid closure.
Reconstruction was performed with miniplate fixation and iliac bone grafts for the bony defects (Figure 1B). Necrotic cheek muscle, mainly masseter, was débrided. The orbicularis appeared marginally viable but was all preserved. The soft tissues were reposited anatomically and secured (Figure 1C).
A 90-year-old man (Figure 2) had recurrent morpheic BCC (Figure 2A). Three previous excisions had been performed on separate occasions, with reconstructions including direct closure, a semicircular lateral cheek advancement flap, and a nasal chondromucosal composite graft with cheek advancement. Mohs micrographic excision resulted in a total eyelid defect including the canaliculi and canthal tendons (Figure 2B).
Case 2 with basal cell carcinoma excision. A, Preoperative multiply recurrent basal cell carcinoma. B, Following Mohs excision. The defect involves the full thickness of the upper and lower eyelids. Residual preseptal orbicularis has been secured over the cornea. C, Reconstruction, with pedicled orbicularis flaps secured over an upper eyelid free tarsal graft and a lower eyelid hard palate graft. D, A free skin graft placed for the eyelid anterior lamella defect and a skin advancement flap for the subbrow defect. E, One month postoperatively with graft necrosis. Large areas of the free skin graft supported by the orbicularis flap failed. F, Result 3 months postoperatively without any further intervention. The upper eyelid covers the visual axis and ptosis repair is planned.
Posterior lamellar repair was achieved using a free tarsal graft from the contralateral upper eyelid for the upper eyelid and a hard palate graft for the lower eyelid. These were secured to residual tissues at the medial and lateral canthi and to the forniceal conjunctiva using absorbable sutures. Bipedicled flaps of the remaining preseptal and orbital orbicularis were formed in the upper and lower eyelids and advanced to the eyelid margins to cover the posterior lamellar composite grafts (Figure 2C). A single large free skin graft from the supraclavicular fossa was placed over the eyelids and a central fenestration created to form the new palpebral aperture. The remaining subbrow defect was repaired using a laterally based forehead flap (Figure 2D).
A 65-year-old woman (Figure 3) had multiple recurrences of medial canthal BCC (Figure 3A). Three excisions and reconstructions had previously been performed. Modified en-face frozen-section margin-controlled excision resulted in a total eyelid defect including the canthal tendons and canaliculi and an extensive medial canthal defect involving the lacrimal sac (Figure 3B).
Case 3 with basal cell carcinoma excision. A, Preoperative appearance with recurrent basal cell carcinoma. B, The defect following en-face margin-controlled excision. C, Nasal chondromucosal grafts were secured for posterior lamella. D, The midline forehead flap was elevated for anterior lamellar repair. E, The flap was secured and drains were placed. F, Appearance 6 months postoperatively.
A large nasal septal chondromucosal graft was harvested and divided to reconstruct separate upper and lower eyelid posterior lamellae (Figure 3C). The grafts were secured to medial and lateral tissues and the forniceal conjunctiva with absorbable sutures. A single midline forehead flap was used for the anterior lamella (Figure 3D and E). Upper and lower eyelid drains were placed. Flap division was performed at 6 weeks with restoration of a small palpebral aperture.
A 77-year-old man (Figure 4) had multiple recurrences of lateral canthal BCC (Figure 4A). Previous reconstructions included a Mustardé cheek rotation flap and Fricke forehead flap. Radiotherapy had been given to the lateral canthal area 10 years previously. Mohs micrographic excision resulted in contiguous 55 × 10-mm upper eyelid and 46 × 13-mm lower eyelid defects after 5 stages and 15 sections. The defect involved the full thickness of the upper and lower eyelids including the tarsi, canthal tendons, inferior fornix, canaliculi, and lacrimal sac (Figure 4B).
Case 4 with basal cell carcinoma excision. A, Preoperative appearance with recurrent basal cell carcinoma. B, Following Mohs excision, showing the total eyelid and lacrimal sac defect. C, The planned islanded pedicled flap was marked with Doppler ultrasonographic localization of the superficial temporal artery branch. D, The pericranial flap was marked after elevation of the forehead flap in the subgaleal plane. E, The pericranial flap was tunneled under glabellar skin to form the lower eyelid posterior lamella. F, The islanded pedicled forehead flap was mobilized. G, The forehead flap positioned in the upper eyelid over a posterior lamella free tarsal graft, and a lower eyelid free skin graft. H, Necrosis and contraction of the lower eyelid free skin graft at 4 weeks after repair. Expansion of the upper eyelid flap was due to an underlying cyst formed by trapped tears. I, Division of the upper eyelid flap revealing well-formed fornices from the lacrimal cyst. J, Appearance 10 months postoperatively on attempted eyelid closure.
A midline pericranial flap was raised and tunneled under the glabellar skin to form the lower eyelid posterior lamella and to provide a blood supply for an overlying free supraclavicular skin graft (Figure 4E). For the upper eyelid, a free tarsal graft was secured to the forniceal conjunctiva and medial and lateral canthal tissues. An islanded, pedicled suprabrow forehead flap based on the anterofrontal superficial temporal artery branch was planned for the anterior lamella of the upper eyelid. The artery was identified by Doppler ultrasonography preoperatively and marked (Figure 4C). The flap was elevated on its vascular pedicle (Figure 4F) and tunneled under the remaining lateral canthal skin to form the anterior lamella of the upper eyelid. The reconstructed upper and lower eyelids were secured together, leaving a small central palpebral aperture (Figure 4G). A drain was placed in the forehead.
In the case with trauma, exposure keratopathy resulted from severe lagophthalmos and absent Bell's phenomenon and required a temporary central suture tarsorrhaphy postoperatively. In the cases following tumor reconstruction, adequate corneal protection was achieved in the immediate postoperative period.
Grafted tissue in the reconstructed eyelids failed in 3 cases. The free skin grafts over an orbicularis flap in case 2 (Figure 2E) and the posterior lamellar hard palate graft in case 6 underwent partial necrosis; however, these did not require acute revision. In case 4, the lower eyelid free skin graft placed over a pericranial flap was lost, as it was compromised by vascular congestion of the large upper eyelid pedicled island forehead flap (Figure 4H). This resulted in the upper eyelid flap forming the anterior lamella of both eyelids, which required unplanned division at 6 weeks to expose the eye and create a palpebral aperture (Figure 4I).
All of the patients had some degree of rigid eyelids that neither opened nor closed; lagophthalmos ranged from 1 to 4 mm and resulted in corneal exposure in 5 cases (Figure 1D, Figure 2F, Figure 3F, and Figure 4J). The least corneal exposure was seen in the patients who had secondary division of a single eyelid flap and very small horizontal palpebral apertures. The best eyelid function was seen in case 6, where there was preservation of pretarsal orbicularis. Further surgery to address eyelid abnormalities was performed or planned in all of the cases (Table 3). Ptosis, lower eyelid retraction, and ectropion were the problems addressed.
Other than the case with trauma that involved lacrimal gland avulsion, all of the patients had epiphora following reconstruction. Conjunctivodacryocystorhinostomy was offered to 2 patients but declined.
Useful vision was retained in all of the patients (Table 3). Mild exposure keratopathy was present in 3 cases, but corneal problems reduced vision in only 1 case.
No cases of periocular malignancy had recurrence at the final follow-up.
Total eyelid defects are rare. In this series encompassing 15 years of experience from 4 oculoplastic centers, only 6 cases were identified.
The most commonly reported cause of total eyelid defect is trauma.3- 5 In our case of trauma, the avulsed tissues had been ischemic for several hours before replantation but did survive, demonstrating that because of the good vascular supply in the periocular area, efforts should be made to retain all of the available tissue.
It is rare for skin malignancies to require excision of the full thickness of both the upper and lower eyelids without involvement of the orbit. Malhotra et al15 identified 1 case of upper and lower eyelid BCC involvement in 1295 cases following Mohs surgery. The encircling BCCs seen in 4 of our cases followed recurrence of lesions previously excised from the canthal regions and closed with flaps of tissue, possibly bringing residual disease closer to the opposite canthus. Encircling involvement was not suspected prior to margin-controlled excision.
Corneal protection is the urgent concern in the reconstruction of large eyelid defects. If there is any delay in reconstruction, corneal lubrication and moist chambers should be used.
There are many methods that may be applied to reconstruct full-thickness eyelid defects.1 In our cases, autologous composite tissue grafts were chosen to provide rigid posterior lamellar support and mucosa. Hard palate and nasal septal chondromucosa can provide sufficient tissue for both eyelids, whereas free tarsoconjunctival grafts can be used for only 1 eyelid. Free tarsal grafts are associated with fewer complications than hard palate grafts in the upper eyelid.16 A vascularized composite flap of nasal chondromucosa from the lateral nasal wall has also been described17; however, the amount of tissue available is sufficient for only 1 eyelid.
It is perhaps not necessary to use rigid tissue in the posterior lamella during the primary procedure. We found that with large bilamellar repairs, the resulting eyelids were relatively stiff, immobile, and rigid even when nonrigid tissue was used for the posterior lamella. This would simplify reconstruction because large mucous membrane grafts, amniotic membrane, or fascial flaps could be considered. Lack of rigid support may lead to late complications related to eyelid margin instability18; however, rigid tissue can be grafted as a secondary procedure if necessary.1,8
Despite the lack of canthal tendons, we were able to find sufficient medial and lateral rigid fixation for all of the composite grafts, either to remnants of the deep components of the canthal tendons or to reflected periosteal flaps. The remaining forniceal conjunctiva was also secured to the graft, but no effort was made to reattach the levator aponeurosis or lower eyelid retractors during the initial procedure because corneal exposure was a greater postoperative concern than ptosis.
The presence of a free tissue graft in the posterior lamella demands an overlying vascular flap for the anterior lamella. A single large flap from the midline forehead or a pedicled superficial temporal artery–based scalp island flap19 can be used to cover both eyelids, with separation of the flap after several weeks to re-form the palpebral aperture. Superficial temporal artery–based flaps tend to have poor venous drainage and may become congested postoperatively.19,20
If the anterior lamellae of the upper and lower eyelids are to be reconstructed individually, a variety of options exists. For the lower eyelid, rotation, transposition, and advancement flaps from the cheek may be constructed. In the upper eyelid, lateral cheek advancement and forehead transposition flaps may be used.1 Patients who have had previous eyelid surgery may not have all of the flap options available. Flaps of scalp skin are thicker than the normal eyelid and may require revision debulking to improve mobility of the eyelids.2
Mobilized, pedicled orbicularis flaps may be used to support free grafts of both the posterior and anterior lamellae (sandwich flaps).21 Although orbicularis has a good blood supply, care should be taken in the presence of defects involving the pretarsal and preseptal muscle because the marginal and peripheral vascular arcades will also be deficient. In 1 of our cases, a free skin graft supported by an underlying pedicled orbicularis flap failed. Free tissue flaps with microvascular anastomosis may also be used to reconstruct the anterior lamella, and flaps based on the dorsal metacarpal artery22 and dorsalis pedis6 to the eyelids have been described following burns.
While these methods of repair have produced good structural and functional results in reconstruction of isolated upper or lower eyelid defects, the functional results in the case of total eyelid defect were not as good regardless of the techniques used. All of our cases of bilamellar eyelid repair had some degree of eyelid rigidity manifested by ptosis and lagophthalmos. The protractors of the eyelid—the pretarsal and preseptal orbicularis—were lost, and muscle in the reconstructed eyelid was poor in achieving eyelid closure. Although the levator remains intact, ptosis repair in this setting may result in significant lagophthalmos and corneal exposure. It was performed cautiously in 1 case to clear the visual axis.
Exposure keratopathy was seen in most cases and was well tolerated. Less corneal exposure was seen in patients who had a single anterior lamellar flap divided at a secondary procedure than in those who had reconstruction designed to create independent upper and lower eyelids. This may be related to the small horizontal palpebral aperture (10-15 mm) created in these patients.
In all of our cases, some degree of eyelid malposition existed after the primary repair. With extensive reconstruction, the tarsoligamentous sling of the eyelid and muscle of the anterior lamella are compromised. Further surgery to correct ectropion, ptosis, or eyelid retraction is likely to be necessary.
Epiphora occurred in all of our cases with an intact lacrimal gland. Thai et al6 elected to perform conjunctivodacryocystorhinostomy to avoid tear pooling within the enclosed conjunctival fornix in their case. Tear drainage to prevent infection is probably not necessary and could be achieved by maintaining a small palpebral opening at the medial canthus. Without tear drainage in an eye with an enclosed conjunctival sac, as in our case 4, a lacrimal cyst with expanded conjunctival fornices may occur. This unexpectedly provided abundant conjunctival mucosa when the fused eyelids were later separated (Figure 4I).
With extensive periocular defects, preservation of the eye complicates reconstruction and it may seem that better aesthetic results could be obtained with loss of the eye.2 Our patients who underwent extensive reconstructive surgery for the repair of total eyelid defects all expressed a strong desire to retain the eye and were keen for further surgery to improve the postoperative eyelid function. Vision was retained and no patients required the eye to be condemned to total tarsorrhaphy and banked as a spare.
Adequate corneal protection can be achieved with reconstruction aiming to create 2 functional eyelids. The use of vascularized flaps, including such options as pericranial tissue and islanded free flaps, should be considered instead of free grafts to avoid problems due to poor vascularity. Ptosis and lagophthalmos with stiff, immobile eyelids and epiphora remain significant postoperative problems; however, useful vision can be preserved.
Correspondence: Raman Malhotra, FRCOphth, Corneoplastic Unit, Queen Victoria Hospital, Holtye Road, East Grinstead RH19 3DZ, West Sussex, England (email@example.com).
Submitted for Publication: April 14, 2007; final revision received August 23, 2007; accepted August 30, 2007.
Financial Disclosure: None reported.
Previous Presentation: This work was presented at the 2006 joint meeting of the British Oculoplastic Surgery Society and the European Society of Ophthalmic Plastic and Reconstructive Surgery; September 16, 2006; London, England.
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