Reconstruction of eyelids defects after congenital , traumatic, iatrogenic causes

1. Reconstruction of Eyelids
Defects
Mohamed A. S. M. El-Rouby, M D
Professor of Plastic, Burn and Maxillofacial Surgery Department
Ain Shams University, Cairo, EGYPT

2. • Eyelids
• are complex structures
• play a role in protecting the globe and maintaining the integrity of
tear film with their dynamic movement.
• Eyelid defects
• can be in form or in function
2

3. Wound
Reconstruction
Restore & Replace
"like with like.“
Aesthetic
Reconstruction
+ Anatomical integrity
+ Physiological function
+ Cosmesis & blending
3

4. OBJECTIVES
1. Anatomical integrity
• Lining: mucosal surface
• Margin: No stratified squamous epithelium, No lashes.
• Frame: Flexible & firm tissue (Tarsus).
• Normal horizontal tension (Medial & Lateral canthal tendon positions)
2. Physiological function
• Restore mobile upper eyelid without ptosis or lagophthalmos.
3. Cosmesis & blending
• acceptable cosmetic appearance in relation to the contralateral eyelid
(symmetry of height, contour, scleral show, and skin fold)
4

5. 5

6. Etiology
Timing
Preoperative Planning
• Patient assessment
• Defect analysis
• Principles & guidelines
•Surgical Procedures
Postoperative care &
complications
STEPWISE
APPROACH FOR
RECONSTRUCTION
6

7. ETIOLOGY OF DEFECTS
Anatomical Defects Congenital defects
Functional defect Acquired defects
7

8. A- Anatomical Defects: Congenital
Coloboma of upper lid Coloboma of lower lid
Fascial cleft Epicanthal fold
8

9. A- Anatomical Defects: Acquired
Basal Cell Ca. Squamous Cell Ca. Malignant Melanoma
Trauma Burn StyeIatrogenic
9

10. B- Functional Defects: Congenital
Entropion
Ptosis
Ectropion
Telecanthus
10

11. B- Functional Defects: Acquired
Entropion Ectropion
Ptosis Retraction Telecanthus
11

12. C- Biomechanical Effects
• Periorbital factors:
• Forehead and brow (aging - injury – flaps)
• Eyeball (exophthalmos – enophthalmos)
• Cheeks (injuries – flaps – VII palsy)
• General factors:
• Medical diseases (renal failure)
• Vitamin Deficiency
• Facial Palsy
Effects:
• Ptosis
• Retraction
• Ectropion
• Entropion
• Discoloration
12

13. TIMING
• Congenital defects
- with exposed cornea  within the first week
- without exposed cornea  may be delayed for a year
• Traumatic defects  within a few hours
• After Tumor excision  immediately, (MOH’s or Frozen section)
13

14. PREOPERATIVE
PLANNING
Patient assessment
Defect Analysis
14

15. PREOPERATIVE PLANNING
• Patient
• age, general health, malignancy, anticoagulants, visual status and expectation
• Defect
• Etiology, Timing of presentation, Extent and Missing tissue.
• Periorbital tissues (soft tissue or bony).
• Surgeon’s own expertise
• Facilities.
15

16. Defect 3D Analysis
• Obvious & hidden injuries (traumatic and congenital defects)
• Horizontal & Vertical extent  measured and photographed.
• Lamellar planes & Functional units for both lids:
• Configuration and amount of residual tarsus
• Structures for canthal fixation
• Type of tissue “like-for-like” replacement.
• Amount of tissue required for reconstruction
16

17. Defect 3D Analysis (continue)
• Periorbital and midface assessment
• Associated injuries to forehead, cheek and nose
• Orbital skeleton
• Contour deformity
• Eyelid-Cheek vector
• Contralateral lid
• Measurements
• Shape & Position
• Tone
17

18. Surgical Zones Spinell and Jelks 1993
• Zone I, upper eyelid.
• Zone II, lower eyelid.
• Zone III, medial canthal area &
lacrimal drainage system.
• Zone IV, lateral canthal area.
• Zone V, periocular contiguous areas
(glabella, eyebrow, forehead, temple,
malar, nasojugal and nasal areas).
18

19. PRINCIPALS AND GUIDELINES
19

20. 1. Documentation: measurement, photography
2. Rule out occult injuries.
3. Laissez faire technique causes contracture.
4. Primary closure is first choice.
5. Tension should be drawn horizontally.
6. Avoid medial canthotomy, Lateral canthotomy on the lower limb of the
ligament.
7. In lacerated wounds (the orbital septum?) (debatable).
8. The lower eyelid can safely be used as donor for upper eyelid defect.
9. Reconstruction by innervated orbicularis muscle flap (dynamic) or with a
tendon sling (static) are superior to cartilage graft in the lower eyelid.
10. Hughes tarsoconjunctival flap, should be avoided in children.
11. The flap pedicle should be above the level of the canthal ligaments.
20

21. 1. Documentation: measurement, photography
2. Rule out occult injuries.
3. Laissez faire technique causes contracture.
4. Primary closure is first choice.
5. Tension should be drawn horizontally.
6. Avoid medial canthotomy, Lateral canthotomy on the lower limb of the
ligament.
7. In lacerated wounds (the orbital septum?) (debatable).
8. The lower eyelid can safely be used as donor for upper eyelid defect.
9. Reconstruction by innervated orbicularis muscle flap (dynamic) or with a
tendon sling (static) are superior to cartilage graft in the lower eyelid.
10. Hughes tarsoconjunctival flap, should be avoided in children.
11. The flap pedicle should be above the level of the canthal ligaments.
21

22. 1. Documentation: measurement, photography
2. Rule out occult injuries.
3. Laissez faire technique causes contracture.
4. Primary closure is first choice.
5. Tension should be drawn horizontally.
6. Avoid medial canthotomy, Lateral canthotomy on the lower limb of the
ligament.
7. In lacerated wounds (the orbital septum?) (debatable).
8. The lower eyelid can safely be used as donor for upper eyelid defect.
9. Reconstruction by innervated orbicularis muscle flap (dynamic) or with a
tendon sling (static) are superior to cartilage graft in the lower eyelid.
10. Hughes tarsoconjunctival flap, should be avoided in children.
11. The flap pedicle should be above the level of the canthal ligaments.
22

23. 1. Documentation: measurement, photography
2. Rule out occult injuries.
3. Laissez faire technique causes contracture.
4. Primary closure is first choice.
5. Tension should be drawn horizontally.
6. Avoid medial canthotomy, Lateral canthotomy on the lower limb of the
ligament.
7. In lacerated wounds (the orbital septum?) (debatable).
8. The lower eyelid can safely be used as donor for upper eyelid defect.
9. Reconstruction by innervated orbicularis muscle flap (dynamic) or with a
tendon sling (static) are superior to cartilage graft in the lower eyelid.
10. Hughes tarsoconjunctival flap, should be avoided in children.
11. The flap pedicle should be above the level of the canthal ligaments.
23

24. 1. Documentation: measurement, photography
2. Rule out occult injuries.
3. Laissez faire technique causes contracture.
4. Primary closure is first choice.
5. Tension should be drawn horizontally.
6. Avoid medial canthotomy, Lateral canthotomy on the lower limb of the
ligament.
7. In lacerated wounds (the orbital septum?) (debatable).
8. The lower eyelid can safely be used as donor for upper eyelid defect.
9. Reconstruction by innervated orbicularis muscle flap (dynamic) or with a
tendon sling (static) are superior to cartilage graft in the lower eyelid.
10. Hughes tarsoconjunctival flap, should be avoided in children.
11. The flap pedicle should be above the level of the canthal ligaments.
24

25. 1. Documentation: measurement, photography
2. Rule out occult injuries.
3. Laissez faire technique causes contracture.
4. Primary closure is first choice.
5. Tension should be drawn horizontally.
6. Avoid medial canthotomy, Lateral canthotomy on the lower limb of the
ligament.
7. In lacerated wounds (the orbital septum?) (debatable).
8. The lower eyelid can safely be used as donor for upper eyelid defect.
9. Reconstruction by innervated orbicularis muscle flap (dynamic) or with a
tendon sling (static) are superior to cartilage graft in the lower eyelid.
10. Hughes tarsoconjunctival flap, should be avoided in children.
11. The flap pedicle should be above the level of the canthal ligaments.
25

26. 1. Documentation: measurement, photography
2. Rule out occult injuries.
3. Laissez faire technique causes contracture.
4. Primary closure is first choice.
5. Tension should be drawn horizontally.
6. Avoid medial canthotomy, Lateral canthotomy on the lower limb of the
ligament.
7. In lacerated wounds (the orbital septum?) (debatable).
8. The lower eyelid can safely be used as donor for upper eyelid defect.
9. Reconstruction by innervated orbicularis muscle flap (dynamic) or with a
tendon sling (static) are superior to cartilage graft in the lower eyelid.
10. Hughes tarsoconjunctival flap, should be avoided in children.
11. The flap pedicle should be above the level of the canthal ligaments.
26

27. 1. Documentation: measurement, photography
2. Rule out occult injuries.
3. Laissez faire technique causes contracture.
4. Primary closure is first choice.
5. Tension should be drawn horizontally.
6. Avoid medial canthotomy, Lateral canthotomy on the lower limb of the
ligament.
7. In lacerated wounds (the orbital septum?) (debatable).
8. The lower eyelid can safely be used as donor for upper eyelid defect.
9. Reconstruction by innervated orbicularis muscle flap (dynamic) or with a
tendon sling (static) are superior to cartilage graft in the lower eyelid.
10. Hughes tarsoconjunctival flap, should be avoided in children.
11. The flap pedicle should be above the level of the canthal ligaments.
27

28. 1. Documentation: measurement, photography
2. Rule out occult injuries.
3. Laissez faire technique causes contracture.
4. Primary closure is first choice.
5. Tension should be drawn horizontally.
6. Avoid medial canthotomy, Lateral canthotomy on the lower limb of the
ligament.
7. In lacerated wounds (the orbital septum?) (debatable).
8. The lower eyelid can safely be used as donor for upper eyelid defect.
9. Reconstruction by innervated orbicularis muscle flap (dynamic) or with a
tendon sling (static) are superior to cartilage graft in the lower eyelid.
10. Hughes tarsoconjunctival flap, should be avoided in children.
11. The flap pedicle should be above the level of the canthal ligaments.
28

29. 1. Documentation: measurement, photography
2. Rule out occult injuries.
3. Laissez faire technique causes contracture.
4. Primary closure is first choice.
5. Tension should be drawn horizontally.
6. Avoid medial canthotomy, Lateral canthotomy on the lower limb of the
ligament.
7. In lacerated wounds (the orbital septum?) (debatable).
8. The lower eyelid can safely be used as donor for upper eyelid defect.
9. Reconstruction by innervated orbicularis muscle flap (dynamic) or with a
tendon sling (static) are superior to cartilage graft in the lower eyelid.
10. Hughes tarsoconjunctival flap, should be avoided in children.
11. The flap pedicle should be above the level of the canthal ligaments.
29

30. 1. Documentation: measurement, photography
2. Rule out occult injuries.
3. Laissez faire technique causes contracture.
4. Primary closure is first choice.
5. Tension should be drawn horizontally.
6. Avoid medial canthotomy, Lateral canthotomy on the lower limb of the
ligament.
7. In lacerated wounds (the orbital septum?) (debatable).
8. The lower eyelid can safely be used as donor for upper eyelid defect.
9. Reconstruction by innervated orbicularis muscle flap (dynamic) or with a
tendon sling (static) are superior to cartilage graft in the lower eyelid.
10. Hughes tarsoconjunctival flap, should be avoided in children.
11. The flap pedicle should be above the level of the canthal ligaments.
30

31. OPTIONS FOR
RECONSTRUCTION
31

32. Surgical Modalities
• Primary closure  FTSG  composite graft  Pedicle flap  Local flap
• Partial thickness:
• Anterior lamella: <50% > 50%
• Posterior lamella
• Full thickness:
• small (<25% in young & 33% in elder age)
• moderate (25%–50% in young & 33%-66% in elder age)
• large or total loss defects (> 50% in young & >66% in elder age).
32

33. Upper Eyelid Partial thickness
33

34. Upper Eyelid Full thickness
34

35. Upper Eyelid Full thickness
35

36. Upper Eyelid Full thickness
36

37. Lower Eyelid Partial thickness
37

38. Lower Eyelid Full thickness
38

39. Lower Eyelid Full thickness
39

40. Lower Eyelid Full thickness
40

41. Upper eyelid Flaps Lower eyelid Flaps
41

42. Medial Canthal Region
42

43. Lacrimal System
43

44. Lateral Canthal Region
Reinsertion of the lateral canthus is at Whitnall
tubercle, 2-4 mm above medial canthus
44

45. Muscle problems
Problem Cause Surgical Procedure
Lagophthalmos
Loss of pretarsal orbicularis Transposed preseptal orbicularis flap
No orbicularis function Golden weight, FTSG, Magnets
Blepharospasm Overacting orbicularis Botulinum toxin, partial excision of orbicularis
Ptosis
Levator present Repair, Plication
Levator absent Frontalis sling or transfer
Retraction
Upper retractors Levator recession + temporalis fascia spacer
Lower retractors
Spacer palatal graft for conjunctiva with lateral
canthopexy
45

46. Complex Defects
From “Elbanoby TM, Elbatawy A, Aly GM, Ayad W, Helmy Y, Helmy E, et al. Bifurcated superficial temporal artery island flap for
the reconstruction of a periorbital burn: an innovation. J Plastic Reconstructive Surgery Global Open. 2016;4(6)”.
• Bifurcated superficial temporal artery island flap
• Free flap
• Face Transplantation
46

47. POSTOPERATIVE CARE &
COMPLICATIONS
47

48. - Direct Closure Complications:
Notching
Wound dehiscence
Tension
Suture milia, granuloma.
- Graft Complications:
Scar/web formation.
Graft hypertrophy,
- Eyelid sharing flaps Complications:
Hughes tarsoconjunctival flap eyelid malposition
48

49. • Infection
• Scarring or Web Formation
• Hematoma & Retrobulbar Hemorrhage  Blindness
• Dry Eye Syndrome (Keratoconjunctivitis Sicca)
• Epiphora
• Chemosis
• Diplopia
• Asymmetry
• Retraction
• Ectropion
• Ptosis
49

50. RECENT ADVANCES IN EYELID
RECONSTRUCTION
The Aesthetic Reconstruction
Tissue engineering
Allografts applications
Periorbital Considerations in Face Transplantation
Navigation-Guided Surgery
50

51. • The Aesthetic Reconstruction (Concept)
• Tissue engineering (Conjunctiva & Tarsus)
• Allografts applications (Tarsus)
• Periorbital Considerations in Face Transplantation (complex defects)
• Navigation-Guided Surgery (nasoethmoidal fractures)
51

52. CONCLUSION
52

53. • Proper preoperative planning can help prevent the
incidence of complications.
• Accommodation with the principles, guidelines and
recent modalities for eyelid reconstruction will
provide several options for aesthetic and functional
outcomes.
53

54. • References:
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2010;63(9):1420-33.
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an innovation. J Plastic Reconstructive Surgery Global Open. 2016;4(6).
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55. Thank You