Eyelid reconstruction — Principles and defect-based algorithm

The principle that orders everything else

Eyelid reconstruction has six goals, and their order matters because when they conflict the order decides: preserve lid function; achieve a stable lid margin; ensure complete closure protecting the globe; maintain vertical lid height; create a smooth, epithelialised inner surface, since any roughness against the cornea erodes it; and only then maximise aesthetics and symmetry. The planning criterion comes from general facial reconstruction: restore units, do not fill defects. A patch of skin from elsewhere, exactly the size of the hole, leaves a visible reconstruction even when it heals well. Hence the value of thinking in periorbital aesthetic subunitsZones of the periocular region with uniform skin, thickness and texture whose borders follow natural creases; reconstructing the whole subunit camouflages better than reconstructing the defect alone and, when the defect occupies most of one, enlarging it to the subunit borders before reconstructing.

The two lamellae and the blood-supply rule

Every eyelid defect is analysed in two layers. The anterior lamella is skin and orbicularis. The posterior lamella is tarsus and conjunctiva, providing the lid’s structural rigidity and the smooth surface that meets the cornea. Reconstructing a full-thickness lid means replacing both, and from that comes the rule that most shapes planning: one lamella may be replaced with a graft, but not both. A graftTissue transferred without its own blood supply, surviving only if the recipient bed revascularises it needs a vascularised bed; if both layers are grafts there is nothing to feed them and the result is necrosis. So at least one of the two layers must be a {{pedicled flap|Tissue mobilised keeping its own vascular pedicle, so it arrives alive at its destination}}. In practice this means two valid combinations: an anterior skin flap over a posterior tarsoconjunctival graft, or a posterior tarsoconjunctival flap — Hughes — covered by a skin graft.

First decision: does it involve the lid margin?

Defects sparing the lid margin

Here the direction of tension rules. Horizontal closure is well tolerated; vertical tension on the lower lid produces retraction or ectropion, so incision lines are oriented vertically to leave the resulting tension horizontal. A point of tissue economy that matters in the eyelid: classic elliptical excision sacrifices up to 160 % of the area of the lesion removed, so where every millimetre of skin counts it is worth using modified ellipses such as the double-S or the O-Z plasty. As for what to cover with, the hierarchy is clear: local skin flaps are preferred to free grafts, because they contract far less, because colour and texture match, and because the region has a rich blood supply that also allows free grafts to be harvested from it for the posterior lamella. And a caution: healing by secondary intention is not an acceptable strategy in the eyelid, since the incidence of cicatricial ectropion is considerable.

Where to take the skin from, in order of preference

Upper lid with margin loss

Lower lid with margin loss

The named flaps, one sentence each

Tenzel: a semicircular skin flap rotating from the lateral canthus, allowing the remaining lid segment to advance; the workhorse for 25-50 % defects in either lid. Hughes: a tarsoconjunctival flap taken from the upper lid, advanced into the lower and covered with a skin graft; it rebuilds the posterior lamella with its own blood supply, at the cost of keeping the eye closed until the pedicle is divided. Cutler-Beard: its reciprocal, a full-thickness lower lid flap passed beneath the margin to reconstruct the upper. Mustardé: a large cheek rotation flap for extensive lower lid defects, always needing a tarsal substitute. Tripier: a pedicled myocutaneous flap from the upper lid, useful when there is redundant skin above. Fricke: a laterally pedicled supraciliary flap, the alternative when the cheek is unavailable. All share the same logic: they supply the vascularised layer that allows the other to be grafted.

Medial and lateral canthus: the problem is fixation

At the medial canthus a small defect can be covered with a full-thickness skin graft or a local flap, and in selected cases even left to granulate; large ones call for forehead or glabellar flaps, with two drawbacks worth anticipating: their thickness, often requiring a second thinning stage or laser resurfacing, and the fact that they hinder detection of recurrence in the oncological patient. What admits no shortcut is canthal anchoring: it must be fixed to periosteum or directly to bone with heavy permanent suture, wire or a miniplate, since lax fixation leaves a displaced canthus and permanent epiphora. If the lacrimal system is involved, it needs specific reconstruction. At the lateral canthus, transposition, advancement or rhomboid flaps work, and there is an elegant option for the posterior lamella: horizontal strips of periosteum or deep temporal fascia anchored to the lateral orbital rim, turned and fixed to the lid to rebuild the entire canthal posterior lamella.

Bilamellar defects involving both lids

These are rare and complex, and here the order of priorities stops being theoretical. The upper lid is reconstructed first, because it protects the cornea. Whenever possible the upper and lower conjunctival fornices are mobilised and temporarily sutured in front of the cornea — or a full-thickness skin graft is placed — to secure healing and protect the globe meanwhile. The palpebral fissure is opened in stages, not all at once. In the most extensive defects the superficial temporal artery flaps come into play: the retrograde-flow auricular island flap, the postauricular island flap, the axial bilobed or the bifurcated flap, which allow single-stage reconstruction of combinations of brow, upper lid, lower lid and lateral canthus.