Operative Techniques in Otolaryngology (2011) 22, 35-46

Reconstructive designs for the eyelids

Craig N. Czyz, DO, FACOS,a Kenneth V. Cahill, MD, FACS,b Jill A. Foster, MD, FACSa,b
From the aDivision of Ophthalmology, Section of Oculofacial Plastic Surgery, OhioHealth Doctors Hospital, Columbus, Ohio; and the b Department of Ophthalmology, Division of Oculofacial Plastic Surgery, The Ohio State University, Columbus, Ohio. KEYWORDS
Medial canthus; Eyelid tumor; Reconstruction; Graft; Flap General reconstructive principles unique to the eyelids may be used to guide successful eyelid and periorbital reconstruction following tissue excision. Eyelid tumors involving the medial canthus region and/or lacrimal system add to the complexity of reconstructive planning. The nature of the defect, patient and tissue factors, and surgeon preference guides repair design choices. This article discusses eyelid and periorbital reconstruction options. 2011 Elsevier Inc. All rights reserved.

Reconstructive surgical planning for the eyelids is inuenced by several factors including the nature of the defect, the health and age of the patient, the availability, elasticity, and integrity of surrounding tissues, and the surgeons experience and preferences. This article discusses eyelid and periorbital reconstruction options. In general, the following principles provide a guide to successful eyelid and periorbital reconstruction: 1. If both anterior and posterior eyelid lamellae are to be reconstructed, only one layer can consist of a graft; the other must be composed of a vascularized ap. Although the rich vascularity of the face and eyelids allows one to test the boundaries of reconstructive principles used elsewhere in the body, graft-on-graft reconstruction has a high failure probability. 2. The surgeon must re-create adequate canthal xation to suspend the eyelid by the medial and lateral canthal tendons 3. Periocular wound tension lines may be taut in the horizontal direction, but should be closed under a minimal amount of vertical traction. 4. The surgeon must perform any appropriate direct closure of the defect prior to sizing a graft 5. Tissue characteristics should be matched as best as possible for grafts and aps 6. Complexity of technique(s) with improvement(s) in outcome should be well balanced.
Address reprint requests and correspondence: Craig Czyz, DO, FACOS, 1100 Oregon Ave, Columbus, OH 43201. E-mail address: dsp4000@aol.com. 1043-1810/$ -see front matter 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2011.01.005

In reconstruction of defects involving the eyelid margin, the following goals help to create a successful outcome: 1. Development of an aligned and stable eyelid margin 2. Maintenance or creation of a conjunctiva-like posterior eyelid surface 3. Provision of sufcient horizontal and vertical eyelid dimensions for maximal function 4. Insurance of adequate eyelid closure to avoid exposure sequelae 5. Insurance of optimal eyelid symmetry and cosmesis (tissue of appropriate color, texture, and thickness). Tumors involving the medial canthal region and/or lacrimal system add to the complexity of reconstructive planning. The literature is replete with reports of various types of skin-muscle aps to repair medial canthal defects.1-5 However, while providing surface coverage, many of these techniques fail to address the issues of eyelid function and stability and to consider the issue of lacrimal drainage. To properly design a comprehensive surgical reconstruction plan, an intimate knowledge of the regions anatomy and function is crucial.

Clinical anatomy
Eyelids
The average distance between the upper and lower eyelids, the vertical palpebral ssure, is 8-10 mm in primary

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(straight) gaze.6 The upper eyelid margin rests approximately 2 mm below the superior corneal limbus. The lower eyelid margin should be at or 1 mm above the inferior corneal limbus so that no sclera is visible between the limbus and eyelid. The horizontal width of the palpebral ssure from medial to lateral canthus is approximately 28-30 mm.7 The lateral canthal angle is positioned approximately 2 mm higher than the horizontal meridian of the medial canthal angle. The normal upper eyelid has a travel distance of 14-16 mm from downgaze to upgaze.8 The motion of the eyelids along with orbicularis contracture provides the impetus for the lacrimal pump mechanism, the disruption of which can result in epiphora. Anatomically, the upper eyelid consists of seven distinct layers (Figure 1). These layers from anterior to posterior are (1) skin and subcutaneous tissue; (2) orbicularis oculi muscle; (3) orbital septum; (4) orbital fat; (5) levator and Mllers muscles (eyelid retractors); (6) tarsus; (7) conjunctiva. The anatomy of the lower eyelid is similar to that of the upper eyelid with two distinct differences. In the lower eyelid, the capsulopalpebral fascia and inferior tarsal muscle are analogous to the upper eyelids levator and Mllers muscles, respectively. These lower eyelid structures are less well dened and developed than their upper lid counterparts. The eyelids are divided into surgical units of anterior and posterior lamella. The anterior lamella is composed of skin and orbicularis oculi muscle and the posterior of the tarsus and conjunctiva. The middle lamella is a conceptual space consisting of everything between the anterior and posterior lamella.9

Figure 2 tures.

Anterior view of deeper eyelid and periorbital struc-

The tarsi are rm, dense plates of specialized brous connective tissue that serve as the structural support of the eyelids.10 At its center, the upper eyelid tarsal plate has a greater vertical dimension (10-12 mm) than the lower eyelid tarsal plate (4 mm).11 Both upper and lower tarsal plates measure approximately 1 mm in thickness and taper toward their attachments.12 The upper and lower eyelid tarsal plates have sturdy attachments to the periosteum via the canthal tendons medially and laterally (Figure 2). Mechanical disruption or involutional change of either supporting tendon can result in displacement of the tarsi. The meibomian glands, holocrine sebaceous glands that secret the oil component of the tear lm, are located within the tarsus. The eyelid margin has a rectangular prole (Figure 3). The cutaneous epithelium on the anterior surface and the conjunctiva of the posterior surface are separated by nonkeratinized epithelium. The gray line is visible along the

Figure 1

Cross-section of the orbital and periorbital anatomy.

Figure 3

Cross-section of the eyelid margin anatomy.

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Lacrimal system
The lacrimal system comprises the puncta, canaliculi, common canaliculus, lacrimal sac, and nasal lacrimal duct (Figure 4). The puncta is located at the eyelid margin and connects to the canaliculi in both the upper and the lower eyelids. The upper eyelid punctum lies slightly nasal to the lower eyelid punctum and they slightly protrude above the eyelid margin. The canaliculi travel 2 mm vertically from the puncta and then turn medically to parallel the eyelid margin for a total length of 8-10 mm. The upper and lower canaliculi merge into a common canaliculus prior to entering the lacrimal sac in approximately 90% of patients, with the remainder entering separately.16 The valve of Rosenmueller lies at this junction, preventing regurgitation of uid within the lacrimal sac into the common canaliculus. This is not a true valve but an orientation of the tissues that act similar to a valve. The lacrimal sac is 12-15 mm in length and lies within the lacrimal sac fossa, which comprises the maxilla anteriorly and the lacrimal bone posteriorly. The superior one third of the lacrimal sac is above of the medial canthal tendon, while the remainder is below the tendon.17 The lacrimal sac fossa is adjacent to the middle meatus within the nose usually at or just anterior to the tip of the middle turbinate. The lacrimal sac drains into the nasal lacrimal duct that is approximately 12-18 mm in length. The nasal lacrimal duct empties into the nasal cavity under the inferior turbinate with ow controlled by the valve of Hasner.

Figure 4 Composite view of the lacrimal system anatomy. Measurements indicate adults.

center of the eyelid margin. The gray color results from the darker color of the supercial portion of the orbicularis oculi muscle anterior to the tarsus, known as the muscle of Riolan lying just deep to the epithelium.13 The gray line is often confused with the mucocutaneous junction of the eyelid margin, which is actually located posterior to the meibomian gland orices along the eyelid margin. The gray line is a surgically important landmark in reconstruction, canthoplasty, and other surgical procedures involving the eyelids. The palpebral conjunctiva lines the posterior surface of the upper and lower eyelids (Figures 1 and 3). The conjunctiva that envelops the globe is the bulbar conjunctiva. The fornices are the areas of transition between bulbar and palpebral conjunctiva. Conjunctiva is composed of nonkeratinizing squamous epithelium. The conjunctiva contains the accessory lacrimal glands of Wolfring and Krause and the mucin-secreting goblet cells.12 The function of the conjunctiva is to lubricate, support, and protect the ocular surfaces.11 The upper and lower eyelids are highly vascularized by an anastomosing network of vessels from the internal and external carotid arteries.14,15 The exact formation of the network seems to have mild anatomical variation between individuals. This rich blood supply contributes to the high survival rate of grafts and aps in periocular reconstruction. It also reduces the need to design ap construction based on specic vessels.

Medial canthus
The structure of the palpebral ssure is maintained by the tarsal plates in combination with the medial and lateral canthal tendons (Figure 2). The medial canthal tendon is formed by the merging of two tendinous arms originating from the anterior and posterior lacrimal crests. The arms fuse temporal to the lacrimal sac and then redivide into two different arms that attach to the upper and lower eyelid tarsal plates. The tendinous attachment at the anterior lacrimal crest is robust, whereas that of the posterior lacrimal crest is delicate but crucial in maintaining a posterior vector that aligns apposition of the eyelids to the globe.12

Figure 5 Medial canthal tendon defect. The entire medical canthal tendon was resected in this patient. A combination of miniplate and suture material has been used to reconstruct the medical canthal tendon and superior and inferior arms (crus).

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Figure 7 Lid margin sutures. (A) The photograph illustrates the proper suture placement for classic direct lid margin defect closure. Sutures can be seen in the tarsus (white) and lid margin locations (black). (B) Once sutures are tied, they are draped and secured by the skin sutures to prevent corneal defects.

Reconstructive considerations
Medial canthus
One of the primary tenets of cancer surgery is to completely remove the lesion and obtain margins devoid of atypia without regard to the challenges it may present in performing repair. This is especially critical in the medial canthal region where spread of the primary tumor to the nearby sinuses can in turn result in extension to the brain and ultimately mortality. Tumor margins should be microscopically evaluated and determined free of atypia before reconstruction is undertaken. Reconstructive planning in the medial canthal region is complex because of the variety of structures that can be involved, the unique contours, and the multitude of techniques available. If the defect is restricted to the anterior lamella, spontaneous granulation or full-thickness skin graft (FTSG) can be employed, with FTSG being a more common and faster healing technique.18 For larger anterior defects, or those lacking a vascular bed for FTSG survival, various transposition or advancement aps can be employed, such as a glabellar forehead ap or nger ap.1-5 When the defect involves full-thickness medial eyelid(s) or sacrice of the medial canthal tendon, the remaining eyelid margin must be reapproximated and xated to periosteum or bone. Full-thickness eyelid defects involving more than 50% of the lid rarely can be closed and reapproximated primarily to the canthal tendon. In these instances both anterior and posterior lamellar components must be addressed via lid-sharing techniques, free grafts, and aps. Defects involving the lacrimal system add a degree of com-

plexity and may require either primary microsurgical reconstruction or delayed repair depending on the amount of disruption and the nature of the excised tumor. Facial plastic surgeons are familiar with skin grafting techniques and the various aps used in medial canthal reconstruction. However, when eyelid reconstruction is incorporated into the repair, modications to standard ap and grafting techniques may be required. Full-thickness skins grafts to the eyelids and canthus must be thinner than those used on other areas of the face. Consequently, pre- and postauricular grafts debrided of their subcutaneous tissues work best. Advancement and rotational aps of thicker forehead and cheek tissue must also be thinned. This can decrease their vascular perfusion, their ability to support a posterior lamellar graft, and even their own survival. If necessary, a ap can be thinned as a secondary procedure, but this is disruptive in the canthal areas. When the medial canthal tendon is disrupted or completely lost, the remaining eyelid portion of the tendon must be xated to the area of the tendenous origin to ensure proper alignment and support of the eyelid(s). If any tendon remains on the anterior or posterior lacrimal crest, direct reattachment with braided, absorbable, polyglycolic acid suture (Vicryl; Ethicon, Somerville, NJ) or monolament, nonabsorbable polypropylene (Prolene; Ethicon) suture is possible. The anterior limb of the tendon can be disrupted without causing malposition of the medial canthus if the posterior limb remains intact.19 When no tendon material remains for anchoring the eyelid, suture can be used to xate the to the periosteum of the posterior lacrimal crest (Figure 5). In cases where periosteum is absent or of insufcient quality, a titanium miniplate can be xated to bone

Figure 6 Reconstructive options for eyelid defects. (A) Direct primary closure. (B) Direct primary closure with canthotomy/cantholysis. (C) Adjacent tarsoconjunctival ap with FTSG. Note in B, the lid is everted over a Desmarres retractor. (D) Free tarsoconjunctival graft and skin-muscle ap. (E) Bucket Beard lower eyelid vascular advancement ap with lamellar spacer graft and adjacent skin-muscle ap. (F) Lower eyelid switch ap. (G) Glabellar/median forehead ap with free lamellar graft. T tarsus; C conjunctiva; TC tarsoconjunctival.

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Operative Techniques in Otolaryngology, Vol 22, No 1, March 2011 margin alignment and sturdy tarsal reapproximation are the keys to a successful outcome. Traditional techniques for eyelid reapproximation use one or more deep sutures of 6-0 Vicryl to pull together the two sides of the tarsus followed by margin sutures to bring the eyelid margin together. The tarsal sutures are placed 4-5 mm peripheral to the eyelid margin and then are left loose until the eyelid margin sutures are placed. Classic lid margin sutures are placed in three locations across the lid margin: from gray line to gray line, then lash line to lash line, and then mucocutaneous junction to mucocutaneous junction (Figure 7A). The tarsal suture(s) is tied to take traction off the wound, and then the eyelid margin sutures are tied, leaving long tails on the suture. The ends are then draped

and the tendon sutured to the plate.20 Alternatively, or when the bony anatomy precludes use of a miniplate, transnasal wiring may be employed. One must also take into account the nature of the tumor, as metallic-based implants or wires can produce artifact in future scans of the area.

Eyelids
Small defects of the upper and lower eyelid Small eyelid defects ( 33% involvement) are repaired by direct primary closure (Figure 6A). An additional 2-5 mm of advancement of the lateral portion of the lid can be accomplished via a canthotomy, and cantholysis of the superior or inferior arms of the lateral canthal tendon should wound tension necessitate. Anterior and posterior eyelid

Figure 8 Reconstructive options for lower eyelid defects. (A) Direct primary closure with canthotomy/cantholysis and semicircular (Tenzel) ap. (B) Hughes upper eyelid tarsoconjunctival ap and FTSG. (C) Mustard ap with free lamellar graft.

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41 to remain. Alternatively a free tarsal graft from the contralateral upper lid or tarsal substitutes can be used. The anterior lamella is then reconstructed with an adjacent advancement or transposition ap should the eyelid skin display sufcient laxity. In the lower eyelid, midface elevation may also be required to prevent lower eyelid retraction and ectropion. Large defects of the upper and lower eyelid Large eyelid defects ( 50% involvement) are the most challenging reconstructions to design and perform. The amount of tissue loss usually requires both grafting and advancement of adjacent tissues. In defects of this size it is paramount that the posterior lamella be addressed for the resulting lid reconstruction to have sufcient structural support to function. A free tarsoconjunctival graft can be harvested from the contralateral upper lid to repair the posterior lamellar aspect of the defect (Figure 6D). The anterior portion can be composed of a sliding skin-muscle ap of adjacent eyelid tissues if there is sufcient laxity. Alternatively an FTSG can be harvested from the contralateral upper eyelid or other preferred sources (pre/postauricular, clavicular). A slight overestimation of tissues should be grafted as there is a tendency for the reconstructed areas to retract.21 When sufcient tarsus or conjunctiva is not available, a hard palate graft is a viable alternative that provides both support and a posterior mucosal surface for the lower eyelid.22 Alternatively a nasal septal cartilage graft with intact mucoperichondrium can be used.10 While these tissues are successful in the lower eyelid, use in the upper lid is limited by the propensity for corneal irritation caused by the roughness of the surface of these grafts. If sufcient tarsus remains for lid margin stability, oral mucosa or acellular dermis can be grafted as a conjunctival substitute in fornix reconstruction. When tarsus is decient, ear cartilage covered with by vascularized conjunctiva can repair the poster lamella along the lid margin. As previously noted, a vascularized ap must be in apposition with any free graft. Because of the movement of the upper eyelid, replacement of the posterior surface often requires an ocular conjunctival surface. The Cutler-Beard procedure consists of advancing a full-thickness eyelid ap from the ipsilateral lower eyelid including conjunctiva and skin. The counterpart to the Hughes ap for lower eyelid defects, the CutlerBeard differs in that it classically performed many supply tissues for both posterior and anterior reconstruction. While convenient, lower lid deformity and upper lid entropion are common complications. A secondary procedure is also required for ap division. In a slightly more complicated procedure, the Bucket Beard, some of the lower lid retraction complications of the Cutler-Beard may be avoided using the vascularized ap of the lower lid to provide conjunctiva and blood supply, but moving the remaining skin from below the brow in the upper lid in a bucket handle ap to become the new upper eyelid margin23 (Figure 10A-G). A tarsal substitute of cartilage, tarSys (IOP, Costa Mesa, CA), or thick acellular

and tied into the skin sutures above or below the eyelid margin (Figure 7B). Moderate defects of the upper and lower eyelid Moderate eyelid defects (33-50% involvement) can potentially be reconstructed by direct closure with canthotomy and cantholysis (Figure 6B). When sufcient horizontal lid mobilization or tissue is not provided with canthotomy/ cantholysis, a semicircular rotational ap (Tenzel) can be constructed with an arching incision above or below the lateral canthal angle (Figure 8A). The ap is then advanced medially, allowing the lid to be closed in a direct fashion. A reconstructed lateral canthus is created by securing the remaining lid portion of the tendon to the intact arm of the lateral canthal tendon. In the absence of the lateral canthal tendon, the tendon may be re-created using lateral orbital rim periosteum and deep temporalis fascia. To re-create the lower tendon, the surgeon draws a rectangular ap oriented obliquely superiorly toward the temporal hairline (Figure 9). The ap is always made a bit longer than one thinks is needed. The scalpel incises the rectangular ap; then the temporalis fascia is peeled off the muscle, and the periosteum is elevated away from the rim with a Freer elevator. The ap is then ipped into the lower lid with the temporalis fascia ending up on the medial location of the newly formed lateral canthal tendon. The ap remains attached on the internal aspect of the lateral orbital rim. The same technique is used to re-create the upper lateral canthal tendon; only the design of the original ap is oriented obliquely down toward the earlobe and again is ipped so the posterior aspect of the ap that was on the bone is now oriented anteriorly. In cases where lid structural support is lacking, tarsal sharing or tarsoconjunctival ap procedures can be used. An adjacent tarsoconjunctival ap can be formed and advanced supporting the posterior lamella (Figure 6C). In the lower eyelid, the modest vertical height of the tarsus allows only horizontal sharing if sufcient tarsus for lid stabilization is

Figure 9 Lateral canthal tendon reconstruction. The gray lines represent the outline of the periosteal ap created for tendon reconstruction.

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Figure 10 Bucket Beard. (A) Near total upper eyelid excision. (B) A full-thickness incision is made in the lower eyelid as outlined. The full-thickness ap is dissected leaving an intact bridge of eyelid margin including the marginal arcade vessel and tarsus. The image shows the ap advanced under the eyelid margin bridge into the upper eyelid defect. A piece of acellular dermis material has been placed anterior to the conjunctiva to serve as the middle lamellar support. (C) A bucket-handle ap is created using skin just below the eyebrow. (D) The bucket-handle ap is transposed inferiorly over the conjunctival ap and acellular graft to re-create the upper eyelid margin and anterior lamella. (E) An FTSG is used to reconstruct the brow ap harvest site. (F) In a second-stage procedure, the lower eyelid ap is separated with a scissors or blade. The bucket handle ap becomes the new upper eyelid margin. The lower eyelid skin is reposited into the lower eyelid. (G) Appearance 6 months following second stage.

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43 primary thinning when used for upper lid repair and will require a secondary procedure to take down the bridge ap. The eyelid may also require secondary thinning procedures. The skin type match is not as good as some of the alternatives and care needs to be taken not to include hair follicles if possible. If a signicant portion of the upper lid is being replaced, grafts or aps of mucosal tissue are placed on the backside of the ap. Medial canthal xation of the tissue helps to re-create the contour of the upper lid. Large defects of the lower eyelid The modied Hughes technique is often the procedure of choice for large lower eyelid defects (Figure 8B). In the Hughes technique, a vascularized ap of upper lid conjunctiva and tarsus is created and advanced into the lower lid defect. It is sutured into place to remaining tarsus or to the canthal angle reconstruction. To prepare the ap, the upper eyelid is everted over a Desmarres retractor and the tarsus is marked to protect the 4 mm of tarsus along the eyelid margin (Figure 11A). The remainder of the vertical height of the tarsus may be borrowed for the lower eyelid. The scalpel is used to incise the tarsus, and then the tarsus is elevated off the posterior surface of the levator aponeurosis using a Wescott scissors. At the top of the tarsus, the dissection plane continues, separating conjunctiva from Mllers muscle. The conjunctiva is usually released up to the junction of the aponeurosis and Mllers muscle. The tarsus and the attached conjunctiva are then lined up with the defect in the lower eyelid (Figure 11B). The edges of the tarsus

dermis, should be sandwiched between the anterior bucket handle ap and posterior lamella provided by the lower lid Cutler-Beard ap. A skin graft is placed below the eyebrow to replace the skin used for the bucket handle ap (Figure 6E). When the eyelids are separated at two to six weeks, the skin from the Cutler-Beard ap returns to the lower eyelid. This technique diminishes the postoperative retraction seen with a classic Cutler-Beard and results in a better contour of the postoperative upper eyelid margin. A lower eyelid switch ap is another type of full-thickness lower eyelid pedicle graft (Figure 6F). The lower lid margin is rotated into the upper eyelid. While there is the benet of the lower eyelid lashes being in proper position when rotated into the upper lid, there is a signicant disadvantage in the form of the large lower lid defect that is created. This defect must be repaired in a secondary procedure with a posterior lamellar graft and a cheek rotation ap to cover the anterior portion of the defect. There is added risk of seventh nerve palsy from ap dissection as well as lower lid retraction from the weight and subcutaneous tissue contraction of the cheek ap.21 Additionally, a second procedure is required to sever the bridge approximately three to six weeks after placement. This technique is primarily of historical signicance. For combined defects of the upper eyelid and the medial canthus, a glabellar (median forehead) ap may be rotated to provide tissues for repair of the anterior lamella of the upper lid and medial canthus (Figure 6G). The ap requires

Figure 11 Tarsoconjunctival ap (Hughes). (A) The upper lid is everted over a Desmarres retractor and the dotted outline marks the margins for ap dissection. (B) The ap is transposed into the lower eyelid defect, but not yet sutured. Note the alignment of the tarsal edges vertically and horizontally. The conjunctival bridge obscures view of the ocular surface. (C) FTSG placed over the tarsoconjunctival ap to repair the anterior lamellar defect. (D) The conjunctival ap is divided using a groove director to protect the ocular surface and a no. 11 blade to divide the ap.

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Figure 12 Rotational cheek ap (Mustard). (A) Large lower eyelid defect extending inferiorly into the midface. (B) The Mustard ap is rotated into position and a clavicular FTSG is placed in the defect created by rotation of the ap.

of the eyelid and the ap are trimmed to meet at right angles. Partial thickness bites of a 6-0 Vicryl suture align the remaining tarsus in the eyelid with the tarsus of the ap. If the defect in the lower eyelid is vertically extensive, there may be some gap in the conjunctiva in the inferior cul-de-sac. It is better to line up the tarsal edges to meet at the lid margin than to pull the ap tarsus down in to the defect. The anterior lamella is reconstructed with an FTSG taken from contralateral eyelid or pre/postauricular area (Figure 11C). This results in a conjunctival bridge from the upper eyelid across the pupil into the lower defect for two to six weeks. Once the lower eyelid graft is revascularized, a second procedure divides the ap (Figure 11D). It is sometimes necessary to smooth over irregularities of the new eyelid at the time of the separation. Amblyopia should be considered when planning reconstruction involving eyelid closure in young children. The Mustard cheek ap works well for a large anterior lamellar defect (Figure 8C). It can be considered a progression

of the smaller Tenzel rotational ap and used with any separate posterior lamellar repair technique. Consideration of this procedure should be made in any large lower eyelid defect when eyelid closure is a concern such as a monocular state or children with amblyopia risk. It has the advantage of being able to repair defects with extensive vertical involvement that extend down the lower lid into the cheek (Figure 12A, B). This may also be needed in patients who have had a previous tarsal conjunctival ap where the tissue is usually too tight for an additional ap to work.

Combined upper and lower eyelid defects

Defects of any size involving both upper and lower eyelids are reconstructed following the same principles as isolated lid defects. Similarly there is no alteration in the decision-making process if medial canthal structures or the lacrimal system is also involved. There exists no singular ap that can address all full-thickness upper and lower

Figure 13 Lacrimal involvement of lower eyelid lesion. (A) Lesion excision of the medial lower eyelid involving the punctum and canaliculus. The transected proximal end of the canaliculus can be seen (arrow). (B) A monocanalicular is placed in the distal opening of the canaliculus and the lid defect is repaired. The mouth of the stent is usually seated in the punctum; however, since the puncta was sacriced with the lesion, the stent opening will serve as the new lower lid punctum (arrow).

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Figure 14 Decision tree outlining surgical design options for upper and lower lid reconstruction with or without medical canthal, tendinous, and/or lacrimal involvement.

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eyelid and medial canthus defects. Thus, a minimum of two aps is required for these types of combined defects.4

References
1. Harris GJ, Logani SC: Multiple aesthetic unit aps for medial canthal reconstruction. Ophthal Plast Reconstr Surg 14:352-359, 1998 2. Chao Y, Xin X, Jiangping C: Medial canthal reconstruction with combined glabellar and orbicularis oculi myocutaneous advancement aps. J Plast Reconstr Aesthet Surg 63:1624-1628, 2010 3. Meadows AE, Manners RM: A simple modication of the glabellar ap in medial canthal reconstruction. Ophthal Plast Reconstr Surg 19:313-315, 2003 4. Motomura H, Taniguchi T, Harada T, et al: A combined ap reconstruction for full-thickness defects of the medial canthal region. J Plast Reconstr Aesthet Surg 59:747-751, 2006 5. Onishi K, Maruyama Y, Okada E, et al: Medial canthal reconstruction with glabellar combined Rintala aps. Plast Reconstr Surg 119:537541, 2007 6. Read SA, Collins MJ, Carney LG, et al: The morphology of the palpebral ssure in different directions of vertical gaze. Optom Vis Sci 83:715-722, 2006 7. Whitnall SE: The Anatomy of the Human Orbit and Accessory Organs of Vision (edn 2). London, Oxford Medical Publishing Group, 1932, pp 115-123 8. Nerad JA: Oculoplastic Surgery. St. Louis, Mosby, 2001, p 171 9. Collin JRO: A Manual of Systematic Eyelid Surgery (ed 3). Oxford, Butterworth-Heinemann, 2006, pp 16-23 10. Milz S, Neufang J, Higashiyama I, et al: An immunohistochemical study of the extracellular matrix of the tarsal plate in the upper eyelid in human beings. J Anat 206:37-45, 2005 11. Doxanas MT, Anderson RL: Eyebrows, eyelids, and anterior orbit, in Clinical Orbital Anatomy. Baltimore: Williams and Wilkins, 1984, pp 57-88 12. Anatomy. In: Basic and Clinical Science Course. Section 7. In: Hold JB (ed): Orbit, Eyelids, and Lacrimal System. San Francisco: American Academy of Ophthalmology, 2007-08, pp 141-149 13. Wulc AE, Dryden RM, Khatchaturian T: Where is the gray line? Arch Ophthalmol 105:1092-1098, 1987 14. Erdogmus S, Govsa F: The arterial anatomy of the eyelid: importance for reconstructive and aesthetic surgery. J Plast Reconstr Aesthet Surg 60:241-245, 2007 15. Lopez R, Lauwers F, Paoli JR, et al: The vascular system of the upper eyelid. Anatomical study and clinical interest. Surg Radiol Anat 30: 265-269, 2008 16. Orhan M, Govsa F, Saylam C: Anatomical details used in the surgical reconstruction of the lacrimal canaliculus: cadaveric study. Surg Radiol Anat 2009 [epub ahead of print] 17. Nerad JA: Oculoplastic Surgery. St. Louis, Mosby, 2001, p 50 18. Lowry JC, Bartley GB, Garrity JA: The role of second-intention healing in periocular reconstruction. Ophthal Plast Reconstr Surg 13: 174-188, 1997 19. Collin JRO: A Manual of Systematic Eyelid Surgery (ed 3). Oxford, Butterworth-Heinemann, 2006, p 149 20. Howard GR, Nerad JA, Kersten RC: Medial canthoplasty with microplate xation. Arch Ophthalmol 110:1793-1797, 1992 21. Collin JRO: A Manual of Systematic Eyelid Surgery (ed 3). Oxford, Butterworth-Heinemann, 2006, pp 115-145 22. Leibovitch I, Malhotra R, Selva D: Hard palate and free tarsal grafts as posterior lamella substitutes in upper lid surgery. Ophthalmology 113: 489-496, 2006 23. Facial Reconstructive and Aesthetic Surgery Meeting: Salt Lake City, UT, in Foster JA: The Bucket-Beard: A New Reconstruction Technique for Large Upper Eyelid Defects, 2007 24. Spinelli HM, Shapiro MD, Wei LL, et al: The role of lacrimal intubation in the management of facial trauma and tumor resection. Plast Reconstr Surg 115:1871-1876, 2005 25. Mathers WD, Lane JA, Zimmerman MB: Tear lm changes associated with normal aging. Cornea 15:229-234, 1996

Lacrimal system involvement

Microsurgical repair of the lacrimal system can be combined with various eyelid and medical canthal reconstructions. In the case of malignancy, until tumor recurrence can be ruled out, lacrimal surgery that creates a pathway for tumor spread into the sinuses or nasal cavities is avoided. Length of clinical surveillance without signs of recurrence prior to lacrimal repair varies depending on lesion type, with melanoma and sebaceous cell requiring the longest interval. Partial interruptions of the canaliculus of the upper or lower eyelid can be repaired primarily with silicone intubation and surgical reanastomosis of the canalicular ends (Figure 13A, B). Some patients are asymptomatic if there is one normal functioning canaliculus and good position of both lids. If both canaliculi have been sacriced, options are tempered by the nature of the lesion and the remaining tissues. Crawford (JEDMED, St. Louis, MO) stents or Infant Bika (FCI ophthalmics, Marsheld Hills, MA) intubation is used for bicanalicular and Mini Monoka (FCI) or MonoCrawford (FCI) stents for monocanalicular stenting. Silicone tubing can also be used to stent the upper and lower lacrimal systems without the need to intubate the nasolacrimal duct. The silicone stents are generally left in place three months and then removed. Silicone intubation as part of the primary repair demonstrates a high success rate in maintaining a patent, functional drainage system in the absence of direct lacrimal system involvement.24 Following primary reconstruction and sufcient tumor surveillance, in cases where the patient has symptomatic epiphora and primary lacrimal repair is unsuccessful or the nature of the tumor does not allow for it, then a conjunctivodacryocystorhinostomy with Jones tube placement can be offered. If the patient is asymptomatic regarding tearing, further intervention to reestablish a lacrimal drainage system is not required. Older patients are less symptomatic with epiphora because of the age-related decrease in tear function.25

Conclusions
It is nearly an impossible task to cover every permutation of defects and the available reconstructive choices for this highly complex facial region. The goal of this article is to provide a summary of the pertinent anatomy, fundamental reconstructive principles, and workhorse techniques available for successful functional and cosmetic outcomes. Figure 14 illustrates a decision tree outlining the reconstructive options discussed.