Reconstruction of the Upper Eyelid

Abstract

Normal physiologic mechanisms of the upper eyelid are essential for preservation of the eye. Normal function and good cosmesis usually go hand in hand, but preservation of function is the more important of the two priorities. The general considerations in choosing a reconstruction technique include the restoration of: 1. A smooth conjunctival surface to line the eyelid and protect the cornea 2. Structural support of the tarsal plate 3. A smooth, nonabrasive lid margin 4. Normal vertical eyelid movement without ptosis or lagophthalmos 5. Normal horizontal tension with normal medial and lateral canthal tendon positions To cover small defects, the conjunctival lining may be rotated or advanced. For larger defects, the lining may be replaced with a buccal mucous membrane graft or a contralateral conjunctival graft. The tarsal plate usually requires 4 mm of vertical height to provide adequate eyelid support. If the 4 mm is unavailable, it may be replaced with lower lid tarsus, a free tarsal graft from the opposite lid, a free cartilage graft, a polytetrafluoroethylene graft, or a preserved sclera graft. The eyelid margin must be free of trichiasis or surface epithelium, which might abrade the cornea. When levator function is preserved following traumatic or surgical defects of the eyelid, ptosis can usually be avoided or corrected. The levator aponeurosis separates the orbital and palpebral portions of the lacrimal gland, and lacrimal tissue should be preserved when dissecting in the lateral canthal, lateral levator, and lateral anterior orbital areas. Lagophthalmos of the upper eyelid is usually due either to adhesion of the orbital septum to the tarsal plate or to external vertical skin shortage. Proper horizontal tension can be achieved by measuring full-thickness defects while gently pulling the edges of the defect toward each other. Careful measurement reduces the risk of excessive or deficient horizontal length following reconstruction. Skin grafts in the upper eyelids should be covered with a moderate pressure dressing for 4 to 6 days to prevent buckling or subgraft hematoma. Full-thickness skin grafts are preferred to split-thickness grafts for optimal tissue match and coloration. Upper eyelid sutures may be permanent or absorbable. Most external permanent sutures are 7-0 caliber.