 Naevus involving upper eyelid margin |
 Full-thickness eyelid excision |
 Postoperative result |
|
Naevus involving upper eyelid margin |
Full-thickness eyelid excision |
|
Postoperative result |
5-1-Tumor excision :
-excisional biopsy of a small lesion may be sufficient.
-excision with extensive margin of surrounding tissue is necessary for a malignant tumor ; frozen sections of the margins around a resected area at the time of surgery allows a complete tumor removal before eyelid reconstruction.
-full-thickness excision is indicated for a malignant tumor which extends to within 3 mm. of the lid margin.
-excision has to be large when the tumor invade local tissues : the eye, the periosteum, or the lacrimal drainage system.
5-2-Eyelid reconstruction
*Anterior lamellar defects
Direct skin closure
For small lesions, direct skin closure is easy to perform in the upper preseptal area, because of the excess of skin. In pretarsal areas, the defect should be sutured vertically to reduce the risk of an ectropion.
Laisser-faire
Laisser-faire is indicated preferentially for medial canthal defects : once the tumor excision done, the wound is packed with vaseline gauze. The defect will heal by granulation in one to three weeks, depending on its surface area.
 Tumor involving lower eyelid |
 Magnified view |
 Defect after tumor excision |
 Result after Laisser-faire |
Skin flaps
When direct closure or laisser-faire is not possible, a local skin flap is preferable to a skin graft for cosmetic reason. Several types of skin flaps may be used in ophthalmic plastic surgery :
-local advancement flaps : U flap, H flap, O-T flap, O-Z flap, V-Y flap.
-rotational flaps : Tenzel flap.
-transposition flaps : Z flap, rhomboïd flap, various pedicle flaps : nasojugal flap, upper lid flap, forehead flap, mid-line frontal flap.
 Lower eyelid basal cell carcinoma |
 Rhombic flap |
 Rhombic flap sutured into the defect |
 Postoperative result |
Skin grafts
When skin flap is not possible, a skin graft is performed. A full-thickness graft is preferable to a split thickness graft, because split thickness grafts become usually pigmented and retracted.
Donor sites for full-thickness grafts are : preseptal upper lid skin, post-auricular skin, supraclavicular fossa. Donor sites for split-thickness grafts are : inner arm, thigh.
Once the full-thickness graft obtained, the fat is excised from the graft, in order to improve its take. The graft is tailored to fit the defect. A bolster holds the graft in contact with its bed with tie over sutures. The bolster and sutures are removed after one week.
 Lower eyelid basal cell carcinoma |
 Marked excision area |
 Full thickness graft from post auricular skin |
 Postoperative result |
*Posterior lamellar defects
Posterior lamellar flap :
A tarso-conjunctival flap may be obtained from the upper lid tarsal plate, provided the lower 4 mm. of the tarsal plate are intact. This flap is indicated for posterior lamellar defects of the lower lid.
Posterior lamellar graft :
The posterior lamella may be reconstructed by a tarsal graft obtained from the upper lid tarsal plate, or by a full-thickness graft of mucosa : mucosa of the lower or upper lip or of the cheek, hard palate mucosa which is stiffer.
*Full-thickness defects
Repairing a full-thickness eyelid defect requires the reconstruction of both anterior and posterior lamellae. One of the reconstructive lamellae has to be well vascularised, in order to support the second lamella. Combination of a flap and a graft, or combination of two flaps are possible. Combination of two grafts must be avoided, for it leads to necrosis.
Repairing a vertical full-thickness eyelid defect depends on the horizontal extent of the defect :
-Defect affecting less than 25 % of the lid margin : direct closure
-Defect affecting less than 33 % of the lid margin : direct closure with cantholysis and septolysis.
- Defect affecting less than 50 % of the lid margin : lateral rotational flap
 Basal cell lower eyelid carcinoma |
 Before a full thickness lower eyelid excision |
 Lateral canthal rotational flap |
 Postoperative result |
- Defect affecting more than 50 % of the lid margin : different pedicle flaps : Kollner flap for lower eyelid, Cutler-Beard flap for upper eyelid.
