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| ORIGINAL ARTICLE |
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| Year : 1988 | Volume
: 36
| Issue : 3 | Page : 113-115 |
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Reconstruction of the lower lid using the upper lid
SM Betharia, Sushil Kumar
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, A.I.I.M.S., Ansari Nagar, New Delhi 110029, India
Correspondence Address:
S M Betharia
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, A.I.I.M.S., Ansari Nagar, New Delhi 110029
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 3255698 
The lower lid reconstruction was carried out by using the upper lid in a total of 4 cases of meibomian gland carcinoma, neurofibroma and post-traumatic totally avulsed IoNNer lid. Excellent cosmetic and functional results 'Here obtained. The various important points in the surgical steps are highlighted.
How to cite this article:
Betharia S M, Kumar S. Reconstruction of the lower lid using the upper lid. Indian J Ophthalmol 1988;36:113-5 |
Lower lid reconstruction is required for a better cosmetic appearance as well as to avoid epiphora. A large number of techniques for the repair of lower lid colobomas have been described from time to time. Hughes [1] first described a technique of rebuilding the lower lid by using the tarso-conjunctival advancement flap from the upper lid with a vertical advancement skin flap from the cheek or a full thickness free skin graft to restore the skin-muscle lamina. Sugar [2] reported the tarso-conjuctival sliding graft technique for the reconstruction. Youens [3] et al and Fox [4] described the use of a full thickness lid autograft for the repair of large lower lid defects. Cies and Bartlett [5] described repair of the lower lid by using tarso-conjunctiva from the upper lid to line a rotated skin flap from the cheek. Callahan [6] and Putterman [7] suggested a technique of viable composite grafting in eye lid reconstruction. The use of the lateral canthal area to reconstruct the lower lid was first advocated by Imre [8]. Tenzel [9] described a technique in which a semi-circular graft from the lateral canthal area was used to reconstruct the lid margin defect upto one half of the length of the lid. Mustarde [10] described a huge cheek rotation flag to reconstruct the lower lid. Steinkogler [11] used a medical pedicle rotation flap of the cheek and showed advantages over the use of temporal pedicle cheek flap or the frontal cheek flap. Fox [12 ] was the first to recommend the use of the upper lid for the reconstruction of the lower lid. Hecht [13] and English and Mcdermott [14] also used the upperlid successfully to repair the lower lid defect.
In this communication we are reporting the successful use of the upper lid for reconstruction of the lower lid (a reverse Cutler-Beard technique).
| Material and Methods | |  |
4 cases of colobomas of the lower lid were operated, for repair of the defect by using the upper lid. The details of the extent and the causes of colobomas are given in [Table - 1].
Surgical Steps
Surgical repair was done under general anaesthesia in two stages.
Stage I : The tumor mass was . excised in toto in the lower lid and the extent of the coloboma produced was measured. A horizontal incision was made in the upper lid at the site of the lid fold after marking with gentian violet. Then two vetical incisions were made upwards to mobilise the full thickness advancement flap from the upper lid. The size of this flap was equal to the size of the coloboma in the lower lid. The flap was then sutured to the lower lid defect in two layers. The deeper layers including the levator, Muller's muscle and the conjunctiva was sutured with 5-0 chromic cat-gut and the superficial skin muscle layer with 5-0 black silk. The skin and conjuctiva of the upper lid bridge flap was sutured with continuous 5-0 black silk.
Stage II : This was done after two months of the Ist stage. The upper lid bridge flap was lifted up by lid retractor and the incision was marked with a slight concavity downwards on the upper lid advancement flap covering the lower lid defect. An incision was made on this mark after putting an iris repositor beneath the flap to avoid damage to the globe. Following this the levator and conjunctiva in the upper flap was carefully identified and sutured back on to the tarsal plate in the upper lid bridge after making its margins raw, with 5-0 cat-gut. The skin muscle lamina was mobilized and sutured to the skin muscle layer of the , upper lid bridge with 5-0 black silk. The skin and the conjunctiva of the newly formed lower lid was gently mobilized and continuous suture was applied with 5-0 black silk. Post-operatively patients were put on systemic antibiotics and anti-inflammatory agents. Sutures were removed after 10 days of each stage.
| Results | | |
Excellent cosmetic and functional results were obtained in all four cases. The upper lid which was used to reconstruct the lower lid retained its full normal function, with normal excursion and without any lagophthalmos. [Figure - 1][Figure - 2][Figure - 3][Figure - 4][Figure - 5]
| Discussion | | |
Till today most of the surgeons believe that the lower lid can be used for the reconstruction of the upper lid but not vice-versa. Mustarde is one of the firm advocates of the above principle. The apprehension behind this principle seems to be the damage to the levator muscle causing disturbance to the normal functioning of the upper lid. However, he suggested a cheek rotation flap for the reconstruction of the lower lid. This particular technique has got its own drawbacks which include a huge scar mark on the face and complications in the form of ischaemia and post-operative necrosis of the flap with subsequent deformities of the lid and face as reported by Weiss. [15] Several other techniques described using the lateral canthal region for the reconstruction may not be adequate enough to repair the total lower lid defects. Fox intitially suggested use of the upper lid in the reconstruction of the lower lid and subsequently Hecht, English and Mcdermott successfully reproduced the technique.
This paper highlights how the technique suggested by Fox of using the upper lid can be easily and safely used for the total reconstruction of the lower lid. Nothing happens to the function of the levator palpebrae superioris. However, certain important steps which need to be emphasized are :
1. The incision should be placed at the site of the lid fold so that in the final cosmetic look the scar mark is hidden.
2. The width of the upper lid bridge flap should be sufficient enough to prevent damage to the marginal arcade thereby preserving its blood supply.
3. The vertical incisions made in the upper lid must be of adequate. length so as to achieve proper mobilization of the upper lid advancement flap to cover the defect in the lower lid.
4. The suturing of flaps must be tension free and the undermining of the skin muscle lamina should be adequate to achieve the same.
5. Damage to the globe while opening the palpebral aperture must be prevented by placing an iris repositor beneath the full thickness advancement flap joining the two lids. The line of incision should be with a slight concavity downwards.
6. The levator muscle should be carefully identified and sutured back in the second stage so as to keep the upper lid functioning.
7. Lid notching, entropion and ectropion should be avoided while attaching g the levator on the tarsal plate.
The noteworthy merits of this technique include
a) The scar mark in the upper lid is hidden in the lid fold,
b) Levator function is undisturbed, c) No lagophthalmos,
d) Matching of the lid position with the fellow eye in all gazes.
| References | | |
| 1. | Hughes, W.L., Arch. Ophthalmol. 17:1008-1017, 1937.  |
| 2. | Sugar, S.H., Am. J. Ophthalmol. 27:109-123, 1944. |
| 3. | Youens, W.T., Westphal, C., Bartfeld, F. and Youens, H.T. Jr. Arch Ophthalmol. 77:226-229, 1967. |
| 4. | Fox, S.A. Am. J. Ophthalmol. 67:941-945, 1969. |
| 5. | Cies, W.A. and Barlett, R.E. Ann. Ophthalmol. 7:1497-1500, 1975. |
| 6. | Callahan, A. 45:539-545, 1951. |
| 7. | Putterman, A.M. Am. J. Ophthalmol. 85:237-241, 1978. |
| 8. | Imre, J. Tr. Ophthalmol. Soc. U.K., 57:494-508, 1957. |
| 9. | Tenzel, R.R. Arch. Ophthalmol. 93:125-126, 1975. |
| 10. | Mustarde, J.C. Repair and reconstruction in the orbital region, 2nd Ed., Williams & Wilkins Co., Baltimore, Pg. 111, 1980. |
| 11. | Steinkogler, F.J. Br. J. Ophthalmol. 68:507-510, 1984 |
| 12. | Fox, S.A. Trans. Am. Acad. Ophth. Oto., 58:580-585, 1954 |
| 13. | Hecht, S.D. Arch. Ophthalmol. 84:760-765, 1970 |
| 14. | English, F.P. and Me. Dermett, N.D. Br. J. Ophthalmol. 57:747-749, 1973. |
| 15. | Weiss, I.S. Ophth. Surg., 6:42-44, 1975. |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]
[Table - 1]
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