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Year : 2006  |  Volume : 54  |  Issue : 3  |  Page : 149-158

Techniques of periocular reconstruction

Oculoplastic Unit, Sydney Eye Hospital, Save Sight Institute, University of Sydney, Sydney, Australia; and SuVi Eye Hospital and Research Centre, Kota, Rajasthan, India

Correspondence Address:
Vidushi Sharma
SuVi Eye Hospital and Research Centre, A-475, Indra Vihar, Kota, Rajasthan, India

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0301-4738.27064

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Eyelid and periocular reconstruction is often needed in ophthalmic practice, as a result of defects created by excision of lesions or following trauma. A variety of techniques have been described for the repair of these defects. However, it is important to have a knowledge of the basic principles underlying all these techniques and the advantages and disadvantages of each, so as to ensure the selection of the optimal technique in a particular case. Different authors have popularized different techniques based on individual preferences and experiences and a brief overview of the different techniques will be helpful to compare them. The articles referenced in this manuscript were looked up through PubMed by feeding the keywords 'periocular reconstruction' and 'eyelid reconstruction' and then looking for relevant cross-references. In this review, we have discussed the various techniques available and also illustrated them diagrammatically to have a quick overview of the topic.

Keywords: Cutler-Beard technique, eyelid reconstruction, hughes technique, periocular flap, periocular reconstruction, skin flap.

How to cite this article:
Sharma V, Benger R, Martin PA. Techniques of periocular reconstruction. Indian J Ophthalmol 2006;54:149-58

How to cite this URL:
Sharma V, Benger R, Martin PA. Techniques of periocular reconstruction. Indian J Ophthalmol [serial online] 2006 [cited 2022 Dec 5];54:149-58. Available from: https://www.ijo.in/text.asp?2006/54/3/149/27064

Eyelid and periocular reconstructions are frequently required for defects due to trauma or following excision of neoplasms. Reconstruction techniques have evolved over time and excellent results can now be achieved with a combination of ingenious flaps and grafts. While defects involving eyelid margins are given a lot of attention, defects in the periocular area are sometimes repaired, without much attention to cosmesis. A poorly performed reconstruction or the injudicious selection of a technique may be harmful for the eye and may necessitate further surgical correction.[1] The exact technique to be used, depends on the defect size, location and the elasticity of the surrounding tissues, which in turn depends on the patient's age. A graded approach consisting of direct approximation, horizontally oriented advancement flaps, rotation flaps and free skin grafts, in that order, depending on the defect, should give good results in all cases.[2] The aims should be to achieve normal eyelid function and eye protection, with a good cosmesis. This article discusses various techniques commonly used for periocular reconstruction with their advantages and disadvantages, with an emphasis on different flaps. The articles referenced in this manuscript were looked up through PubMed using the keywords 'periocular reconstruction' and 'eyelid reconstruction' and then looking at cross-references. Alternative keywords were also fed for the commonly used techniques, such as Hughes and Cutler-Beard.

General considerations in periocular reconstruction

1. The eyelids can be divided into 2 lamellae, the anterior skin-muscle and the posterior tarso-conjunctival lamella. Both need to be replaced for structural integrity and cosmesis. In general, one of these two lamellae needs to be reconstructed as a flap to ensure adequate vascularization and the other lamella can then be replaced with a free graft. However, there have been attempts to reconstruct the whole lower eyelid with a single thick flap.[3]

2. There are a number of natural lines in the periocular area, which can hide surgical scars. The incisions should be placed along the relaxed skin tension lines or the skin wrinkle lines (which are more or less similar), to avoid prominent scarring.[4] An exception should be made to avoid tension on free margins of the eyelids, where a horizontal ellipse may produce ectropion on direct closure [Figure - 1].[5] When scars are not placed along these natural lines, curved scars are less conspicuous than straight scars.[5] The upper lid crease can be used for most skin incisions involving the upper eyelid.[5]

3. The cosmetic result depends to a large extent on the symmetry between the two sides, which should not be compromised.[5]

4. The rich vascular supply in this area provides excellent postoperative healing, but also predisposes the patient to greater swelling, bruising (which is not so obvious in dark skin) and ecchymosis of the thin tissues.[5] The patient should be informed about this preoperatively.

5. Sutures should always be placed with any knots on the cutaneous side, to avoid corneal irritation.

6. Sutures should be passed to ensure that the suture loop is wider in the deeper layers than in the superficial layers, to evert the edges and avoid depressed scars. This is achieved by passing the needle perpendicular to the skin surface and not in a tangential manner, as is often done [Figure - 1].[6]

7. Traction sutures placed on the lower or the upper eyelid during the healing phase may be useful in avoiding lid retraction and ectropion. Postoperative massage may also help in this regard.

Advantages of flaps

Various types of flaps can be fashioned in the periocular tissues. While skin and skin-muscle flaps are commonly used, tarsoconjunctival flaps are useful in reconstruction of the posterior lamella. The advantages of using flaps as compared to a free skin graft for anterior lamellar reconstruction are:

a. Flaps have some degree of their own blood supply and therefore heal faster.[4]

b. The color and texture is best matched by the use of adjacent skin. The thin upper eyelid skin may be suitably replaced by a full-thickness skin graft, but in the thicker skin of the lower eyelid and especially the periocular regions, this may not be a good match.[2],[4],[5],[7]

c. Skin flaps do not contract as much as skin grafts.[4]

d. The adnexal structures have a better chance of survival in flaps, thus contributing further to a normal appearance.[5]

e. Flaps avoid additional surgery at a remote site and are easily mobilized in the relatively elastic skin of the face.

f. Flap thickness can be varied according to the defect depth, whereas skin grafts should always be of minimal thickness to ensure survival.[8]

g. Flaps can be fashioned so as to exert traction in a horizontal direction, thus avoiding any pull on the lid margin which can cause ectropion.[8]

h. The main source of blood supply to the facial skin is from underlying muscles and therefore flaps do not have to be based on a specific blood vessel (axial pattern flaps), but rather can be of a random pattern.[4],[9] These random pattern flaps can have a much higher length to width ratio (up to 1:6) as compared to other areas of the body, due to the rich blood supply.[6] Myocutaneous flaps have the added advantage of greater vascularity and may sometimes retain some muscular function.[10]

Despite these advantages, upper eyelid skin is best replaced by thin skin grafts, preferably taken from the contralateral upper eyelid. Even though flaps from the preseptal upper eyelid skin may be advanced into marginal defects, the use of thicker periocular flaps is inadvisable as they are bulky and the levator may not be able to lift the resultant bulky eyelid.[11]

Basic types of flaps [Figure - 2]

The various flaps used in this area can be divided into 5 types:

a. Sliding flap: Where the skin surrounding a simple ellipse is undermined to close the defect.

b. Advancement flap [Figure - 3] a, b, c, d and e: The surrounding skin is fashioned into a three sided flap, which is dissected and advanced on its own long axis to close the adjacent defect.[4]

c. Rotation flap: These flaps are commonly used in the periocular area, where the directly adjacent skin is lifted and rotated on itself to fill the defect.[4]

d. Transposition flap: In these flaps, the skin not directly adjacent, but close to the defect, is lifted over the intervening skin and fitted into the defect. The angle of rotation in these flaps should not be too large, as a large degree of rotation at the flap base may compromise blood supply to the tip.[4]

e. Island flap [Figure - 3]f: This flap consists of a free island of skin and muscle, where the flap is freed from all sides, but remains attached to a central subcutaneous pedicle; the flap can now be considerably advanced in any direction to fill in the defect and the flap site can be repaired by direct closure.

  Limberg rhomboid flap Top
[Figure - 4]a and b, [Figure - 5]a and b

This is one of the most useful flaps and can be used in any area of skin[12] including the periorbital area. Originally described by Alexander Limberg in 1946, the basic concept consists of creating a rhomboid defect and using a triangular flap drawn in a rhomboid shape, which can be rotated into the adjacent defect. The term 'rhomboid' refers to the shape of the defect, while the flap is essentially triangular.[13] However, in the periocular area, the defects following excision of malignancies are usually circular or oval and it has been described that the triangular flap can be rotated into the circular defect, without converting the defect into a rhomboid.[13] This ensures that no normal tissue is unnecessarily excised and it allows an infinite number of possible flap orientations rather than the original rhomboid technique, where only 4 orientations are possible [Figure - 4]a.[13] This does entail fitting of a "square flap into a circular hole", but this is usually not a problem with the elastic periocular tissues with undermining.[13] The base of the triangle should be parallel to the orbicularis oculi fibers, for defects above or below the eyelids, to avoid ectropion. This flap is not useful for excessively longitudinal defects or for those that involve a major portion of the eyelids or the lid margin.[13]

  Bilobed flap Top
[Figure - 6][Figure - 7]a, b

The bilobed flap was originally described by Esser in 1918 for reconstruction of defects of the nasal tip, which he described as 'a skin flap composed of two lobes, forming an angle and with a common skin pedicle'.[9],[14] The proximal and distal lobes are of the same height as the defect, but are about 20-40% less wide than the adjacent defect[9] and fashioned with the long axis in the direction of relaxed skin tension lines, to allow closure along these lines.[15] This flap is widely used for reconstruction of circular defects of the nose, cheek and forehead and has been found to be useful for medial canthal defects as well.[15] It consists of 2 adjacent transposition flaps on a common pedicle,[15] such that the first flap fills in the original defect and the second smaller flap fills in the defect left by the first flap. Dog ear deformities may be a problem and need to be excised.[9] The angle between the two lobes can be varied from 30° to 120°, to take advantage of areas with lax skin and to ensure closure of incisions along relaxed skin tension lines.[15] The pedicles should be sufficiently broad to ensure viability of the flaps and closure should be done with sufficient undermining to avoid tension on the suture line.[15]

  Island flaps Top

The island flap or a subcutaneous pedicle flap for eyelid reconstruction was described by Kazanjian in 1949.[16] The island flaps have a stalk of attachment to the underlying tissues at the center, as opposed to the pedicled flaps which have an attachment at the medial or the lateral end, on which they can be rotated or transposed. The island flaps can be advanced in any direction and are useful for covering an adjacent defect, especially in areas like the forehead, glabella and the medial canthus. The island flap can be smaller than the primary defect and the site of the flap can be closed primarily or it can be filled with another flap similar to a bilobed flap. The upper lid preseptal skin can also be used with a central muscle pedicle as an island flap.[16] The lower border of these flaps corresponds to the lid crease and the flap can then be passed through a subcutaneous tunnel into the defect.[16]

  Tarsoconjunctival flaps and grafts Top

Wendell Hughes first described a tarsoconjunctival flap in 1937,[17] which was based on an earlier procedure described by Dupuy-Dutemps, who had also described the dacryocystorhinostomy flaps.[3] This flap [Figure - 8]a,[Figure - 9] a, b and c has undergone many modifications since its original description wherein: (1) the upper lid was divided into 2 lamellae at the mucocutaneous junction, (2) the posterior lamella was advanced into the lower lid defect without dissecting the levator or Muller's muscle, (3) the anterior lamella was formed by advancement of cheek skin, (4) an eyelash transplantation from the upper lid was performed 4 weeks later and (5) finally the flap was divided 12 weeks postoperatively.[17] While conventional teaching advocated division of the flap at 4-6 weeks, it is now recommended to divide the flap at 2 weeks to allow earlier visual recovery[18] and division at 1 week has also been reported.[19] In a series of accidental premature dehiscence of the Hughes flap, the final aesthetic and functional results were surprisingly good, giving further evidence that the flap can be divided earlier.[20],[21] Various authors have also used free tarsal grafts [Figure - 9]d, especially if the anterior lamella is reconstructed by a flap rather than a free graft and this obviates the need for a second surgery.[3],[22],[23],[24] When a Hughes procedure is used in combination with a free skin graft, sutures may be passed through the partial thickness of tarsus and through the skin graft, to ensure good apposition of the graft to the host bed, similar to the bolsters used in skin grafts elsewhere.[25] Hughes flap and free tarsoconjunctival grafts are very useful for reconstruction of central defects of the lower eyelid, involving about 60-80% of the length[17],[26] and can also be used for defects involving the entire eyelid, if medial and lateral periosteal flaps are used for anchoring the flap.[27] In these large flaps, some Muller's muscle can be left attached to the flap to provide better vascularization.[27] For defects involving the lateral canthus, a laterally based tarsoconjunctival transposition flap from the ipsilateral opposite eyelid, may be used. This was originally described by Hewes for the reconstruction of the lower eyelid and provides a one-stage reconstruction [Figure - 8]b.[28] In all techniques which employ a tarsal flap from the upper eyelid, it is crucial to leave 3-4 mm of the upper eyelid tarsus for lid margin support and to prevent upper lid entropion.[17] It is also important to dissect the levator and Muller's muscle from the superior border of the tarsus, to prevent postoperative upper lid retraction and notching.[17] When dividing the flap, the tarso-conjunctiva should be cut above the skin muscle edge and the conjunctiva can be sutured to the skin edge to provide a smooth lid margin. However, it has been suggested that the lid margin be allowed to heal by granulation,[17] to avoid having a chronically inflamed lid margin, as the conjunctiva blocks the Meibomian gland openings. A reverse Hughes procedure to reconstruct the upper eyelid has also been described, but this normally provides only a thin 2-3 mm strip of tarsus for reconstruction.[29]

  Cutler-Beard technique Top
[Figure - 10][Figure - 11]

The Cutler-Beard technique or the bridge flap was described in 1955[30] and is used for large defects of the upper eyelid such as sebaceous carcinoma of the upper lid, which is considerably more common than other lid tumors in India.[31] It uses a full thickness (cutaneo-myo-conjunctival) flap of the lower eyelid, which usually does not contain any tarsal plate, as its superior border is placed 5 mm below the lower eyelid margin to preserve the marginal vascular arcade. After 6-8 weeks, the flap is divided at the level of the desired upper lid margin and the pedicle of the flap is repositioned into the donor lower lid.[32] Potential complications include bridge necrosis, lower eyelid ectropion, poor upper eyelid contour, as well as retraction and cicatricial entropion of the upper eyelid.[32] The absence of any tarsus in the original technique, compromises the structural integrity of the upper eyelid and the posterior lamella without tarsus contracts over a period of time, producing entropion.[32],[33] Wesley and McCord described the use of preserved donor sclera between the two lamellae of the Cutler-Beard flap.[34] However, the use of donor sclera is not universally favored due to reports of sloughing of the eyelid and concerns with slow virus transmission and shrinkage.[33] Ear and nasal cartilage[11] have been used and it is reported that the prolonged edema and shrinkage seen with scleral grafts, can be avoided with the use of ear cartilage.[32],[35] In cases where there is at least 3 mm of residual tarsus in the upper lid, it can be advanced into the marginal defect.[36],[37] Such defects are seen following trauma or Moh's excision and not following excision of malignancies without pathological control, as the whole width of tarsus is generally sacrificed in the absence of any method, to know the width of tarsal involvement. A free tarsal graft from the contralateral upper lid[36],[38] or rotation of a vertical strip of tarsus in the horizontal direction has also been described, to replace the posterior lamella;[39] the anterior lamella can then be replaced either with a myocutaneous flap from surrounding skin or as an advancement flap from the lower eyelid, in a modified Cutler-Beard fashion.[35]

  Tenzel's flap Top

Tenzel flap is a semicircular skin-muscle flap, a type of advancement-rotation flap which is fashioned from the skin beyond the lateral canthus and can be used for both the upper and lower eyelid [Figure - 12]a.[40] The vertical extent should not cross the eyebrow for inferior eyelid defects and the flap should stay within the orbital margin or the arc defined by the eyebrow.[40] The upper or the lower crus of the lateral canthal tendon is divided at the orbital rim through a lateral canthotomy performed under the flap and the flap is rotated into the adjacent defect.[40] The lateral attachment of the orbital septum should also be divided to allow free rotation.[40] The diameter of the flap ranges from 10 to 20 mm.[40] The flap is not always circular and the horizontal or the vertical dimension may be greater than the other, depending on the defect.[40] The effectivity of Tenzel flap can be further enhanced by use of a Z-plasty at the end of the flap, which recruits more tissue from the vertical temporal area, to provide horizontal tissue to the eyelid [Figure - 12]b. This extension into the temporal area with Z-plasty is known as McGregor flap and is useful for both the upper and the lower eyelid.[41]

  Glabellar flap Top
[Figure - 13]

The glabellar flap was first described by McCord and Wesley[42] and involves an inverted V incision in the median forehead area between the eyebrows, which is partly closed as a Y and the rest of the flap is rotated into the adjacent medial canthal defect. It can also be seen as a combination of a V-Y and a rhomboid flap. A small area may have to be excised at the tip, to achieve a comfortable fit of the flap into the defect.[42] In an excellent review, the construction of the flap has been described in a step-wise manner.[43] The width of the initial V fills the height of the defect and the height fills the width. The initial V therefore, should be constructed to take into account not only the horizontal size of the defect (which corresponds to the height of the V), but also the depth of the medial canthus (which will require a greater height of the V) and the height of the defect, which will necessitate a broader base of the V.[43] The apex of the V can be shifted from the midline towards the side of the defect and the angle of the V should be between 45°-60°, as a larger angle makes a cosmetically unacceptable bulky flap on the root of the nose, while a narrow angle compromises blood supply.[43] The advantages of the glabellar flap are, that it is a relatively quick procedure, has a good vascular supply and can also be used for deep defects as it is a thick flap. The disadvantages are, that it does not give a natural depth to the medial canthus, results in a bulky nasal bridge and draws the eyebrows together.[42] Some patients may later need surgical debulking of the nasal bridge, as the size of the flap is considerable, compared to the defect.[15] Scar contracture may cause webbing. It also results in prominent scars that cross the relaxed skin tension lines of the forehead. In patients with continuous eyebrows or synophrys, continued hair growth in the flap is a cosmetic disadvantage.[42] This flap is best used for small defects above the medial canthal tendon. As the defect becomes larger or more inferior, there is considerable tension at the nose where the flap is rotated, giving unsatisfactory results.[15]

  Tripier flap Top

Tripier first described the use of an innervated myocutaneous flap in the form of a bipedicle flap (with lateral and medial pedicles) from the upper lid, for reconstruction of a lower lid defect in 1889.[44] The advantage is that it contains muscle fibers and therefore provides some bulk as well as increased vascularity. However, it is debatable whether it actually provides muscle function, as originally described by Tripier.[44]

  Fricke flap Top

Fricke flap was first described by Jochim Fricke in 1829.[45] It is a laterally-based, mono-pedicle transposition flap raised above the eyebrow, which can be used for reconstruction of the upper or lower eyelid. It is now uncommonly used. It is useful for shallow defects of the lower lid, which involve almost the entire eyelid length.[45] A Hughes procedure may be technically difficult in these cases and a Mustarde flap entails very wide dissection and sacrifice of normal tissues, to convert the original defect into a V.[45] Asymmetrical brow height following the procedure is a major disadvantage, but this can be reduced to some extent by a rigorous postoperative downward massage of the eyebrow.[45]

  Periosteal flaps Top

Periosteal flaps are very useful for reconstruction of large eyelid defects or those placed extremely laterally or medially.[46] In defects where there is no residual tarsus, the tarsal graft or flap can be sutured to periosteal flaps fashioned from the adjacent periosteum and the base of the flap is placed at the site of the desired position of the canthal tendons.[27] The flaps should be sufficiently wide to provide strong attachment and a width of about 4 mm throughout the length of the flap is recommended.[27] The disadvantage includes some blunting of the canthal angles, especially laterally.[46] Care should be taken, not to place a free skin graft directly over a periosteal flap, as periosteal flaps have poor blood supply.[46]

  Medial canthal defects Top

The medial canthus is one of the most difficult areas to reconstruct, as skin here is in short supply. The region also has a natural concavity which is cosmetically important and lacrimal structures, which may not function properly in the event of an eyelid malposition, even if they are structurally intact. A contracted scar may lead to webbing. Direct closure is hardly ever possible or desirable. Bilobed flaps, skin advancement flaps, rhomboid flaps[44] and small V-Y flaps or combinations of these, provide best results.[42] A larger or more inferior defect can be closed by a combination of a glabellar flap with a nasolabial island flap [Figure - 14]a and b[15] or a nasolabial V-Y advancement flap.[47] It has also been shown that small circular central defects at the medial canthus, especially those less than 1.5 cms in diameter and those distributed equally above and below the medial canthal tendon, may heal well by secondary intention (laissez-faire), specially in older patients with thin skin, giving excellent cosmetic results and a natural concave appearance.[5],[7] Medially based myocutaneous transposition flaps from the upper lid are also described.[48] It is also necessary to reconstruct the medial canthal tendon and the lacrimal structures, if injured. Full-thickness skin grafts were traditionally used, but in addition to other disadvantages of skin grafts such as poor color and texture match, they are especially problematic in slightly deep defects, where the skin graft does not fill the defect and postoperative contraction of the graft produces distortion of tissue contours.[15] When marking a flap for a medial canthal defect, it is preferable to take skin from the root of the nose or forehead. If inferior nasolabial skin is advanced, care should be taken to avoid lower lid ectropion on closure.

In conclusion, there are a variety of techniques available for periocular reconstruction. Usually, when there are many options to achieve the same purpose, it indicates that none of them is satisfactory. However, in the case of eyelid reconstruction, knowledge of various techniques is needed, as different procedures may be required, depending on the location and size of the defect.

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  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10], [Figure - 11], [Figure - 12], [Figure - 13], [Figure - 14]

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Limberg rhomboid...
Bilobed flap
Island flaps
Cutler-Beard tec...
Tenzel's flap
Glabellar flap
Tripier flap
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Periosteal flaps
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