Eyelid reconstruction surgery

Key points at a glance

Eyelid reconstruction is a general term for surgical procedures that restore function and appearance for eyelid defects caused by tumor removal, trauma, burns, or congenital anomalies.
The eyelid has a two-layer structure: the anterior lamella (skin and orbicularis muscle) and the posterior lamella (tarsus and conjunctiva), and reconstruction is performed for each layer separately.
At least one of the two layers must be reconstructed with a vascularized flap.
The choice of procedure is determined by the size of the defect (as a proportion of eyelid length), its depth, and its location.
In eyelid lacerations medial to the punctum, always check for canalicular rupture, and repair within 48 hours after injury is preferred.
For posterior lamella reconstruction, there are several graft options such as tarsoconjunctiva, hard palate, auricular cartilage, and oral mucosa.
Reconstruction of the posterior lamella using acellular dermal matrix and tissue engineering approaches is still at the research stage.

1. What is eyelid reconstruction?

Eyelid reconstruction is a general term for surgical reconstruction performed for eyelid defects caused by tumor removal, trauma, congenital anomalies, burns, and similar conditions, with the goals of preserving eyelid closure, maintaining the tear film, securing the visual field, and restoring appearance.

The history of representative procedures is as follows. The Cutler-Beard method was reported in 1955 by NL Cutler and C Beard. The Hughes tarsoconjunctival flap was reported in 1937 by Wendell Hughes. The Tenzel semicircular advancement flap was reported in 1975 by RR Tenzel.

Indications are broadly divided into congenital and acquired. Congenital causes include coloboma, Goldenhar syndrome, and Treacher Collins syndrome. Acquired causes include after tumor removal, trauma, burns, after radiation therapy, and iatrogenic causes (complications after cosmetic surgery).

Among malignant eyelid tumors, basal cell carcinoma accounts for more than 80% in Western countries. In Asia, squamous cell carcinoma (7–40%) and sebaceous carcinoma (3.4–29%) are relatively more common ¹⁾.

Q When is eyelid reconstruction needed?

The main indications are eyelid defects after tumor removal, trauma, burns, congenital anomalies, and after radiation therapy. Iatrogenic causes, such as lagophthalmos after cosmetic surgery and cicatricial eyelid retraction, are also included. The surgical method is chosen according to the size, depth, and location of the defect.

2. Main symptoms and clinical findings

Symptoms noticed by the patient

Symptoms associated with incomplete eyelid closure: corneal dryness, foreign body sensation, tearing, and reduced vision.
In traumatic cases: pain, swelling, and bleeding.
After burns: restricted eye movement and difficulty opening the eye due to eyelid-globe adhesions²⁾.

Clinical findings (findings the doctor confirms during the examination)

Systematically check the assessment items directly related to choosing the surgical method.

Depth of the defect: distinguish between full-thickness defects (both anterior and posterior lamellae) and anterior lamella only.
Size of the defect: surgical choice differs by proportion to eyelid length (small: 25–50%, medium: 50–75%, large: over 75%).
Location of the defect: medial, central, lateral. Whether the inner canthus or outer canthus is involved.
Injury to the lacrimal drainage system: lacerations medial to the punctum may involve canalicular injury. Confirm with irrigation and probing.
Presence of levator muscle rupture: a cause of traumatic ptosis. Expose the laceration and observe whether rupture is present.
Degree of damage to each layer: assess the condition of the skin, orbicularis oculi muscle, tarsal plate, conjunctiva, levator muscle, and Müller muscle individually.
Mobility and laxity of surrounding tissues: in older adults, tissue laxity is greater and reconstruction is easier.

Q In what cases should a canalicular laceration be suspected in an eyelid laceration?

A canalicular laceration should always be suspected in an eyelid laceration medial to the punctum. Confirm it with irrigation testing or probing, and if a laceration is found, repair within 48 hours after injury is desirable.

3. Causes and risk factors

Tumor removal: The most common cause. Occurs after removal of basal cell carcinoma, squamous cell carcinoma, sebaceous carcinoma, melanoma, and others¹⁾.
Trauma: Eyelid laceration. In blast trauma, 41.6% of eye injuries are said to be eyelid lacerations.
Burns: Scarring contracture and eyelid-globe adhesions caused by chemical burns and flame burns²⁾.
Congenital anomalies: Coloboma, Goldenhar syndrome, Treacher Collins syndrome, Fraser syndrome.
After radiation therapy: Defects due to fibrosis and necrosis of surrounding tissue.
Iatrogenic: Lagophthalmos and cicatricial eyelid retraction after cosmetic surgery³⁾.

4. Diagnosis and examination methods

History taking, visual inspection, and imaging tests

History taking and visual inspection: Assess the depth of the laceration, whether a foreign body is present, and whether a fracture around the orbit is suspected.
CT scan: of the orbit, head, and face. Essential for checking foreign bodies and fractures.

Evaluation of the defect

Classify the defect systematically and use it as the basis for choosing the surgical method.

Evaluation item	Classification / findings to confirm
Depth	Full-thickness / anterior lamella only
Size	Small (25–50%) / Medium (50–75%) / Large (>75%)
Location	Medial, central, or lateral; involvement of the medial canthus or lateral canthus.

Confirming canalicular laceration: confirm with irrigation through the punctum and bougie insertion.
Check for levator rupture: Expose the laceration and observe whether the muscle or aponeurosis is torn.
If the tumor is removed: It is necessary to confirm negative margins with an intraoperative frozen section¹⁾.
Spinelli-Jelks classification (5 periorbital zones): Zone 1 (upper eyelid), Zone 2 (lower eyelid), Zone 3 (medial canthus), Zone 4 (lateral canthus), Zone 5 (surrounding tissues)⁴⁾.

5. Standard treatment methods

Basic treatment principles

In eyelid reconstruction, the two layers are reconstructed separately: the anterior lamella (skin and orbicularis oculi muscle) and the posterior lamella (tarsus and conjunctiva). At least one of the two layers should be reconstructed with a vascularized flap, and the other may be a free graft³⁾. The knots of the sutures should always be placed on the skin side to avoid corneal irritation.

Suturing eyelid lacerations

Without eyelid margin laceration: Bring the wound edges together accurately and suture them. There is often no skin defect.
With eyelid margin laceration: First place a temporary suture at the eyelid margin with 6-0 nylon, then secure it with a mosquito forceps, and then suture the tarsus with 6-0 nylon. Align the lash line or gray line precisely. If there is a bulbar conjunctival laceration, suture it; if the Müller muscle or levator muscle is torn, suture that as well. If the medial or lateral canthal tendon is torn, fix it back in its original position. Close the eyelid skin with 7-0 nylon, and close the area around the eyebrow and nasal root with buried 6-0 nylon sutures.
Debridement: Keep it to a minimum. Remove only clearly crushed or contaminated tissue.
Cleaning and anesthesia: Use infiltration anesthesia with 0.5–1.0% lidocaine with epinephrine. Remove foreign bodies such as sand, mud, and glass fragments with saline.

Procedure selection by defect size

Choose the procedure according to the defect size.

Small (25–50%)

Direct closure: After pentagonal wedge excision, use buried vertical mattress sutures (far-far-near-near-near-near-far-far). Use 6-0 Vicryl.

Lateral canthotomy + cantholysis: Add this when there is tension (33–50%).

Moderate (50–75%)

Tenzel semicircular advancement flap: Advance in a semicircle from the lateral canthus toward the temporal side. Perform lateral canthotomy + inferior cantholysis. Disadvantage: loss of the lateral eyelashes.

McGregor flap: Add a Z-plasty to the end of the Tenzel flap to increase vertical tissue recruitment.

Large (over 75%)

Cutler-Beard method (upper eyelid defect): A two-stage full-thickness advancement flap from the lower eyelid. Divide the pedicle after 6–8 weeks. Disadvantages: lymphedema, lower eyelid ectropion, no eyelashes. Contraindicated in monocular patients and infants because of the risk of amblyopia.

Hughes tarsoconjunctival flap (lower eyelid defect): Raise a flap from the tarsus of the upper eyelid (4 mm above the lid margin) and advance it. Disadvantages: possible upper eyelid retraction and redness from conjunctival dryness.

Lid switch flap (large upper eyelid defect): Move the full-thickness lower eyelid together with the eyelashes. The only technique that can provide eyelashes. Divide the pedicle after 2–3 weeks.
Mustarde cheek rotation flap: Useful for anterior lamella reconstruction of large vertical defects.
Glabellar flap: Anterior lamella reconstruction for an inner canthal defect. Combination of a V-Y flap and a rhomboid flap. Completed in a single stage.

Graft selection for posterior lamella reconstruction

The characteristics of the grafts used for posterior lamella reconstruction are shown below.

Graft	Characteristics	Key considerations
Tarsoconjunctival graft	Gold standard. Can be used for defects of up to 75% of eyelid width	Complication rate: 43% in East Asians, 84% in White people (ectropion and entropion are most common)⁵⁾
Hard palate mucoperiosteum (HPM)	Histologically similar to tarsoconjunctival tissue	Potential corneal irritation due to keratinized epithelium³⁾
Auricular cartilage	Thin and elastic. Good long-term graft take. No significant postoperative resorption or contraction.	More flexible than septal cartilage and easier to harvest³⁾
Nasal septal mucocartilage	Contains goblet cells and mucous glands, providing substitute mucus	After thinning, it is shaped to fit the curvature of the tarsal plate⁵⁾
Oral mucosa	Highly elastic and well vascularized	Low structural strength; cannot be used alone. It must be combined with cartilage³⁾

Techniques for anterior lamellar reconstruction

Full-thickness skin graft: Split-thickness skin grafts should not be used³⁾.
Propeller flap: Rotate an island flap around its axis (90–180 degrees). Nasolabial flaps or cheek flaps can be used. Few complications, with good color and texture match. Low risk of ectropion and lower eyelid retraction⁶⁾.
Step ladder V-Y advancement flap: A stepwise V-Y advancement flap from the cheek. No complications in all 5 cases. It sacrifices less healthy skin and can be done in a short time. Less invasive than the Mustardé flap⁷⁾.
Myotarsocutaneous flap: An island flap with the orbicularis oculi muscle as the pedicle. Designed to match the upper and lower eyelid sulci to make the scar less noticeable. The eyelid margin (including the eyelashes) can be placed at the center of the defect⁸⁾.
Nasolabial flap: Rich blood supply from perforators of the facial and angular arteries. Good match in color and texture. The donor-site scar is hidden within the nasolabial fold⁴⁾.

Repair of canalicular laceration

In eyelid lacerations medial to the punctum, always check for canalicular laceration.
Repair within 48 hours after injury is preferable.
General anesthesia is preferable (swelling from local anesthetic infiltration makes it difficult to identify the cut ends).
After inserting a silicone tube, suture the canaliculus with 8-0 Vicryl or nylon. The tube is usually left in place for 1 to 2 months.

Traumatic ptosis

Traumatic ptosis is classified as neurogenic (oculomotor or sympathetic nerve injury), myogenic (levator or aponeurotic rupture), aponeurotic, or mechanical (scarring).

Neurogenic and aponeurotic: Observe for up to 6 months after injury before considering surgery.
If levator or aponeurosis rupture is evident: Attempt suturing the ruptured site.

Anesthesia

Local anesthesia: 2% lidocaine + epinephrine 1:80,000 to 1:200,000. Onset within 5 minutes, duration about 1 hour. If a longer effect is needed, use an equal mixture of lidocaine and 0.5% bupivacaine.
Topical anesthesia: 1% ametocaine, 0.4% oxybuprocaine.
General anesthesia: General anesthesia is indicated for extensive repair or lacrimal canalicular repair.

Q In eyelid reconstruction, how are the anterior and posterior lamella used?

The anterior lamella (skin and orbicularis muscle) and the posterior lamella (tarsus and conjunctiva) are reconstructed separately. At least one of the two layers should be reconstructed with a vascularized flap, and the other may be a free graft (tarsoconjunctival, hard palate, auricular cartilage, oral mucosa, etc.). If free grafts are used for both layers, there is a risk of necrosis.

Q What types of grafts are used for posterior lamella reconstruction?

The tarsoconjunctival graft is the gold standard, but it is difficult to use when the defect exceeds 75% of the eyelid width. Alternatives include hard palate mucoperiosteum, auricular cartilage, nasal septal mucocartilage, and oral mucosa. Oral mucosa has low structural strength and cannot be used alone; it must be combined with cartilage.

6. Pathophysiology and detailed pathogenesis

Eyelid anatomy

The eyelid consists of two layers: the anterior lamella (skin and orbicularis muscle) and the posterior lamella (tarsus and conjunctiva), with the gray line as the boundary.

Tarsus: Dense fibrous tissue. Length 28 to 29 mm, thickness 1 mm. Height: upper eyelid 10 mm, lower eyelid 3.5 to 5 mm.
Normal palpebral fissure: horizontal 28–30 mm, vertical 10–11 mm. The outer canthus is about 2 mm higher than the inner canthus.
Vascular supply: The medial eyelid artery (a branch of the ophthalmic artery) and the lateral eyelid artery (a branch of the lacrimal artery) anastomose to form the marginal arterial arcade (2–3 mm from the eyelid margin) and the peripheral arterial arcade.
Lymphatic drainage: Most of the upper eyelid and the outer half of the lower eyelid → preauricular lymph nodes. The inner upper eyelid and inner half of the lower eyelid → submandibular lymph nodes.

Functional significance of the posterior lamella

The posterior lamella has three functions: mechanical support (tarsus), a smooth mucosal surface (conjunctiva), and lipid secretion (meibomian glands)⁵⁾.

Conjunctiva: consists of non-keratinized stratified columnar epithelium and goblet cells (5–10%). Mucin secretion stabilizes the tear film⁵⁾.
Meibomian glands: Branched acinar sebaceous glands. They secrete lipids (meibum) and reduce tear evaporation⁵⁾.
Need for flap reconstruction: At least one layer must be reconstructed with a flap that has blood supply, or necrosis will occur³⁾.

7. Latest research and future prospects (research-stage reports)

Acellular dermal matrix (ADM)

Human-, porcine-, and bovine-derived ADM has been studied as a posterior lamellar spacer graft. Its efficacy and safety have been demonstrated in level II–III clinical studies.

In a report comparing mean contraction rates, ADM was 57% compared with 16% for palatal mucosa⁵⁾. In terms of contraction, ADM is inferior to palatal mucosa, but it has the advantage of avoiding donor-site complications.

TarSys (decellularized porcine small intestinal submucosa)

It is a xenograft material containing collagen types I, III, and IV. Concerns remain about infection and inflammatory reactions⁵⁾.

Tissue-engineered tarsal equivalent

A tissue-engineering approach using PLGA + bone marrow mesenchymal stem cells + TGF-β1 plasmid DNA is being studied.

In a rabbit model study (Dai 2019), ECM deposition and meibomian gland acinar formation were confirmed 8 weeks after transplantation⁵⁾.

3D-bioprinted scaffold

A method is being studied in which a PCL scaffold is coated with a decellularized matrix from adipose-derived mesenchymal stem cells and seeded with SZ95 sebaceous gland cells.

In Chen et al.’s study, meibomian gland acini-like structures and neutral lipid secretion were confirmed 1 month after subcutaneous transplantation in nude mice⁵⁾.

Synthetic polymers

Research using synthetic polymers such as PLA, PCL, PLGA, and PPF is advancing. Findings in animal models suggest support for goblet cell growth during conjunctival repair. The PPF-HEMA copolymer is said to cause less inflammatory response than ADM and to allow better tissue ingrowth⁵⁾.

Decellularized amniotic membrane transplantation

It has anti-angiogenic, anti-inflammatory, and anti-scarring properties. It is the most widely used substitute for conjunctival reconstruction. It epithelializes over 3 to 6 weeks and is absorbed within 6 months⁵⁾.

8. References

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Pinto A, Caneira M, Caneira F, Conduto D, Gouveia C.. Optimizing Surgical Correction of Symblepharon Secondary to Lower Eyelid Burn Scar. Cureus. 2024;16(12):e75933. doi:10.7759/cureus.75933. PMID:39830575; PMCID:PMC11740195.
Miotti G, Zeppieri M, Rodda A, Salati C, Parodi PC.. How and when of eyelid reconstruction using autologous transplantation. World J Transplant. 2022;12(7):175-183. doi:10.5500/wjt.v12.i7.175. PMID:36051449; PMCID:PMC9331409.
Malviya V, Goyal S, Bansal V.. Reconstruction of Lower Eyelid with Nasolabial Flap for Anterior Lamella and Turnover Flap for Posterior Lamella. Surg J (N Y). 2022;8(1):e56-e59. doi:10.1055/s-0041-1742177. PMID:35136838; PMCID:PMC8813331.
Yan Y, Ji Q, Fu R, Liu C, Yang J, Yin X, et al. Biomaterials and tissue engineering strategies for posterior lamellar eyelid reconstruction: Replacement or regeneration?. Bioengineering & translational medicine. 2023;8(4):e10497. doi:10.1002/btm2.10497. PMID:37476060; PMCID:PMC10354782.
Hayat N, Jan S, Aslam S, Asghar MS.. Outcomes of Propeller Flap in Eyelid Reconstruction. Cureus. 2021;13(4):e14509. doi:10.7759/cureus.14509. PMID:34079657; PMCID:PMC8159342.
Yamashita K, Shimada K, Aoki K, Ito N, Komiya T, Ida Y, Usui Y, Goto H, Matsumura H.. Step ladder VY advancement flap for lower eyelid reconstruction after resection eyelid malignant tumors. Int Ophthalmol. 2024;44(1):296. doi:10.1007/s10792-024-03203-9. PMID:38951372; PMCID:PMC11217083.
Takasu H, Yagi S, Taguchi S, Furukawa S, Ono N, Shimomura Y.. Lower Eyelid Reconstruction Using a Myotarsocutaneous Flap while Considering the Superior and Inferior Palpebral Sulci. Plast Reconstr Surg Glob Open. 2022;10(3):e4147. doi:10.1097/gox.0000000000004147. PMID:35317459; PMCID:PMC8929522.

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