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Introduction
CHAPTER 38 Reconstruction of the
Eyelids
Andrea Willey Richard Caesar
SUMMARY
Eyelid reconstruction lies at the crossroads of multiple surgical specialties, and
presents distinct challenges for the periocular surgeon.
The unique multilaminate composition of the eyelids, freely mobile yet bound by
fixed bipolar attachments, is vulnerable to tensional forces that require diligent management to preserve their unique anatomic and functional relationships.
Beginner Pearls
Preoperative evaluation and collaboration with ophthalmic and oculoplastic
specialists when indicated is essential for optimal outcomes.
Knowledge of and familiarity with the management of tension are essential to
periocular surgery.
Tension on the lid margin should be assessed pre-, post-, and intraoperatively to
ensure the lid remains in optimal position snug against the globe.
Expert Pearls
Keeping tension parallel to the lid margin is the cornerstone of periocular repairs, and
is often balanced with placing incisions along relaxed skin tension lines.
Transposition flaps and rotation flaps are useful for many periocular defects.
Primary repair of full-thickness lid defects is fundamental to more advanced
reconstructive techniques.
Donโt Forget!
Reconstruction of larger full-thickness lid defects involves a progressive approach
with a combination of techniques to repair the anterior and posterior lamella.
Suspension sutures should be used routinely to support periocular repairs and avoid
ectropion, even when the canthal support has not been disrupted by tumor extirpation.
Pitfalls and Cautions
Full-thickness skin grafts must be appropriately sized with the defect on full stretch to
avoid excessive wound contraction and ectropion.
Complications include bleeding, infection, hematoma, chemosis, epiphora, dry eye,
suture granuloma, trichiasis, lid notching, scleral show, asymmetry, ectropion, and webbing.
Even mild ectropion can cause significant epiphora and discomfort and may require a
slit-lamp examination to evaluate for corneal abrasion.
Patient Education Points
Select patients undergoing extensive surgery around the eye may have a preoperative
ocular examination and consultation with an oculoplastic surgeon to ensure a smooth transition of care if needed.
Both ectropion and webbing tend to occur 2 to 4 weeks postoperatively during
maximal wound contraction. Correction usually requires flap revision and canthopexy procedures.
Billing Pearls
Excisions and repairs on the eyelid rely on the standard code series; keep in mind that
placement of suspension sutures in a linear repair is likely sufficient to elevate a layered closure to complex status.
CHAPTER 38 Reconstruction of the