Reconstruction Of The Eyelid May Include:
- Eyelid lesions such as benign moles or vascular lesions
- Open defects left from Moh’s surgery for skin cancer
- Lacerations from facial trauma
- Scar deformities from previous eyelid surgery
Eyelid reconstruction is a very common procedure performed in plastic surgery because of the complexity and precision needed to effectively treat this area.
The upper eyelid functions in the blink mechanism to help protect and lubricate the eye. The lower eyelid has a minor function in the blink mechanism but acts more for tear maintenance on the eye.
Upper And Lower Eyelids Are Composed Of:
- Skin: the eyelid skin is very thin and loose to accommodate for function
- Cartilage: upper and lower eyelids have a cartilaginous plate that adds stiffness to their margins
- Muscle (Orbicularis Oculi): which contribute to the movement and tone of the eyelids
- Mucosa: this is the smooth thin lining of the eyelid which helps to lubricate the eye.
The goal of eyelid reconstruction is to preserve the form and the function of the eyelids. The complexity of the reconstructive procedure is related to the location, the thickness and the size of the eyelid defect.
Dr. Trussler has significant experience in the reconstruction of the eyelid after Mohs surgery and after facial trauma.
What Are My Eyelid Surgery Options?
The method of eyelid reconstruction depends on the size and thickness of the defect. There are multiple common methods of plastic surgery reconstruction including:
Straight line closure: brings the two edges of the open wound together creating a straight-line scar. This is very commonly used at the eyelid margins, though all layers need to closed accurately and separately.
Rotational flap: brings tissue beside the open defect over to cover the open wound. This typically requires another incision so that the adjacent tissue can be rotated.
Pedicled flap: brings tissue from another area close to the open wound on a “leash” of blood vessels and skin so that the living flap of skin and mucosa can be transferred a larger distance to cover the area.
Skin graft: a partial thickness or full thickness piece of skin is taken from another area called a “donor site” and then placed on the open area. This skin graft adheres to the open wound and survives as a skin covering to defect.
Composite graft: is similar to a full thickness skin graft but also includes a layer of fat or mucosa which all adheres to the wound to cover and fill the open area.
Free tissue transfer: skin, muscle and/or bone are taken from a donor site on the body and then transplanted by suturing the blood vessels of the flap to blood vessels near the open wound using an operative microscope. The “free flap” is living, growing tissue used to cover large and complex areas of Moh’s surgery.
There are common scar conditions in the eyelid that can be treated with reconstructive techniques.
- Ectropion: Previous eyelid surgery and/or trauma can lead to lower eyelid retraction (ectropion), which makes the eye susceptible to chronic irritation and dryness because the lower eyelid is pulled down and away from the globe.
- Entropion: Scarring on the inside of the eyelid can lead to an entropion, which is the turning of the eyelid inwards and making the eye susceptible to irritation from the eyelashes.
- Notching: Scar deformities can lead to notching in the eyelid margin.
Consideration
Location and size are the main issues when considering eyelid reconstruction. Small defects on the eyelid can be closed in a straight-line. In difficult areas, like the margin of the eyelid or corners of the eyelids, even small defects may require more complex reconstructive procedures such as rotation or pedicle flaps. Proper alignment of each layer is important as well as the maintenance of tear ducts to ensure proper tear drainage. In laceration repair and the correction scar deformities of the eyelid, these borders of the eyelids should be precisely aligned to prevent notching. Larger areas on the eyelids may be covered with adjacent skin and mucosa or complex rotational flaps. Free tissue transfer may be indicated in entire eyelid reconstruction.
Reconstruction of the eyelid after Mohs surgery can often be coordinated the same day or the day after the clearance procedure. Simple reconstructive procedures can be performed in an office-based setting under local anesthesia, but more complex procedures may need to be performed in the operating room.
Scar deformities of the eyelid usually require additional tissue grafts to add lining and stability to the eyelid after the scar id released. Supportive procedures called canthopexies or canthoplasties are vital to the maintenance of the eyelid position and prevent secondary ectropion.
Expectations
The reconstructive goals for the eyelid are the removal of the lesion and closure of the open area or the correction of the scar deformity with the maintenance or improvement of form and function.
For the eyelid area, the protection of the eye is the main goal and the replacement of eyelid tissue with similar tissue is important for maintenance of eyelid function. Complex pedicle and rotation flaps combined with tissue grafts are more commonly used to reconstruct this area as compared to other areas of the face. In the reconstructive process, there may be more incisions and/or donor sites created to harvest the tissue used for closure. These incisions will form scars which will heal and fade over time. Additional procedures may be needed such as scar revisions, flap division, and inset, and scar care after the area of eyelid surgery is healed.
Eyelid Surgery
Eyelid Reconstruction is usually an outpatient procedure performed either under local or general anesthesia. The eyelid is very sensitive and in order for Dr. Trussler to perform precise and complex procedures, the patient needs to be comfortable.
Benign lesions of the eyelid can be removed and closed by Dr. Trussler. Suspicious or malignant lesions may be referred to a Moh’s surgery specialist. Mohs surgery is performed on an outpatient basis in your dermatologist’s office. After the cancerous tissue has been removed completely, the open wound is typically dressed with gauze and arrangements will be made to consult with Dr. Trussler, a reconstructive plastic surgeon, that day or the day after the procedure. Closure of the open area may take place at that time either in the office or in the operating room as an out-patient procedure. Eyelid reconstructive surgery after Moh’s surgery or after trauma may take one to two hours, and depending on the complexity of the procedure and the location can usually be performed with local anesthesia with or without twilight sedation.
Straight line closure: can usually be performed in the office under local anesthesia and the wound edges may be removed and then elevated so that they can be brought together with limited tension and closed accurately with stitches under the eyelid in the cartilagenous tissue and in the skin or mucosa of the eyelid. The majority of traumatic lacerations of the eyelid can be closed in this fashion.
Rotational flap: the design of the flap takes into account the size of the open area and the amount of locally available skin. The flap is incised, elevated and then rotated into place with the donor area closed in a straight line and the flap secured with stitches in the skin. Scar deformities of the eyelid are typically incised with the scar tissue released, and then the defect is closed with local flaps referred to as Z-plasties which can help align the important borders of the eyelid without tension.
Pedicled flap:the design of the flap takes into account the size of the open area, the location of the pedicle which includes the blood vessels, and the location of the donor site for the flap. The flap is incised, elevated and then rotated into place with the donor area closed in a straight line and the flap secured with stitches in the skin. Pedicle flaps in the eyelid may rotate tissue from the upper eyelid to fill the lower eyelid defect and vice versa. These are left in place for 10 days to 3 weeks until they are divided. Pedicle flaps may need a secondary procedure which divides the skin bridges and blood vessels after a couple of weeks of healing. This technique can bring a significant amount of skin from a distant area which will cover the open area with living tissue and restore form and function to the area of Moh’s surgery.
Skin graft: a partial thickness or full thickness piece of skin is taken from another area called a “donor site” and then placed on the open area of Moh’s surgery. This skin graft adheres to the open wound and survives as a living skin covering to defect. Split thickness donor sites will heal on their own and are covered with an occlusive dressing, where as a full thickness graft donor site is closed with stitches. Skin grafts are commonly used in eyelid reconstruction.
Composite graft: is similar to a full thickness skin graft but also includes a layer of fat or mucosa which all adheres to the wound to cover and fill the open area. The graft donor site is closed with stitches. Eyelid composite grafts are commonly used for the lining of the eyelid for treatment of scar deformities. These composite grafts are typically harvested from the mouth.
Free tissue transfer: skin, muscle and/or bone are taken from a donor site on the body and then transplanted by suturing the blood vessels of the flap to blood vessels near the open wound using an operative microscope. The “free flap” is living, growing tissue used to cover large and complex areas of Moh’s surgery. This is a complex total eyelid and cheek reconstructive technique which Dr. Trussler has significant experience. The procedure can take over 6 hours and requires a short hospitalization after for free flap care.
Eyelid tendon tightening (canthopexy) or repositioning (canthoplasty) can be performed through a lower eyelid incision and are typically performed to help support the eyelid in the healing process and to help prevent secondary ectropion.
The incisions for most reconstructive procedures are closed with deeper absorbable sutures and a combination of dissolvable and durable sutures in the skin. In pedicle flaps, there may be open areas which area dressed in non-adherent gauze and anti-bacterial ointment. All eyelid incisions are dressed only with an ointment that is safe for the eye and cooling gel eye masks.
Eyelid Surgery Recovery
Recovery from eyelid reconstruction depends on the type of treatment performed.
After any eyelid procedure, it is important to hydrate the eyes as the eyelids heal. Lubricating eye drops, ointments, and gel eye masks all help to maintain moisture on the eyes which can be prone to dryness secondary to the swelling around the eyelids. Swelling and bruising are common after eyelid surgery. Cold compresses and head elevation help to limit this. Eyelid surgery is more annoying than painful in its recovery.
Patients can usually return to work within two days after a simple upper eyelid reconstruction, but at least two weeks should be taken off after lower eyelid surgery. Strenuous activities and exercise should be avoided for at least three weeks after the surgery. Swelling and other side effects usually subside within two weeks after surgery. More prolonged recovery may be seen in patients undergoing combination type procedures like pedicle flaps and mucosal grafts. Dr. Trussler will give you specific instructions on how to care for your eyes after surgery.
Results of eyelid reconstructive procedure are visible as swelling and bruising subside and will continue to improve for up to 6 weeks after the surgery. Scar care will be started at the three-week point after surgery to help fade scars. Dermabrasion and laser resurfacing may be needed to help flatten the areas of reconstruction. Revision procedures and flap divisions may usually be considered at the three weeks to a three-month point after surgery, however, scars will typically take about one year to fully mature and fade. Dr. Trussler may recommend lower eyelid stretching at the 3-week point of the recovery from a lower eyelid procedure to help reduce swelling and scarring.
Patients with realistic goals for eyelid reconstruction are generally very happy with the relief that these procedures can give and this can be appreciated almost immediately. The exact results depend on the patient’s eyelid function and scar healing.
Dr. Trussler will provide patients with specific aftercare instructions in order to facilitate proper healing and successful results.
*Disclaimer: Results and individual patient experience may vary.
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