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Eyelid reconstruction – posterior lamella


Introduction

In a full-thickness reconstruction of the upper or lower eyelid it is important to reconstruct the posterior lamella of the lid to give support to the reconstructed anterior lamella. In the upper lid it is essential that the posterior lamella is lined with mucosa. In the lower lid this is less important but still desirable. If a skin flap is available for the anterior lamella the posterior lamella may be reconstructed with either a flap or a graft. If, however, a free skin graft is to be used for the anterior lamella the posterior lamella must be reconstructed with a vascularised flap.

To estimate the length of posterior lamella required, pull gently on the edges of the defect to reduce the horizontal extent and eliminate horizontal lid laxity. The remaining defect is the length of the reconstruction required.

Classification

  • Grafts

    • oral mucous membrane

    • tarsal plate

    • hard palate

    • nasal septal cartilage

    • tarsomarginal graft

  • Flaps

    • Hughes' tarsoconjunctival flap

    • lateral periosteal flap

    • tarsal transposition flap (Hewes)

Grafts to reconstruct the posterior lamella

Choice of operation

In the upper lid tarsal plate from the same or opposite upper lid, oral mucous membrane, hard palate or a tarsomarginal graft is used.

In the lower lid the posterior lamella must provide added support because of the effect of gravity. Oral mucosa alone will not be sufficient to support a thin skin flap; it may be acceptable, although not ideal, as a lining for a thicker flap. In general a graft of tarsal plate, hard palate, sclera or cartilage is preferable.

The reconstructed lids need support from the canthal tendons. If a canthal tendon has been compromised in the surgical excision it must be reconstructed with one of the methods described below.

Preparing the grafts

See Ch. 2 , Sect. D , for methods of taking oral mucous membrane, auricular cartilage, tarsal plate, hard palate and sclera. See 16.2 for the method of taking nasal septal cartilage with mucoperichondrium and 16.3 for taking a tarsomarginal graft.

16.1

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