Practical Plastic Surgery

Full-thickness defects of the lower eyelid involve the skin, orbicularis muscle, tarsus and conjunctiva. The reconstructive hierarchy for these defects is as follows:

1.Primary closure

2.Lateral canthotomy (division of the canthus) with cantholysis (division of the canthal ligament) and primary closure

3.Lateral extension with semicircular flap (Tenzel flap)

4.Lateral extension with Z-plasty (McGregor flap)

5.Upper lid tarsoconjunctival flap (modified Hughes flap) with skin graft or local flap

6.Cheek advancement flap (Mustarde flap) with or without a chondromucosal graft Primary closure can usually be achieved for defects one-fourth to one-third of

the lid margin. Parallel excision of the tarsal plates should be performed to avoid notching (Fig. 31.3). Absorbable sutures approximate the tarsus and nonabsorbable sutures approximate the skin. If a gap of a few millimeters prevents primary closure, a lateral canthotomy with cantholysis and closure is required. The lateral palpebral fissure is incised and the lower limb of the lateral canthal ligament is detached, thus allowing relaxation of the lateral portion of the lower lid. The lateral canthotomy incision is often carried superolaterally to create a semicircular flap for additional mobility (Fig. 31.4). An extra few millimeters can also be gained by adding a Z-plasty

Figure 31.3. Primary closure of lower eyelid defect. Primary closure can be achieved for small defects. Tarsal plate edges that are not perpendicular to the upper eyelid margin tend to cause buckling or notching of the final closure. The tarsus is closed using fine absorbable sutures. The knots must be tied away from the conjunctiva to prevent corneal irritation. The skin is closed with fine nonabsorbable sutures.

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Figure 31.4. Closure of eyelid defect using canthotomy with cantholysis and a semicircular flap (Tenzel). A lateral incision through the palpebral fissure is carried superolaterally. Although Tenzel used a full semicircle incision, most surgeons now agree that a full semicircle is not necessary to gain adequate mobility. The inferior limb of the canthal ligament is divided (middle illustration). The tissues are mobilized medially and the wound is closed. The tarsus is approximated by the method outlined in Figure 31.3.

to the lateral incision (Fig. 31.5). All of these described techniques provide lining, structural support and cilia-bearing skin cover.

These maneuvers are usually not adequate for large defects (>50%). In such cases, lining, support and cover are required via other means. Two options exist for lining and support: the upper eyelid tarsoconjunctival flap (modified Hughes) and chondromucosal composite grafts. The tarsoconjunctival flap (modified Hughes) involves harvesting a flap of conjunctiva with attached tarsus from the upper eyelid (leaving 3-4 mm of inferior tarsal edge intact and separating the levator and Müller’s muscles) and advancing this superiorly-based flap to the lower eyelid defect (Fig. 31.6). These flaps can cover up to 50% of lower eyelid posterior lamella defects. Coverage is obtained using a skin graft, local skin-muscle flap, or large cheek advancement flap (Mustarde). Larger lower lid defects prohibit borrowing from the upper lid for fear of upper lid distortion.

Cartilage, mucosal, or composite (chondromucosal) grafts are a better option for lining and support in larger defects. Options for these grafts include auricular cartilage grafts, mucosal grafts from the mouth (hard palate or buccal mucosa) and nasal septal chondromucosal grafts. Choice of graft is dictated by size of defect and the surgeon’s familiarity with the technique. Ear cartilage grafts are commonly used

Figure 31.5. Lateral extension with Z-plasty (McGregor). In the original description, the lateral extension was aimed superolaterally (shown) in the curve of the lower eyelid to minimize the risk of cicatricial ectropion. However, this Z-plasty technique can also be used to gain additional mobility after making a semicircular flap as outlined in Figure 31.4. The limbs of the Z-plasty must be oriented vertically.

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Figure 31.6. Tarsoconjunctival flap (modified Hughes). Although used mainly for lower eyelid reconstruction, this flap can also be applied for upper eyelid reconstruction. The distal end of the flap is designed 3-4 mm above the upper eyelid margin to leave enough tarsus for upper eyelid stability. The superiorly-based composite tarsoconjunctival flap is raised (leaving Müller’s muscle behind) and sutured into the defect.

Figure 31.7. Cartilage-mucosa graft for lower lid reconstruction. Large lower lid defects usually require replacement of missing tarsoconjunctiva with free cartilage with or without attached mucosa. The graft can be covered with a laterally-based skin-muscle flap (shown) or by other means (see text for detail).

in larger defects. Thin cartilage from the scaphoid fossa is strong yet pliable, donor site morbidity is low, and the exposed surface of the cartilage becomes epithelialized by surrounding conjunctiva over several weeks. Hard palate mucosal grafts are advantageous because of intrinsic support and mucosal lining. In contrast, buccal mucosal grafts are too thin for support and their primary uses are for lining and lid margin reconstruction. Nasal septal chondromucosal grafts are advantageous because they provide significant structural support in addition to mucosal lining. Availability and ease of access allows these grafts to be commonly used for reconstruction of total or near-total lid loss. Chondromucosal grafts need flap coverage (with an adequate vascular bed) to survive.

Skin cover options for large lower lid defects include medial/lateral skin-muscle flaps (Fig. 31.7), large cheek advancement flaps (Fig. 31.8) or bipedicled Tripier flaps. These well-vascularized flaps can provide nourishment for primary chondromucosal grafts while covering very large lower eyelid defects (>75%).

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Figure 31.8. Advancement cheek flap (Mustarde). A large cheek flap can be raised to cover large defects of the lower eyelid. A triangular excision is necessary prior to flap inset. Support and lining are provided by a graft (see text for detail).

Upper Eyelid Reconstruction

Small partial defects of the upper eyelid can be closed primarily with a skin graft or a local flap. Local flap choices are somewhat limited but include a V-Y flap from lateral eyelid or temporal skin (best choice) and a midline forehead flap (poor choice). If local flaps are not available, skin grafts may provide adequate coverage. The best donor site is the contralateral upper eyelid; however it provides limited tissue. Other choices include grafts from behind the ear and the inner upper arm. Additional skin graft length should be used to account for graft contracture.

Full-thickness defects of the upper eyelid are addressed by:

1.Primary closure

2.Lateral canthotomy and cantholysis with primary closure

3.Lateral extension with semicircular flap (Tenzel)

4.Lateral extension with Z-plasty (McGregor)

5.Sliding upper eyelid tarsoconjunctival flap (modified Hughes) covered by skin graft or local flap

6.Lower eyelid full-thickness switch flap (Mustarde) or bridge flap (Cutler-Beard

flap)

These methods are similar to methods for correction of lower eyelid defects. However, because constant blinking causes significant surface interaction between the upper eyelid and the cornea, inner irregularities in the upper eyelid are less forgiving. Sutures in the conjunctiva or thick cartilage grafts can scratch the cornea and lead to keratitis.

Full-thickness defects of the upper eyelid are addressed by primary closure, a semicircular flap or the Cutler-Beard flap. These methods are similar to the methods for correction of lower eyelid defects described above. However, because constant blinking causes significant surface interaction between the upper eyelid and the cornea, inner irregularities in the upper eyelid are less forgiving. Sutures in the conjunctiva or thick cartilage grafts can scratch the cornea and lead to keratitis.

Primary closure of full-thickness upper eyelid defects is feasible for defects up to 25% of the upper eyelid. As in the lower eyelid, the incision through the tarsus is made perpendicular to the lid margin to avoid buckling of the tarsus. Absorbable sutures approximate the tarsus and nonabsorbable sutures approximate the eyelid skin (Fig. 31.9). If primary closure cannot be achieved, a lateral canthotomy and

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Figure 31.9. Primary closure of upper lid defect. Primary closure can be achieved for defects smaller than 25% of the lid. Closure method is similar to closure in small lower lid defects (see Fig. 31.3). However, because of its repetitive gliding action on the cornea, the upper eyelid is less forgiving of inner lining irregularities.

cantholysis can be performed. A lateral incision is made in the canthus, and a relaxing incision is made in the upper limb of the canthal tendon.

If a larger defect is present, additional mobility is usually obtained by performing a semicircular flap. Defects up to 50% can be closed in this manner. With the canthotomy and cantholysis already performed, the lateral incision of the canthotomy is extended inferolaterally in a semicircular fashion. The flap is then advanced into the defect (Fig. 31.10). Similar to lower lid reconstruction, a Z-plasty (McGregor) gives the semicircular flap additional mobility. The Cutler-Beard flap may be utilized for defects greater than 50% of the upper eyelid. This flap uses full-thickness tissue from the lower eyelid to reconstruct the upper eyelid. A full-thickness horizontal incision is made just inferior to the lower tarsus. Vertical incisions are made inferiorly from the lateral edges of the horizontal incision. The flap is then advanced superiorly under the intact lower tarsal bridge (Fig. 31.11). The flap is divided after 6-8 weeks. Table 31.1 provides a summary of the above-mentioned procedures and serves a guide to eyelid reconstruction. Although many other eyelid reconstructive techniques have been described, they are beyond the scope of this limited chapter.

Figure 31.10. Semicircular flap (Tenzel) for upper eyelid defects. After canthotomy and cantholysis (not shown), the lateral incision is extended inferolaterally. Additional mobility can be obtained with a Z-plasty (McGregor) in the manner shown in Figure 31.5.

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Figure 31.11. Lower eyelid bridging flap (Cutler-Beard). Large (>50%) defects of the upper eyelid can be closed with lower eyelid tissue as shown. The proposed flap is tunneled under a lower eyelid bridge to provide closure. The base of the flap is then divided at a second stage.

Complications

Some of the more common complications seen in eyelid reconstruction include:

•Asymmetry

•Lower lid laxity

•Lagophthalmos

•Ectropion

•Intropion

•Infection

•Conjunctivitis

•Trichiasis (turning inward of the lashes)

Pearls and Pitfalls

•Defects less than 25% of the eyelid can almost always be repaired by a layered primary closure.

•Small, medial, partial-thickness defects can be allowed to granulate instead of primary closure.

•Only use mucosa for reconstructing conjunctival defects, never skin. Remember that the graft will significantly contract in size so harvest a graft much larger than the defect.

•Convert a wedge shaped defects into a pentagonal shape before closure. This will help minimize tension that can lead to lid retraction.

•Always approximate the grey-line as a first step in closure of upper lid defects.

•A useful technique for lid support is to turn over a laterally-based strip of periosteum that can substitute for tarsus.

Suggested Reading

1.Achauer BM, Eriksson E, Guyuron B et al. Plastic Surgery: Indications, Operations, and Outcomes. St. Louis: Mosby Inc., 2000.

2.Aston SJ, Beasley RW, Thorne CHM. Grabb and Smith’s Plastic Surgery. 5th ed. Philadelphia: Lippincott-Raven Publishers, 1997.

3.Evans GRD. Operative Plastic Surgery. New York: McGraw-Hill Companies, 2000.

4.Della Rocca RC, Bedrossiam EH, Arthurs BP. Ophthalmic Plastic Surgery: Decision Making and Techniques. New York: McGraw-Hill Companies, 2002.

5.Larrabee Jr WF, Sherris DA. Principles of Facial Reconstruction. Philadelphia: Lippincott-Raven Publishers, 1995.

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Figure 32.1. Surface anatomy of the nose: the aesthetic subunits. (1) Dorsum, (2) sidewall, (3) tip, (4) soft triangle, (5) alar-nostril sill, (6) columella.

It must also be noted that the thickness of the skin of the nose varies considerably. The skin of the upper dorsum and sidewalls of the nose (zone I) is smooth, thin, relatively nonsebaceous and moves fairly easily over the underlying skeleton. The skin of the supratip, tip and alae (zone II) is thick, dense and sebaceous. Finally the skin of the soft triangles, alar magins, infratip and columella (zone III) is smooth, thin and relatively nonsebaceous, but unlike the dorsum and sidewalls is densely adherent to the underlying cartilaginous skeleton and does not move easily.

Preoperative Considerations

As with all surgery, routine preoperative risk stratification should be undertaken, particularly when planning an extensive multi-staged reconstruction. A plan should be outlined for “replacing like with like.” A functional nose must possess three basic elements: lining, support and cover. Options for replacing these tissues are outlined in Table 32.1. Several authors advocate the use of a preoperative or intraoperative template to plan the design of flaps. Classically the aluminum foil wrapper from a chromic suture is used to create a three dimensional template of the nasal subunits

which need to be replaced. This template is then flattened out to reveal the actual 32 size of the flap or skin graft which needs to be harvested. Skin defects comprising greater than 50% of a given aesthetic subunit should be enlarged to encompass the entire subunit to avoid noticeable scars and contour deformities within individual subunits. One must be cautious when analyzing the defect. Factors such as edema, scarring, previous attempts at repair, wound contracture, secondary healing, gravity

and skin tension can all distort the true size and shape of the defect, and one must take any or all of these factors into account.

Table 32.1. Autogenous tissue options for nasal reconstruction

Lining

Full-thickness skin graft

Turnover flap

Nasolabial lining flap

Bipedicle alar margin ribbon flap

Contralateral mucoperichondrial flap

Septal pivot flap

Microvascular free flap

Support

Septal cartilage

Conchal cartilage

Costal cartilage (6th through 9th ribs)

Costocondral junction graft (usually 8th rib)

Cranial bone graft

Iliac crest bone graft

Costal bone graft

Surface Coverage

Local advancement flap

Preauricular skin graft

Bilobed flap

Nasolabial flap

Paramedian forehead flap

Scalp flap

Microvascular free flap

Operative Technique

Primary Closure

The relatively mobile nature of zone I skin can allow for primary closure of some small defects. As always, lines of relaxed skin tension should be utilized when able. The relatively thick, immobile nature of zone II and III skin makes for difficult mobilization. If primary approximation of the wound results in unacceptable tension or deformity, a skin graft or local flap should be used.

Skin Graft

Skin grafts can be of use in reconstruction of fairly superficial defects of the nose, particularly the nasal sidewalls which are planar subunits and well approximated by the flat contraction of a skin graft (as opposed to the convex contraction of a flap reconstruction). Appropriate donor sites in terms of color and texture match include preauricular and supraclavicular skin. Full-thickness skin should be used to minimize contraction and provide the best match for the depth of the defect. When

32relevant, perichondrium and periosteum at the recipient site should be preserved to facilitate skin graft take. Full-thickness defects including some nasal cartilage can also be addressed through an appropriately designed composite graft including auricular skin and cartilage.

Locoregional Flaps

The relatively mobile skin of the nasal dorsum and sidewalls can be used in a typical V-Y advancement fashion for small defects. The bilobe and rhomboid flaps

can be used to address small defects of the nasal dorsum and sidewall, but in practice often generate distorting dog ears which must be carefully planned so as not to distort the normal contours of the nasal surface. The skin of the glabellar region can be mobilized in an advancement, V-Y, or transposition fashion to address defects of the upper third of the dorsum or sidewall.

The nasolabial flap has been used for reconstruction of defects of the nasal alae since the earliest descriptions of facial plastic surgery. The flap can be advanced or rotated into place based on an inferior or superior pedicle respectively, relying on random extensions of an axial blood supply derived from the angular branch of the facial artery. The flap provides reliable coverage, and the donor defect is easily concealed in the natural crease of the nasolabial fold. The superiorly based flap generally requires secondary revision of the cone of tissue generated by rotation of the flap into place. The inferiorly based flap results in a donor defect which can often be closed primarily and requires revision only to correct any excessive distortion of lip height.

The paramedian forehead flap is the workhorse for larger full-thickness defects of the lower two-thirds of the nose. Forehead skin is the ideal donor for the thick, sebaceous skin of zone II, and convex contracture of the flap results in an ideal contour match for the nasal tip and alae. The flap is based on random extensions of axial blood supply from both the supratrochlear and supraorbital arteries. The flap is designed over the contralateral supratrochlear artery to allow for greater ease of rotation. The base should include approximately 1.5 cm of width, with incisions designed to fall naturally into the procerus and corrugator skin creases. The distal portion of the flap is shaped based on a foil suture-package pattern designed to match the nasal subunits requiring replacement, taking care to accurately account for shortening of the flap with rotation. The distal flap is elevated in the subdermal plane to better approximate the depth of the defect it will be filling. The remainder of the flap is transitioned to a submuscular plane to optimize the vascular pedicle. The flap is divided after a period of three weeks allowing for inosculation of the distal flap.

Composite Flaps and Free Tissue Transfer

Significant loss of underlying structural elements and nasal mucosal lining require adequate replacement. Conchal, septal or rib cartilage may be harvested and shaped into structural support grafts to provide stability for overlying soft tissue reconstructions. Nasal lining may be provided by skin grafts, locoregional flaps or free microvascular tissue transfer. Contralateral mucoperichondrial flaps and facial artery musculomucosal flaps have been described for nasal lining. Recent reports have described the use of radial forearm skin as a thinned free flap for replacement of nasal lining in extreme defects.

Postoperative Care

The extent of postoperative care depends on the complexity of the repair. Head elevation, cold compresses and avoidance of nose blowing are recommended. Incisions should be washed daily to avoid crusting which makes suture removal very 32 difficult. Intranasal saline spray should be used when needed. Skin grafts can be bolstered using cotton soaked in mineral oil and covered with Xerform® which is

held in place with nylon sutures. Splints may be employed if significant osteocartilagenous reconstruction was undertaken. Use of devascularized tissues (cartilage, skin, or bone grafts) generally indicates some period of postoperative antibiotic coverage. Patients should be adequately counseled as to the multi-stage nature of more extensive reconstructions.