Overview of Lower Eyelid Reconstruction
The eyelids play an important role in keeping our eyes healthy. If a person has cancer or has experienced an injury to their eyelids, it’s very important to take special care. This care not only ensures that the eyelids look normal (cosmesis refers to preserving or restoring the normal appearance) but also that they can perform their job properly.
Anatomy and Physiology of Lower Eyelid Reconstruction
The eyelid consists of two main parts – the front layer, or anterior lamella, and the back layer, or posterior lamella. The anterior lamella includes the skin and the muscle that helps close the eye, called the orbicularis oculi muscle. The posterior lamella, on the other hand, is made up of a thin lining called the conjunctiva and a firm plate-like tissue called the tarsus.
If eyelid reconstruction is required, it’s crucial to address both layers of the eyelid. We can use spare skin or tarsus-conjunctiva grafts, which are like patches of tissue, to replace any damaged bits in either of the layers. That can only happen when the other healthy layer has a good blood supply, because it helps the graft to grow.
However, it’s not common to repair both layers at the same time. This is because, doing so may affect the blood supply needed for the grafts to be successful.
Why do People Need Lower Eyelid Reconstruction
The most common type of skin cancer that affects the eyelid is called basal cell carcinoma (BCC). This usually occurs on the lower eyelid more often than the upper one. Skin cancer on the eyelid can be treated by removing (excising) the cancerous growth with a method that checks to make sure all the cancer has been removed (called ‘frozen section control’), or by working with a specialized skin cancer surgeon (a Mohs surgeon) to excise the lesion.
Because removing cancer often means removing a portion of the lower eyelid, reconstructing this area is a common challenge in the field of eye plastic surgery. Besides cancer, injuries might also lead to lower eyelid defects. Various procedures are available to rebuild the lower eyelid, and these depend on how large the defect is and on specific factors related to the patient’s health and circumstances.
Who is needed to perform Lower Eyelid Reconstruction?
If you have skin cancer, you may have to see a special type of doctor called a Mohs surgeon. They’re trained to remove skin cancer in a process that leaves as much healthy skin as possible. This can be especially helpful to you.
After the Mohs surgeon removes the cancer, you may then need surgery to help repair the area where the cancer was. This is done by another specialist known as an oculoplastic surgeon. They specialize in surgery around the eyes, and they can help you recover and look your best after your skin cancer has been treated.
How is Lower Eyelid Reconstruction performed
If a small part of your eyelid is damaged (usually up to 1/4 of its width), the doctor can typically fix it by stitching the two cut edges together. This is done in two steps: one layer to close the inner part of the eyelid (the tarsus) and another to close the skin. The stitches at the edge of the eyelid are usually horizontal to help the healing process and prevent a notch from forming. If your eyelid is very flexible, the doctor may be able to use this technique even if a larger part of the eyelid is damaged.
If the defect is a bit larger, between 1/4 and 1/2 of the width of the eyelid, one option may be to cut and loosen the outer corner of the eye (the lateral canthus) to provide more flexibility, allowing the edges to be stitched closed more easily. The doctor can also use a flap of tissue from the nearby bone to support the back layer of the eyelid and help close a larger defect.
For medium-sized defects, covering between 1/3 and 2/3 of the eyelid, a technique that uses a rotating skin flap, also known as Tenzel semicircular flap, could be used. This flap is cut from the outer part of the eye and rotated to cover the defect. This tackles the problem of the front part of your eyelid (includes skin and muscle) but doesn’t address the issue with the back part (the conjunctiva and tarsus). The doctor can pair this approach with a flap of tissue from the nearby bone to provide support for this back section of your eyelid and deal with a larger defect.
For large defects, possibly involving the entire lower eyelid, a procedure known as a Hughes procedure may be used. This involves creating a flap from the upper eyelid, which includes a part of the tarsus and conjunctiva, and stitching it to the lower eyelid defect. This provides a new back layer for the eyelid. After the procedure, a second surgery is typically performed about 4 to 6 weeks later to separate the upper and lower eyelids and reconstruct the edges of the eyelids.
Ensuring the correct height and support of the lower eyelid is crucial to prevent turning out (ectropion) and pulling back (retraction) of the eyelid after the surgery. The doctor might decide to connect the upper and lower eyelids temporarily or connect both eyelid edges to the eyebrow to provide elevated support. If the eyelid is particularly lax before or after the operation, a procedure called lateral tarsal strip might be necessary to repair it. Sometimes during the healing process, scar tissue can cause the lower eyelid to turn out, so the doctor may take this into account.
In cases of very large defects, a mid-face lift could be used to repair the lower eyelids and significant front part of the eyelid. In this technique, support for the back part of the eyelid still needs to be provided from either the upper eyelid or potentially from a graft from the hard palate (roof of your mouth) to avoid closure of the eye. Meanwhile, the front part of the eyelid is covered by the mid-face lift.
Possible Complications of Lower Eyelid Reconstruction
Complications from the procedure might include the graft or flap (the transplanted tissue) not taking well, the forming of thickened skin areas (scar tissue), the wound opening up (dehiscence), infection, the eyelid turning outward (ectropion), and the issue coming back or reoccurring. Other problems might include uneven eyelid edges, which could make it feel like something is in the eye and lead to dry eyes. In some cases, there may also be a need for more surgical procedures to adjust the eyelid’s shape and function to be better.
What Else Should I Know About Lower Eyelid Reconstruction?
It’s important to tailor each eye surgery to the individual patient’s conditions, as everybody is different. Factors like loose eyelids (or eyelid laxity), the patient’s age, and the condition of their other eye all play a crucial role in determining the best surgical approach.
For instance, a specific procedure called a Hughes flap, which involves covering the eye for 4 to 6 weeks, might be avoided in children. This is because blocking a child’s vision for that long might lead to a condition called deprivation amblyopia, which is a form of vision impairment that happens if their eyes don’t receive enough visual stimulation during a crucial period of their growth.
The same goes for people who can only see with one eye (monocular vision). It wouldn’t be a good idea to block their only sighted eye for an extended period with a Hughes flap procedure.
And of course, just like after any cancer treatment, it’s important to keep a close eye on the patient’s recovery to make sure the cancer doesn’t come back.
