Overview of Upper Eyelid Reconstruction
Upper eyelid reconstruction is a type of surgery used to fix problems with the upper eyelid. These problems can happen because of things like removing tumors, injuries, or birth defects like a coloboma, which is a hole in one of the structures of the eye. Sometimes, skin cancers that have been removed by a process called Mohs micrographic surgery can also need extra thought when planning this type of operation.
Fixing the upper eyelid is more complicated than fixing the lower eyelid, and doctors need to think carefully about how they do it. This is because it depends a lot on where the damage is, and how much of the eyelid is affected.
The eyelids are really important for the face. Not only do they make us look the way we do, but they also have the job of protecting our cornea (the clear front part of the eye) and the eyeball. There are also special glands in the eyelids that make a type of oil. This oil helps keep our eyes from getting dry by stabilizing the tear film, which is a thin layer of tears that covers and protects our eyes.
For the upper eyelid to do its job, it has to be able to close over the cornea when we blink, but also be able to move enough to not block our vision when we open our eyes. If the eyelid droops, called ptosis, it can affect both how we see and how we look. Therefore, a good upper eyelid reconstruction surgery should aim at fixing any of these possible problems that can happen because of eyelid damage.
Anatomy and Physiology of Upper Eyelid Reconstruction
The structure of the upper eyelid is complex and plays a big role in surgery. There are several crucial details about the eyelid’s structure that guide the way it is reconstructed. One of the first things to understand is what part of the eyelid is affected. The upper eyelid has two main layers (or ‘lamellae’), which are separated by a layer containing the orbital septum, fat, and the upper eyelid retractor muscle. The front layer is made up of skin and a muscle called the orbicularis muscle, while the back layer consists of a tough, fibrous structure called the tarsus and the inside lining of the eyelid (the palpebral conjunctiva).
The skin on the eyelid is the thinnest skin on the body, partially because it has fewer structures like hair and oil glands. This is important to bear in mind when considering using a skin graft. The orbicularis muscle, which helps close the eyelid, is controlled by a branch of the facial nerve called the zygomatic branch. Since the front and back layers of the eyelid are made of different types of tissue, the surgeon might use different types of grafts or flaps for repairing each.
The amount of tarsus left is also crucial to examine because it provides the main support to the eyelid. It’s important to have an exact understanding of the size of the tarsus for a precise repair. The tarsus is typically 28 to 29 mm wide and 1 mm thick. Its highest point is about 10 mm in the middle and gets thinner around the edges. The tarsus also contains glands called meibomian glands, which help keep the eye moist, and the roots of the eyelashes. A piece of muscle called the levator aponeurosis holds the tarsus in place.
The lining on the inside of the eyelid helps lubricate the cornea (the front part of the eye) and globe (the eyeball). Any tissue used to replace the back layer of the eyelid must create a stable edge for the lid, closely fit the cornea and globe, but not scratch the cornea with hair roots or other cells.
The blood supply to the upper eyelid is also a critical aspect to consider. The majority of the blood to the upper eyelid comes from arteries which form two arcs in the upper eyelid. The veins in the upper eyelid drain into different places based on whether they’re in the front or back part of the upper lid. The system that drains fluid from tissues (the lymphatic system) in the upper eyelid goes to the lymph nodes near the jaw and in front of the ears.
The outside two-thirds of the eyelid drains fluid to the nodes in front of the ears, while the inside one-third drains to the nodes near the jaw. Before any growth is removed, it is vital to know where the eyelid drains fluid to and check those areas for any signs of illness.
Why do People Need Upper Eyelid Reconstruction
If there’s a problem with the eyelid, sometimes it can cause both functional problems, like difficulty seeing or blinking, and cosmetic issues, like a change in appearance. In these instances, doctors may perform a surgery to fix the eyelid, also known as eyelid reconstruction. However, sometimes this surgery might not fully fix the problem, and so a second surgery, or revision surgery, might be necessary.
When a Person Should Avoid Upper Eyelid Reconstruction
A graft or flap – which are medical procedures where tissues are moved from one area of the body to another – need to heal properly in order to be successful. Irradiated tissues – tissues that have been exposed to radiation therapy – may not be suitable for these procedures because radiation can affect their ability to heal properly.
Moreover, it’s important for any tumor to be fully removed before starting reconstruction work. If there’s a leftover or residual tumor in the eyelid, it’s not safe to proceed with the repair. Finally, the method of reconstruction might change depending on whether it can potentially hide or mask a hidden recurrence or reappearance of the cancer.
Equipment used for Upper Eyelid Reconstruction
Normal surgical tools are used when rebuilding the eyelid. To rebuild the eyelid, sometimes doctors use tissues taken from other areas of the body. However, in some cases, artificial grafts are used instead. Artificial tarsal grafts (which is the dense connective tissue that makes up most of your eyelid) are often used as filler material when there isn’t enough of the patient’s own tarsus to use for the repair. For example, doctors may use something similar to an acellular matrix, which acts like a framework for new cells to grow on over time, or a porcine acellular dermal matrix, which is a type of tissue graft made from pig skin.
Who is needed to perform Upper Eyelid Reconstruction?
Reconstructive surgery, often done to rebuild a part of the body affected by a tumor or disease, is usually carried out by a specialist doctor known as an oculoplastic surgeon, plastic surgeon, or facial plastic surgeon. These surgeons might also be the ones who initially remove the tumor. An exception can occur if the treatment involves Mohs surgery, a specific surgical technique used for treating skin cancer.
A pathologist, a doctor who studies diseases, is needed to make sure the entire tumor has been removed before rebuilding the affected body part starts. However, depending on how severe the cancer is, additional doctors may be required. For example, if the cancer has spread to other body organs or lymph nodes (small glands that filter harmful substances from the body), additional specialists like an oncologist (cancer doctor), radiation oncologist (a doctor who specializes in treating cancer with radiation), or other medical specialists may be needed.
An ophthalmologist, an eye doctor, may be required to deal with any complications relating to the eyes and often a full eye check is done before any surgery. If the patient is a child or the problem is a birth defect or a syndrome, there may be a need for additional children’s doctors or specialists. The need for a team approach in such treatments is highlighted in the latter part of this article.
Preparing for Upper Eyelid Reconstruction
Before any eyelid reconstruction surgery, a comprehensive check-up is necessary to make sure the patient is healthy enough for the procedure. This includes looking at their past and present health conditions, especially conditions like diabetes or a history of smoking that could affect the healing process post-surgery. Doctors need to make sure that the patients can safely undergo the operation. If the patient has other health conditions that might make surgery risky, the doctor will discuss the pros and cons of the procedure with the patient. Those patients whose eyelids were impacted due to injuries or birth anomalies might need additional evaluations by other specialists to rule out related issues.
Preparing for the surgery includes understanding the type of reconstruction technique to be used. What technique is chosen depends on the size and position of the affected area. Doctors will assess the structures in the front or back of the eyelid, the strength and health of the eyelash line, the remaining blood supply for any tissue grafting, and the stress that could be put on the eyelid after surgery. Some ways the doctor may repair your eyelid can sometimes be more complex than others. For example, reconstructing any part that involves the eyelash line can be more challenging. The stress on the eyelid after surgery will affect the risk of the surgical wound reopening, and it also indicates the chance of eyelid retraction, which is more likely with upper eyelid surgeries than lower ones. All of these aspects play a role in deciding the best way to proceed with your eyelid reconstruction.
How is Upper Eyelid Reconstruction performed
When it comes to reconstructing any part of the body, the approach should always be considered carefully and personalized to the individual patient. The patient’s own thoughts and feelings should be taken into account when deciding how to proceed. It’s important to note that there is no one-size-fits-all method to use when fixing any type of damage, and that includes damage to the eyelids. The best approach will depend on several factors, including which parts of the eyelid structure are involved, the size of the damaged area, and the surgeon’s judgment and preferences.
Let’s start with damages that are only in the front part of the eyelid structure. These types of damages can be fixed in several ways. We can allow it to heal by itself (a method called secondary closure), or we can sew it up right away (primary closure). In other cases, we can use skin from another part of the patient’s body to fix the damaged area (a skin graft). If the eyelid edge is involved, we might also use a skin graft that includes the eyelid edge.
Letting the damaged area heal by itself is usually only recommended for smaller defects that are less than 1 cm, and that are in the central or inner corner of the eyelid. This method has the least risk of complications, and it’s usually better for people who have a short life expectancy, who may not tolerate surgery very well, or who have a condition that makes it difficult for wounds to heal properly, such as a skin disorder called xeroderma pigmentosum.
On the other hand, sewing up the wound right away is usually a good option if we happen to have extra skin near the damaged area that we can use. However, we have to be very careful to sew along the natural direction of skin tension in the eyelid to avoid additional problems like eyelid retraction (an issue where the eyelid is turned outward), eyelid distortion, or lagophthalmos, a condition where the eyelid can’t close fully.
If the damaged area is larger than 1 cm, we might consider other options, such as a skin flap (which involves shifting skin from an undamaged area to cover the damaged area) or a skin graft. Skin flaps are usually preferable because the skin is similar to that of the eyelid and has less risk of shrinking over time. But, we need to make sure not to use skin that has hair, as the hair can irritate the eye.
For larger defects, we could use a skin graft where we take a full thickness of skin from the upper eyelid of the other eye, or another hairless area of skin, and use that to repair the defect. If the graft needs to be placed, it should be done in a specific region above the eyelash line and fixed to the tarsus, which is a stiff piece of tissue in the eyelid that gives it its shape.
Repairing the damages that involve the eye margin can be a bit more complicated. One of the methods involves taking full-thickness tissue from the upper eyelid of the opposite eye and using it to repair the defect. Another possible method is by converting the defect to a full-thickness one and closing that primarily. Here, the wound edges are brought closer without any tension and then sutured.
If both the front and back parts of the eyelid are damaged, the fixing process can be more complex. There are a lot of techniques that can be used, like sewing it up right away, direct closure with skin and muscle grafts, closure with combined grafts, or the tarsoconjunctival flap method (which involves using tissue from the upper eyelid to fix any full-thickness defects in the lower eyelid). Complete upper eyelid defects can be repaired with various techniques as well.
For smaller defects in the back part of the eyelid that make up less than a third of the eyelid length, these can also be closed directly. For any repair involving the eyelid margin (the edge of the eyelid), it is crucial that the alignment is properly done by following the meibomian orifices (small openings on the edge of the eyelid from which a type of eye lubricant called meibum is secreted), gray line, and eyelash line.
Possible Complications of Upper Eyelid Reconstruction
Just like any surgical procedure, reconstructing the eyelid can come with a variety of complications. Some issues are generally related to surgery, while others are more specific to this type of operation. Complications can involve either the eyelids or the eye itself. Severe complications like blindness can occur, but these are quite rare. There could also be complications related to the area from where any graft or flap (tissues used in the reconstruction) is taken, or if any existing diseases, like cancer, aren’t fully treated. It’s also important for the surgeon to consider the patient’s mental wellbeing, as any changes to their appearance can impact their self-esteem.
Infections or bleeding can occur after any surgery, and these can affect the results. These can happen either at the original site of the surgery or where the graft or flap was taken from. There’s also a risk that the wound might split open or that the graft or flap might fail. In some cases, the edge of the eyelid might become uneven. However, this can be prevented by careful surgical techniques and ensuring the wound edges come together well. Using certain methods and having a good surgical plan can also limit the chances of the wound reopening. For any type of graft, there’s a chance it might not heal right or shrink, causing the eyelid to turn inwards or outwards. Several options exist to treat such complications, like lubricating the eye, injecting steroids into the skin, using a special tool (dermabrasion) to rub away skin, or resurfacing the skin with a laser. However, often, another operation is required.
Making sure the eyelid is in the right position is essential for successful reconstruction, especially to make sure the edge of the eyelid is right against the eye. For the upper eyelid, there’s a risk it might be pulled back too far, which could affect the results of the surgery negatively. But this risk can be lowered by carefully detaching the muscles that lift the lid from the graft. Another complication of upper eyelid reconstruction is ptosis, a drooping or falling of the upper eyelid. This can be prevented by correcting the level of the drooping based on how well the muscle that lifts the eyelid (levator palpebrae superioris) is working. There’s also a chance of getting double vision and eye misalignment if the muscles that move the eye get stuck, especially if the floor of the eye socket is damaged. Tests can be done after the surgery to check for this complication, and it can be treated conservatively or with more surgery if needed.
Another concern for people getting upper eyelid reconstruction is hair loss from the eyelashes or eyebrow. While tattoos and nylon stitches might hide this hair loss, they don’t address the need for these hairs to protect the eye from mechanical damage. Hair grafting, a better option for patients, uses hair from the back of the scalp for eyebrows. For eyelashes, individual hair follicles are taken and put into the stiff part of the eyelid (tarsus).
What Else Should I Know About Upper Eyelid Reconstruction?
As addressed earlier, issues with the eyelids might be distressful for patients because their appearance and usefulness is affected by the upper eyelid. The psychological influence of these issues should be given suitable consideration. Those with other mental health conditions might need to see a mental health expert. Moreover, if the required planning for a surgical procedure isn’t properly done, or if the correct method is not followed, it can lead to patients experiencing further discomfort. Possible complications to the eyelid or the eye itself have been discussed. There could be a need for additional treatments, including several corrective surgeries or eye surgeries.
