Forehead Skin Flap for Total Upper and Lower Eyelid Reconstruction
J. C. MUSTARDÉ
A considerable number of flaps have been included in this section for historical purposes. Modern surgeons avoid advancing or stretching tissues for lid reconstruction because of the problem of lid wound contraction. The multiple-stage procedures also have given way to single-stage methods of reconstruction. Splitting of the tarsus longitudinally has lost considerable favor because of the inherent difficulties. Closing the eye for prolonged periods of time (over 10 to 14 days) should be avoided. Prolonged stenting with the use of tarsorrhaphies was done to prevent wound contraction. The reader is asked to consider simpler procedures for reconstruction of the eyelids, such as the one presented by McGregor. This shifts similar tissue into the eyelid area and the advancement is gained by a Z-plasty placed laterally.
Total simultaneous reconstruction of both upper and lower eyelids is rarely required. Technically, the lower eyelid could be reconstructed by means of a cheek rotation flap lined by a composite graft of nasal septal mucosa and cartilage. The main problem, however, is reconstruction of the upper lid, because the ideal materials for carrying out the operation are no longer available. Skin for upper lid reconstruction must inevitably be brought in as a flap from the periphery of the orbit, and this means skin of a much thicker type than normal eyelid skin. Lining can be obtained either from the remaining conjunctiva in the fornices or as a free graft of mucosa. However, the chief difficulty is the absence of muscular activity in the new eyelid, particularly the closing activity of the orbicularis muscle, but also, to a lesser extent, the lifting action of the levator palpebrae muscle (1).
All instances of simultaneous upper and lower eyelid reconstruction reported to this author have been the result of trauma. The damage to the surrounding tissue, beyond the confines of the lids themselves, has usually been extensive enough to rule out the immediate use of a cheek rotation flap, even for reconstructing the lower lid. The problem of producing eyelids that not only will open sufficiently wide to provide useful vision, but also will close adequately enough to afford a sufficient degree of protection to the cornea is, indeed, grave in the absence of adequate muscle function. Options open to the surgeon faced with the problem of having to totally reconstruct both eyelids at one time may be extremely limited.
In such circumstances, and provided a useful eye is still present, the main consideration is the preservation of the sight in that eye, even if this means occluding it for some considerable time. This is, in effect, “banking” the affected eye against the possibility that some day the patient will have only one seeing eye. It can then be exposed and lids constructed that will afford some degree of protection, as well as permitting the use of the eye itself, even if only to a limited degree.
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