Lower eyelid reconstruction with semicircular flap







Table 39.1

Indications for surgery









Upper or lower eyelid defect from skin cancer removal
Scarring or notching of eyelid
Focal entropion or madarosis causing functional or aesthetic concerns


Table 39.2

Preoperative evaluation











Size and dimensions of defect
Age of patient
Eyelid laxity
Prior eyelid, facial surgery or trauma


Introduction


Reconstruction of eyelid defects requires the surgeon to have an artistic intuition with regard to balancing structure, function and aesthetics. Many factors will shape the final decision as to the type and technique of reconstruction. This is influenced by the age of the patient, degree of skin and eyelid laxity, visual factors (monocular versus binocular status), and surgeon preference.


The goals of any eyelid reconstruction should be to recreate the bi-lamellar structure with a smooth eyelid margin and contour, preservation of the normal vertical excursion and appropriate horizontal tension. Depending on the amount of horizontal laxity, a semicircular flap can be useful in defects ranging in size from 30 to 60% of the horizontal eyelid length. With greater amounts of laxity, even larger defects can be reconstructed.


Originally described by Tenzel in 1975, the semicircular flap remains a workhorse in the surgical repertoire for both upper and lower eyelid reconstruction. The advantages of the procedure include the re-creation of the normal bi-lamellar eyelid architecture without the use of grafts, an unoccluded visual axis for use in monocular patients and optimum cosmesis. The disadvantages include the potential for scarring in the soft tissues lateral to the canthus, a non-cilia-bearing reconstructed eyelid segment laterally, and the potential for notching at the reconstructed juncture of the native and advanced eyelid segments.




Surgical Technique





Figures 39.1A and 39.1B


Skin marking

The semicircular flap is ideally suited to reconstruct eyelid defects up to 50% ( Figure 39.1A ). To reconstruct a lower eyelid defect, a superiorly arcing semicircle is drawn lateral to the lateral canthus ( Figure 39.1B ). For upper eyelid defects, the arc should be oriented inferiorly. The lateral extent of the mark should be just inside the brow. It is important to create an arc radius of at least 1.5 cm as the arc will flatten as the semicircular flap is advanced.



Figures 39.2A and 39.2B


Skin incision and flap development

A skin incision is made with a #15 Bard-Parker blade ( Figure 39.2A ). As the incision travels further away from the canthus, the skin transitions to the thicker section near the brow. Because of this, the thickness of the flap will vary, being thinner and consisting of only skin and muscle near the canthus to incorporating the subcutaneous fat plexus near the brow. It is important to raise as thick a flap as possible ( Figure 39.2B ). The canthal apparatus should remain intact during flap creation.

May 16, 2019 | Posted by in Reconstructive surgery | Comments Off on Lower eyelid reconstruction with semicircular flap
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