Modified Tessier Flap for Reconstruction of The Upper Eyelid

EDITORIAL COMMENT

This flap accomplishes the objective of total upper eyelid reconstruction, particularly because it utilizes skin and underlying muscle, which actually improves the viability of the flap, as well as providing sufficient tissue for restoring the entire horizontal diameter of the upper eyelid.

There are a number of options available for major upper eyelid reconstruction. The flap originally described by Tessier (1) was a nasojugal flap used in the reconstruction of a total defect in the lower eyelid. However, a modified Tessier flap (skin-muscle nasojugal flap), combined with a buccal mucous membrane graft, allows for total reconstruction of an upper eyelid defect. This includes the anterior and posterior lamella, attachment to the levator aponeurosis so that the eyelid can
move up and down, and provision of an adequate blood supply to the reconstructed eyelid, especially in patients previously irradiated (2).

INDICATIONS

The modified Tessier flap is especially indicated for major reconstruction of the upper eyelid when the lower lid cannot be utilized for a bridge graft, if the upper lid has been sacrificed in removing a large tumor, or if it has been lost due to trauma. The skin-muscle flap described should be lined with mucosa to help form the posterior lamella of the eyelid. Mucosa is taken from the mouth in the buccal region, but may also be taken from inside the lip. Alternatively, conjunctiva may be taken from the upper fornix of the contralateral eye, but this may not be appropriate if the patient has disease in that area, or does not want the uninvolved eye approached surgically.

ANATOMY

Because the thickness of a flap from the nasojugal area is greater than that of upper eyelid skin and orbicularis, more stability is provided to the reconstructed lid and this decreases the need for tarsal replacement. Also, the excellent medial canthal blood supply, particularly the angular artery and some of its tributaries, allows for an increased length-to-width ratio of the flap. The flap will be rotated to the upper lid to cover a buccal mucosal flap.

The posterior lamella of the eyelid consists of conjunctiva; in this reconstruction, buccal mucous membrane is chosen for replacement. Buccal mucous membrane is somewhat thicker than conjunctival mucous membrane; therefore it provides stability to the lid, to a certain extent decreasing the need for any tarsal replacement. For the anterior lamella, both the skin and muscle of the flap that lie on the superficial aspect of the mucosal graft afford an adequate replacement.

FLAP DESIGN AND DIMENSIONS

After conjunctival replacement, the modified Tessier flap is developed. An almost vertical flap is marked out in the orbitonasal angle and nasojugal region. Its base is centered over the angular vessels and lies above the level of the medial canthal ligament, allowing the flap to reach 90° of transposition. To rotate the flap into the upper lid, more torsion is necessary than in rotation to the lower lid; this is achieved by having the upper arm of the flap base extend more onto the surface of the nose, allowing for rotation into the upper lid and decreasing the potential for compromise of the circulation due to kinking (see Fig. 25.3).

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