Skin-Muscle-Tarsoconjunctival (Esser) Flap From The Lower to The Upper Eyelid



Skin-Muscle-Tarsoconjunctival (Esser) Flap From The Lower to The Upper Eyelid


J. C. MUSTARDÉ



While two basic layers of skin and mucosa must always be provided in reconstructions of the upper eyelid, a permanent stiffening layer to counter the effects of gravity and time is not needed, as it is in lower lid reconstruction. However, there is an even greater need to provide a stable margin because of possible damage to the cornea if the squamous epithelium of the outer layer should come in contact with the cornea during the constant upward and downward excursions of the lid.

Any technique that relies solely on providing the two basic layers, joined along their free edges by a scar, ignores the fact that in a normal upper lid the skin of the lid immediately above the margin is fixed, albeit indirectly, to the extension of the levator aponeurosis. This prevents the skin from sliding down over the eyelid margin. It is an anatomic entity virtually impossible to reproduce in a reconstructed upper lid whose basis has been the provision of a skin layer and a lining layer that are not already adherent to each other by natural means.




ANATOMY

Since the marginal vessels are relatively large for such a small flap, its viability is extremely good, despite 180° rotation of the flap. It is important to realize that the marginal eyelid vessels lie about 3 mm from the lid margin and immediately beneath the layer of the orbicularis muscle.


OPERATIVE TECHNIQUE


Defects of Up to Half the Upper Eyelid

Because of the degree of stretch in eyelid tissues (that permits defects of up to a quarter of the lid to be closed directly), it is necessary to take a flap from the lower lid of not more than one-quarter of its width (approximately 6 to 7 mm). Hence the lower lid can be closed directly (Fig. 23.1) after the division of the vascular pedicle 2 weeks later.

The marginal vessels should not be damaged. Moreover, the pedicle width should not be less than 5 mm, and the various wounds must not be closed under tension. For reconstructions of this size, the hinge of the flap should lie directly below the center of the upper lid defect. It can be placed on either side, whichever is more suitable, always remembering that the lower lid punctum should never be sacrificed.


Defects Between Half and Three-Quarters of the Upper Eyelid

If the defect in the upper lid is a few millimeters greater than half the upper lid width, the lower lid flap will be a few millimeters larger than a quarter of the width of the lower lid (Fig. 23.2). This small additional segment of lower eyelid must be reconstructed by moving a small lateral cheek rotation flap lined with conjunctiva or with a composite nasal septal graft of cartilage and mucosa (see Chapter 13).

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Jun 26, 2016 | Posted by in General Surgery | Comments Off on Skin-Muscle-Tarsoconjunctival (Esser) Flap From The Lower to The Upper Eyelid
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