The Eyelids

10.1055/b-0034-99032

The Eyelids

Upper Eyelid

Direct Closure

Direct closure is suitable for defects that involve up to one quarter (~8 mm) of the eyelid margin (semicircular flap closure, Fig. 9.1 ).

Semicircular Flap Closure of Beyer-Machule and Riedel (1993)

( Fig. 9.2 )

Larger defects involving up to one half of the lid margin can be closed by advancing a semicircular skin flap medially ( Fig. 9.2a ). The lid margin is sutured first ( Fig. 9.1 ). Next the tarsus and orbicularis muscle are approximated with 6-0 interrupted Vicryl sutures (Ethicon, Hamburg-Norderstedt, Germany), and the skin is closed with 7-0 interrupted monofilament sutures ( Fig. 9.1a, b ). The lid margin is approximated with three stay sutures, two of which are placed deeply (close to the eyeball) and one more superficially (Beyer-Machule and Riedel 1993). Large upper lid defects are rare and should be repaired only by surgeons who are experienced in eyelid surgery.

**a, b** Direct primary closure of an **upper eyelid defect** involving up to one quarter of the length of the lid margin (~8 mm). a The lid margin is closed with 6-0 or 7-0 PDS sutures. The tarsus and orbicularis muscle are then approximated with interrupted 6-0 absorbable sutures. b Continuous 7-0 monofilament suture. The ends of the adjacent deep intermarginal sutures are tied on the anterior lid margin to prevent them scratching the eye. Traction sutures are left long and taped to the cheek.

**a, b** **Lateral semicircular flap closure of an upper eyelid defect** involving one quarter to one half of the length of the lid. a A lateral canthotomy of the upper palpebral ligament is performed to facilitate advancement of the lateral skin. b All the wounds are closed (see **Fig. 9.1** ). The same technique is used for the lower lid.

Switch Flap

( Fig. 9.3 )

Analogous to the Abbé lip switch, this flap can be rotated from the lower eyelid into a full-thickness upper eyelid defect involving up to one quarter of the length of the lid margin ( Fig. 9.3a, b ). The eye itself is covered with a special protector to prevent corneal injury. The lower lid defect is closed directly with continuous 6-0 monofilament ( Fig. 9.3b ), followed by placement of both the upper lid sutures ( Fig. 9.3c ).

Upper Eyelid Reconstruction of Fricke and Kreibig

( Fig. 9.4 )

Large portions of the upper (and lower) eyelid can be reconstructed with a narrow transposition flap that is raised above the eyebrow on a lateral pedicle. Thick split retroauricular skin grafts can also be used.