Small partial defects from the upper eyelid can be closed primarily with a skin graft or perhaps a local flap. Local flap choices are somewhat limited but include a V-Y flap from lateral eyelid or temporal skin (best option) and a midline forehead flap (poor choice).
If local flaps are not available, skin grafts may provide adequate coverage. The very best donor site is the contralateral upper eyelid; nevertheless it provides limited tissue. Other choices include grafts from behind the ear and also the inner upper arm. Additional skin graft length should be accustomed to take into account graft contracture. Full-thickness defects from the upper eyelid are addressed by:
These methods are similar to methods for correction of lower eyelid defects. However, because constant blinking causes significant surface interaction between the upper eyelid and the cornea, inner irregularities in the upper eyelid are less forgiving. Sutures in the conjunctiva or thick cartilage grafts can scratch the cornea and result in keratitis.
Full-thickness defects from the upper eyelid are addressed by primary closure, a semicircular flap or the Cutler-Beard flap. These methods are the same methods for correction of lower eyelid defects. However, because constant blinking causes significant surface interaction between your upper eyelid and the cornea, inner irregularities in the upper eyelid are less forgiving. Sutures in the conjunctiva or thick cartilage grafts can scratch the cornea and lead to keratitis.
Primary closure of full-thickness upper eyelid defects is simple for defects up to 25% of the upper eyelid. As in the lower eyelid, the incision with the tarsus is created perpendicular towards the lid margin to avoid buckling from the tarsus. Absorbable sutures approximate the tarsus and nonabsorbable sutures approximate the eyelid skin. If primary closure cannot be achieved, a lateral canthotomy and cantholysis can be carried out. A lateral incision is created in the canthus, and a relaxing incision is created in the upper limb of the canthal tendon.
If your larger defect exists, additional mobility is usually obtained by performing a semicircular flap. Defects up to 50% could be closed in this manner. With the canthotomy and cantholysis already performed, the lateral incision of the canthotomy is extended inferolaterally in a semicircular fashion. The flap is then advanced into the defect. Much like lower lid reconstruction, a Z-plasty (McGregor) provides the semicircular flap additional mobility.
The Cutler-Beard flap may be utilized for defects greater than 50% from the upper eyelid. This flap uses full-thickness tissue from the lower eyelid to reconstruct top of the eyelid. A full-thickness horizontal incision is created just inferior to the lower tarsus. Vertical incisions are made inferiorly from the lateral edges of the horizontal incision. The flap is then advanced superiorly underneath the intact lower tarsal bridge. The flap is split after 6-8 weeks.
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Note: This article was sent to us by: Keith Hayes at 02142011
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