Total Eyelid Reconstruction full lecture by Kami Parsa, M.D. in Beverly Hills
[Surgery Theater Productions] [Masters Educational Series] [Total Eyelid Reconstruction] [Kami Parsa M.D. Beverly Hills, CA] Hi my name is Kami Parsa this lecture is on the total eyelid reconstruction. I am an oculoplastic surgeon in Beverly Hills.
The goal of this lecture really is to give you a better understanding of what it involves when we are talking about eyelid reconstruction and hopefully you can avoid complications such as this. Obviously the top priority on any eyelid reconstruction is to protect the eyeball. So what's happened with this patient is that she had some trauma subsequent to that the revision that the reconstruction that she had was not sufficient enough that did not address some of the principles of what we're talking about and so the function of the eyelid was completely lost and unfortunately this patient was had gone blind from her trauma. Now the principle of principles of eyelid reconstruction involve number one, restoring eyelid anatomy, number two preserving eyelid function that is going to provide protection for the eyeball, and last but not least, achieving acceptable cosmetic outcomes.
And I would say the priorities is, as I said, you start with Anatomy you get to make sure you have a functioning eyelid and then at the end cosmesis. Now some basic principles, I say that in surgery, Anatomy is the alphabet. If you don't know your Anatomy, you should not be operating on that region. So you need to know your Anatomy backwards and forwards and close your eye and be able to kind of tell based on relationships where you are. A lot of times when we talk about trauma cases or patients that have had skin cancers removed, you need to understand the foundation of it and that begins with Anatomy. Next you got to keep everything anatomically correct. A lot of times that I'm doing revisional cases I note during surgery that the previous surgeon didn't understand the anatomy well enough to respect the tissue planes so everything was just closed without really care and I think that part of extra touch to understand to implement in your techniques is important. Understand that your options for replacing each layer and we'll talk about this in a sec second and last one, but not least least, grafts do require a vascular supply so when we talk about that in your reconstruction format you need to understand that if you're going to use a graft where is the blood supply is gonna come from.
So now the eyelid is a bilamellar structure, there's an anterior lamella and a posterior lamella, the anterior lamella involves the skin and the orbicularis muscle. As you know the skin on that on the eyelid is very thin it's one of the thinnest in the body there is no subcutaneous fat and it should not be replaced by a thick skin if possible. The orbicularis is obviously important in eyelid closure and it's again part of the anterior lamella. Posterior lamella involves the Tarsus, which is a backbone of the eyelid and conjunctiva which is the mucosal surface that protects the eye, without this layer you're gonna have problems with the eye survival. So we'll see it in the anatomical, this is a section of it that you see, the anterior lamella which involves the skin and the orbicularis muscle, orbicularis muscle is innervated by the seventh cranial nerve and the posterior lamella involves the Tarsus and the conjuctiva, it's on the upper eyelid and the lower eyelid and respecting these two tissue planes is very important and when we talk about eyelid reconstruction you need to address both of them or you are gonna have some problems. So again on a different plane, we're showing the skin the eyelid crease here, the levator aponeurosis is extending here. This is the Tarsus and the orbicularis muscle is shown here so anterior lamella here and posterior lamella involves the Tarsus and the conjuctiva. Similarly on the lower eyelid, conjunctiva, Tarsus, orbicularis muscle, and the skin.
So there are three fat pads on the lower eyelid and there's only two fat pads on the upper eyelid. The lacrimal gland is divided by the levator aponeurosis and it is, as you know, is involved in tear production. So the key another key thing when we talk about the eyelid is the lateral and medial canthus, they at the lateral junction, it's attached to the whitnall's tubercle and really the anchorage point of the eyelid is based on this attachment so when we talk about eyelid reconstruction you really need to have that in mind of how that's going to play a role. This is a picture from netter, as you know, this is this is the septum. The anterior lamella has been removed so we're just seeing the septum in this structure and the lateral canthus is here. The medial canthus has two cruses, one is the anterior crus which and the posterior crus, both of them hug the lacrimal sac, which is the tear drainage system for the eye.
Now the again when we talk about eyelid reconstruction the posterior crus is the most important part and in that so when when there is a trauma you need to have that in mind if you're just attaching the anterior crus, the eyelid Anatomy is going to be deformed. So let's talk about options for replacing skin and muscle, you obviously can use an advancement flap, which we will talk about, lid sharing flaps we will talk about as well, free skin graft, again a graft and that will be used you need to talk about where is the blood supply gonna come from and in eyelid reconstruction typically the best skin to borrow from is the contralateral eyelid if the patient is older and they have a little bit of dermatochalasis, if not then you can use post auricular skin or supraclavicular skin or under the arm skin, but there are multiple different options for replacement and in order of priority these are the ones that I use. Now options for replacing the Tarsus, you can use Tarsus from the contralateral eyelid. The gold standard that I typically like is the hard palatal graft because it has its thicker it has a nice consistency as the same as the Tarsus. There are some acellular dermal grafts such as Alloderm and Endoragen, I've been using Endoragen for a while and I in the past three to four years and I really like it I don't like to use Endoragen on patients who have had a significant amount of scar tissue. Typically hard palatal graft is the best option. You can also use cartilage from ear or nasal septum. Now the key in surgery when you're talking about eyelid surgery one common mistake I see that the wrong type of instruments are used so it's important to have at least this basic set of instruments, number one a 15 blade, a Westcott scissor (a sharp one and a blunt one), Castroviejo needle holder, typically I use a 0.3 forcep because you're dealing with very fine tissue and you don't want to use a big forcep that causes problems, it's small and a larger damar retractor is also included in this.
A rake and a double prong skin hook, these are good during retraction during surgery to have good tissue manipulation. I use a Colorado tip cautery for my cutting and I always use an eye globe protector and eye shield the plastic form of it is my my preference because it just protects the globe the best, and a caliper too for precise measurements during surgery. So we're gonna go through some cases, this is a 68 year old with a sebaceous cell carcinoma of the right lower eyelid. So the patient had undergone Mohs surgery and they had removed this portion of the the defect.
The idea was how are we going to proceed with the reconstruction so we're thinking the first thing I do when I see cases like this is I describe the defect so we have a full thickness defect involving more than 2/3 of the lower eyelid so the first question is how are we gonna replace the posterior lamella and how are we gonna replace the anterior lamella. So for the posterior lamella, we decided, for the anterior lamella we decided to do a simple advancement flap as you see there's a flap that we've outlined here and we, for the posterior lamella, a hard palatal graft is used as I mentioned I like to replace Tarsus with this and I think it's the gold standard on that. So typically we go in and remove the part of the hard palatal, palate, which is thinned out and you could go ahead and get rid of epithelial layer on this but we don't really do this I don't do this routinely but you cut it to fit the posterior lamella and it's anchored to the lateral canthus on the inferior defect that we have and there is an advancement flap that is made to bring that the anterior lamella forward on this. And as you see this is post-operative patient about three to four months later with proper eyelid closure and proper eyelid form.This is a seventy year old male with squamous cell carcinoma that involved the upper eyelid and post Mohs surgery the patient had a large defect, full defect involving the upper eyelid also missing significant amount of the anterior lamella but eh. So there are different options for this too, we decided to proceed with a bipedicle flap on this case again there are multiple ways to do these procedures and you have different ways on doing that reconstruction. So the posterior lamella was done with a hard palatal graft, you can also use a tarsal graft from the contralateral eyelid which would be a good idea on this this type of case. Then the bipedicle flap basically is going to supply the Tarsus that we had so we create a bipedicle flap that is brought down, it supplies, gives the blood supply to the posterior lamella and then we get a skin graft to cover this top part from the contralateral eyelid and this is the patient post-operatively doing well.
So specific techniques for total upper eyelid reconstruction, now if the entire upper eyelid is missing, you can use Cutler- Beard which is also known as a lower lid bridge flap. Basically you are going to borrow skin, muscle, and conjunctiva from the lower eyelid to reconstruct the upper eyelid and basically um we make an incision. You want to make this above the initial incision about five millimeters inferior to the eyelid margin and that allows you to get eh, we can use a westcott scissor to get a nice flat form underneath this and that, once that bridge is formed you can now attach that to the inferior part of the conjuctiva to the levator you see on this picture and the skin edges will be reapproximated with it with any kind of suture that you want and it could be an absorbable stitch or a removable stitch that you come back to and basically the bridge stays intact like this for about two to four weeks and once everything's healed up you can go ahead and open everything up and allow from a functioning eyelid and with which really the key with this procedure is that you're protecting the globe with this procedure.
It's a 59 year old with basal cell carcinoma, again you have a defect involving the two-thirds of the lower eyelid. A full thickness Hughes tarsoconjuctival flap is used for this reconstruction. Basically the eyelid is everted on the upper eyelid and a part of the Tarsus is fashioned to fit the defect for the posterior lamella and the lower eyelid and basically we bring this flap down and attach the Tarsus to the defect to this part of the defect and um, at the level of lateral canthus, do the same thing and then the skin graft could be placed over here to reconstruct the anterior lamella. So again for this defect we went through this process of asking ourselves where is the defect where is the, how are we gonna use a graft or a flap and where is the blood supply is gonna come to supply the graft, for this the blood supply for this skin graft came from the upper eyelid. Now two to three weeks later you can go ahead and open that flap in the patient so this is how it looks as it's healing and later on you can go ahead and just open that and it'll be much much improved. Now just gonna go over one last one extreme eyelid defect, so there's a patient who had a sebaceous cell carcinoma and involved a lower eyelid and post-op post Mohs excision she had significant amount of anterior and posterior lamellar defect so now a temporalis flap was used temporoparietal flap was used in this fashion just to supply the blood supply for the anterior and posterior lamella and this is an Endoragen that we use was used for the posterior lamella. Now you can use other things, such as all the things we talked about, hard palatal graft, an Endoragen, and the temporalis fascia is going to come in to supply the blood to allow blood supply for this portion and then we went ahead and put a skin graft on top of that which allows a proper healing of that of the posterior defect.
So initially when you look at this healing it doesn't look that good, but after everything he goes, it looks really good with a functioning eyelid and the functioning eye. So use of pericranial flaps is a 52 year old with a nodular ulcerative basal cell carcinoma that extended and this is a case that was done in Bascom Palmer Eye Institute, David C was involved in this patient, wouldn't care of this patient so these are some of his slides that you see. So a big defect that was involved over here, now pericranial flap was is fashion now to help with the reconstruction as you see when we have a large defect like that it becomes an issue so pericranium is exposed and it's used as the blood supply to really reconstruct the anterior and posterior lamella with this. So a you know a hard palatal graph could be used for that anterior and posterior lamellar defect and the pericranial flap covers that and then we can on top of that put skin grafts as you see to cover the defect.
So this obviously is a very extreme case of it and the goal is goal here is not much it to think about cosmesis but really overall is to think about the functioning of the eyeball and I think with this technique that was achieved. So in conclusion, when you're dealing with these kind of defects the most important priority as I mentioned is to protect the globe. [This has been a surgical theather production].
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