Grabb’s Encyclopedia of Flaps Head and Neck

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together the free margins of the flap and the conjunctiva. The sutures used to approximate the tarsal plates have
a very low tensile strength, and it is important to make sure that there is no tension on the suture line.
Completion of the Z-Plasty
At the time of initial elevation of the transposed flap in preparation for its transfer, the triangular flap designed as
part of the Z-plasty is also elevated, in readiness to be rotated downward into the triangular secondary defect
that opens up when the transposed flap is advanced medially. When this triangular flap has been rotated into the
defect and sutured in position, suturing of the skin is completed lateral to the outer canthus. In most elderly
patients there is considerable laxity in the tissue above the suture line, and some adjustment in tension and
trimming of the upper margin may be required to make the suture line lie neatly.
The point has been made that in designing the flap its upper margin runs upward as well as laterally to give the
reconstructed eyelid segment adequate height and prevent ectropion. When the reconstruction has been
completed, the lateral tip of the transposed flap ends up at a significantly higher level than preoperatively, so that
the final suture line lateral to the outer canthus is steeper than before, an advantageous change in direction,
since any scar contracture will pull the eyelid upward as well as laterally.
OPERATIVE TECHNIQUE: UPPER EYELID DEFECTS
As in the lower eyelid, the three methods of closing V-shaped defects as the V increases in breadth—direct
suture, direct suture with lateral canthotomy, and advancement medially of the transposed flap with Z-plasty—
are applicable to comparable defects of the upper eyelid (Fig. 12.2). In the case of
the transposed flap, the design and technique mirror those used for the lower eyelid, with the flap based
superiorly and the skin incision following the downward curve of the upper eyelid. Division of the slip of the
lateral canthal ligament to the upper eyelid allows the flap to be advanced medially, and the secondary defect is
closed with the Z-plasty designed over the lateral end of the transposed flap. Mobilization to allow advancement
of the flap involves division of orbicularis muscle fibers and the orbital septum in addition to the upper eyelid slip
of the lateral canthal ligament. The upper fornix, into which the lacrimal ducts open, lies behind the orbicularis
and the orbital septum and should escape injury, although awareness of their presence is likely to add to the
natural caution of the surgeon dissecting in that area. In practice, no deficit in tear production has been seen.
Removal of a wedge of the levator muscle as part of the resection results in less functional deficit than one might
expect. Although the main insertion of the levator tendon is central, it has extensions on both sides that reach
each of the canthi. These extensions seem to retain sufficient attachment to the remnant of the tarsal plate on
each side of the V resection to provide adequate function. As with the lower eyelid, the method works best and is
technically easier if tarsal plate is present in both sides of the defect, but it is still possible to use this method
when the defect is close to a canthus, although with a little more difficulty. The main fault in design is likely to be
failure to plan the flap to provide adequate vertical height in the reconstructed lid.

FIGURE 12.2 Application of the triad of reconstructive techniques to V-shaped defects of the upper and lower
eyelids. (From McGregor, ref. 1, with permission.)
FIGURE 12.3 A,B: Examples of the technique of V excision and flap transposition as applied to defects of the
lower eyelid.
FIGURE 12.4 A,B: Examples of the technique of V excision and flap transposition as applied to defects of the
upper eyelid.
Patients requiring this reconstruction frequently have considerable laxity in the upper eyelid, and this

reconstruction is likely to add to it because of the dog-ear that develops at the apex of the V with transfer of the
flap medially. If necessary, the reconstruction can be revised subsequently.
The amount of mobilization required in reconstructing a defect that approaches two-thirds of the breadth of the
lower eyelid is considerable. In view of the much greater anatomic complexity of the upper eyelid and the major
contribution played in function by the levator muscle, it is probably wise to restrict the reconstruction to defects of
less than half the width of the upper lid rather than the two-thirds possible when the lower lid is involved.
SUMMARY
Probably the greatest virtues of this technique are its simplicity, safety, and reliability, as well as the fact
that it is applicable to either eyelid (Figs. 12.3 and 12.4). Provided the flap is designed correctly and the
reconstruction is not pushed beyond its proper limits, particularly as used in the upper eyelid, it gives little
trouble.
References
1. McGregor IA. Eyelid reconstruction following subtotal resection of upper or lower eyelid. Br J Plast Surg
1973;26:346.
2. McGregor IA, McGregor FM. Cancer of the face and mouth. Edinburgh: Churchill Livingstone, 1986.

Chapter 13
Cheek Rotation Skin (Mustardé) Flap to The Lower Eyelid
J. C. MUSTARDÉ
Reconstruction of the full thickness of an eyelid requires two basic layers: a skin-covering layer and a mucous-
secreting layer. One of these layers can be a free graft, but at least one must be in the form of a flap with a
continuous blood supply.
INDICATIONS
Eyelid tissues, including the tarsal plate and margin, will stretch to some degree, and a defect of about a
quarter of the lower lid width can be closed directly. Closure of a defect only a few millimeters greater than a
quarter of the lower lid width can usually be obtained by dividing the lower crus of the lateral canthal
ligament. Where this does not allow sufficient relaxation to permit closure, a cheek rotation flap can then be
used.
In defects involving from one-quarter to one-half of the eyelid, a comparatively small cheek rotation is
required. Because of the stretch of tissues just alluded to, the dimension of the actual full-thickness lid
reconstruction that must be carried out will be only about a quarter of the original width of the lid, i.e., about
6 to 7 mm. It is probable that adequate lining for the reconstructed segment will be available from the
tissues of the lower fornix (Fig. 13.1).
FIGURE 13.1 Reconstruction of a quarter to a half of the lower lid. A small rotation of the cheek is sufficient
to provide skin cover, while lining can often be obtained from the conjunctiva in the lower fornix. (From
Mustardé, ref. 1, with permission.)
This does not provide a very defined, stable margin, but such a small sector of the lid is involved, lying in an
area where the cornea is unlikely to be affected, that the instability of the reconstructed margin may be of
little importance. If adequate conjunctiva is not available, however, or if the reconstructed area is wider than
about 6 mm, it is best to line the reconstructed part of the lid with a small composite nasal septal graft.
Where a defect greater than half the eyelid exists and the width of the reconstructed lid part is greater than
one-quarter of the lid width, a much larger cheek rotation skin flap must be used. This presents no great
problem in itself, but the instability of the weak reconstructed margin, both with respect to the possibility of it
turning outward (which will produce epiphora) or turning in (where the squamous epithelium may come to

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rub on the cornea), as well as the lack of permanent support to the reconstructed lid segment, must be
taken into account.
A mucus-secreting lining for the skin flap can be provided by using a graft of any mucosal surface.
However, there will be no orbicularis muscle in the reconstructed lid segment, and because of the constant
lifting action of the orbicularis muscle, skin flaps, mucosal grafts, and even tarsal plate from another
eyelid will slowly stretch under the influence of gravity and time (witness the end result in seventh nerve
palsy affecting a completely normal lower eyelid). It is therefore necessary in a reconstruction of any extent
in a lower eyelid to provide not only a mucus-secreting lining, but also some supportive material that will
permit the fashioning of a permanently stable margin and that also will give constant positive support to the
reconstructed segment of the lid (1).
FLAP DESIGN AND DIMENSIONS
I believe that the best foundation for lower eyelid reconstruction is to use a flap for the skin layer. Skin for this
purpose may be obtained from almost any region around the orbit, but one of the simplest and most logical
techniques is to use a cheek rotation flap to carry the thin skin that lies lateral to the lateral canthus into the
region of the reconstructed eyelid. The incision line of the flap should curve upward and outward from the lateral
canthus. The length of the cheek incision, as well as the amount of undermining to be carried out, is determined
on a trial-and-error basis by constantly checking whether the flap can be rotated across to fill the defect. Rotation
of the cheek flap is facilitated by resecting a skin triangle below the eyelid defect (Fig. 13.1C).

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FIGURE 13.2 Composite graft of nasal septal cartilage, along with mucosa on one side. Note excess mucosa,
which will form the lid margin. A: Cartilage surface outward. B: On edge with mucosa above. C: When the graft
is covered by a skin flap, it produces a lining layer for the reconstructed lower lid, permanent support to the lid,
and a stable mucosa-covered margin. (From Mustardé, ref. 1, with permission.)
OPERATIVE TECHNIQUE
The ideal material that produces the desired effects in reconstruction of defects greater than half the eyelid is a
graft of nasal septal cartilage that still retains mucous membrane on one surface. Such a composite graft can be
obtained easily if the alar base is temporarily detached to allow greater access to the nasal septum. The
cartilage layer may be thinned carefully to about 1-mm thickness (Fig. 13.2). This also will result
in a tendency for the remaining cartilage to curve concavely toward the mucosal layer and hence conform to the
eyeball.
FIGURE 13.3 Reconstruction of lower eyelid defects of greater than half the lid width, showing rotation of skin
flap after resection of “relaxing” triangle and use of a composite nasal septal graft to line and support the
reconstructed lid segment. (From Mustardé, ref. 1, with permission.)
In carrying out the reconstruction (Fig. 13.3), the cheek rotation flap will probably have to be carried down in front
of the ear for some distance, and it must be thoroughly undermined in the subcutaneous layer (as in a face lift) to
permit easy rotation without tension. The composite septal graft is held in position using running 6-0 Prolene
sutures to coapt the nasal mucosal edges to conjunctiva, and a similar over-and-over suture should be used to
fix the top edge of the mucosal fringe to the skin, after the mucosal fringe has been turned forward over the
upper edge of the cartilage (Fig. 13.4). A light pressure dressing should be applied over the reconstructed lid
segment to prevent a hematoma formation, that might separate the overlying skin flap from the composite graft.
The pull-out sutures may be left for 1 week, but the 6-0 sutures should be removed in 5 days.

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FIGURE 13.4 Reconstruction of lower eyelid defects of greater than half the lid. A-C: Stages of the
reconstruction along the lines described in Figure 13.3. D,E: Postoperative result, showing well-supported,
stable, lower eyelid margin with mucosa-lined fornix. F: Another patient, showing tube placed in remnant of lower
canaliculus (see text). (From Mustardé, ref. 1, with permission.)
When resection of a tumor involves the medial side of the lid and the canaliculus is divided, the medial wall of the
canaliculus that remains should be slit for 3 to 4 mm and a small 1-mm tube should be left in situ for 10 days in
hopes that it will produce a passageway to drain tears (Fig. 13.4F).

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FIGURE 13.5 Total reconstruction of the lower lid. A: Preoperative appearance, showing design of resection of
tumor and triangle of skin below tumor that needs to be excised. B: Composite nasal septal graft in position.
Note fringe of mucosa along top edge of cartilage to form lid margin. C,D: Insertion of 5-0 Prolene suture to hitch
subcutaneous flap tissue to periosteum of orbit. E: Postoperative appearance 1 year after surgery. Note
absence of drooping lid. F: As in part E, but showing support given to lid by cartilage of graft and the stable
mucosa-covered margin with deep inferior fornix. (From Mustardé, ref. 1, with permission.)

FIGURE 13.6 A-C: Total reconstruction of the lower lid. This figure demonstrates the extent of resection and the
amount of cheek to be rotated to cover the large composite nasal septal graft. (From Mustardé, ref. 1, with
permission.)
The technique for total reconstruction of the lower lid is merely an extension of the technique just described. All
the dimensions are increased to produce a reconstruction of the required size (Figs. 13.5 and 13.6). The incision
line of the skin flap will almost certainly benefit from the use of a back cut, and it is important that the cartilage in
the graft should be of sufficient size to rest on the lower orbital margin, thus avoiding later drooping of the
reconstructed lid. The sheer weight of the large cheek flap will call for the insertion of one or even two
permanent sutures of 5-0 Prolene, hitching subcutaneous flap tissue to the periosteum of the orbital margin.
SUMMARY
One of the best ways to reconstruct the lower eyelid is to use a cheek rotation flap lined with a septal
chondromucosal graft when needed.
Reference
1. Mustardé JC. Repair and Reconstruction in the Orbital Region, 2d ed. Edinburgh: Churchill Livingstone,
1980; Chap. 7.

Chapter 14
Cheek Rotation Skin (Imre) Flap to The Lower Eyelid
G. S. PAP
EDITORIAL COMMENT
The McGregor flap (Chapter 12) should be considered as a first option for lower lid reconstruction, because
it is simpler to execute, includes potions of the lateral orbicularis muscle, scar is more acceptable and often
avoids scleral show.
During the years before World War I, Professor Imre designed the cheek-skin flap that now bears his name (1, 2,
3, 4, 5, 6, 7). The area of the Imre flap can be extended to embrace all tissue from the lower lid downward and
from the nasolabial crease laterally (4). This flap uses local tissue similar in texture to that of the defect site, and
it avoids a secondary defect. Incisions are placed along the natural wrinkle lines, and repair of a simple or
composite defect can be achieved in one operation.
INDICATIONS
The Imre skin flap is indicated for reconstruction of partial or total defects of the lower lid, defects below the
lower lid, defects at or below the medial canthus, cicatricial ectropion, and avulsion of the lower lid at the
medial canthus. It also can be used, in conjunction with other local skin flaps, for repair of defects in the
periorbital region. These include defects at or above the medial canthus, where the Imre flap is used in
conjunction with a sliding flap of skin from the forehead at the medial end of the brow; defects at or below
the medial canthus, where the Imre flap is used with the adjacent nasal skin as an advancement flap along
the nasolabial fold; for correction of an uneven palpebral fissure; or for repositioning of the medial canthal
ligament in trauma patients (8).
FIGURE 14.1 Imre flap design for various defects of the lower lid. A: For repair of one-third of the lower lid.
B: For repair of two-thirds of the lower lid. C: For repair of total loss of the lower eyelid. (From Pap, ref. 8,
with permission.)
FLAP DESIGN AND DIMENSIONS
The Imre flap is a sliding flap. It uses advancement along a curved incision, with a Burow's triangle raised at its
distal end. The flap consists of skin and subcutaneous tissue and is of equal thickness throughout its length. In

composite defects, it may be lined with remnants of conjunctiva from the lower fornix of the eyelid or with a
composite mucosa and cartilage graft from the nasal septum (see Chapter 13). The excision of Burow's triangle
is a constant and pivotal feature. The design of the flap varies with the location and size of the defect.
OPERATIVE TECHNIQUE
Suturing of the flap donor site is always begun at the end farthest from the primary defect. Sutures are placed in
such a fashion that they first transfix the lower wound margin. The sutures then advance the flap and
simultaneously push and raise it upward, to make it rest in its new location after seven to eight sutures.
FIGURE 14.2 The flap is undermined to the end of the dotted line. The excess is excised and the flap is
advanced to fill the defect. A second flap may be used in a similar manner. (From Imre, ref. 1, with permission.)
FIGURE 14.3 A: Basal cell carcinoma of the medial canthus. B: Design of the Imre flap repair. C: Repair is

completed with a Frost suture to help support the lid. D: Final result. The lid margin is a little lower than normal.
(Courtesy of Dr. M. Spira.)
For repair of the lateral half of the lower lid, the skin margin below the curved incision is not undermined (Fig.
14.1A). For repair of oval or round defects on the lower eyelid, the flap should be equal in width to the vertical
height of the defect. The flap and all wound margins and incisions need to be widely undermined. While suturing,
the flap is advanced upward and medially, and the opposite margin of the cheek is shifted in a temporal direction
(Figs. 14.2 and 14.3B).
For repair of a defect below the lateral lid, the cheek flap resembles the design in Figure 14.3B. The flap is again
of equal width with the diameter of the defect, and the flap base almost reaches a horizontal line that extends
from the upper margin of the defect. It is imperative that all wound margins be generously undermined.
Occasionally, redundant skin at the end of the flap near the defect needs to be excised.
For total reconstruction of the lower lid, the length of the incision is about five times the distance from the tip of
the flap to the new lid margin. The original Burow's triangle is converted into a crescent-shaped skin defect at the
base of the flap. The flap is widely undermined beyond the line extending from the lateral canthus to the temporal
side of the crescent-shaped defect (Figs. 14.1C and 14.2). If there is enough conjunctiva available, it can be
used to line the upper margin of the flap (9). In patients in whom there is not enough conjunctiva, the margin of
the flap can be lined with a tarsoconjunctival flap from the upper lid (Fig. 14.4).
FIGURE 14.4 A: Basal cell carcinoma overlying the lower lacrimal canaliculus. Design of the Imre flap, with the
margins of the excision outlined. B: Flap dissected. C: Repair completed. The anterior edge of the canalicular
gutter is sutured to the superior border of the flap. D: Final result. (From Bennett and Werb, ref. 9, with
permission.)
SUMMARY

The Imre flap can be used to reconstruct partial or complete defects of the lower cyclid.
References
1. Imre J Jr. Lidplastik. Budapest: Studium Kiadasa, 1928.
2. Imre J Jr. New principles in plastic operations of the eyelids and face. JAMA 1921;76:1293.
3. Imre J Jr. In: Thiell R. ed., Ophtalmologische Operationslehre. Leipzig: Thieme-Verlag, 1942;87-108.
4. Metzger JT, Imre J Jr. The Imre flap. Plast Reconstr Surg 1959;23:501.
5. Stades FC. Tijdschrit voor Diergeneeskunde (Dutch). Reconstr Eyelid Surg (Suppl) 1987;1:586.
6. Borges AF. W-plasty rotation flap to cover nasal defect. Ann Plast Surg 1990;24:303.
7. Hoffman K, Stadler R. Imre modified bilobed flap rotation graft (Ger). Hautarzt 1993;44:148.
8. Pap GS. A comparison of three methods of eyelid reconstruction. Plast Reconstr Surg 1972;49:513.
9. Bennett JP, Werb A. The preservation of lachrymal drainage following excision of basal cell carcinoma of
the lower eyelid. Br J Plast Surg 1981;38:385.

Chapter 15
Superiorly Based Tarsoconjunctival Advancement (Hughes,
Landholt, Köllner) Flap for Reconstruction of The Lower Eyelid
M. A. CALLAHAN
This is one of the oldest, time-tested flaps for eyelid reconstruction. It will result in a reconstructed eyelid of
excellent color match, thickness, and function (1, 2, 3, 4, 5) (Fig. 15.2). The tarsoconjunctival flap for lower eyelid
reconstruction supplies the deficient lower lid with conjunctiva for lining and tarsus for structural support. This
posterior lamella flap should be combined with a free skin graft (or skin flap) to create the new anterior lamella of
the lower lid.
Note that, as originally described, the upper eyelid was split along the gray line. Because of associated
complications, this flap achieved a bad reputation. It is no longer performed as originally described, and even Dr.
Hughes warns against splitting the upper eyelid (6).
INDICATIONS
Application of this technique is limited, in that the vertical height of the upper lid tarsal plate measures 10 to
12 mm, and if more than 7 mm of this tarsal plate is removed, the upper lid may itself become crippled and
deformed. Therefore, this technique is most useful for repair of lower lid defects that are no more than 5 to 7
mm in vertical height. The best results are obtained when the horizontal extent of the defect is less than the
distance from the inner to outer canthus. If necessary, however, the technique can be used to reconstruct
the entire margin of the lower lid.
Defects of the lower lid that extend horizontally the full length of the lid and vertically to the inferior orbital
rim are better repaired by the bipedicle or bucket-handle flap (Tripier) technique, as described in Chapter
17. When the lower lid defect exceeds 7 mm vertically and half the horizontal lid length has been resected,
the Tenzel semicircular flap gives excellent results. The Tenzel flap also can be used in certain patients in
whom a tarsoconjunctival flap is contraindicated.
When all the lower lid must be removed, including the base of the lid past the inferior orbital rim, the
Mustardé cheek rotation flap, as described in Chapter 13, provides the best cosmetic and functional result.
Since the lids are closed for a significant period of time, this flap is not advisable when the patient has
corneal or retinal disease that needs attention or when the lids cover the only seeing eye.
OPERATIVE TECHNIQUE
Figure 15.1 illustrates resection of a lower lid tumor well below the lower lid tarsal plate, leaving a 5- to 7-mm
vertical defect. Two 4-0 silk sutures are placed along the upper lid margin, being careful to avoid the lash
follicles, to evert the lid and expose the inner tarsal surface (Fig. 15.2B). The sutures are anchored to the drapes
with hemostats. A horizontal mattress “tension” suture is placed across the lower lid defect to hold the wound
edges in position temporarily, so that the width of the tarsoconjunctival flap can be estimated. The tension of the
suture should be adjusted to approximate that of the normal lid. Alternatively, the width of the tarsoconjunctival
flap can be estimated before the malignant lesion of the lower lid is resected.
A horizontal incision is made through the conjunctiva and tarsus of the upper lid 3 to 3.5 mm from the lid margin
down to the submuscular fascia of the orbicularis muscles. The vertical limbs of the incision are extended in this

P.43
same plane into the superior conjunctival cul-de-sac. Dissection in this area is best accomplished with a
moistened cotton-tipped applicator, because Müller's muscle bleeds quite profusely unless the lid has been
infiltrated with epinephrine.
Many authorities believe that retraction of the upper lid results primarily from the incorporation of Müller's muscle
and the levator aponeurosis in the flap. These authors stress that it is important to form only a tarsoconjunctival
flap and not to include the upper lid retractors. Of course, this leaves the flap tip and skin graft solely dependent
on the conjunctival blood supply. Inclusion of the upper lid retractor muscles, whose blood supply is derived from
branches of the dorsal nasal, frontal, supraorbital, and lacrimal arteries in the flap pedicle, largely obviates any
chance of slough. As a result, slight retraction of the upper lid must be accepted as a tradeoff. As described
below, retraction of the upper lid can be dealt with by recessing the upper lid retractor muscles at the time of flap
revision.
The profile illustration in Figure 15.1C shows a 3- to 3.5-mm marginal strip of tarsus along the upper lid margin.
The tarsoconjunctival flap has been advanced and sutured into the lower lid defect to form the new posterior
lamella. As illustrated, the most superior extent of the dissection is carried out in such a way that no special
attempt is made to separate Müller's muscle and the levator aponeurosis from the base of the flap.
FIGURE 15.1 A-F: Superiorly based tarsoconjunctival flap reconstruction of a lower lid.
Interrupted absorbable 5-0 catgut sutures are placed between the flap and the lower lid defect, so that neither
suture loop nor knot protrudes posteriorly to irritate the globe (Fig. 15.1D). A retroauricular full-thickness skin
graft is sutured on top of the flap to form the new anterior lamella of the lower lid. As an alternative, if the patient
possesses abundant lower lid skin, a horizontal advancement flap of skin can be brought in either medially or
laterally to cover the tarsoconjunctival flap. Reconstructing the anterior lamella by a vertical advancement flap
from below is to be avoided at all costs, because the lower lid will surely retract after the pedicle is divided.
The skin graft is sutured in place with a tie-over bolster soaked in an ophthalmic antibiotic solution to help inhibit
bacterial growth during the first few postoperative days. A light pressure patch is applied for 48 hours and is
changed on the first postoperative day. If a skin graft has been used, the cotton bolster is left in place for 10 to
14 days.
After the flap has been sutured in place, the patient is committed to a second procedure 2 to 6 months later, at
which time the pedicle is divided. Collateral circulation from the recipient lid is sufficient to support the skin graft
and the flap 6 weeks following reconstruction. However, more time should elapse to allow for scar maturation
and suppleness of the lid, so that the tendency toward retraction of the lower lid will be decreased. In general,

P.44
the wider the flap, the longer the pedicle should be left before division. When dividing the pedicle, a drop of
topical anesthetic is placed in the cul-de-sac and the lid margins and base of pedicle are infiltrated with a local
anesthetic. To protect the globe, two muscle hooks or a grooved director (shown in the upper frame of Fig.
15.1F) should be placed behind the flap, which is then divided with straight scissors, so that a 1- to 2-mm stump
of tarsus and conjunctiva remains above the new lower lid margin (Fig. 15.1F). This will compensate for inward
rotation of the skin surface, which is often accompanied by entropion and trichiasis. If any excess tissue remains
on the posterior lamella after 1 month, it can be trimmed under topical anesthesia.
FIGURE 15.2 A: Preoperative appearance of a right lower lid demonstrating a sclerosing basal cell carcinoma.
The lid margin has been everted slightly by a cotton-tipped applicator. B: Reconstructed lower lid 2 years
following tarsoconjunctival advancement flap and a retroauricular skin graft.
After the pedicle is divided, the upper lid margin is examined for peaking or retraction. If these signs are present,
the posterior aspect of the base of the upper lid is infiltrated with a local anesthetic. The stump of the pedicle
(conjunctiva, Müller's muscle, and levator aponeurosis) is recessed toward its original position in the upper cul-
de-sac (upward smaller arrow in Fig. 15.1F) until the height of the upper lid is 2 to 3 mm below the contralateral
side. The upper lid will remain ptotic for a few days, but this will correct itself with the slight retraction that occurs
as healing progresses. The missing segment of tarsus and conjunctiva in the center of the lid will be replaced by
epithelialized fibrous tissue, and no suturing in the upper lid should be done. The orbit's excellent blood supply
lessens the risk of flap necrosis and slough of the skin graft.
FIGURE 15.3 Complications of Hughes tarsoconjunctival flap showing slight retraction of left upper lid and
notching of the lateral aspect of the lower lid.
At the end of the procedure, an antibiotic ointment (gentamicin) is instilled and the eye is patched for a few
hours, until oozing subsides. The eye should not be patched for a longer period because a readherence of the

raw surfaces may occur.
During eyelid reconstruction, the cornea should be adequately protected by a large contact lens or scleral shell.
The cornea and conjunctiva should be moistened frequently with balanced salt solution (BSS) as the operation
progresses to prevent desiccation. Alternatively, absorbable gelatin sponge, softened by BSS, can be placed
over the cornea and conjunctiva.
If suture keratitis occurs postoperatively, the offending suture should be removed immediately, if possible,
because keratopathy, pannus formation, and irreversible scarring of the cornea may occur. Occasionally,
keratitis may be temporarily managed by a soft contact bandage lens. If a crucial suture in the repair seems to be
the culprit, replace it as soon as possible, in the operating room, if necessary.
CLINICAL RESULTS
Unless a 3-mm bridge or strut of normal tarsus is left along the upper lid margin, notching, loss of lashes, or
upper lid retraction may occur. Retraction and peaking of the upper lid also may occur if the Müller's
muscle-levator aponeurosis complex is advanced inferiorly or resected during the reconstruction. This
complication may be treated by recession of Müller's muscle and the levator palpebral muscle at the time of
pedicle division.
The complications of notch formation and retraction of the upper lid (Fig. 15.3) were corrected by recession
of the upper lid retractors and pentagonal resection of the obtrusive lower lid notch present laterally. This
patient also suffered from keratitis sicca postoperatively and had to wear a soft contact bandage lens for 1
year to allay her ocular discomfort.
If tear secretion is borderline, as documented by Schirmer testing, and the patient has keratitis sicca, an
alternative technique should be considered, since the accessory lacrimal glands, which are concentrated in
the upper cul-de-sac, are disrupted by this operation.
SUMMARY
The tarsoconjunctival flap for lower eyelid reconstruction supplies the deficient lower lid not only with
conjunctiva for lining, but also with tarsus for structural support.
References
1. Czermak W. Die Augenarztlichen Operationen. Vol. 1, 2nd Ed. Berlin: Urban und Schwarzenberg,
1908;253-254.
2. Dupuy Dutemps L. Autoplastie palpébro-palpébrale integrate. Réfection d'une paupière, détruite dans
toute son epaisseur, par greffe cutanée et tarsoconjonctivale prisé a l'autre paupière. Monde Med
1928;38:705.
3. Dupuy Dutemps L. Autoplastie palpébro-palpébrale integrate. Refection d'une paupière détruite dans toute
son epaisseur par greffe cutanée et tarsoconjonctivale prisé a l'autre paupière. Bull Med (Paris)
1929;43:935.
4. Hughes WL. Reconstructive surgery of the eyelids. St. Louis: Mosby, 1943.

5. Köllner O. Verfahren fur den plastischen Ersatz des Unterlides. Munchen Med Wochenschr 1911;58:2166.
6. Hughes WL. A new method for rebuilding a lower lid. Arch Ophthalmol 1966;17:1008.

Chapter 16
Lateral Tarsoconjunctival Flap for Lid Tightening
S. A. LAUER
EDITORIAL COMMENT
Laxity of the lower lid occurs quite commonly in elderly patients. If recognized and corrected by this method,
such postoperative problems as temporary atrophia may be prevented. The lateral tarsoconjunctival flap to
correct horizontal tightness is a relatively effective technique. One of the editors, although preferring to use
a tendon sling for facial paralysis of the lower lid, in fact uses the lateral tarsorrhaphy in mild depressions of
the lower lid. It is an excellent and simple technique to bring the lid back into its normal position without
closing any portion of the lid.
The lateral tarsoconjunctival flap is designed to restore horizontal tension in the lower eyelid. As soft tissues of
the face stretch with age, the tarsoligamentous sling becomes weakened and lax, due primarily to stretching of
the canthal tendons. Constant pulling and stretching of the eyelid eventually can produce an involutional
ectropion, which occurs when horizontal laxity is sufficient for gravity to pull the eyelid away from the eye.
Restoration of tension in the tarsoligamentous sling can be accomplished in a number of ways, some of which
threaten the underlying lacrimal drainage apparatus and the stability of the tear film. Tightening the lateral
canthal tendon (1) with the lateral tarsoconjunctival flap has become the preferred means of restoring horizontal
tension in the lower eyelid.
INDICATIONS
The primary indications for use of the flap are correction of an involutional ectropion or, in some instances,
to provide corneal protection in cases of seventh-nerve paralytic ectropion that do not resolve
spontaneously. In the latter case, the flap is usually employed in combination with implantation of an upper-
lid gold weight to restore upper-lid mobility. Where additional protection of the corneal epithelium is
required, such as with tumors at the cerebellopontine angle that produce fifth- and seventh-nerve palsies,
the lower lid is not only tightened by a lateral tarsoconjunctival flap, but is concurrently elevated with a sling
such as a fascial sling, or by inserting spacer material beneath the tarsus.
The flap can also be utilized to prevent vertical lid retraction after skin excision during a lower-lid
blepharoplasty. In addition, it can be used to correct an entropion, or in-turning, of the lower lid; although
this condition, resulting from a combination of forces, may require additional surgery, the flap alone may be
used to reverse horizontal lid laxity.
Cicatricial ectropion or vertical lid retraction can be produced by scarring and shortening of the skin in the
lower eyelid. The lateral tarsoconjunctival flap can then be used, in combination with skin augmentation with
a full-thickness skin graft or regional skin flap (2, 3) (Fig. 16.1A-C).
ANATOMY
It is now generally accepted that the lateral canthal tendon is a fibrous connective tissue arising from the lateral
ends of the superior and inferior tarsal plates (1, 4). It inserts at the lateral orbital tubercle within the orbit,

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approximately 1.5 mm posterior to the lateral orbital rim. The tendon averages 10.6 mm in length from the lateral
canthal angle to its bony insertion and 6.6 mm in width, with the distance from the midpoint of the tendon to the
frontozygomatic suture averaging 9.7 mm. Superiorly, the tendon is contiguous with the lateral horn of the levator
palpebrae superioris; posteriorly, it is contiguous with the check ligament of the lateral rectus muscle. Both of
these structures also insert at the lateral orbital tubercle. Anteriorly, there is a small pocket of fat (Eisler's fat
pad), which is situated between the orbital septum and the lateral canthal tendon.
There are slips of striated muscle that pass from the overlying pretarsal orbicularis oculi muscle and intermingle
with the connective tissue of the lateral canthal tendon.
FIGURE 16.1 A: Eyelid with vertical lid retraction due to skin loss. B: Release of skin contracture of lid and
suture of lateral canthus to a higher position on the orbital rim. C: Postcorrection of vertical lid retraction with
lateral tarsoconjunctival flap and full-thickness skin graft.
FLAP DESIGN AND DIMENSIONS
The lateral tarsoconjunctival flap is created by transecting the inferior crus of the lateral canthal tendon, and then
using the tarsus to resuspend the lid, approximating the attachment to the lateral orbital tubercle. The flap should
be made slightly longer than the distance between the lateral canthus and the lateral orbital rim. Epithelium-
bearing tissues must be removed from the flap before resuspension of the lid to avoid the development of an
inclusion cyst.
OPERATIVE TECHNIQUE
The procedure can be done under local anesthesia. Injection of the anesthetic is at the lateral canthus and
beneath the conjunctiva of the lateral inferior fornix. A lateral canthotomy is performed with scissors or blade (Fig.
16.2A). The inferior crus of the lateral canthal tendon is selectively cut to avoid horizontal shortening of the lid; it
is easiest to identify the inferior crus by stretching the lid and feeling for areas of resistance on attempted lid
elevation (Fig. 16.2B and C).

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The cut edge of the lid margin is then pulled laterally until horizontal tension has been restored; a mark is placed
along the margin at the point chosen to be the new edge of the lateral canthus. Epithelium-bearing tissue at the
margin lateral to this point is resected. The tarsus is then separated from the overlying pretarsal orbicularis. A
blade is used to scrape conjunctival epithelial cells from the posterior surface of the tarsus. The flap of tarsus
and palpebral conjunctiva remains attached to the capsulopalpebral fascia inferiorly. The flap is measured so
that it is just longer than necessary for reattachment to the lateral orbital rim, and excess tissue is excised (Fig.
16.2C). The last step in the procedure is to resuspend the tarsus to the lateral orbital rim. This is generally
accomplished with a double-armed, permanent, monofilament suture passed in a horizontal mattress fashion.
The suture should be passed several times through the tarsus, because cheese-wiring is common. With the last
pass, the suture should exit the anterior surface of the tarsus. The suture is passed through the orbital
periosteum in a posterior-to-anterior direction, making sure that the path of the needle begins behind the lateral
orbital rim (Fig. 16.2D). The skin is then closed, with special attention to restoring the lid margin at the lateral
canthal angle (5, 6, 7) (Fig. 16.2E).
FIGURE 16.2 A: A lateral canthotomy is planned dividing the fornix. B: The inferior crus of the lateral canthal
tendon is selectively cut. C: The lid will move up easily if the tendon has been cut. D: The lid is sutured by
placing a suture in the tarsal plate and anchored to the medial surface of the orbital rim laterally. E: The skin is
closed, restoring the lateral canthal angle.
CLINICAL RESULTS
Although this flap has now been used for many years in lower-eyelid surgery with excellent clinical results,
there are some points to bear in mind. First, the goal of the surgery is to create tension at the lateral
anastomosis of the lid to the orbital rim. Care must be taken when suturing the lid to the periosteum,
because dehiscence can occur. Steri-strips are helpful in the early postoperative period, to aid in supporting

the lid while the wound is maturing. Second, as with any wound at the lid margin, care must be taken when
suturing the lateral canthal edge, because the eye is very sensitive to disruption of the lid margin. Finally, it
is best to create more tension in the lower lid than is immediately necessary, because the soft tissues can
be expected to relax with time.
SUMMARY
The lateral tarsoconjunctival flap, originally designed for the correction of involutional ectropion, has
evolved into a multipurpose flap that is useful whenever horizontal tightening of the lower eyelid is desired.
References
1. Gioia VM, Linberg JV, McCormick SA. The anatomy of the lateral canthal tendon. Arch Ophthalmol
1987;105:529.
2. Lauer SA. Ectropion and entropion. In Focal Points, vol. 12, no. 10. San Francisco: American Academy of
Ophthalmology, 1994.
3. Jordan DR, Anderson RL. The lateral tarsal strip revisited: the enhanced tarsal strip. Arch Ophthalmol
1989;107:604.
4. Whitnall SE. On a tubercle on the malar bone, and on the lateral attachments of the tarsal plates. J Anat
Physiol 1911;45:426.
5. Rathbun JE. Eyelid Surgery. Boston: Little, Brown, 1994.
6. Hornblass A, Chanig CJ. Oculoplastic, orbital and reconstructive surgery. Baltimore: Williams and Wilkins,
1988.
7. Putterman AM. Cosmetic oculoplastic surgery. Philadelphia: WB Saunders, 1993.

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Chapter 17
Bipedicle Upper Eyelid Flap (Tripier) for Lower Eyelid
Reconstruction
C. D. BUCKO
The bipedicle upper eyelid flap has been used to repair horizontally oriented losses of the lower eyelid, both
marginal and nonmarginal, of less than 10 to 15 mm in vertical height. Usually, when repairing a marginal loss, a
composite chondromucosal graft is used on the undersurface.
INDICATIONS
This flap is useful in replacing the absent central two-thirds of the lower eyelid that results from trauma,
tumor excision, or congenital colobomas. It can be used to replace a horizontal marginal loss in the central
two-thirds of the lower lid, to replace skin loss in the central two-thirds of a lower lid, or to fill in after release
and elevation of the lower lid (cicatricial lesions) where vertical height is less than 10 to 15 mm.
The flap is relatively simple to design and execute and is also a safe flap with a good blood supply. It is
composed of eyelid skin and muscle and is therefore of good texture and color match. If a composite graft is
included, the flap can be used for full-thickness lid replacement (marginal loss). The donor scar is invisible,
and there is no functional loss of the donor lid, since the flap tissue is usually in excess in adults. The flap
can be used to replace the entire central two-thirds of the eyelid.
Disadvantages of the flap include the following: The width of the flap is limited to 10 to 15 mm in adults and
even less in children, and the flap cannot be used for defects of the extreme medial or lateral eyelid. Upper
lid tissue is used to reconstruct the lower lid, and this may cause functional loss if incorrectly used. There
are no eyelashes present in the flap. Two stages are required to complete the reconstruction.
FLAP DESIGN AND DIMENSIONS
The flap is outlined with the inferior edge corresponding to the supratarsal fold from point A to point B (Fig.
17.1A). These two points are located above the medial and lateral canthi, respectively, where the fold
disappears. The superior incision ( CD) is made parallel to line AB (Fig. 17.1A), creating a bipedicled flap
approximately 10 to 15 mm wide, depending on the amount of redundant tissue present in the preseptal area. A
wider flap may be used, but this will require a skin graft to close the donor area.

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FIGURE 17.1 A: Bipedicle flap has been outlined, with inferior edge and supratarsal crease from point A to point
B. Superior edge is 10 to 15 mm above crease. B: Flap is sutured into central defect, leaving bases in canthal
areas intact. Donor area is closed up to bases.
OPERATIVE TECHNIQUE
Complete reconstruction requires at least two stages separated by 1 to 2 weeks, since both bases must be
transected in the second stage, after the flap has secured vascularization from its new bed in the lower lid.
The flap is incised and undermined deep to the orbicularis oculi muscle in the areolar plane between the muscle
and the orbital septum. The donor defect is closed directly with 6-0 nylon skin sutures from the medial base to
the lateral base.
FIGURE 17.2 A: Chondromucosal graft forms internal lamella. B: Chondromucosal graft is obtained from septum
through lateral rhinotomy. C: Flap covers composite graft. D: Bases are transected, and excess is discarded.
Flap is inset into medial and lateral edges of defect. Donor area closure is completed.
The flap is swung inferiorly into the lower lid defect and sutured into place (Fig. 17.1B). In nonmarginal defects, a
one-layer closure of the skin with interrupted 6-0 nylon sutures is sufficient. It is not possible to close the skin at
the medial and lateral edges during this primary stage because of the flap bases. These bases usually become
tubed and will be excised in a second stage.
When closing a marginal defect, the undersurface of the flap must be grafted with a composite chondromucosal
graft (Fig. 17.2A). Neither advancement of the remaining conjunctiva nor use of a superior lid tarsoconjunctival
flap for
lining (Köllner or reverse Landholt-Hughes technique) should be used (1), unless the vertical loss is less than 5
mm (usual width of the inferior tarsal plate). Mucosal advancement may result in entropion and retraction of the
lower lid with scleral “show” (1), and the Köllner technique, if misused, can cause severe upper lid retraction and
lagophthalmos (2).

The chondromucosal graft can be taken from the nasal septum (Fig. 17.2B) or from the upper lateral nasal area.
A lateral alar rhinotomy facilitates taking the graft. Closure of the nasal incision is rapid and simple and leaves
minimal scar. If the septal cartilage is used, it must be thinned before it is sutured into the lower lid. The graft is
trimmed along the superior edge, so that the mucosa extends 2 to 3 mm beyond the edge of the cartilage, to
allow the mucosa to be turned over the edge of the cartilage and meet the skin flap at the new gray line. The
cartilage should extend well below the defect inferiorly to give support to the reconstructed lid. Excision of
additional conjunctiva may be necessary.
The flap is then used to form the anterior surface of the reconstructed lid (Fig. 17.2C). A tie-over bolster to
prevent tubing of the flap has been suggested (2). However, this may interfere with the circulation in the flap.
An eye patch may be applied, but no pressure should be exerted. The bandage can be changed as needed over
the ensuing 10 to 14 days prior to division of the pedicles. Division of the pedicles is usually safe after 10 days.
The upper and lower lid are infiltrated with plain Xylocaine, and the two bases are transected at the margins of
the defect. The ends of the flap are trimmed and inset with 6-0 nylon. The remaining pedicles from the upper lid
are excised, leaving small triangles, rather than returned to the lid, because of the thickening and tubing of the
pedicle tissues (Fig. 17.2D), that result in conspicuous scar.
SUMMARY
The bipedicle upper eyelid flap is a safe and reliable flap that can be used to reconstruct defects of the
central two-thirds of the lower eyelid up to 15 to 20 mm in vertical height.
References
1. Mustardé JC. Repair and reconstruction in the orbital region: a practical guide. Edinburgh: Churchill
Livingstone, 1980. Chap. 11, 122.
2. Callahan A. Reconstructive surgery of the eyelids and ocular adnexa. Birmingham, AL: Aesculapius, 1966.

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Chapter 18
Skin Island Orbicularis Oculi Musculocutaneous Flap for Lower
Eyelid Reconstruction
R. V. ARGAMASO
A substantial loss of lower eyelid tissue may result from trauma or surgery. Reconstruction by skin-flap transfer
has been of particular interest to reconstructive surgeons.
INDICATIONS
In recent years, the introduction of musculocutaneous flaps has increased the survival rate of skin transfers.
In many instances, the quality of results also has improved.
It is noteworthy that long before musculocutaneous flaps became popular, Tripier performed a transposition
of an orbicularis oculi musculocutaneous flap from the upper to the lower eyelid in 1889 (1). The same
concept was elaborated on for repair of lower lid defects after tumor ablation (2). The Tripier flap was
further modified by converting the skin component into an island on a bipedicled orbicularis oculi muscle
that was then transferred to the lower lid for correction of severe ectropion (3).
Described below is a skin island orbicularis oculi musculocutaneous flap obtained from the suprabrow area
and used for reconstruction of the lower eyelid. The upper eyelid was not a suitable donor, since it was also
partially damaged.
ANATOMY
The orbicularis oculi is a flat, circular muscle arising from the nasal part of the frontal bone, frontal process of the
maxilla, and anterior surface of the medial palpebral ligament. The pretarsal and preseptal sections occupy the
eyelids, while the orbital portion surrounds the orbits, spreading to the temple and down to the cheeks. The
muscle layer is relatively thinner within the eyelids than that which surrounds the orbits.
The latter forms a complete ellipse without interruption. Its upper fibers blend with those of the frontalis and
corrugator muscles.
FIGURE 18.1 A: Diagram of the skin island outlined above the eyebrow. The flap should be as wide as the
defect of the lower lid. Broken lines delineate the muscle pedicle. B: The skin island is sutured in place. The
muscle pedicle, actually wider than the width of the skin island, lies in a subcutaneous tunnel.
The blood supply comes from three main sources. Branches of the facial artery penetrate the muscle from its
inferomedial aspect. The superficial temporal artery sends several branches approaching the lateral side. The

internal maxillary artery also contributes by way of the supraorbital and infraorbital arteries. These vessels
interlace with one another within the muscle to form arcades that give out branches to the overlying skin. The
veins follow the locations of the main arteries.
Filaments of the temporal and zygomatic branches of the facial nerve innervate the orbicularis oculi muscle.
FLAP DESIGN AND OPERATIVE TECHNIQUE
A lenticular island of skin is outlined adjacent to the eyebrow (Fig. 18.1). The inferior boundary is along the full
extent of the follicular line. Skin and subcutaneous fat are incised. Below the bulbs of the hair follicles, the knife
is beveled in order to cut a wider strip of muscle than the overlying skin island.
At the lateral angle of the skin incision, muscle continuity is kept intact so that a pedicle can be developed for the
musculocutaneous flap. This is a critical area where the skin is undermined very superficially to prevent injury to
the blood vessels entering the muscle. Skin undermining is continued inferiorly in the same superficial plane
above the orbicularis ring.
FIGURE 18.2 A: A 20-year-old woman who sustained a gunshot wound to her face. The injury involved
comminuted fractures of the floor and rim of the left orbit, total disruption of the left globe, subtotal destruction of
the lower eyelid, and partial avulsion of the upper eyelid. Initial treatment consisted of debridement of the
contents of the left socket and wound closure using the remnants of lid skin to cover the concavity of the orbit.
Reconstruction of the orbital floor and rim was performed with rib grafts. The cavity was resurfaced with mucosal
grafts obtained from the cheeks. B: Close-up of skin island flap. C: Moderate inversion of the reconstructed lid
margin secondary to contracture of the mucosal graft requires additional surgery. Eyebrow scar is comparable to
that following a direct brow lift procedure.
The skin-muscle flap is then elevated starting medially from its tip toward its base near the temple. The pivot
point should be at the same horizontal level as the outer canthus or palpebral fissure. An arc of rotation is
established that will allow the flap to sweep over the entire territory of the lower lid.
A tunnel is made beneath the lateral canthal skin for the entry of the flap toward its final destination. There
should be ample space for the pedicle to settle in without undue compression. The apex of the flap should reach
the medial canthus. The muscle layer of the flap is spread out by sutures over the orbital fibers of the recipient
bed and tied over bolsters on the skin.
The flap is lined either by advancing conjunctiva at the inferior sulcus or by a free graft of mucosa obtained from
the inside of the cheek.
CLINICAL RESULTS
The use of upper lid skin in the patient illustrated in Figure 18.2 was not feasible because this was also
traumatized and somewhat deficient. Rotation of a Mustardé flap (4) would have

P.51
sacrificed normal facial skin and produced unwanted scars on the face. A free-flap transfer to restore lower
lid form is a formidable undertaking, and therefore, a skin island orbicularis oculi musculocutaneous flap
was designed.
Since the skin and muscle components of the suprabrow area are thicker than those of normal eyelids, the
island flap would appear bulkier than when upper lid tissues are employed. Also, pigmentation of the
suprabrow skin seems lighter than that of most lid skin. In other patients, some eyebrow hair may be
present within the area of the skin island. For these reasons, this flap should be considered and
recommended only when other more ideal flaps are not available.
Dissection of the muscle pedicle should be restricted to a limited area to avoid injury to the zygomatic and
temporal fibers of the facial nerve. Transient weakness in eyelid closure has been observed. Loss of
elevation of the eyebrow is more common because of complete transection of the frontalis muscle insertion
into the orbicularis, but this may be a small price to pay for the correction of functional and aesthetic
deformities of the lower eyelid.
SUMMARY
A one-stage transfer of a skin island musculocutaneous flap of orbicularis oculi from its supraorbital
segment is described as an alternate method for reconstruction of the lower eyelid.
References
1. Tripier L. Lambeau musculo-cutané en forme de point. Gaz Hopitaux 1889;62:1124.
2. Goldstein MH. Orbiting the orbicularis: restoration of muscle ring continuity with myocutaneous flaps. Plast
Reconstr Surg 1983;92:294.
3. Siegel RJ. Severe ectropion: repair with a modified Tripier flap. Plast Reconstr Surg 1987;80:21.
4. Mustardé JC. The use of flaps in the orbital region. Plast Reconstr Surg 1970;45:146.

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Chapter 19
Cheek V-Y Advancement Skin Flap to The Lower Eyelid
I. J. PELED
M. R. WEXLER
EDITORIAL COMMENT
This procedure is probably not the best choice among the various alternatives available. To be successful,
the V-Y advancement must overcompensate. The medial and lateral extent of the Y limbs should be the
canthal ligaments, to prevent retraction and possible ectropion.
Several methods of lower eyelid reconstruction have been reported, including rotation cheek flaps (1, 2, 3),
musculocutaneous orbicularis flaps (4), partial- or full-thickness upper eyelid flaps (5, 6, 7, 8, 9), nasolabial and
supraorbital flaps (10), and full-thickness skin grafts for coverage (11). These have been combined with
conjunctival flaps and chondromucosal grafts for lining (11, 12).
Using the reliable V-Y advancement principle described by Gillies (13) [later modified to an island
subcutaneously based by Kutler (14) in fingertip reconstruction] and the triangle of cheek skin discarded during
reconstruction in the Mustardé cheek rotation skin flap (3), the lower eyelid can be reconstructed by covering a
chondromucosal graft with a V-Y advancement cheek flap (15).
INDICATIONS
Lower eyelid reconstruction is performed fairly often following tumor ablation, trauma (avulsion, burns), or
when using a lower eyelid flap for reconstruction of the upper lid. When the remaining defect is wider than
one-third of the lower eyelid,
direct suturing should not be attempted, and local or distant tissue is necessary.
FIGURE 19.1 Schematic drawing of lower eyelid defect and subcutaneous-based triangular cheek skin flap
(A'B'BA, eyelid defect; ABC, triangular cheek skin flap; A'B'C', sutured flap; CC', V-Y advancement).
This technique involves only one stage. There is no dog-ear to revise later, no discarding of healthy tissue,

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and the upper eyelid remains intact. Use of the technique does not preclude later use of the rotation cheek
flap, if necessary.
FIGURE 19.2 A: Extensive basal cell carcinoma of the left lower eyelid. B: Defect following tumor ablation.
Note the lines drawn for the V-Y flap. C,D: Good cosmetic and functional results 6 months following
operation. (From Peled et al., ref. 15, with permission.)
ANATOMY
The V-Y cheek flap is a random one that is subcutaneously based in the nasolabial area, which is very richly
supplied by branches of the facial artery. Wide lateral undermining between the dermis and the subcutaneous
tissue allows upward advancement without tension and does not jeopardize the blood supply of the flap.
FLAP DESIGN AND DIMENSIONS
The triangular flap is drawn in the cheek under the defect (Fig. 19.1). The width of the flap is the same as the
width of the defect, and the height of the flap is 11ú2 times greater.
OPERATIVE TECHNIQUE
After design of the flap in the cheek below the defect, the skin of the V-Y flap is incised to the subcutaneous
plane and is undermined laterally, carefully preserving all the subcutaneous tissue attachments.
The flap is advanced upward until it reaches the desired position of the eyelid border without tension. It is
anchored medially and laterally to the orbital periosteum with two nonabsorbable sutures. This maneuver
compensates for gravity and avoids ectropion. The flap donor area is closed in a Y fashion. Lining of the defect
is obtained with a nasal chondromucosal graft taken from the nasal septum (12) or lateral nasal wall (16) and it is
then sutured to the remaining conjunctiva (see Chapter 13).
CLINICAL RESULTS
The only disadvantage in the technique occurs in defects with a vertical height greater than 12 mm, where

the skin that is advanced upward is thicker and may be hairy in males. No complications were encountered,
and cosmetic and functional results have been satisfactory as seen in the patient in Figure 19.2 (17).
SUMMARY
The cheek V-Y advancement skin flap can be effectively used for wide defects of the lower eyelid.
References
1. Hagerty RF, Smoak RD. Reconstruction of the lower eyelid. Plast Reconstr Surg 1966;38:52.
2. McGregor IA. Eyelid reconstruction following subtotal resection on upper or lower lid. Br J Plast Surg
1973;26:346.
3. Mustardé JC, Jones LT, Callahan A. Ophthalmic plastic surgery up-to-date. Birmingham, AL: Aesculapius,
1970.
4. Anderson RL, Edwards JJ. Myocutaneous flaps for major eyelid and canthal reconstruction. In: Bernstein
L, ed., Plastic and reconstructive surgery of the head and neck, Vol. 11. New York: Grune & Stratton,
1981;306.
5. Gorney M, Falces E, Jones H, et al. One-stage reconstruction of substantial lower lid margin defects. Plast
Reconstr Surg 1969;44:592.
6. Jones HM. One-stage composite lower lid repair. Plast Reconstr Surg 1966;37:349.
7. McCoy FJ, Crow ML. Adaptation of the switch flap to eyelid reconstruction. Plast Reconstr Surg
1965;35:633.
8. Orticochea M. Total reconstruction of the eyelid. Br J Plast Surg 1977; 30:44.
9. Pollock WL, Colon GA, Ryan RF. Reconstruction of the lower eyelid by a different lid-splitting operation.
Plast Reconstr Surg 1972;50:184.
10. Paletta FX. Lower eyelid reconstruction. Plast Reconstr Surg 1973; 51:653.
11. Macomber WB, Wang MK. Total reconstruction of upper and lower eyelids in the treatment of cancer.
Clin Plast Surg 1978;5:501.
12. Mustardé JC. Reconstruction of the upper lid and the use of nasal mucosal grafts. Br J Plast Surg
1969;21:367.
13. Gillies H. Plastic surgery of the face. London: Frowdes, Hodder & Stoughton, 1920;20.

14. Kutler W. A new method for fingertip amputation. JAMA 1947;133:29.
15. Peled I, Kaplan H, Wexler MR. Lower eyelid reconstruction by V-Y advancement cheek flap. Ann Plast
Surg 1980;5:321.
16. Paufique L, Tessier P. Reconstruction totale de la paupiere superieure. In: Troutman RC, Converse JM,
Smith B, eds., Plastic and reconstructive surgery of the eye and adnexa. Melbourne: Butterworth, 1962.
17. Peled IJ, Wexler MR. The usefulness and versatility of V-Y advancement flaps. J Dermatol Surg Oncol
1983;9:12.

Chapter 20
Laterally Based Tarsoconjunctival Transposition Flap to The
Lower Eyelid
C. BEARD
J. H. SULLIVAN
In this method of up to total lower eyelid reconstruction, the tarsoconjunctiva and skin are obtained from
separate, rather than contiguous, areas (1, 2). The procedure was developed to be used in place of the popular
Hughes operation (3), the latter requiring occlusion of the eye for several weeks (see Chapter 15). This visual
deprivation was troublesome to many patients, particularly those with less than good vision in the unoperated
eye.
INDICATIONS
This operation can be used for almost any lower lid reconstruction when the defect is too large for direct
closure. Since it is based laterally, this flap is ideally suited for defects that extend to the lateral canthus. If
the most lateral portion of the lower lid is intact, it must either be transferred to the nasal side of the defect
as a full-thickness, inferiorly based pedicle flap or simply excised to allow space for the proximal portion of
the transposition flap. Since the operation works well for total lower lid reconstruction, we have found it
simpler to excise the normal temporal lid tissue.
ANATOMY
We believe that the tarsoconjunctival flap retains much of its vascularity through its conjunctival plexus. In most
instances, the pedicle contains terminal branches of the superficial temporal and transverse facial arteries.
Despite its narrow base, the flap blanches with pressure, recolors with release of pressure, and oozes blood
from its raw surface. It is possible, however, that the tip of the flap acts as a free graft.
FLAP DESIGN AND DIMENSIONS
The flap contains tarsus and conjunctiva from the upper lid, is based at the lateral canthal tendon, and is
transposed to the lower lid on a narrow pedicle. The length of the flap is determined by applying lateral traction
on the nasal remnant of the lower lid to narrow the defect and then marking the upper lid opposite the cut nasal
edge of the lower lid defect. The flap is taken from the upper portion of the tarsus. The width of the flap to be
developed is about 4 mm, or slightly less than half the tarsal width.
OPERATIVE TECHNIQUE
The operative technique is illustrated in Figure 20.1. The lower lid tumor is removed under frozen-section control.
The upper lid is everted on a Desmarres retractor. A vertical incision is first made at the predetermined mark
defining the length of the flap. The incision is made into an L shape by a horizontal extension parallel to the lid
margin. The L is converted to a U by a parallel horizontal incision through conjunctiva and Müller's muscle along
the upper tarsal border. It extends into the palpebral conjunctiva beyond the lateral extent of the tarsus. The
upper incision is continued laterally to a point above the canthus, and the inferior incision is carried into the
lateral fornix.
The tarsoconjunctival flap thus outlined is elevated at first along the anterior tarsal surface and then posterior to

the lateral canthal tendon until the lateral wall of the orbit can be felt with the dissecting scissors. A small triangle
of conjunctiva below the lateral canthal tendon is excised to create a bed for the proximal end of the flap (Fig.
20.1B).
The flap is rotated 180° (from the everted upper lid) on its horizontal axis until its conjunctival surface faces the
globe. It is stretched into position to fill the posterior aspect of the lower lid defect. It should hug the globe firmly.
Insufficient tension may result in ectropion. If the flap is lax, it must be shortened appropriately. The tip of the flap
is sutured to the free edge of the lower lid tarsus with interrupted 6-0 plain catgut. The inferior edges are
approximated with a running suture. It is not necessary to close the donor site in the upper lid. We initially
sutured conjunctiva and Müller's muscle to tarsus, but occasionally we observed upper lid retraction. By allowing
the wound to granulate, we have seen no ill effects.
We have not attempted to cover the flap with a full-thickness skin graft, but we believe a split-thickness graft
could be used if necessary. In most instances, skin cover can be accomplished by an advancement flap from
below. If skin cannot easily be elevated to the lid margin, a horizontal relaxing incision can be made over the
orbital rim. The resulting defect can be covered with a full-thickness retroauricular or supraclavicular skin graft.
We have, on one occasion, successfully provided skin cover by a transposition flap from the upper lid, forming
back-to-back flaps.
FIGURE 20.1 A: The tumor is excised. The dotted line shows the extent of the tarsoconjunctival flap. B: The lid
is everted. (Note that the lid is actually everted with a Desmarres retractor and not sutures, as shown in the
illustration.) Lateral traction is placed on the remaining nasal lid. The extent of the flap is marked. The flap is
elevated and rotated 180° on its horizontal axis and into position in the lower lid. A triangle of conjunctiva is
excised beneath the lateral canthal tendon. C: The flap is sutured into position with 6-0 plain catgut. An inferior
skin advancement flap is prepared. If necessary, a relaxing incision is made at its base. D: The skin is advanced.
The lid margin is sutured with 6-0 plain catgut; the skin, with 6-0 silk. If necessary, a full-thickness skin graft is

used to fill the defect over the orbital rim.
CLINICAL RESULTS
The complications that have been observed are entropion and deformity of the canthal angle. Ectropion has
been the result of transposing too long a tarsoconjunctival flap and not the result of vertical skin shortage.
Correction has been made by horizontal lid shortening.
The canthal deformity consists of a visible band of tarsoconjunctiva behind the angle. Lysis of the band,
after lid healing, has relieved this condition. We have not seen damage to the lacrimal secretory function.
Necrosis of the tarsoconjunctival flap or skin coverage has not been observed in any of our patients.
SUMMARY
A one-stage tarsal transposition procedure is useful for repair of lower eyelid defects too large for simple
closure. The posterior layer of the reconstructed lid is furnished by a laterally based tarsoconjunctival flap
from the upper lid. The anterior layer is supplied by skin flaps and grafts as needed.
References
1. Hewes EH, Sullivan JH, Beard C. Lower eyelid reconstruction by tarsal transposition. Am J Ophthalmol
1976;81:512.
2. Gomey M, Falces E, Jones H, Manis JR. One-stage reconstruction of substantial lower eyelid margin
defects. Plast Reconstr Surg 1969;44: 592.
3. Hughes WL. Reconstructive surgery of the eyelids, 2d Ed. St. Louis: Mosby, 1954;135.

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Chapter 21
Nasolabial Skin Flap to The Lower Eyelid
C. E. PALETTA
F. X. PALETTA SR.
Over the course of my career, I (F.X.P.) have used many different techniques to reconstruct the lower eyelid (1,
2, 3, 4). Some of these techniques include (1) the nasolabial flap, (2) the upper eyelid skin flap, (3) the
supraorbital skin flap, (4) the midforehead skin flap, (5) the cervical tube skin flap, (6) the full-thickness skin flap,
and (7) the Hughes procedure (Fig. 21.1). I have found each of these procedures to be successful (5, 6, 7, 8).
Some are obviously more appropriate in selected patients. Donor site morbidity and scarring are often
determining factors in technique selection.
When I first used the nasolabial skin flap for lower eyelid reconstruction, I felt that it would be necessary to
perform secondary procedures such as an additional mucous membrane graft for lining (9), a fascial sling for
support, and
reconstruction of the lacrimal apparatus for tear drainage. Follow-up on these patients, however, has
demonstrated that additional procedures are rarely necessary.
FIGURE 21.1 Diagrammatic outline of several neighboring regional area flaps used to reconstruct the lower
eyelid. (From Paletta, ref. 8, with permission.)
INDICATIONS
Based on my experience, the nasolabial flap can be used for partial or total lower eyelid reconstruction. In
the older patient, the primary indication is reconstruction following resection for carcinoma. In younger
individuals, loss of tissue in this area was usually from traumatic avulsion or following surgical excision of
tumors. There have also been occasional cases of lower eyelid tissue loss from infectious causes. Finally,
in the neonatal population, congenital defects of the lower eyelid can present for reconstruction.
FLAP DESIGN AND DIMENSIONS

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The nasolabial flap is easily elevated under local anesthesia in the adult patient. General anesthesia is required
in the younger patient. This flap is usually performed directly following tumor excision. Free tumor margins are
determined by frozen section. If there is uncertainty about whether all the margins are free of tumor, the lower
eyelid defect is covered with a sterile dressing (such as Biobrane, sterile saline gauze, or Xeroform) until
permanent sections confirm that all margins are free of tumor. The outline of the skin flap is in the adjacent
nasolabial fold (Fig. 21.2). The flap is based superiorly, so that it can easily be rotated to the lower eyelid
position. A small dog-ear is usually created during the transposition of the flap. This can either be excised
primarily, or, if there is concern over compromise to the blood supply of the flap, the dog-ear can be
removed as a secondary procedure 6 to 12 weeks later. These flaps can readily be elevated without delay
because of their excellent blood supply. The width of the flap is usually 1.5 to 2.0 cm, and the length depends on
the width and location of the lower eyelid defect. While rarely necessary for lower eyelid reconstruction, the
superiorly based nasolabial flap can extend as far as the ipsilateral oral commissure.
FIGURE 21.2 Technique of nasolabial flap reconstruction of lower eyelid. A: Outline of the area to be excised in
the lower eyelid and the nasolabial flap to be elevated. B: The flap is transferred to the lower eyelid, and the
donor site is closed. (From Paletta, ref. 8, with permission.)
FIGURE 21.3 A: A 65-year-old man with an extensive basal cell carcinoma of the lower eyelid. B: Excision of the
lower eyelid and immediate repair with a nasolabial flap. C: Reconstructed lower eyelid 3 weeks following
operation. (From Paletta, ref. 8, with permission.)
OPERATIVE TECHNIQUE
When dealing with a skin malignancy such as basal cell carcinoma of the lower eyelid, surgical resection may
require full-thickness excision of the palpebral margin, skin, tarsal plate, and conjunctiva. Following resection or
creation of the lower eyelid defect, the soft tissue requirements are either measured or a template is made of the
defect. The nasolabial flap is then designed with its proximal base adjacent to the medial aspect of the lower
eyelid defect. The nasolabial flap is then infiltrated with a local anesthetic (usually 1% Xylocaine with epinephrine
1:100,000). The flap is raised beginning distally in a soft-tissue plane approximately two-thirds the depth

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between the deep dermis and the underlying facial musculature. This plane of flap elevation ensures adequate
vascularity of the flap without adding excessive fatty tissue in the lower eyelid region. The soft tissue of the
cheek is then widely undermined and advanced toward the nose for closure in the nasolabial line. The superior
portion of the flap is sutured to the bulbar conjunctiva with a 5-0 absorbable suture (either chromic catgut or
polyglycolic acid suture). The knots of these sutures are buried to avoid irritation of the globe or cornea. To
provide a sling effect, it is best to inset the flap under a slight amount of tension. The inferior portion of the
nasolabial flap is sutured to the upper cheek skin with either 6-0 nylon or silk. Either a light dressing or no
dressing may be used, but care must be given to postoperative eye care and wound cleansing with hydrogen
peroxide and antibiotic ointment (Figs. 21.3, 21.4, 21.5). The nonabsorbable sutures are removed in 5 to 7 days
(4).
FIGURE 21.4 A: Right lower eyelid 6 years following reconstruction with a nasolabial flap of the entire lower
eyelid for melanoma in a 34-year-old man. B: No restriction of upward gaze. (From Paletta, ref. 8, with
permission.)
FIGURE 21.5 A: Recurrent basal cell carcinoma of the left medial canthus and lower eyelid in a 38-year-old
woman. B: Six months following repair with a nasolabial skin flap, there is drooping of the reconstructed lid
margin. (From Paletta, ref. 8, with permission.)
CLINICAL RESULTS
In our series of over 100 lower eyelid reconstructions utilizing the superiorly based nasolabial flap, there has
been no case of complete or partial flap necrosis. There have been minor complications in 5% of patients.
These include slight ectropion, excess
fat in the skin flap in some of the young patients, and some scleral exposure below the limbus of the eye.
One patient required a fascial sling to correct excessive scleral exposure. Epiphora was seen occasionally,
but rarely persisted in the majority of patients. In cases where the lower canaliculus was excised or
obstructed by scar, the upper canaliculus appeared adequate to control tearing. In male patients, hair
growth in the transposed flap did not present itself as a problem. This was primarily because the flap's
design rarely required including the lowermost portion of the nasolabial flap where facial hair is more
prominent.

SUMMARY
The superior nasolabial flap is an excellent choice in the reconstruction of major lower eyelid defects. Its
main advantages are that it can be done easily under local anesthesia; it is a one-stage procedure; the
donor site is usually adequate and presents little donor-site morbidity; and it provides an adequate amount
of local tissue for large defects of the lower eyelid.
References
1. Paletta FX. Early and late repair of facial defects following treatment of malignancy. Plast Reconst Surg
1954;13:95.
2. Hughes WL. A new method for rebuilding a lower lid. Arch Ophthalmol 1966;17:1008.
3. Berkeley R. Total lid reconstruction with plastic repair. Am J Surg 1969; 118:741.
4. Hecht SD. An upside-down Cutler-Beard bridge flap. Arch Ophthalmol 1970;84:760.
5. Smith B, English FP. Techniques available in reconstructive surgery of the eyelid. Br J Ophthalmol
1970;54:450.
6. Fox SA. A procedure for lower lid reconstruction. Arch Ophthalmol 1971; 85:79.
7. Pap GS. A comparison of three methods of eyelid reconstruction. Plast Reconstr Surg 1972;49:513.
8. Paletta FX. Lower eyelid reconstruction. Plast Reconstr Surg 1973;51:653.
9. Millard DR. Eyelid repair with chondromucosal graft. Plast Reconstr Surg 1962;30:267.

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Chapter 22
Laterally Based Transverse Musculocutaneous Flap for Lower
Eyelid Reconstruction
C. D. BUCKO
EDITORIAL COMMENT
It is recommended that this flap be used as a musculocutaneous flap to ensure circulation to the distal end
of the skin flap. We feel that the modification presented in this chapter is a significant advance over the
original Fricke flap (that was harvested from the area above the eyebrow).
One of the best flaps that can be used to reconstruct the lower eyelid is a laterally based transverse
musculocutaneous flap from the upper eyelid.
INDICATIONS
This flap can be used to replace tissue loss from the lateral two-thirds of the lower lid resulting from trauma,
tumor excision, and congenital colobomata. More specific applications are (1) to replace lost skin and
muscle of the lateral two-thirds of the lower lid and cheek of up to 15 to 20 mm in vertical height, (2) to
replace a full-thickness loss of the lateral two-thirds of the lower lid of up to 15 to 20 mm in vertical height,
(3) to reconstruct lost lateral canthal soft tissue, and (4) to fill in the defect when raising the position of the
lateral lower lid margin (as a result of congenital or severe senile ectropion or Treacher Collins syndrome)
(1, 2, 3, 4).
The flap is simple to design and execute; it is a safe flap with a good blood supply. Texture and color are
similar to that of lost tissue, and the flap can be used as a full-thickness replacement, if a graft is included
on the undersurface. The donor site is invisible, and there is no functional loss in the donor area, since
tissue is usually in excess in adults.
FLAP DESIGN AND DIMENSIONS
The flap is usually elevated in the submuscular plane to include innervated and vascularized preseptal
orbicularis muscle and the overlying skin. The tarsal plate is located beneath the flap and is not included. The
orbital septum and levator aponeurosis are left intact deep to the preseptal orbicularis layer.
A simple, easy to execute, safe flap can be designed. The flap can be raised as a random flap, as a
musculocutaneous flap, or as a composite flap in conjunction with a chondromucosal graft on its deep surface for
replacement of a full-thickness lid loss.
The base of the flap is located at the lateral orbital rim (AB in Fig. 22.1A), and the apex is located on the medial
supratarsal fold corresponding to the medial edge of the lower lid defect ( C and C' in Fig. 22.1A). Primary
closure of the donor site can be obtained if the flap is less than 15 to 20 mm wide at the central portion and base,
depending on the amount of redundant donor skin and muscle (less in children). A wider flap could be used, but
skin grafting of the donor site would be required.

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FIGURE 22.1 A: Triangular flap is outlined using point A at lateral orbital rim, point B at edge of defect, and point
C at apex on supratarsal crease. B: Flap has been transposed and sutured into recipient bed. Suture at lateral
canthus gives support to lid. Donor site is closed along supratarsal crease.
FIGURE 22.2 A: Chondromucosal composite graft is used for posterior lamella in marginal defect. B: Flap
covers anterior defect.
The inferior edge of the flap (CB in Fig. 22.1A) corresponds to the supratarsal fold and extends from the apex
(point C) to point B, located at the most inferolateral edge of the lower lid defect. Point A, at the base, lies over
the orbital rim at the level of a horizontal line connecting the medial and lateral canthi. The distance between
points A and B, the base of the flap, can be up to 15 to 20 mm in adults. The superior edge of the flap begins at
point A, at the base, and tapers to point C, at the apex. If additional flap length is needed to extend to the medial
third of the lower lid, point C can be moved into the medial canthal area or even onto the lateral nose without fear
of flap necrosis if the flap is used as a musculocutaneous flap.
OPERATIVE TECHNIQUE
The flap is pivoted into the lower lid defect and sutured with 6-0 nylon skin sutures (Fig. 22.1B). If the full
thickness of the lower lid needs reconstruction, the posterior lamellar defect is closed by using a
chondromucosal composite graft (Fig. 22.2A)
and the anterior defect is covered by the flap (Fig. 22.2B). This graft can be taken from the nasal septum (see
Chapter 17) or from the upper lateral nasal cartilage through a lateral rhinotomy. The graft should extend from
the free margin down to the orbital rim in order to create a stable lid if more than two-thirds of the lid is being
reconstructed.
The lateral canthus can be reinforced with a 4-0 mattress suture from the lateral orbital rim periosteum slightly
above the lateral canthus to the undersurface of the flap at the lateral canthus (Fig. 22.1B). The donor area is
closed with 6-0 nylon sutures (muscle sutures are not needed).

CLINICAL RESULTS
See Chapter 17.
SUMMARY
The laterally based transverse musculocutaneous flap is a safe, reliable, simple flap that can be used to
reconstruct defects of the lateral two-thirds of the lower lid of up to 15 to 20 mm in vertical height.
References
1. Callahan A. Reconstructive surgery of the eyelids and ocular adnexa. Birmingham, AL: Aesculapius, 1966;
293-296.
2. Fricke JCG. Die Bildung neuerAugenlider (Blepharoplastik) nach Zerstorungen und dedurch
hervorgebrachten Auswartswendungen derselben. Hamburg: Perthes & Brasser, 1829.
3. Mustardé JC. Repair and reconstruction in the orbital region: a practical guide. Edinburgh: Churchill
Livingstone, 1980;55-56.
4. Soll DB. Entropion and ectropion. In: Soll DB, ed., Management of complications in ophthalmic plastic
surgery. Birmingham, AL: Aesculapius, 1976;194.

Chapter 23
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.
INDICATIONS
To overcome the tendency for the covering layer to slide down under the force of gravity while the levator
muscle tends to pull the lining layer upward, an ideal solution is to rotate a flap of the full thickness of the
lower lid into the upper lid defect. Such a flap has its own stable, normal margin and its own built-in
adhesion of the area of skin immediately proximal to the margin to the underlying structures of the lid (albeit
to a lesser extent than in the upper lid). This flap, which is actually the reverse of the flap described by
Esser, will preserve the marginal eyelid vessels in its base, and after a 2-week interval, they can be divided.
At that stage, the problem is resolved by closure of the resulting lower eyelid defect (see Chapter 13) (1).
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.

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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).
It should be noted that where a defect of more than half the upper lid is present, the cut edge of the levator
palpebral muscle must be sutured to the connective tissue of the lower lid flap. No great care is required to judge
exactly at what level this attachment should be made, since the patient will balance the level of the two upper
eyelids to obtain equal light appreciation (Fig. 23.3).
Subtotal and Total Defects of the Upper Eyelid
Unless the defect is only 2 to 3 mm greater than half the width of the upper eyelid, the preceding technique
should not be used. A more balanced two-stage procedure is required (Fig. 23.4). Stage 1 consists of designing
a full-thickness flap of the lower
eyelid that has a broad pedicle (7 to 8 mm) and that is large enough to fill the upper lid defect. If there is any
remnant of the upper lid, then the pedicle should be designed on that side so that the wound to be closed
primarily along the upper lid margin will be the most central one, closest to the pupil.
FIGURE 23.1 A-D: Reconstruction of defects of up to half the width of the upper eyelid. Because of the stretch
of lid tissues, a small flap of only a quarter of the width of the lower lid needs to be rotated into the upper lid
defect. E: Postoperative result. Note the stable margin in the reconstructed upper lid, with no tendency for the

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skin to roll down over the margin. (From Mustardé, ref. 1, with permission.)
In subtotal and total defects of the upper lid (Fig. 23.5), the end of the flap is turned up and sutured into the
upper lid defect in layers (including suturing the levator muscle to the connective tissue) as far as can be done
without putting the tissues under tension. In the nonunited areas, skin may be joined temporarily to conjunctiva to
minimize infection and the formation of granulation tissue.
Stage 2 consists of dividing the base of the lower eyelid flap, setting it completely in place in the upper lid, and
reconstructing the resulting lower lid defect by using a cheek rotation flap lined with a composite nasal septal
graft of mucosa and cartilage (see Chapter 13).
SUMMARY
The best tissue for reconstruction of the upper eyelid is that obtained from the lower eyelid. The upper
eyelid is the most difficult to reconstruct, since it must be movable. The first principle of sound eyelid
reconstruction is to use the lower lid to reconstruct the upper lid, but use other sources to reconstruct the
lower lid.
FIGURE 23.2 Defects between half and three-quarters of the width of the upper lid. Reconstruction of the
upper lid is carried out by transferring a flap slightly larger than one-quarter the width of the lower lid. This
necessitates bringing in a small cheek flap to reconstitute the lower lid when the pedicle on the full-
thickness flap is divided. (From Mustardé, ref. 1, with permission.)

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FIGURE 23.3 Tumor of the upper eyelid that left a defect of over half the width of the upper eyelid after
resection. A-C: First stage of the surgery. D, E: Postoperative appearance showing stable margin in the
upper lid reconstruction. Lower lid reconstruction was carried out by lining the cheek flap with conjunctiva. It
would have been advisable to have used a small composite nasal septal graft to obviate the postoperative
droop of the reconstructed segment of the lower eyelid. (From Mustardé, ref. 1, with permission.)

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FIGURE 23.4 Subtotal reconstruction of the upper lid. A small remnant of upper lid is preserved on the
medial side, and thus the hinge of the lower lid flap that will be used is designed on the medial side to
ensure good primary union in the upper lid scar that will be closest to the cornea. A-D: Resection of upper
lid tumor, design and raising of full-thickness lower lid flap, and insertion of free end into upper lid defect. E,
F: Division of the base of the lower lid flap and completion of the flap insertion into upper lid defect. G:
Reconstruction of the lower lid with a composite nasal septal graft in situ. H: Rotation of the cheek flap to
complete reconstruction of lower lid. I-K: Postoperative views showing functioning upper lid with a stable
margin. The reconstructed part of the lower lid also can be seen, and the support given to this segment by
the composite graft is well demonstrated. (From Mustardé, ref. 1, with permission.)

FIGURE 23.5 Reconstruction of large defects of the upper lid (see text for details of technique). Note that
where a remnant of the upper lid is left, the base of the flap to be raised from the full thickness of the lower
lid should be on the side of the largest remnant. Where no upper lid remains, the base of the lower lid flap
should be placed on the lateral side to establish lymphatic drainage as quickly as possible in the
reconstructed upper lid. (From Mustardé, ref. 1, with permission.)
Reference
1. Mustardé JC. Repair and reconstruction of the orbital region, 2d Ed. Edinburgh: Churchill Livingstone,
1980; Chap. 11.

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Chapter 24
Inferiorly Based Skin-Muscle-Conjunctival Advancement (Cutler-
Beard) Flap From The Lower to The Upper Eyelid
C. BEARD
J. H. SULLIVAN
EDITORIAL COMMENT
In using so much of the full-thickness skin and conjunctiva of the lower lid to recreate the upper lid, the
danger of a significant portion of patients developing ectropion is something to be considered before
selecting this procedure for use.
The upper eyelid is far more important functionally than the lower lid, since it is responsible for almost all the
protection of the cornea. Without an adequate upper lid, the globe cannot survive long as a useful organ.
Reconstructive procedures for major upper eyelid repair are few and complex. The inferiorly based skin-muscle-
conjunctival advancement flap has withstood the test of time. This two-stage procedure can be used for total lid
replacement, yet it is one of the simplest of the upper eyelid reconstructive operations.
INDICATIONS
The advantages of this procedure are its usefulness in correcting large upper lid defects, its simplicity, and
the surprising freedom from deformation of the lower lid (1). The necessity for prolonged visual obstruction
with this procedure may be a problem in an occasional patient. A much shorter period of occlusion is
possible with the Mustardé “switch flap” (2). It may be possible to reduce the period of occlusion thought to
be necessary with the Cutler-Beard flap, but we have not attempted to do so.
ANATOMY
This flap consists of an inferiorly based full-thickness lower lid flap (skin, orbicularis muscle, orbital septum, lower
lid retractors, and conjunctiva) advanced beneath the lower lid margin to replace the upper lid.
OPERATIVE TECHNIQUE
The procedure (Fig. 24.1) begins with complete removal of the upper lid tumor under frozen-section control or
freshening of the margins of traumatic or congenital defects. Remnants of the remaining lid are held under
moderate traction to lessen the width of the defect. The measurement of this width is used to determine the width
of the full-thickness lower lid flap. A horizontal skin incision of the same distance is made. It is deepened at one
end into the inferior fornix. Using scissors, a full-thickness horizontal incision is completed immediately below the
tarsus to the width of the skin incision. Full-thickness vertical scissor cuts are made from the ends of the
horizontal cut to the extreme depths of the inferior fornix, forming a rectangular flap. The flap is mobilized by
undermining the skin inferiorly over the orbital rim. It is then advanced posterior to the bridge of the lower lid
margin into the upper eyelid defect, where it rests without tension.
A two-layered closure of the upper lid to the lower lid is sufficient; 6-0 plain catgut is used to approximate the