Operative Technique in Plastic Surgery – Kevin C.Chung

Postoperative
■ Early mobilization is encouraged.
■ Nasogastric or PEG tube should be used for feeding initially.
■ The donor site is typically covered with a split-thickness skin
graft with bolster or VAC dressing. Addition of a splint for 7 days
is helpful as well.
Complications
■ A watertight closure on the mucosal side is critical; good oral care
and frequent examination minimize salivary leak.
■ The majority of complications arise at the donor site, typically the
sequelae of loss of the paratenon during flap harvest. Exposed
tendon often causes failure of the skin graft and tethering of the
tendon with functional diminishment.
POSTOPERATIVE CARE
■ Patients routinely stay in the hospital for 7 to 14 days.
■ Flap monitoring is performed by experienced nursing and house staff by
clinical examination and handheld Doppler. The authors prefer flap checks q
15 minutes × 2 hours, q 30 minutes × 1 hour, q 1 hour × 48 hours, and q 2
hours until day 4.
■ Patients typically are out of bed by postop day 1 and ambulating either the
same day or on postoperative day 2.
■ Oral care with normal saline swish and spit begins on POD no. 3 along with
clear liquid diet when sufficient healing has occurred with diet advancing to
soft diet on days 5 to 7.
OUTCOMES
■ Despite its shortcomings, the radial forearm remains the best option for
reconstruction of subtotal lip defects.
■ It allows for single-stage reconstruction or skin and mucosa and restores oral
competence and adequate stomal size.
■ Color match and lack of vermilion are long-term issues. Tattooing can be used
to improve cosmetic outcomes by simulating the vermilion.
COMPLICATIONS
■ The majority of complications are at the radial forearm donor site.
■ Loss of the paratenon during flap harvest is the most common issue. Exposed
tendon often causes failure of the skin graft and delay of wound healing.
Secondary effects of this complication are tethering of the tendon with

functional diminishment.
■ Care must be taken to evaluate the circulation of the hand with an Allen test
preoperatively. Failure to recognize an incomplete arch can lead to catastrophic
loss of blood flow to the digits.
■ Major issues at the recipient site are early salivary leak or tensioning issues of
the palmaris graft.
■ Overtensioning of the palmaris can lead to bowstringing of the lip and
difficulty with eating. Undertensioning can lead to issues with oral
competence.
REFERENCES
1. Kolhe PS, Leonard AG. Reconstruction of the vermilion after “lip-shave”. Br
J Plast Surg. 1988;41(1):68-73.
2. Carvalho LM, et al. V-Y advancement flap for the reconstruction of partial
and full thickness defects of the upper lip. Scand J Plast Reconstr Surg Hand
Surg. 2002;36(1):28-33.
3. Sakai S, et al. A compound radial artery forearm flap for the reconstruction of
lip and chin defect. Br J Plast Surg. 1989;42(3):337-338.
4. Carroll CM, et al. Reconstruction of total lower lip and chin defects using the
composite radial forearm—palmaris longus tendon free flap. Arch Facial Plast
Surg. 2000;2(1): 53-56.
5. Granick MS, Newton ED, Hanna DC. Scapular free flap for repair of massive
lower facial composite defects. Head Neck Surg. 1986;8(6):436-441.
6. Lengele BG, et al. Total lower lip functional reconstruction with a
prefabricated gracilis muscle free flap. Int J Oral Maxillofac Surg.
2004;33(4):396-401.
7. Reinert S. The free revascularized lateral upper arm flap in maxillofacial
reconstruction following ablative tumour surgery. J Craniomaxillofac Surg.
2000;28(2):69-73.
8. Serletti JM, et al. Total lower lip reconstruction with a sensate composite
radial forearm-palmaris longus free flap and a tongue flap. Plast Reconstr
Surg. 1997;99(2):559-561.

20
CHAPTER
Section VII: Eyelid
Direct Closure and Lateral
Cantholysis
Aaron Fay and John Nguyen
DEFINITION
■ The primary objectives of eyelid reconstruction are to
■ Restore anatomic alignment and dynamic function of the eyelids
■ Create a stable eyelid margin with acceptable vertical lid height of both
anterior and posterior lamellae
■ Maintain adequate eyelid closure
■ Optimize appearance and symmetry
■ Full-thickness eyelid defects involving up to one-third of the margin can be
repaired by direct closure, depending very much on the age of the patient,
though sometimes the addition of a lateral cantholysis is required to allow
adequate mobilization of the lateral lid.
ANATOMY
■ The eyelids are conceptually considered as the anterior and posterior lamella
(FIG 1). The anterior lamella consists of skin and orbicularis oculi muscle. The
posterior lamella contains tarsus and palpebral conjunctiva.
■ The gray line is an important landmark that separates these two lamellas.
This line is important for eyelid margin repair and represents the superficial
portion of the orbicularis oculi muscle known as the muscle of Riolan. From
the eyelid margin to the superior (upper lid) or inferior (lower lid) edge of
tarsus, the upper eyelid tarsal plate is approximately 10 mm tall centrally and
tapers toward the medial and lateral canthal tendons, whereas the lower eyelid
tarsal plate measures approximately 4 mm high and tapers slightly.

■ Above the upper eyelid crease, eyelid anatomy is substantially different, where
the concept of lamellae begins to break down. The posterior lamella in this
anatomic region includes the conjunctiva, Mueller muscle, and the aponeurosis
of levator palpebrae superioris. Most authors now consider a “middle lamella”
that includes the preaponeurotic fat and orbital septum. This leaves the
orbicularis oculi and skin to constitute the anterior lamella.
■ The lateral eyelid also incorporates the palpebral lobe of the lacrimal gland.
The lower lid contains analogous structures but notably contains a third fat pad
laterally (whereas the lacrimal gland occupies that space in the upper lid). The
canthal tendons suspend the eyelids medially and laterally and the lacrimal
drainage system including the punctum, canaliculus, common canaliculus, and
the medially located lacrimal sac.
■ Vascular supply to the eyelids is provided by the marginal arcade, near the
eyelid margins, and the peripheral arcades, coursing along the superior tarsal
edge in the upper lid and along the inferior tarsal edge in the lower lid.
■ Palpebral width, on average, measures 30 mm in adults. The lower lid
typically rests at the inferior corneal limbus, with the lateral canthus 2 mm
higher than the medial canthus. The upper lid rests slightly inferior to the
superior corneal limbus with the peak of the upper lid between the medial
corneal limbus and the medial border of the pupil.
■ The skin of the eyelid is unique in that it is the thinnest skin found anywhere
on the body and is devoid of subcutaneous fat, hence an intimate connection
with orbicularis oculi, another thin layer covering the orbital septum from lid
margin to brow.
PATHOGENESIS
■ Eyelid margin defects can be partial thickness or full thickness, may occur at
different positions on the eyelid, and most commonly result from trauma in
young men.
■ Lacrimal injury may concurrently exist, especially when the laceration is in the
medial canthal region. This is more common in children.
■ Mechanisms include tissue stretch, crush, avulsion, or tear. Tissue loss is rare,
so direct closure without the need for cantholysis is typically performed.
■ Resection of malignant eyelid tumors (most often basal cell carcinoma,
squamous cell carcinoma, and sebaceous cell carcinoma) results in defects of
various sizes. Because surgical margins are needed, these surgeries often cause
large defects that may require cantholysis when closing primarily.

■ Closure of larger eyelid defects requires local flaps such as Tenzel semicircular
flap which is discussed in subsequent chapters.
NATURAL HISTORY
■ Incomplete closure of eyelid defects can lead to eyelid notching, exposure,
entropion, ectropion, trichiasis, corneal injury, eyeball rupture, and corneal
blindness.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Assessment of the eyelid defect typically occurs after stabilization of life-
threatening conditions in patients with traumatic injuries.
■ History should include nature of the injury; type of trauma; the extent of
trauma; prior ocular and periocular surgical history; visual changes; tetanus
vaccination status of the patient and the assaulting animal in case of bites;
recent food or liquid ingestion; and drug allergy. Bite, hook, or clawing trauma
may be suggestive of canalicular laceration.
FIG 1 • A. Anatomy of the eyelid demonstrating the
components of the anterior and posterior lamellas. B.
Position of the gray line separating the anterior and
posterior lamella.
■ A detailed assessment of the defect must include the width, height, and eyelid

layers involved.
■ A defect in the medial canthal region requires an additional examination for
canalicular and medial canthal tendon integrity; complete eyelid eversion is
indicative of loss of canthal tendon attachment.
■ In many cases, the medial canthal tendon can be assessed quickly by
distracting the upper and lower lid margins laterally and observing the degree
of migration of the medial commissure.
■ When a laceration appears to involve the medial eyelid, the punctum should
be dilated and the canaliculus probed. Superficial-appearing lacerations in this
region are notoriously misleading.
■ The eyelid is also inspected for scarring or previous incision sites. Prior
irradiation, burn injury, or skin conditions such as scleroderma and ichthyosis
may limit the amount of skin stretching needed for primary wound closure.
■ Laxity of the lid, especially in elderly patients, is also examined as it may
facilitate closure and precluding the need for cantholysis.
■ In cases of trauma, careful examination for debris or retained foreign bodies
or eyeball laceration (“ruptured globe”) is important. Globe injuries typically
dictate the timing of lid repair.
NONOPERATIVE MANAGEMENT
■ Small eyelid margin defects involving the anterior lamella without lid laxity
may heal adequately by secondary intention. Similarly, small lacerations
involving only the anterior lamella without significant tension may be
amendable to adhesive repair with cyanoacrylate.
SURGICAL MANAGEMENT
■ Lid margin reconstruction is one rare instance in that near perfection can be
achieved in many cases. Three months after repair, the surgical site can often
be undetectable.
■ This requires meticulous apposition of anterior and posterior lamellae.
■ Horizontal tension should be maximized at the expense of the vertical
tension.
■ Parallel wound edges perpendicular to the lid margin are desirable, and
minimal excision of wound edge tissues should be performed.
■ At the completion of the repair, the lid margin should show a mild eversion
at the fusion site in order to avoid notching as the healing wound contracts
linearly.

■ A delayed repair, whether due to late presentation or surgically planned,
typically requires debridement of the epithelialized wound edges. In a defect
with canalicular involvement, it is best to repair as soon as possible; however,
canalicular repair can still be achieved up to 48 hours after initial injury.
T E C H N I Q U E S
■ Wound Preparation
■ The wounds and the lateral canthal region, if needed, are infiltrated with 2%
lidocaine with 1:100 000 epinephrine.
■ After cleansing with ophthalmic povidone-iodine (1:20 dilution), a scleral
shell can be inserted for ocular protection.
■ Apposition of the wound edges using two toothed Adson forceps will
indicate the amount of tension and whether primary closure would require
canthotomy and cantholysis.
■ Primary Wound Closure
■ The eyelid margin is repaired using 6-0 silk sutures, which are left long and
draped away from the wound awaiting incorporation into subsequent skin
sutures. These more pliable sutures are less likely to cause corneal injury than
a rigid monofilament. Three sutures are placed along the margin—the first
through the gray line, second through tarsus, and third through the lash line.
■ The suture bites should be equidistant from the wound on each side of the
defect, and the vertical excursion of the bite should be longer than the
horizontal excursion of the bite to facilitate wound eversion (TECH FIG
1A–F).
■ The tarsal edges are then apposed and sutured with partial-thickness 6-0
polyglactin suture. In order to pass intratarsal sutures and to avoid the
conjunctival surface, the S-14 spatulated needle is preferred. Precise
alignment of the tarsal edges will maintain proper apposition of the posterior
lamella (TECH FIG 1G,H).
■ Minor to moderate amount of anterior lamella tension can be relieved with
placement of interrupted 6-0 polyglactin sutures through the orbicularis oculi,

particularly at the level of the primary lid crease (TECH FIG 1I).
■ The skin is closed with 6-0 nylon sutures. The long ends of the lid margin
silk sutures are incorporated into the second nylon suture away from the lid
margin (TECH FIG 1J,K).
TECH FIG 1 • A,B. Full-thickness lower eyelid defect

measuring one-fourth to one-third the length of the lid
margin. This type of defect can often be closed using
the direct closure method alone. C,D. The cardinal
suture is placed through the gray line (muscle of
Riolan) symmetrical across the defect. The posterior
lid margin edge is checked for alignment before
accepting this suture. Silk is preferred because it is
soft and well tolerated by the ocular surface. E,F.
Three sutures are placed through the lid margin: the
first through the gray line, the second through the
tarsus, and the third through the lash line. Each suture
is symmetrical as shown in C, but need not be equal
in dimension. G. Lamellar sutures are placed through
the tarsus to avoid the conjunctival surface. (Margin
sutures not shown here.) H. Three silk sutures are tied
along the lid margin. Two sutures are shown in the
tarsus. I. Following tarsal approximation, orbicularis
oculi is closed with buried polyglactin sutures. J,K.
The long ends of the silk sutures are incorporated into
the second skin sutures (nylon).
■ Canthotomy and Cantholysis
■ A skin incision is made from the lateral canthus toward the lateral orbital
rim, approximately 1 cm, running along a lateral canthal rhytide if possible
(TECH FIG 2A–C).
■ Curved Stevens scissors are then used to divide the lateral canthal tendon
along its length by following the skin incision down to the lateral orbital rim
(TECH FIG 2D).
■ The scissors are then angled inferonasally to strum and then lyse the inferior
crus of the lateral canthal tendon. The cantholysis can be performed
progressively until the desired laxity is achieved (TECH FIG 2E–G).
■ Following completion of the primary wound closure, the skin and orbicularis
edges in the lateral canthal region can be closed with 6-0 fast-absorbing gut

sutures (TECH FIG 2H–J).
TECH FIG 2 • A. Full-thickness lower eyelid defect
measuring one-third to one-half the length of the lid
margin. This type of defect can often be closed using
direct closure method provided the lateral canthal
tendon is released. B,C. A linear incision is created
with a no. 15 blade, extending 1.5 cm from the lateral
commissure toward the orbital rim. D. This incision is
extended through the lateral canthal tendon using
curved Stevens tenotomy scissors to create a full-
thickness canthotomy. E. Following lateral
canthotomy, the tendon is divided into superior and
inferior crura or rami. F,G. The lateral lid margin is
secured with toothed Adson forceps, traction is placed
on the inferior ramus of the lateral canthal tendon, and

Stevens scissors are introduced in the space between
the myocutaneous flap and conjunctiva to
perpendicularly transect the taut inferior ramus close
to the orbital rim, which is called cantholysis. The
scissors are directed downward (toward the tip of the
nose) to approach the inferior ramus of the tendon.
This is facilitated by manually distracting the lower
eyelid away from the orbital rim in a perpendicular
plane. H. The lid margin is closed using a series of 6-0
silk sutures. I. Tarsus is closed using 6-0 lamellar-style
polyglactin sutures in order to avoid damage to the
ocular surface. J. Following closure of the wound, the
lateral canthal angle is reformed using 6-0 nylon or
resorbable sutures.
PEARLS AND PITFALLS
Ophthalmic
examination
■ In trauma cases, a complete ophthalmic examination is critical to
avoid missing a ruptured globe injury that would need repair first.
■ Obtain a CT scan if there is concern for orbital injury or foreign
body.
Technique
■ Avoid excessive cantholysis that can cause ectropion or dehiscence.
Suturing
■ When placing the cardinal silk suture through the gray line, cross the
two ends of the suture and pull in opposite direction while observing
the alignment of the posterior edge of the lid margin. If the edge is
not perfectly aligned, the suture should be removed and replaced.
POSTOPERATIVE CARE
■ Topical antibiotic ointment can be used 3 times per day until first
postoperative visit at 1 week.
■ Typical ointments are bacitracin ophthalmic preparation or erythromycin
ointment.

■ The lids may appear tight but will relax overtime with avoidance of
manipulation of lid by patients.
■ Nylon and silk sutures are typically removed 7 to 10 days after repair.
OUTCOMES
■ A smooth lid margin resting at the inferior corneal limbus is desirable.
COMPLICATIONS
■ Wound dehiscence may occur with excessive wound tension or when the
tissues have been chronically inflamed.
■ Because of the friable nature of a dehisced wound, careful manipulation is
required to resuture the already damaged tissue edges.
■ Canthotomy and cantholysis may be needed during dehiscence repair if there
is significant tissue tension.
■ Eyelid notching can be avoided by ensuring eversion of wound edges at the
margin with silk sutures.
■ Ectropion may occur as a result of aggressive cantholysis and would need
repair with resuspension of the lateral canthal tendon.
SUGGESTED READINGS
Devrukhkar VN, Hedge RJ, Khare SS, et al. Evaluation of isoamyl 2-
cyanoacrylate tissue adhesive in management of pediatric laceration: an
alternative to suturing. Ann Maxillofac Surg. 2015;5(1):49-54.
Herzum H, Holle P, Hintschich C. Eyelid injuries: epidemiological aspects.
Ophthalmologe. 2001;98:1079-1082.
Ing E, Ing T, Emara B. Ocular adnexal injuries from industrial blunt hook
trauma. Can J Ophthalmol. 2002;37(3):177-178.
Jordan DR, Ziai S, Gilbert SM, et al. Pathogenesis of canalicular laceration.
Ophthal Plast Reconstr Surg. 2008;24(5):394-398.
Murchison AP, Bilyk JR. Canalicular laceration repair: an analysis of variables
affecting success. Ophthal Plast Reconstr Surg. 2014;30(5):410-414.
Slonim CB. Dog bite-induced canalicular lacerations: a review of 17 cases.
Ophthal Plast Reconstr Surg. 1996;12(3):218-222.

21
CHAPTER
Tenzel Semicircular
Rotational Flap
John Nguyen and Aaron Fay
DEFINITION
■ The Tenzel semicircular rotational flap was initially described by Dr. Richard
Tenzel in 1978.1-3
■ It is conceptually similar to the classic Mustarde cheek rotation flap but
provides better dynamic reconstruction of the various eyelid lamellae with less
tissue rearrangement.
■ The Tenzel flap utilizes the rotation of a semicircular musculocutaneous flap
beginning at the lateral canthus, extending either downward (for upper eyelid
reconstruction) or upward (for lower lid reconstruction) to close full-thickness
defects of the eyelid ranging from one-third to two-thirds of the horizontal
length of the eyelid margin.
■ Both the anterior lamella (skin and orbicularis muscle) and the posterior
lamellar (tarsus and conjunctiva) are addressed in a single-stage operation. The
final postoperative appearance of the flap is superior to skin grafting or the
larger Mustarde flap.4
■ A large defect up to two-thirds of the horizontal length of the lower eyelid can
be repaired with the Tenzel semicircular flap.
ANATOMY
■ The upper and lower eyelids meet at the lateral canthus, a tendon-ligament
complex that is firmly attached to Whitnall tubercle, 2 to 4 mm deep to the
lateral orbital rim. The anterior eyelid lamella (skin and orbicularis oculi) is
continuous in this region.
■ The thin eyelid skin transitions to thicker facial skin that contains
subcutaneous fat, and the orbicularis oculi extends approximately 2.5 cm

beyond the lateral orbital rim.
■ Posteriorly, the suborbicularis oculi fat lies anterior to the periosteum of the
zygomatic bone.
■ The periosteum of the orbit (periorbita) and zygomatic bone condense at the
orbital rim to form the arcus marginalis; the strong periosteum can be useful
to provide elevation support for the flap (FIG 1A,B).
■ Arterial supply is derived from the lacrimal artery, giving rise to the
zygomaticotemporal artery, exiting the lateral orbital wall at midorbit, and to
the zygomaticofacial artery, running inferolaterally to exit through a small
foramen in the zygomatic bone.
■ Both the zygomaticofacial nerve and the zygomaticotemporal nerve arise from
the maxillary nerve.
■ The zygomaticofacial nerve leaves the orbit inferolaterally through the
zygomaticofacial foramen along with the artery and supplies the skin of the
malar eminence.
■ The zygomaticotemporal nerve similarly egresses the zygomatic bone
superiorly to supply the anterior temple (FIG 1C,D).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Eyelid defects occur most commonly from trauma or tumor resection. Other
causes include burns and congenital abnormalities.
■ Basal cell carcinoma is the most common eyelid malignancy (90%); squamous
cell carcinoma, sebaceous cell carcinoma, and cutaneous melanoma are
neoplasms that involve the eyelids in order of decreasing frequency.
■ The biologic behavior of the tumor should be a key consideration in
reconstructing a large eyelid defect as it can affect long-term prognosis.
■ Factors such as the size and orientation of the defect, patient age, vascular
supply to surrounding tissues, previous treatment (both surgical and
radiation), and age of the wound should also be carefully assessed, as any of
these can affect surgical plan and outcome.
■ The Tenzel flap is most useful when there is sufficient lateral canthal skin
laxity and there is at least a small portion of the full-thickness eyelid available
on either side of the defect.
■ It can be used when there is no tarsus on the lateral side of the defect, but
optimal results will require a periosteal flap or tarsal replacement graft such as
hard palate mucosa, auricular cartilage, nasal septal chondromucosal graft,

free tarsoconjunctival graft, allograft, or xenograft to provide the stability that
is normally provided by the tarsus.
■ Without proper structural support, the lateral portion of the eyelid is likely to
roll inward, causing chronic ocular surface injury.
■ In cases of irradiation or burn injury, the Tenzel flap is preferred over grafting
as the flap provides its own vascular supply.
NONOPERATIVE MANAGEMENT
■ In general, significant eyelid defects require surgical repair.
■ Nonoperative management of large eyelid defect can lead to eyelid notching,
scarring, entropion, ectropion, trichiasis, and lagophthalmos with corneal
exposure causing corneal injury, infection, eyeball rupture, and blindness.
FIG 1 • Anatomy (A,B), blood supply (C), and sensory
nerve innervation (D) of the eyelids.

SURGICAL MANAGEMENT
Preoperative Planning
■ Initial analysis begins with estimation of the actual size of the defect by
grasping both edges with toothed Adson forceps and pulling them together.
■ If the edges are within 1 to 2 mm of one another, primary closure with lateral
cantholysis may be all that is required.
■ A larger defect up to two-thirds of the eyelid constitutes an excellent
candidate for Tenzel flap for reconstruction (FIG 2).
■ For larger defects, Hughes or Cutler-Beard flaps may be more effective
(discussed in separate chapters).
Positioning
■ The patient is positioned in the supine position and prepped with Betadine 5%
Sterile Ophthalmic Prep Solution.
■ A corneal shield is used to protect the eye.
Approach

FIG 2 • Lower eyelid defect resulting from basal cell
cancer excision that is suitable for Tenzel flap
reconstruction.
T E C H N I Q U E S
■ Tenzel Flap Reconstruction for the Lower Eyelid
Design and Flap Elevation
■ Beginning precisely at the lateral canthus, a semicircular superior arching
line is drawn with a diameter of approximately 20 to 25 mm extending
toward the lateral eyebrow line; the mirror image is used for the upper eyelid
reconstruction (TECH FIG 1A,B).
■ The area is infiltrated with 2% lidocaine with 1:100 000 epinephrine.
■ A no. 15 Bard-Parker blade is used for skin incision.
■ Electrodissection using a monopolar electrode with an ultrasharp tungsten tip
is performed to undermine and to develop the myocutaneous flap.
■ A lateral cantholysis of the inferior crus of the lateral canthal tendon is made
beneath the flap and is critical to the mobilization flap.
■ The flap is thoroughly undermined and advanced medially for closure of
the eyelid defect (TECH FIG 1C).
Tarsal Edge Repair and Flap Inset
■ The tarsal edges should be incised anew as necessary so they are perfectly
perpendicular to the lid margin, sacrificing as little tissue as possible.
■ The tarsal edges are then apposed and sutured with partial-thickness 6-0
polyglactin suture (S-14 spatulated needle) (TECH FIG 2A).
■ The eyelid margin is repaired using 6-0 silk sutures, which are left long and
draped away from the wound awaiting incorporation into subsequent skin
sutures.
■ Three sutures are placed along the margin—the first through the gray line,
second through the tarsus, and third through the lash line.
■ The suture bites should be equidistant from the wound on each side of the
defect, and the vertical excursion of the bite should be longer than the
horizontal excursion of the bite to facilitate wound eversion.

■ Minor to moderate amount of anterior lamella tension can be relieved with
placement of interrupted 6-0 polyglactin sutures through the orbicularis
oculi, particularly at the level of the primary lid crease.
TECH FIG 1 • Schematic representation of the Tenzel
flap for reconstruction of a lower eyelid defect. A. Flap
markings. Circular areas shown with dotted lines are
undermined to elevate flap in the submuscular plane.
B. Flap markings in a patient with a lower eyelid basal
cell cancer. C. Flap elevation and transection of the
lower crus of the lateral canthal tendon.
TECH FIG 2 • A. Suturing the tarsal edges after flap
elevation and lateral canthal tendon transection. B.
Lateral canthal fixation of the flap tissue is performed

to prevent lateral sagging and to minimize tension on
the repaired defect.
■ The skin is closed with 6-0 nylon sutures.
■ The long ends of the lid margin silk sutures are incorporated into the
second nylon suture away from the lid margin.
■ To prevent lateral sagging and poor opposition of the lower eyelid to the
globe and to minimize tension on the repaired defect, the lateral canthal
fixation of the flap tissue is performed with placement of 4-0 polyglactin on a
semicircular needle to secure the deep surface of the flap to the inner aspect
of the superolateral rim periosteum (TECH FIG 2B).
■ Improved eyelid contour can be obtained by incorporating a lateral orbital
rim periosteal flap.
■ The flap is typically 8 to 10 mm wide, and the length is determined by
measuring the distance from the rim to the lateral end of the tarsus on the
flap.
■ It is hinged at the arcus marginalis, typically based at least midpupil, and
angled superiorly 45 degrees to follow the eyelid contour and to provide
upward pull on the lid.
■ It is sutured to the lateral tarsal edge of the mobilized flap.
Donor-Site Repair
■ The semicircular donor site is closed in layers with 5-0 or 6-0 polyglactin
sutures in a buried fashion for the muscles and 6-0 polypropylene sutures for
the skin (TECH FIG 3).
■ An excision of the Burrow triangle or extension of a skin incision may
sometimes be necessary to prevent trapdoor deformity.

TECH FIG 3 • A,B. Flap advancement and final
closure of the defect and donor site.
■ Posterior Lamellar Flap
■ For larger defects or for those without the tarsus at the lateral edge, a
posterior lamellar graft may be necessary to provide extra stability.
■ Auricular cartilage, hard palate mucosa, nasal septal chondromucosal graft,
free tarsoconjunctival graft, allograft, or xenograft can be used after
harvesting in the usual manner.
■ The tissue should be cut into rectangular fashion to snugly fit into the space
between the lateral most tarsal edge and the lateral orbital tubercle.
■ 5-0 polyglactin sutures are used to secure the graft in place on both ends.
■ If a periosteal flap or mucosal graft is used laterally, conjunctival
advancement is unnecessary.
■ Otherwise, the conjunctiva is advanced from the inferior fornix to the
superior skin margin of the Tenzel flap, and it is secured with 7-0 chromic gut
or polyglactin sutures.
PEARLS AND PITFALLS

Corneal
protection
■ Protect the cornea during the procedure with a corneal shield.
■ Complete canthotomy and cantholysis are necessary to ensure
sufficient mobilization of flap for wound closure.
■ Lateral canthal fixation is critical to prevent postoperative lid
sagging or poor globe apposition.
■ Conjunctival lining of the posterior lamellar graft helps to prevent
formation of symblepharon, adhesion of conjunctival/eyeball to the
flap.
Hemostasis
■ Meticulous hemostasis is critical.
Dressing
■ Dressing contact lenses are useful in some cases to treat/prevent
corneal epitheliopathy.
POSTOPERATIVE CARE
■ Topical antibiotic ointment is used three times per day until first postoperative
visit at 1 week.
■ Typical ointments are bacitracin ophthalmic preparation or erythromycin
ointment.
■ The lids may appear tight but will relax overtime with avoidance of
manipulation of lid by patients.
■ Nylon and silk sutures are removed 7 to 10 days after repair.
■ Temporary upper lid ptosis secondary mechanical dragging of the flap on the
lateral upper lid tissue usually resolves after several weeks.
OUTCOMES
■ A smooth lid margin resting at the inferior corneal limbus along with upward
contour of the lid at the lateral canthus is desirable.
■ Erythema along the eyelid margin in the area of the flap fades over time to
give more normal appearance except for madarosis (loss of eyelashes).
COMPLICATIONS
■ Wound dehiscence may occur with excessive wound tension especially with
incomplete lateral canthotomy and cantholysis or when the tissues have been
chronically inflamed.
■ Because of the friable nature of a dehisced wound, careful manipulation is
required to resuture the already damaged tissue edges.
■ Eyelid notching can be avoided by ensuring eversion of wound edges at the
margin with silk sutures.

■ Ectropion may occur in case without lateral canthal fixation to the orbital rim.
REFERENCES
1. Anderson RL, Edwards JJ. Reconstruction by myocutaneous eyelid flaps.
Arch Ophthalmol. 1979;97:2358-2362.
2. Levine MR, Buckman G. Semicircular flap revisited. Arch Ophthalmol.
1986;104:915-917.
3. Tenzel RR, Stewart WB. Eyelid reconstruction by the semicircle flap
technique. Ophthalmology. 1978;85:1164.
4. Weinstein GS, Anderson RL, Tse DT, et al. The use of a periosteal strip for
eyelid reconstruction. Arch Ophthalmol. 1985;103:357.

22
CHAPTER
Eyelid Reconstruction With
the Hughes Flap or Cutler-
Beard Flap
Larissa Habib and Brian Marr
DEFINITION
■ The Hughes flap was originally described in 1937 and has been modified to
increase efficacy and minimize postoperative complications.
■ It is an effective vertical lid-sharing procedure that can achieve good
functional and cosmetic results for lower eyelid greater than 50% defects
resulting from trauma or cancer excision.
■ It involves a tarsoconjunctival advancement flap to recreate the lower lid
posterior lamella.
■ The anterior lamella is recreated using a full-thickness skin graft or a local
skin flap.1
■ The Cutler-Beard flap is a cutaneoconjunctival advancement flap from the
lower lid that is used for very large (greater than 70%) defects in the upper
eyelid.
■ Indications are tumor resection, trauma, and congenital defects.
■ The goal is to provide lid apposition to protect the eye, good aesthetic quality,
and good mobility.2
ANATOMY
■ The upper and lower eyelids meet at the medial and lateral canthus with the
lateral canthus sitting 2 to 4 mm higher than the medial (FIG 1).
■ The palpebral fissure is approximately 28 to 30 mm in length and 9 to 10 mm
in height.
■ The eyelid anatomy can be divided into anterior and posterior lamellae.
■ The anterior lamella consists of the skin and the orbicularis oculi muscle.

■ The eyelid skin is the thinnest in the body (lesser than 1 mm). The epidermis
receives its nourishment from a deeper connective tissue layer as it lacks
blood vessels and lymphatics. There is a sparse amount of fat in the preseptal
and preorbital skin, and fat is absent in the pretarsal skin.
■ The orbicularis oculi is loosely adherent to the skin and divided into orbital
and palpebral portions. The palpebral is further divided into pretarsal and
preseptal. The palpebral portion functions in blinking and voluntary winking.
The orbital portion is for forced closure.
■ The posterior lamella consists of the tarsus and the conjunctiva.
■ The tarsal plate is composed of dense fibrous tissue. It is approximately 1
mm thick and provides the structural support of the eyelid. The upper eyelid
tarsus extends from the punctum to the lateral canthus and is 30 mm long and
7 to 10 mm high, with the highest portion being centrally. The lower tarsus is
only 3.8 mm wide. The ciliary border contains meibomian gland orifices that
provide the lipid layer of the tear film. The medial and lateral ends are
attached to the orbital rim by the medial and lateral palpebral ligaments.
FIG 1 • A,B. External and sagittal section depicting the
eyelid anatomy as well as surrounding structures.
■ The conjunctiva is a mucous membrane that covers the sclera and the inner
eyelids. The palpebral conjunctiva is adherent to the tarsus and then

continues as the orbital conjunctiva where there is a plane that allows
dissection from the Mueller muscle. At the fornix, the conjunctiva reflects
anteriorly to become the bulbar conjunctiva.
■ Upper eyelid retractors
■ The levator palpebrae superioris arises at the orbital apex and courses
anteriorly for 40 mm ending in the aponeurosis 10 mm behind the septum. At
this junction, it changes direction to vertical and then inserts inferiorly onto
the lower third of the tarsal plate. In addition, some fibers pass anteriorly to
form the eyelid crease.
■ The Mueller muscle originates from the undersurface of the levator at the
muscular aponeurotic junction and then travels between the levator and the
conjunctiva to insert on the superior border of the tarsus. It is innervated by
the sympathetic nervous system.
■ The lower eyelid retractors are an extension of the inferior rectus muscle.
■ They pass anteriorly and envelop the inferior oblique before joining the
inferior transverse ligament to become the capsulopalpebral fascia and
inserting at the inferior border of the tarsal plate.
■ A small portion of the retractors joins with Tenon capsule at the inferior
fornix and courses anteriorly to form the lower lid crease.
■ Blood supply is derived from both the internal and external carotid arteries.
■ Medially, two palpebral branches (superior and inferior marginal arteries)
arise from the ophthalmic to supply the upper and lower lid. These arteries
then travel horizontally as the marginal arcades that lie on the tarsal plate (4
mm from the upper margin and 2 mm from the lower margin).
■ Laterally, the lacrimal artery provides branches to both the upper and lower
lids, which travel horizontally to anastomose with the marginal arcades.
■ The external carotid contributes through branches of the facial, superficial
temporal, and infraorbital arteries.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The preoperative evaluation includes a detailed examination of the extent of
the lid defect, in particular, the extent of involvement of the anterior and
posterior lamellae.
■ The adjacent skin, contralateral upper eyelid, postauricular, and
supraclavicular areas should be inspected for potential donor skin.
IMAGING

■ Preoperative photos should be taken to document the extent of the defect.
■ Imaging with CT or MRI can be considered based on etiology of the defect, in
particular in trauma situations to assess other injuries or embedded foreign
body.
SURGICAL MANAGEMENT
Preoperative Planning
■ In determining whether a Hughes procedure is appropriate, one must consider
the size and location of the defect as well as the status of the other eye.
■ An alternative procedure may be preferred if there is limited vision in the
opposite eye as vision will be temporarily obscured by the vascular flap.
■ The extent of the posterior lamella defect and the anterior lamella defect
must be determined to assess the size the flap as well as to determine the
donor site for the skin graft.
■ The extent of the posterior lamella defect and the anterior lamella defect must
be determined to assess the size of the Cutler-Beard flap.
■ It is also important to assess the visual function of the contralateral eye as this
procedure requires closure of the eye for up to 3 weeks.
Positioning
■ For the Hughes flap, the patient should be supine with the postauricular area
and contralateral eye exposed after draping.
■ For the Cutler-Beard flap, the patient should be supine with both eyes exposed
after draping.
T E C H N I Q U E S
■ Hughes Flap
Flap Creation
■ Local anesthetic is injected into the pretarsal upper lid as well as
subconjunctivally above the superior tarsal margin.
■ The upper eyelid is everted using a Desmarres retractor to gain access to the
conjunctiva and tarsal plate.

■ A horizontal incision is marked 4 mm from the lash line to match the length
of the posterior lamellar defect of the lower lid (TECH FIG 1A).
■ The tarsus and conjunctiva are incised horizontally, and then the incision is
extended vertically from both ends toward the fornix.
■ The tarsus and conjunctiva are dissected away from the levator aponeurosis
to the level of the Whitnall ligament so that the flap can be pulled downward
to cover the defect without too much tension (TECH FIG 1B).
■ The flap is then advanced to the lower lid and sutured to remnants of tarsus
medially or laterally with 5-0 Vicryl on P-2 needle (TECH FIG 1C,D).
■ To cover the flap and recreate the anterior lamella, an advancement skin flap
or free skin graft can be considered depending on the size of the defect as
well as the laxity of the skin (TECH FIG 1E).
TECH FIG 1 • A. The upper lid is everted on a
Desmarres retractor, and an initial incision to match
the length of the lower lid defect is made through
conjunctiva and tarsus, 4 mm from the lash line. B.
The tarsoconjunctival flap is dissected away from the

levator and the sutured into place in the defect. C,D.
The free skin graft sutured over the pedicle flap. E.
Photograph showing the vascular pedicle in place in
the lower lid defect, with the overlying free skin graft.
Separation of Flap
■ The flap is separated 4 to 6 weeks postoperatively.
■ A muscle hook is used to lift the flap from the conjunctiva, and Westcott
scissors are used to separate the graft along the lower lid.
■ The conjunctiva is sutured to the lower lid margin using 6-0 chromic gut.
■ The conjunctiva should be slightly higher than the skin surface to protect
the cornea and to impart better appearance.
■ Mueller muscle and levator aponeurosis are dissected away from the
overlying skin and allowed to retract back.
■ Cutler-Beard Flap
Flap Creation
■ The lower lid is measured and marked horizontally to match the upper eyelid
defect. The mark is extended vertically to the fornix.
■ An attempt should be made to fashion the flap to fit the defect without
much modification to preserve as much tissue as possible.
■ Local anesthetic is injected into the upper eyelid defect and the pretarsal
lower lid as well subconjunctivally.
■ A full-thickness horizontal incision with a no. 15 blade is made 4 to 5 mm
below the lash line, leaving the lower eyelid margin and tarsus intact.
■ This is important so as to avoid the marginal artery that provides essential
blood supply to the remaining lower eyelid.
■ Westcott scissors are then used to extend the incision laterally and
medially. The incision is then extending vertically to the fornix (TECH
FIG 2B).
■ The flap is divided into a conjunctivocapsular layer and a superficial skin
and orbicularis layer.
■ The deeper layer is sutured to the remaining conjunctiva of the upper lid
superiorly, medially, and laterally with 7-0 Vicryl (TECH FIG 2C).

■ The skin and orbicularis layer are then sutured to the margin of the upper lid
with interrupted 6-0 chromic gut (TECH FIG 2D).
TECH FIG 2 • A. Patient with a sebaceous cell
carcinoma of the upper eyelid prior to excision. B. An
incision corresponding to the upper eyelid defect is
made through the lower eyelid. C. The lower eyelid
flap is sutured into the upper eyelid defect. D. Patient
with Cutler-Beard flap in place.

Separation of Flap
■ At 4 to 6 weeks, the flap is separated.
■ A muscle hook is used to lift the flap from the conjunctiva and Westcott
scissors are used to separate the graft.
■ The conjunctiva is cut so that there is an extra 1 to 2 mm for some eversion
after it is sutured to the skin. This improves long-term appearance and
prevents rubbing of the corneal surface by the skin edge.
■ The retracted portion of the lower flap is reattached to the bridged lower
eyelid (TECH FIG 3).
TECH FIG 3 • Final result after flap separation.
PEARLS AND PITFALLS
HUGHES FLAP
Indication
■ Lower lid defects ≥50%.
Technique
■ Ensure 4-mm remaining tarsus in the upper lid. Consider free graft
if sufficient anterior lamellae to support it.
■ Ensure complete dissection from upper lid retractors to prevent

postoperative upper lid retraction.
Postoperative
care
■ Advise the patient the limitations of temporary monocular vision.
■ At stage 2 or when opening the flap, take care to contour a smooth
line with the remaining eyelid margin for a good cosmetic result.
CUTLER-BEARD FLAP
Indication
■ Upper lid defect greater than 70%.
Technique
■ Horizontal incision 4 mm below lash line to avoid compromise of
donor eyelid blood supply.
■ Ensure 1–2 mm of redundant conjunctiva when separating graft to
improve appearance.
■ In patients who may need more upper eyelid support, a second
procedure can be done using AlloDerm, hard palate, or ear
cartilage.
■ If the defect extends medially or laterally, the graft may not be
sufficient, and additional revision may be necessary to reform the
canthal angle.
■ When dividing the flap, take care to form or align the medial and
lateral canthal angles with the divided flap edge.
POSTOPERATIVE CARE
■ Antibiotic steroid ointment combination with patch for 48 hours.
■ The ointment should be continued twice a day for a week.
■ The graft is separated at 4 to 6 weeks.
OUTCOMES
■ In a series of 125 cases using the Hughes flap,3 15.2% had minor perioperative
complications including trichiasis (9.6%), pyogenic granuloma (1.6%), and
corneal ulceration (4%).
■ Major perioperative complications included flap necrosis (0.8%) and flap
dehiscence (1.6%).
■ Long-term consequences included ocular irritation (16%, 40% resolved at 6
months) and mucous discharge (2.4%).
■ Three cases needed reoperation for trichiasis, ectropion, and lower lid
retraction.
■ Patient satisfaction was reported as 88% with appearance and 80% with
ocular comfort.

■ Most patients do very well after a Cutler-Beard flap, both functionally and
cosmetically. There are, to date, no large case series to describe the outcomes.
■ In a small case series by Carroll, 3 of 10 patients developed cicatricial
entropion after this procedure.4
COMPLICATIONS
■ Hughes flap
■ Complications can occur in the acute or chronic setting. Acute complications
include the following:
• Flap dehiscence
• Skin/flap necrosis
• Trichiasis or abnormal positioning of the eyelashes resulting in growth of
the lashes into the eye resulting in irritation. Mild cases can be treated with
topical medications until swelling resolves. More severe cases may require
ablation of the eyelashes with laser or surgical removal.
■ Chronic complications include the following:
• Entropion
• Ectropion
• Lagophthalmos
• Upper lid retraction
■ Cutler-Beard flap
■ Scarring and retraction of the lower lid
■ Upper eyelid entropion
■ Lid margin irregularity
■ Eyelash loss
■ Bridge flap necrosis
■ Lower eyelid margin necrosis
REFERENCES
1. Hughes WL. Reconstructive surgery of the eyelids. Adv Ophthalmic Plast
Reconstr Surg. 1986;5:25-87.
2. Cutler NL, Beard C. A method for partial and total upper lid reconstruction.
Am J Ophthalmol. 1955;39(1):1-7.
3. McKelvie J, Ferguson R, Ng SGJ. Eyelid reconstruction using the “Hughes”
tarsoconjunctival advancement flap: long-term outcomes in 122 consecutive
cases over a 13-year period. Orbit. 2017;36:228-233.

4. Carroll RP. Entropion following the Cutler-Beard procedure. Ophthalmology.
1983;90(9):1052-1055.

23
CHAPTER
Lower Eyelid Reconstruction
With Palatal Grafts
Farooq Shahzad, Babak J. Mehrara, and Aaron Fay
DEFINITION
■ With proper case selection, lower eyelid reconstruction can be enhanced using
hard palate grafts.
■ Both horizontal deficiency and vertical retraction can be corrected using this
technique.
■ Palatal grafts are not suitable for upper lid reconstruction because the
keratinized surface can abrade the underlying cornea.
ANATOMY
Eyelids
■ For purposes of reconstruction, it is useful to consider the eyelids in three
constituent layers, or lamellae: anterior, middle, and posterior (FIG 1). Below
the lid crease in the region of tarsus, only anterior and posterior layers can be
defined.
■ The anterior lamella comprises skin and orbicularis oculi muscle. Eyelid skin
is the thinnest in the body, entirely lacking subcutaneous fat. This makes skin
matching difficult when placing full- or split-thickness skin grafts. Whenever
possible, eyelid skin grafts are harvested from the contralateral or opposing
eyelids.
• The lashes arise in the anterior lid margin and project anteriorly and
superiorly in the upper lid. In the lower lid, the lashes are less robust,
projecting anteriorly and inferiorly. Lamellar disjunction can produce
eyelash ptosis that interferes with vision.
• Orbicularis oculi is a thin, circumferential striated muscle that can be

conceptualized in three regions: pretarsal, preseptal, and orbital. Pretarsal
orbicularis extends all the way to the lid margin, where it can be visualized
as the “gray line” separating anterior and posterior lamellae. This important
landmark is known as the muscle of Riolan. Responsible for blinking, the
preseptal orbicularis extends from the tarsal periphery (superior edge or
inferior edge of tarsus in the upper or lower eyelids, respectively)
approximately to the level or arcus marginalis around the orbital rim. When
stimulated, this portion of orbicularis produces complete, intentional, mildly
forceful closure with no radial rhytide formation, as used, for example, upon
sleeping. Preseptal orbicularis stimulation is usually accompanied by a Bell
phenomenon (upward rotation of the eyeball). The orbital portion of
orbicularis oculi extends peripherally beyond the arcus marginalis and
eventually interdigitates with frontalis and corrugator muscle superiorly.
This portion of muscle produces tight, forceful eyelid closure accompanied
by glabellar and lateral rhytide formation. Orbicularis oculi originates and
inserts along the raphe near the medial and lateral canthi.
FIG 1 • A. Sagittal section through superior eyelid
showing lamellar anatomy. Below the lid crease, the
anterior and posterior lamellae are well defined.
Anterior lamella consists of skin and muscle, while
posterior lamella consists of tarsus and conjunctiva.
Above the lid crease, three layers of lid are recognized:
conjunctival and retractor muscles constitute the

posterior layer, orbital fat and septum constitute the
“middle lamella,” and skin and muscle constitute the
anterior lamella (extension of SMAS onto the eyelid). B.
Anterior view of eyelids demonstrates the normal
contour and resting position of the upper and lower lid
margins. Note that the superior limbus and inferior
limbus are concealed by the upper and lower lid
margins, respectively.
■ The middle lamella, distinguishable only superior to the primary upper lid
crease (and inferior to the tarsus in the lower eyelid), consists of a fibrous
orbital septum and orbital fat. The orbital septum originates at the arcus
marginalis along the superior orbital rim and inserts onto the distal
aponeurosis of levator palpebrae superioris. This plane defines the anterior
limit of the orbit; the skin and orbicularis represent the terminal extension of
the frontal SMAS, whereas retroseptal tissues (levator muscle, Muller muscle,
and conjunctiva) originate deep within the orbit. These distinctly different
planes fuse along the orbital septum, the “periosteum” of the eyelid.
■ The posterior lamella consists of the conjunctiva, tarsus below the lid crease,
and eyelid retractors above the lid crease. Levator palpebrae superioris
(levator muscle) and Muller muscle (sympathetic eyelid muscle) form the
upper eyelid retractors. In the lower lid, these muscles fuse more completely,
the so-called capsulopalpebral fascia. All structures in the upper lid have
analogues in the lower eyelid. Formed of collagen (not cartilage), the tarsal
plates are the structural elements of the eyelid, lending rigidity, stability, and
directionality especially to the lid margin regions. The center of the upper and
lower lid tarsi are approximately 10 and 4 mm high, respectively. These
structures taper laterally and medially where they fuse with medial and lateral
canthal tendons. Because they taper quite significantly, direct closure of tarsal
defects produces mismatched tarsal elements; the lid margin provides a
template for reconstruction.
■ The medial canthal tendon inserts on the medial orbit via two crura, along the
anterior and posterior lacrimal crest. During reconstruction, it is important to
reconstitute the posterior crus so that the lid hugs the ocular surface all the way
to the caruncle. Without it, the lid can become distracted anteriorly, leaving a
space between the lid margin and ocular surface. The lateral canthal tendon

inserts on the periorbita of the lateral orbital tubercle of Whitnall posterior to
arcus marginalis. Here again, it is important to reattach the tendon posteriorly
in order to draw the lid tightly against the globe all the way to the commissure,
particularly in deep-set eyes and, less importantly, in relatively proptotic eyes.
■ Upper eyelid contour forms a smooth, continuous arc with its apogee typically
at the medial pupil. The upper eyelid margin typically conceals 2 mm of
superior cornea, whereas the lower lid sits at or just above the inferior corneal
limbus. These measures should be evaluated with the patient’s head in neutral
position, as chin-up or chin-down positioning will dramatically alter the lower
lid position. Simultaneous unveiling of the superior and inferior limbus
produces a “Walt Disney eye,” characteristic of thyroid eye disease. An
imaginary line segment connecting the medial and lateral canthi is slightly
canted upward and outward in most patients, the positive canthal tilt. During
reconstruction, the lateral canthus should be placed approximately 2 mm
superior to a horizontal line drawn through the two medial canthi.
■ The blood supply to the eyelid forms anastomoses between internal and
external carotid artery circulations through the marginal and peripheral
vascular eyelid arcades extending across the eyelids. The external carotid
circulation progresses medially through the facial artery and then the angular
artery and laterally through branches of the superficial temporal artery.
Supraorbital, supratrochlear, and infraorbital branches from the ophthalmic
artery form the internal carotid contribution.
Hard Palate
■ The hard palate separates the oral and nasal cavities. The anterior three-fourths
is formed from the horizontal process of the maxilla, whereas the posterior
portion consists of horizontal portion of the palatine bone. The anterior and
lateral periphery of the palate is known as the alveolar arch. Posteriorly, the
hard palate is continuous with the soft palate.
■ The mucosa of the hard palate is tightly bound to the periosteum by a
surprisingly thick fibrous submucosa. The midline mucosal ridge is called the
palatine raphe (FIG 2).
■ The blood supply of the hard palate is via the greater palatine artery that exits
the greater palatine foramen medial to the 3rd molar. This vessel travels
anteromedially and enters the incisive foramen in the anterior palate. The
greater palatine nerve travels with the artery.

PATIENT HISTORY AND PHYSICAL FINDINGS
■ History
■ Historical visual acuity is obtained to help determine visual potential in the
eye. History of dry eye or other ocular pathologies should be obtained, with
ophthalmic consultation as indicated.
■ The etiology of the defect and the need for any further treatments (eg,
radiation, foreign bodies, residual or recurrent malignancy, thyroid disease,
anticipated intraocular surgery) are noted.
■ A history of previous eyelid surgeries or radiation may affect the type of
reconstruction.
FIG 2 • Palatal anatomy.
■ A history of previous palatal surgery is obtained. History of cleft palate is a
relative contraindication.
■ Physical examination
■ Ophthalmic examination should include visual acuity, extraocular muscle

function, presence or absence of Bell phenomenon, and eyelid function.
■ A defect analysis is performed, looking at the following elements: anterior
and posterior lamella, medial and lateral canthal tendons, and the lacrimal
apparatus. Lacrimal involvement in the defect should prompt further
evaluation with likely simultaneous lacrimal reconstruction.
■ The eyelid and periorbital tissues are assessed for suitability for use in
reconstruction. Pre-existing surgical scars and tissue laxity is noted.
■ The palate is examined to ensure its adequacy as a donor site.
SURGICAL MANAGEMENT
■ Hard palate grafts are useful primarily for reconstructing defects in the
posterior lamella of the lower eyelid. Because the graft contains thick fibrous
tissue as well as mucous membrane, it can be used to replace tarsus as well as
conjunctiva. Only tarsoconjunctival grafts and flaps can provide this benefit,
but they are in rare supply and often not available. However, because hard
palate mucosa is keratinized, it can damage the cornea in the early phase before
metaplasia to a nonkeratinized mucosa can take place.
■ Because it is a free graft, the hard palate segment must be conjoined with an
advancement or rotational myocutaneous flap or a temporary or permanent
pedicle of muscle or fascia (eg, Mustarde).
■ The hard palate graft can insert into a full-thickness defect to replace the
horizontal length of the tarsus or in vertical continuity with the tarsus to correct
eyelid retraction (more common).
Preoperative Planning
■ Grafts require a healthy bed of vascularized tissue to survive. For isolated
posterior lamellar defects, the graft can be placed on the intact anterior lamellar
orbicularis muscle.
■ If the eyelid defect is full thickness, anterior lamellar reconstruction needs to
be performed with a vascularized flap.
■ Commonly used local flaps for upper eyelid anterior lamellar reconstruction
include local orbicularis transposition or rotation, Tenzel semicircular, Fricke
temporal transposition, glabellar transposition, and forehead flaps.
■ Commonly used local flaps for lower eyelid anterior lamellar reconstruction
are local orbicularis advancement or rotation flaps, Tenzel semicircular flap,
upper eyelid myocutaneous transposition flap (unipedicled [Fricke] or
bipedicled [Tripier]), nasolabial transposition flap, Imre rotation flap, and

Mustarde cheek rotation flap.
■ A sandwich technique can also be used where the orbicularis muscle is used as
a bed for anterior and posterior lamellar grafts. The orbicularis has a robust
blood supply and can be mobilized into the defect. A skin graft is placed on its
anterior surface and a posterior lamellar graft on its bulbar surface.
Positioning
■ The operation is performed in the supine position.
■ A shoulder roll extends the neck and facilitates visualization of the hard palate.
■ Exposure of the palate is obtained with a Dingman mouth gag. Alternatively, a
side-biting mouth gag and tongue retractor can be used.
■ A lubricated corneal shield is used to protect the eye during surgery.
■ The instruments for eyelid surgery and palatal graft harvest should be kept
separately to minimize contamination of the eyelid wound with oral secretions.
■ Gloves should also be changed when going from the mouth to the eyes to
minimize infection.
T E C H N I Q U E S
■ Harvest of Hard Palate Graft
■ The dimensions of the posterior lamellar defect requiring the palatal graft are
noted.
■ A template of the defect made with a piece of rubber glove or sterile
packaging can be very helpful.
■ Markings are performed with methylene blue. Surface landmarks are marked
to help with orientation.
■ The posterior edge of the hard palate and the palatal midline are marked.
■ The greater palatine vessel is palpated medial to the 3rd molar. Its location
is marked with a dot.
■ The graft can be harvested between the midline, the posterior edge of the
hard palate, and the marginal gingiva. The greater palatine vessel is to be
avoided.
■ The palatial mucosal thickness increases with increased distance from the
marginal gingiva.1 Staying at least 3 to 4 mm anterior to the posterior edge

of the hard palate and toward the midline will prevent inadvertent injury to
the soft palate and the greater palatine neurovascular bundle (TECH FIG
1A).
■ The template is positioned on the palate at the optimal location for
harvesting.
■ The graft is marked a few millimeters larger than the defect to account for
the minor graft contraction that occurs during the first few postoperative
months.2
■ Local anesthetic consisting of bupivacaine with epinephrine is infiltrated into
the mucosa.
■ The needle should not be pushed in up to the palatal bone as this will
hydrodissect the periosteum off the bone.
■ The hard palate incisions are made with a no. 15 blade.
■ Care is taken not to inadvertently push the knife against the palatal bone
and thus incise the periosteum.
■ The graft is then elevated in the submucosal plane using an angled beaver
blade, Freer periosteal elevator (in the submucosal plane), and curved
Stevens scissors (TECH FIG 1B).

TECH FIG 1 • Palatal graft harvest. A. The palate is
marked close to the midline raphe in order to avoid the
palatal artery and nerves. B. Harvest site can be
dressed with processed cellulose fabric to help
maintain hemostasis. C. Harvested graft can be
trimmed to appropriate thickness to match recipient
site tarsus and conjunctiva.
■ The hard palate graft is stored on the back table in an antibiotic solution
(TECH FIG 1C).
■ Hemostasis is ensured with a bipolar electrocautery.
■ If the greater palatine vessel is inadvertently injured, it may need to be tied
off.
■ Surgicel can be sutured onto the raw palatal surface. It controls the minor
oozing from the wound and also covers the surface to decrease postoperative
pain from irritation of the wound.

■ Inset of Hard Palate Graft for Posterior Lamellar
Reconstruction
■ The graft is inspected. If it is too thick, it is trimmed to appropriate
thickness.
■ Any visible mucous glands on the posterior surface of the graft are excised.
■ The graft is inset with its mucosal surface directed posteriorly.
■ It is sutured to the margins of the posterior lamellar defect (ie, laterally to the
remaining medial and lateral tarsal plates and inferiorly or superiorly to the
tarsal remnant or the conjunctiva using 7-0 polyglactin sutures; TECH FIG
2).
■ Suture knots are placed on the deep side of graft away from the ocular
surface.
■ Lateral canthal anchoring is performed if there is any pull on the eyelids or
for lax eyelids.
■ Failure to do so in high-risk patients will result in postoperative ectropion.
■ A bandage contact lens can be placed for corneal protection. This is
especially useful in reconstruction of upper lid posterior lamella.
■ A traction suture can be used to suspend the lower eyelid in cases of
reconstruction of large posterior lamellar defects or when the graft is used as
a spacer for reconstruction of severe lower lid retraction.
■ The suture is removed after 1 week.

TECH FIG 2 • Hard palate graft in recipient bed, in this
case, used to augment lower tarsus for correction of
lid retraction.
PEARLS AND PITFALLS
Graft
harvest
■ The posterior extent of graft harvest should be 3–4 mm anterior to
the posterior edge of the hard palate and toward the midline. This is
to prevent inadvertent harvest of soft palate mucosa, which can result
in a palatal fistula or injury to the greater palatine vessels.
■ A template of the defect aids in marking the graft at an optimal
location on the palate. It should be marked a few millimeters larger to
account for the minor graft contraction that occurs during the first
few months postoperatively.
Corneal
protection
■ The cornea is protected during the procedure with a corneal shield.
Postoperative corneal epitheliopathy can be prevented with a dressing
contact lens, particularly in upper eyelid reconstruction.
Hemostasis
■ At the end of the procedure, hemostasis must be obtained. The
palatal donor site can also be covered by Surgicel cellulose fabric,
which can decrease bleeding and sensitivity of the open wound.
Lateral
canthal
anchoring
■ There should be a low threshold for lateral canthal anchoring in
eyelid reconstruction. Eyelid laxity is usually managed by correctly
sizing the interpositional graft but should be addressed at the time of
reconstruction.
POSTOPERATIVE CARE
■ Oral antibiotics can be used for 24 to 72 hours as needed.
■ Oral hygiene is emphasized. Chlorhexidine gluconate 0.12% squish and spit
after meals and at bedtime is used for 7 to 10 days.
■ Topical lidocaine jelly can be used for pain control.
■ In patients with severe postoperative discomfort, an obturator can be placed
over the donor site to cover the open wound from irritation while it is healing.
COMPLICATIONS
■ The hard palate donor site reconstitutes the mucosa over several weeks. The

time to heal increases with the size of the wound.
■ Delayed healing can occur, usually due to infection.
■ Bleeding is the most frequent complication of hard palate graft harvest,
reported in up to 10% of patients.3
■ If local pressure does not control bleeding, electrocautery or suture ligation is
required.
■ Additional complications include keratin debris at the recipient site in the early
postoperative period4, eyelid or palatal infection, palatal fistula, partial graft
dehiscence, and graft failure.
■ Late complications include lower lid retraction, ectropion, entropion, and
corneal injury.
REFERENCES
1. Studer SP, Allen EP, Rees TC, et al. The thickness of masticatory mucosa in
the human hard palate and tuberosity as potential donor sites for ridge
augmentation procedures. J Periodontol. 1997;68:145-151.
2. Siegel RJ. Palatal grafts for eyelid reconstruction. Plast Reconstr Surg.
1985;76(3):411-414.
3. Wearne MJ, Sandy C, Rose GE, et al. Autogenous hard palate mucosa: the
ideal lower eyelid spacer? Br J Ophthalmol. 2001;85(10):1183-1187.
4. Swamy BM, Benger R, Taylor S. Cicatricial entropion repair with hard palate
mucous membrane graft: surgical technique and outcomes. Clin Exp
Ophthalmol. 2008;36(4):348-352.

24
CHAPTER
Lateral Tarsal Strip
Canthoplasty
Richard H. Caesar
DEFINITION
■ Any lower eyelid laxity or frank ectropion of the lower eyelid that results in a
failure of the lower eyelid to sit smoothly against the globe can lead to
symptoms of epiphora, discomfort, and poor appearance.
■ Lower eyelid tightening is a crucial component of the treatment of lower
eyelid ectropion of any cause.
■ Any entropion of the lower eyelid (inversion of the lower eyelid) will usually
have lower eyelid laxity as a component of the etiology. Lateral tarsal strip can
be used to address this laxity with additional steps to reattach the lower eyelid
retractors.
■ Lateral tarsal strip canthoplasty is a powerful technique for lower eyelid
tightening.1
ANATOMY
■ The lateral canthal tendon attaches the lateral ends of the tarsi to Whitnall
tubercle, 2 mm posterior to the lateral orbital rim formed by the zygomatic
bone.
■ It is the origin of the palpebral and pretarsal orbicularis muscle fibers that pass
to the medial canthal tendon.
PATHOGENESIS
■ Common causes of acquired ectropion include age-related laxity and
cicatricial changes resulting from iatrogenic causes, trauma, or burns.
■ A paralytic ectropion results from a loss of innervation to the orbicularis
muscle and facial elevators.

■ Mechanical ectropions are rare and result from external forces such as eyelid
tumors.
NATURAL HISTORY
■ Acquired ectropion in most cases can only be corrected with surgery.
■ Notable exceptions are temporary paralytic ectropion that can have full
spontaneous recovery and mild cicatricial ectropion secondary to dry skin or
dermatitis. Intensive treatment with emollients, anti-inflammatory agents, and
massage can, on occasion, fully resolve the ectropion.
■ Acquired entropion (lower eyelid inversion with abrading of the
conjunctiva/cornea by the eyelashes) always requires surgery for a permanent
solution.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Notable patient history and physical findings that should be assessed include
appearance, epiphora, and pain/discomfort.
■ Lower eyelid laxity with marginal eversion and conjunctival exposure should
be assessed.
■ Also assess secondary inflammation and thickening of the eyelid margin.
■ Exclude tethering or cicatricial changes of the skin, lower eyelid retractors, or
conjunctiva. Exclude mechanical cause and paralytic cause.
IMAGING
■ Imaging is not usually required, but orbital MRI may be useful to identify the
cause of unusual cicatricial changes to the lower eyelid retractors.
NONOPERATIVE MANAGEMENT
■ Surgery may be avoided with a resolving paralytic ectropion and a treatable
mild cicatricial ectropion.
■ If the patient does not want surgery or is unable to have surgery, the eye can be
kept comfortable by means of intensive ocular lubricants day and night. We
recommend preservative-free hyaluronic acid–based lubricants during the day
and white soft paraffin at night.
■ Involutional entropion can be treated with injection of botulinum toxin to the
lower orbicularis.2
SURGICAL MANAGEMENT
■ Lower eyelid laxity and frank entropion and ectropion repair requires lower

eyelid tightening. This can be achieved by many different techniques to include
wedge resection, skin-sparing wedge resection, lateral canthopexy and lateral
tarsal strip.
■ Concurrent lower eyelid blepharoplasty, skin grafting, heteropalpebral flap,
medial retractor repair, central retractor repair, and surgery to the medial
canthal tendon may also be required.
■ The lateral tarsal strip remains one of the most powerful techniques to tighten
the lower eyelid.
Preoperative Planning
■ The surgeon should define the position of the incision, the degree of eyelid
shortening required, and the angle of placement of the deep suture to the orbital
rim.
■ Concurrent additional procedures should be determined.
■ The vast majority of patients are comfortable with local anesthesia alone, but
sedation and general anesthesia should be available when required.
Positioning
■ The patient is most comfortable lying reasonably flat with a cushion under the
head and knees.
■ The surgery can be done with the patient sitting if required.
■ The surgeon sits to the side of the patient.
T E C H N I Q U E S
00:00 / 00:00

Video p3-c024
■ Markings and Anesthesia
■ Mark the incision from the lateral canthal angle to extend 10 to 12 mm
laterally and inferiorly following the most obvious rhytide (TECH FIG 1A).
■ Mark the extent of the tarsal strip required.
■ Mark the angle of fixation to the posterior orbital rim by following the curve
of the lower eyelid.
■ Instill local anesthetic drops (oxybuprocaine or tetracaine) to the
conjunctival fornix.
■ Injecting local anesthetic (TECH FIG 1B), 2 mL of 2% lidocaine with 1:200
000 epinephrine, superior and inferior to the lateral canthus, is effective and
avoids the marginal arcades.
■ Clean with povidone-iodine and drape the surgical field.
TECH FIG 1 • A. Mark the skin with the incision, the
extent of the tarsal strip, and the position to suture to
the rim. B. Inject local anesthetic at the lateral canthus
superior and inferior to the marginal arcades.
■ Removing the Tarsal Strip
■ With a no. 15 blade, make a primary skin incision, and then perform a lateral
canthotomy and dissect to the orbital rim with blunt-tipped Westcott scissors
(TECH FIG 2A).
■ Expose the orbital rim with blunt dissection.
■ Grasp the exposed lateral edge of the tarsal plate with toothed forceps and
use the scissors to make a pocket anterior to the tarsal plate, between the