Surgical Techniques in Upper Eyelid Reconstruction: A Review of Current Concepts and A Defect-Based Algorithm

Abstract

Reconstruction of the upper eyelid is more demanding than that of the lower eyelid because the upper lid must remain thin, mobile and lined by mucosa in order to protect the cornea, distribute the tear film and clear the visual axis. Defects arise mainly after tumor excision and trauma, and the choice of technique depends on the lamellae involved, the horizontal extent of the defect, the amount of residual tarsus and the integrity of the canthal attachments. This review summarizes the surgical anatomy and the principles that govern upper eyelid repair, and analyses the techniques available for anterior lamellar and full-thickness defects: secondary intention healing, direct closure with canthotomy and cantholysis, local skin and myocutaneous flaps, full-thickness skin grafts, the Tenzel semicircular flap, composite grafts, advancement and sliding tarsoconjunctival flaps, the Cutler-Beard and Mustardé eyelid-sharing procedures, free posterior lamellar grafts and substitutes, the orbicularis sandwich flap and distal pedicled flaps. Reported outcomes and complications are discussed, with attention to the points on which the published sources disagree.