British Journal of Ophthalmology, 1989, 73, 488-493

Simultaneous spontaneous and primary surgical repairof eyelidsHEMANT K MEHTA

From the Department of Ophthalmology, Gwynedd District Hospital, Bangor, Wales

SUMMARY Fifteen patients with suspected malignant lesions of the lower eyelids or inner canthalregion, needing large excisions, were managed as day cases with spontaneous repair andsimultaneous subtotal primary surgical reconstruction under local anaesthesia. For lesionsconfined to the lower eyelid, only those patients requiring full-thickness margin-inclusive (FTMI)excisions of more than half the horizontal extent of the eyelid are included in this study - the largestexcision being 21 x 6 mm. For malignant lesions of the inner canthus, only those patients needingmoderate to large excision of inner canthal skin and orbicularis with simultaneous FTMI excision ofthe medial one-third (8x5 mm) of the upper as well as the lower eyelid are included. The 16thpatient had traumatic loss of inner canthal tissue. The final cosmetic and functional results in all 16patients were satisfactory and comparable with the results of competent and in-toto primarysurgical reconstructions. For large excisions at the inner canthus spontaneous with partial primarysurgical repair allows the use of a less extensive and less elaborate surgical procedure that is withinthe capabilities of most ophthalmic surgeons.

The potential of the lower and upper eyelidsindividually-each on its own-to yield a nearlynormal functional and cosmetic result solely byspontaneous repair after a moderate sized full-thickness margin-inclusive (FTMI) excision has beenestablished.'2 Before that it had long been knownthat a competent primary and in-toto surgical recon-struction after such FTMI excisions also producesnear normal results. So far the combined manage-ment by primary surgical reconstruction of part of theexcised area and simultaneous spontaneous repair ofthe residual defect has not been reported. This studydemonstrates the results of such combined manage-ment after moderate to large FTMI excisions of thelower eyelid, and large deep excisions of innercanthal skin and orbicularis with contiguous FTMIexcisions of medial one-third of the upper as well asthe lower eyelids.

Patients and methods

Fifteen consecutive patients with suspectedmalignant tumours involving the lower eyelidmargin, or inner canthal skin, and needing excisionsCorrespondence to H K Mehta, FRCS, Derwen Deg, Bangor,Gwynedd LL57 2BN.

of 13 mm or more (that is, larger than ½/2 thehorizontal extent of an eyelid) underwent combinedtreatment with spontaneous repair and simultaneouspartial surgical reconstruction under local anaes-thesia as day cases. One other patient involved in atraffic accident had general anaesthesia. The ages ofthese 16 patients ranged between 43 and 88 years,with five patients aged between 43 and 60, sevenbetween 61 and 80, and four between 81 and 88.Their average age was 69 years. The average follow-up period was 17 months, ranging between 6 monthsand 3-8 years.These 16 patients can be subdivided into three

groups: Group 1: Full-thickness margin-inclusive(FTMI) excision of lower eyelid. Five patient hadFTMI excision of more than half the horizontal and6 mm of vertical extent of the lower eyelid. Thesmallest excision was 13x7 mm and the largest was21x6 mm. These FTMI defects underwent partialsurgical reconstruction by one of the following threemethods:

(i) For very large FTMI excision of the lower lid,subtotal full-thickness surgical reconstruction of onlythe central area of the defect was carded out in twolayers-posterior lamellar and cutaneous-with atarsoconjunctival sliding flap from the ipsilateral

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489Simultaneous spontaneous andprimary surgical repair ofeyelids

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Fig. 1 (A) Rodent ulcer of 7years' duration, involving medial two-thirds of left lower eyelid margin and palpebralconjunctiva in a Caucasian male aged 64, treated under local anaesthesia as a day case. (B) FTMI excision of26 x6 mm(including 5mm ofinner canthal skin), with 4x5 mm FTMI excision ofupper eyelid. The extent of excision is shown by thearea xabcfg in Fig. 2. (C, D) The central cross hatched area dehk (Fig. 2) of13x6 mm was repaired in full thickness with atarsoconjunctival slidingflap and a full-thickness postauricular skin graft. The remaining defects xabcdk and efgh (Fig. 2)were allowed to heal by spontaneous repair. (E) Appearance at one week. (F) Final appearance at3 months. Note the author'smodification ofDesmarres' retractor in Fig. C.

upper eyelid, and a full-thickness skin graft (FTSG)to cover the sliding tarsoconjunctival flap. About3 mm of the FTMI defect on either side of thiscentrally reconstructed defect was allowed to heal byspontaneous repair. For the patient depicted in Fig.1A-F a large FTMI excision of 26x6 mm was carriedout. Of this large defect only the central area of 13 x6mm was reconstructed in full-thickness (that is, intwo layers) with a tarsoconjunctival sliding flap fromthe ipsilateral upper eyelid. The sliding flap includeda 3 mm tarsal strip and Muller's muscle. This flap wassutured to the horizontal edge of the remnant of thepalpebral conjunctiva of the lower lid. The anteriorlamella was restructed with a 13 x 6 mm full-thicknessskin graft tethered with marginal and central sutures.The remaining FTMI defects xabcdk and efgh (Fig. 2)were allowed to undergo spontaneous repair. Thetarsoconjunctival flap was severed on the 7th day. Inretrospect this division should have been postponedfor at least three more weeks to avoid the formationof the small notch at the junction of the lateralquarter of the lower lid.

(ii) For moderate to large (13-18x6 mm) FTMIdefects of the lower eyelid only the posterior lamellar

defect was repaired with a tarsoconjunctival flapfrom the ipsilateral upper eyelid. The anteriorlamellar defect superficial to the tarsoconjunctivalflap was allowed to heal by spontaneous repair. Thehorizontal extent of the tarsoconjunctival flap was6 mm less than that of the FTMI excision, as it isusually possible to pull together the sides of FTMIdefects by a quarter (that is, 6 mm) of the full widthof an eyelid. Therefore the entire posterior lamellawas made good without leaving any defect of theposterior lamella. The anterior lamella was notreconstructed with an FTSG, but was allowed to healspontaneously. The tarsoconjunctival flap wassutured to the three sides of the posterior lamellardefect and was divided, under local anaesthesia, as aday case, at a second stage in about three weeks. (Fig.3A-F).

(iii) In two patients the tumour did not involve thelid margin but came to within 3 mm of the margin. Inthese cases an asymmetrical FTMI excision wascarried out. The cutaneous lamellar excisionextended 8 mm downwards from the lid margin and13 mm horizontally. The posterior lamellar excisionwas 3 mm in height from the lid margin and a full

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Hemant K Mehta

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C aFig. 2 Diagramatic representation to simplify descriptionsofthe surgical procedurefor Fig. 1. Vertically striped areasxabcdk and efgh were allowed to heal by spontaneous repair.

13 mm in horizontal extent. Therefore the FTMIexcision was 13 x3 mm, the remaining excision beingof the anterior lamella. In these patients, only theentire anterior lamellar defect was made good withskin graft (FTSG) of 13x 8 mm and the entireposterior lamellar defect of 13 x 3 mm was allowed toheal by spontaneous repair (Fig. 4A-D).Group 2: Large excision of inner canthal skin and

orbicularis with simultaneous contiguous FTMIexcisions ofmedial one-third ofthe upper as well as the

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lower eyelid. In 10 patients in this group such wideexcision was mandatory because the rodent ulcerswere in theatening proximity to the upper and lowereyelids. The average excision in this group was 30x25mm, including the FTMI excisions of the upper andlower eyelids. The inner canthal skin and orbicularisdefect was made good with a skin graft (FTSG) bytethering the skin graft to the periosteum with centraland marginal sutures by the author's technique,described previously.34IThe FTMI defects of themedial one-third (8x5 mm) each of the upper andlower eyelid were allowed to heal by spontaneousrepair (Figs. 5, 6A-E).Group 3: Traumatic lacerations with loss of inner

canthal tissue. There was only one patient in this'group'. She had severe bony injuries of limbs, FTMIlacerations of left upper eyelid, caruncle, plica, andseverance of the medial canthal tendon, as well asloss of an irregular patch of skin and orbicularis about10 mm in diameter overlying the lacrimal sac.Primary surgical repair only of the FTMI lacerationof the upper eyelid was carried out. The remainingperipalpebral wounds were allowed to heal byspontaneous repair.

SURGICAL TECHNIQUE AND MANAGEMENTThe 15 patients with eyelid tumours were treated asday cases. The excision and partial surgical recon-

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3D- 3E 3FFig. 3 (A) Rodent ulcer ofleft lower eyelid margin in a Caucasian male aged 65. (B) FTMI excision 13x 7mm. Ipsilateralupper eyelid is shown everted to obtain a tarsoconjunctival slidingflap of8mm in horizontal extent and including 8x3 mmtarsal strip with attached Muller's muscle. The sides ofthe FTMI excision of13 mm were pulled together by about 6 mm tosuture the 8mm wide tarsoconjunctivalflap to the remnant ofthe lower lid conjunctiva on the three sides. The anterior lamellardefect was allowed to heal by spontaneous repair. (C) Appearance ofthe tarsoconjunctivalflap on the seventh postoperativeday. (D) Appearance at three weeks, immediately after the severance ofthe tarsoconjunctivalflap. The anterior lamellar defecthas healed by nearly 75%. (E, F) Final appearance at three months.

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491Simultaneous spontaneous andprimary surgical repair ofeyelids

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Fig. 4 (A) Keratoacanthoma oftwo years' duration, affecting the right lower eyelid ofa Caucasian male aged 71. Theexcision was asymmetrical in that the cutaneous lamellar excision extended 8mm downwards from the lid margin and was 13mm in horizontal extent. The posterior lamellar excision was 3mm in height and 13mm horizontally. The FTMI defect wastherefore 13x3 mm. (B) The entire anterior lamellar defect was restructured with a 13x8mm FTSG, while the posteriorlamellar defect was allowed to heal by spontaneous repair. (C, D) Final result at three months.

struction was carried out under local anaesthesia withlignocaine 2% and bupivacaine 05% (Marcain) withadrenaline. The patient with traumatic lacerationhad numerous bony injuries for which she hadgeneral anaesthesia. The partial surgical repair of herpalpebral and surrounding injuries was carried out atthe same time. The details of surgical procedures inthe remaining patients have been given above andwith the captions of Figs. 1 to 6.At the end of the partial surgical reconstruction

antibiotic eye ointment was instilled and a Cartellashield was applied as the sole dressing. All patientswere given 2 tablets of cotrimoxazole (Septrin) twicedaily for 5 days and antibiotic eye ointment to beapplied twice daily to the eyelids, the skin graft, and

*its donor site. The patients were seen for the firstdressing at 48 hours, and on the seventh postopera-tive day for removal of sutures. Thereafter thefollow-up period was progressively increased toattain six-monthly follow-up.

Results

The functional and cosmetic results were as normaland satisfactory as the published results of totalsurgical reconstructions of similar defectsimplemented by various competent oculoplasticsurgeons."9 There were no palpebral or ocularcomplications in any patient either during con-valescence or subsequently. In four patients a

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Hemant K Mehta

dFig. 5 Diagramatic representation of Fig. 6. Area abxcdwas allowed to heal by spontaneous repair and included 6x5mm FTMI defect each ofthe upper and lower eyelid. Thereniform cross hatched area was reconstructed with skin graft(FTSG).

planned second stage minor procedure for severanceof the tarsoconjunctival flap from the upper eyelidwas carried out under local anaesthesia as day cases,between one and three weeks after the initial surgery.The single patient in group 3, with traumatic loss ofinner canthal skin, developed a pseudoepicanthic

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fold which improved to almost normal in about sixmonths. She also needed minor secondary surgery tocorrect the stenosed everted left lower lacrimalpunctum. A one-snip dilatation of the punctum andits repositioning by excision of an ellipse of palpebralconjunctiva of the lower eyelid at the inner canthuswas carried out nearly a year after the initial injury.Of suspected rodent ulcers in the 15 patientshistology confirmed the clinical diagnosis in 14.Keratoacanthoma was reported in the remainingpatient. In all the 15 patients complete excision withgood histological clearance was reported. There hasbeen no recurrence of tumour in any of these 15patients.

Discussion

The current teaching of oculoplastic surgery is basedon the assumption that defects created by excision ofpalpebral or peripalpebral lesions must be repairedimmediately by total primary surgical reconstruction.Traditionally, FTMI defects of lower eyelids arereconstituted in two layers-tarsoconjunctival andcutaneous-at least one of which should be a flapwith it blood supply intact. The second layer canthen be a free graft from a remote or adjacent donorsite."" Large defects at either canthus are usually

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Fig. 6 (A) Multicentric rodent ulcer at inner canthus ofa Caucasianfemale aged 65. The extent ofthe excision was 30 mm indiameter and included FTMI excision of6 x5mm ofupper lid and 6x6mm ofthe lower lid. Surgery under local anaesthesia asa day case included skin graft (FTSG) from inner arm sutured with the author's technique ofcentral and marginal sutures, inthe cross hatched area ofFig. 5. The FTMI defects (depicted by vertical striped area abxcd in Fig. 5) and the residual defect ofthe adjoining inner canthal area, were allowed to heal by spontaneous repair. (B, C) Healthy appearance onfirst dressing at 48hours. (D, E) Final appearance at three months and at 18 months.

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Simultaneous spontaneous andprimary surgical repair ofeyelids

repaired with a skin flap from near by.- There are noreports so far of exploiting the combined manage-ment of spontaneous repair simultaneously withprimary surgical reconstruction. Therefore, inaddition to being the first report of such combinedmanagement, this study highlights the followingpoints: (1) Such combined management givessatisfactory cosmetic and functional results. (2)Simultaneous FTMI defects of ipsilateral upper andlower eyelids (8x 5 mm each) heal as effectively andnormally as does a similar FTMI defect of each eyelidindividually as already reported.'2 (3) As a conse-quence of this, large defects at the inner canthus canbe treated simply with a skin graft (FTSG) underlocal anaesthesia on a day basis, with the FTMIdefects of both eyelids being allowed to reform byspontaneous repair. (4) With lesions confined only tothe lower eyelid large FTMI defects yield satisfactoryresults from the various methods of subtotal full-thickness or full-width lamellar surgical reconstruc-tion in conjunction with spontaneous repair of theresidual defect.The most crucial point to emerge from this study is

that large excisions at the inner canthus with simul-taneous FTMI excision of adjacent one-third ofupper and lower eyelids need a less extensive, simplesurgical reconstruction with a skin graft (FTSG),which if secured with the central suturing techniquedescribed by the author34 12 allows consistently goodresults. These central sutures act as a combinedpressing and immobilising agent and thereby preventhaematoma formation under the graft. The patientscan therefore be treated as day cases, without anyrestrictions on their postoperative activity.

It is not possible to obtain such large skin graftsfrom the postauricular region, but the supraclavicu-lar region is an excellent donor site that providesgood colour match. The conventional method ofsurgical repair of large defects at the inner canthus isby a rotational skin flap from the forehead. The maindisadvantage of such a flap is the distortion andscarring produced on a readily visible part of the face.Moreover, such a flap does not necessarily provide agood colour match as seen in some postoperativeresults.""'5 It therefore has no advantage over a largeskin graft (FTSG), especially if the graft is obtainedfrom the supraclavicular region, where the skin ishairless and provides a satisfactory colour match. Inaddition to the reconstruction of the skin defect at theinner canthus conventional surgical managementwould have entailed full-thickness reconstruction inmucosal and cutaneous layers of any coexisting FTMIdefect of the eyelids. Such reconstructions aredifficult and complex procedures that demand theskill of a specialist oculoplastic surgeon, whereas, thecombined spontaneous and partial surgical repair

shown here (Figs. 5, 6) can be carried out by anophthalmic surgeon with an interest in plasticsurgery.The combined management does not confer any

worthwhile advantage in the management ofmoderate or large FTMI excisions confined only tothe lower eyelid, because any surgeon capable ofinstituting a 12 mm wide tarsoconjunctival slidingflap from the upper eyelid could almost as readilyobtain an 18 mm wide flap and a skin graft (FTSG) toreconstruct the entire defect. The same applies tofull-width but lamellar reconstructions. However, forthese large FTMI defects confined to the lower lid,the study documents the feasibility and the scope ofspontaneous repair if only for its scientific interest.By conventional criteria all 16 patients in this studywould have been treated by primary and solelysurgical reconstruction in toto to achieve similarresults.

References

1 Mehta HK. Spontaneous reformation of lower eyelid.Br J Ophthalmol 1981; 65: 202-8.

2 Mehta HK. Spontaneous reformation of upper eyelid.Br J Ophthalmol in press.

3 Mehta HK. Assessment of major intraocular and extraocularsurgery performed as day cases. Trans Ophthalmol Soc UK 1977;97:117-23.

4 Mehta HK. A new method of full thickness skin graft fixation.Br J Ophthalmol 1979; 63: 125-8.

5 Mustard JC. Repair and reconstruction in the orbital region.Edinburgh, London, New York: Churchill Livingstone, 1980:182, Fig. 11. 16.

6 Iliff CE, Iliff WJ, Iliff NT. Oculoplastic surgery. Philadelphia:Saunders, 1979: 247-9, Figs. 9-66 to 9-80.

7 Hatt M. Ophthalmic plastic and reconstructive surgery. Stuttgart,New York: Thieme, 1986: 120, Fig. 9.25.

8 Callahan A. Reconstructive surgery of the eyelids and ocularadnexa. Birmingham, Alabama: Aesculapius, 1966: 279, Figs.287-9.

9 Stasior OG, Callahan A, Korn E, Cerise DP, Kristan RW.Medial canthal reconstruction. In: Smith Byron C, Della RoccaRC, Nesi FA, Lisman RD, eds. Ophthalmic plastic and recon-structive surgery. St Louis, Washington, Toronto: Mosby, 1987;2: 820, Figs. 40.40-45.

10 Mustard JC. Repair and reconstruction in the orbital region.Edinburgh, London, New York: Churchill Livingstone, 1980:92, Fig. 7.1.

11 Collin JRO. A manual of systematic eyelid surgery. Edinburgh,London, Melbourne, New York: Churchill Livingstone, 1983:83-6.

12 Mehta HK. Surgical management of carcinoma of eyelids andperiorbital skin. Br J Ophthalmol 1979; 63: 578-85, Fig. 4.

13 Mustard JC. Repair and reconstruction in the orbital region.Edinburgh, London, New York: Churchill Livingstone, 1980:181-2, Fig. 11:16 A-J.

14 Hatt M. Ophthalmic plastic and reconstructive surgery.Stuttgart, New York: Thieme, 1986: 117, Fig. 9:19.

15 Tenzel RR. Lid reconstruction. In: Smith Byron C, Della RoccaRC, Nesi FA, Lisman RD, eds. Plastic and reconstructivesurgery. St Louis, Washington, Toronto: Mosby, 1987; 2: 798-801, Fig. 39:27-30.

Accepted for publication 20 October 1988.

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