Lower eyelid defects are historically classified according to the percentage of missing width, as this guides the type of reconstructive procedure to be performed.1–4,7 As a result, a progression from primary closure to local flaps to lid-sharing procedures has been recommended with increasing defect width. The shortcoming of this classification system is that it focuses mainly on pretarsal eyelid margin defects, and it does not necessarily predict postoperative outcomes in isolation. For example, type IB defects of less than 25 percent width had similar functional and aesthetic outcomes compared to type IB defects of greater than 50 percent width, although they underwent significantly different reconstructive procedures (primary closure versus lid sharing, respectively) (Fig. 9). Both defect area and width differed significantly between groups; therefore, we accounted for these differences in our analysis. Although controlling for defect area and width reduced the number of statistically significant differences in retraction measurements, significant differences remained. In addition, aesthetic outcomes remained significantly worse for type IV defects. Therefore, the vertical component is a predictor of both aesthetic and functional outcomes, independent of defect size and width. This anatomical classification system can help supplement the width-based system and assist in selecting the right reconstructive procedure.
Several support structures help maintain lower eyelid shape and position. The tarsoligamentous sling provides both medial and lateral support, whereas the orbicularis oculi muscle provides anterior support through its baseline tone and active contraction.1,4,8 Inferior support is provided through several structures, including bone, facial retaining ligaments, and orbital and facial fat compartments. This inferior support is critical for maintaining lower lid position and preventing retraction. The senior author uses the analogy of the Willis Tower in Chicago, where the top narrow segment of the building is resting on a progressively wider base that provides it with the necessary structural support to remain erect. (See Figure, Supplemental Digital Content 5, which shows the Willis Tower analogy. Structural support of the lower eyelid margin is dependent on a progressively wider base of lower eyelid subunit. The risk of lower eyelid malposition increases progressively as more structural support levels are lost, http://links.lww.com/PRS/D580.) Our classification system groups patients based on the amount of structural support lost in a given lower lid defect. This support must be restored with careful planning to maintain lower lid position.
There is no question that the larger the defect and the more vertical subunits involved, the worse the outcome. However, controlling for defect size highlighted a few points that are worth discussing. Type III adjusted change in marginal reflex distance-2 became smaller because this group had larger defect size and width and relatively less retraction, and therefore continued to show a significant difference from type IV across the board. Type 2, in contrast, had higher change in marginal reflex distance-2, although it was not statistically significant, compared with types I and III, perhaps because of the one case of retraction that occurred because of the wrong choice of reconstructive procedure. Finally, the aesthetic scores were not significantly altered and continued to be significantly worse for type IV compared with the other groups.
Type I: Pretarsal Defects
Pretarsal defects involve the lid margin with preservation of inferior eyelid support structures (Figs. 4 and 5) (see Video, Supplemental Digital Content 1, http://links.lww.com/PRS/D576). Our data indicate that pretarsal defects should have excellent cosmetic and functional outcomes. In type IA defects, a full-thickness skin graft or a blepharoplasty skin and/or muscle flap can be safely used, depending on skin laxity.9 Reconstruction of type IB defects follows the classic percentage-of-missing-width paradigm.1,3,4 Primary closure is appropriate for defects less than 25 percent of the lid margin, with lateral canthotomy/cantholysis and/or Tenzel flap to close progressively larger defects.4,10 Once a defect is wider than 50 percent of the lid, notching and thinning of the tarsal plate can develop at the suture line, and a tarsoconjunctival lid-sharing procedure should be used (Fig. 9). If the lacrimal drainage system is involved and the lower canaliculus can be intubated, a lower canaliculotomy over stent can be performed. If a significant portion of the canaliculus is missing, lacrimal system reconstruction can be performed secondarily.
Complications can be minimized by several technical considerations. The key to successful reconstruction is to establish anatomical horizontal tension. This is accomplished through lid-tightening procedures, including a lateral canthoplasty and periosteal flap. The gray line must be meticulously aligned under proper tension to prevent notching. Finally, if a Hughes flap is to be used, a vertical height of at least 4 mm should be transposed into the defect to provide adequate height for the reconstructed lid margin.
Type II: Preseptal Defects
Because the pretarsal segment of the lid is intact, these defects are often the easiest to repair (see Video, Supplemental Digital Content 2, http://links.lww.com/PRS/D577.). Repair complexity depends on defect depth. If the orbicularis oculi muscle is preserved, acceptable cosmesis can be attained with a similar quality full-thickness skin graft from the upper eyelid or postauricular area. A horizontally oriented rotation advancement flap (hatchet flap) that is designed within the boundaries of the preseptal orbicularis can close most defects with excellent cosmetic outcomes.11 The back-cut created in this type of flap eliminates downward pulling forces on the lid that can occur with a pure rotational flap with a short arc. A V-Y advancement flap is also a viable option when the dimensions of the defect permit (Fig. 6).12 For larger defects, a cervicofacial flap may be needed. Finally, larger defects that involve the orbicularis can be closed with a lid-sharing approach using the unipedicled or bipedicled Tripier orbicularis myocutaneous flap if redundant upper lid skin is present.13,14
To prevent complications in this group, vertically oriented flaps should be avoided, as this results in a downward force on the lid margin and cicatricial ectropion, as was seen in one patient.15 If the orbital septum is not involved, this should be left untouched to minimize scarring during healing. Postoperative injection of 5-fluorouracil can help improve cosmetic results of full-thickness skin grafts.16 Canthal tightening is usually not needed when closing a type II defect, except when the defect is large and the flap arc of rotation is in close proximity to the lateral canthus.
Type III: Eyelid-Cheek Defects
Type III defects are preseptal defects that extend into the cheek with preservation of the tarsal plate (see Video, Supplemental Digital Content 3, http://links.lww.com/PRS/D578). They vary in size and depth, and directly compromise lower eyelid soft-tissue and/or skeletal support, which can lead to lower lid retraction. The principles of reconstruction are similar to type II for soft-tissue defects. With large defects, a deep-plane cervicofacial flap provides ideal resurfacing.17–19 Bony reconstruction, with carefully gauged mild overcorrection, is necessary for composite soft-tissue/bone defects, as mobilized cervicofacial flaps are invariably thinner than the thick midface soft tissue. When the defect size is prohibitive of local reconstruction, free tissue transfer should be considered along with skeletal support and soft-tissue resuspension.20,21 Concomitant lower lid tightening should be considered in patients with preexisting lower lid laxity.
Type IV: Complex Pretarsal and Preseptal Defects
Typically, this group of defects are a consequence of aggressive malignancies that require wider and occasionally staged resection, which results in worse soft-tissue edema and chemosis at the time of reconstruction (see Video, Supplemental Digital Content 4, http://links.lww.com/PRS/D579). This group had the worst aesthetic outcomes and the highest incidence of postoperative retraction, and required multiple corrective surgical procedures. With loss of the tarsal plate, preseptal support, and potentially the eyelid-cheek junction, all three levels of support are lost, resulting in a high risk for postoperative malposition (see Figure, Supplemental Digital Content 5, http://links.lww.com/PRS/D580). The only patient who did not develop postoperative retraction in this group had a partial-thickness, skin-only defect in the preseptal segment, and therefore did not lose significant structural support.
Despite our high complication rate, we have several recommendations to help improve outcomes in this challenging group. If a staged resection is planned, a complete tarsorrhaphy should be performed with gentle compression dressing to help minimize chemosis at the time of reconstruction. If the tarsal plate is replaced, consideration should be given to supporting the tarsal graft or flap with a spacer graft for increased support and to overcorrect when gauging the vertical height to minimize postoperative retraction. For the anterior lamella, we recommend judicious use of full-thickness skin grafts to cover the Hughes tarsoconjunctival flap, instead of bringing a blepharoplasty or cervicofacial flap up to cover the lid margin.22–24 These flaps can instead be used for lid-cheek or preseptal reconstruction. Using superiorly based local flaps, when available, such as the paramedian forehead flap, Tripier flap, or a suprabrow (Fricke) flap can potentially help minimize vertical and rotational tension on the lower eyelid margin.25 Free tissue transfer is a final option for large defects, but comes with its own set of problems, including cosmesis.20,21
The series represents a single surgeon’s experience; the choice of flaps, approaches, and techniques used may not be representative of all eyelid surgeons. Because of the small patient cohort, the effect of other potential confounding factors for lower lid malposition, including age, eye vector, radiation therapy, and type of procedure cannot be sufficiently analyzed. The cases do not represent every possible combination of defects; nevertheless, the findings are significant and clinically relevant. A small number of patients had a short follow-up period; however, those patients had smaller, less complex defects and were unlikely to develop long-term retraction. Future studies that include a larger number and variety of defects are needed to validate our findings. Despite these limitations, we believe that this anatomical classification can be a useful tool, as it identifies four distinct groups of defects with unique sets of challenges and predictable outcomes. Each type requires the application of specific reconstructive principles based on the restoration of structural support of the lower lid. This classification can help improve patient counseling by identifying patients at risk for complications.
We propose a new vertical subunit supplement to width-based lower eyelid defect classification. This classification predicts both functional and aesthetic reconstructive outcomes. As the number of vertical components lost increases, one can anticipate a greater risk of lid malposition and a need for more aggressive reconstructive interventions.
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