Complex Eyelid Reconstruction: A Practical Guide for the Mohs Surgeon

Abstract

BACKGROUND A growing body of literature suggests that Mohs micrographic surgeons can safely and successfully perform complex eyelid reconstruction. Given that up to 10 percent of all skin cancers occur on the periorbital skin, it is imperative that Mohs surgeons understand form and function to properly assess the defect and select the appropriate reconstruction method for a variety of eyelid defects. OBJECTIVE Our objective is to provide a thorough understanding of eyelid anatomy with an emphasis on form and function, provide a framework for defect analysis, and an algorithmic approach to defect analysis and appropriate selection of repair. METHODS AND MATERIALS A review of the literature on eyelid reconstruction was performed with specific reference to defect analysis and appropriately choosing repairs that are applicable to Mohs micrographic surgeons. CONCLUSION Mohs micrographic surgeons can safely and successfully perform complex eyelid repairs. An understanding of eyelid anatomy is the first step toward the best surgical outcome, and there are various methods for reconstructing eyelid defects. Defect size, location and analysis of the anterior lamella, posterior lamella, and the canthal regions helps to create an organized operative plan.

An Approach for Mohs Excisions for Sebaceous Carcinoma of the Posterior Lamella

“…3 The value of photodynamic diagnosis using a true Wood's light has been demonstrated in Mohs surgery, but that method required hours of preincubation time with a photosensitizer. 4 Our solution serves as a practical adjunct to the multistep approach of biopsy site identification. 5 To improve biopsy site identification before Mohs surgery, we began to implement the use of a handheld 365-nm Wood's flashlight in a darkened room.…”

“…It is of utmost importance to spare as much of the tarsal plate as possible because even small defects may jeopardize function and require replacement of the posterior lamella with complex reconstructions using periosteal flaps, tarsoconjunctival grafts, fascia, and cartilage. 4 Mohs micrographic surgery is vital for tumors of the posterior lamella because it provides maximal preservation of this tissue that is critical to anatomic structure and function while also ensuring definitive marginal examination and tumor extirpation.…”

Customized Reconstruction of Lower Eyelid Defects

“…In lower eyelid reconstruction, the eyelid is classified into 2 lamellae (anterior and posterior). Skin and the orbicularis muscle make up the anterior lamella, whereas the tarsal plate and conjunctiva make up the posterior lamella 2 . There are several choices for reconstruction, 3–9 depending on the depth, position, and size of the lower eyelid defect.…”

“…Unlike skin grafts, flaps may use the surrounding tissues, with practically no mismatch with the defect region, and have optimal vascular and nerve innervation and functional recovery. Therefore, flaps are the preferable method 2 . If the anterior lamella is reconstructed with a flap, the posterior lamella can be repaired using a free graft (Fig.…”

“…Skin and the orbicularis muscle make up the anterior lamella, whereas the tarsal plate and conjunctiva make up the posterior lamella. 2 There are several choices for reconstruction, [3][4][5][6][7][8][9] depending on the depth, position, and size of the lower eyelid defect. In addition, there may be numerous combinations of reconstruction techniques, depending on how each lamella reconstruction method is used (Fig.…”