Oculoplastic reconstructions of eyelid defects — possibilities and limitations

Abstract

There have been advancements in contemporary therapeutic approaches for treating malignant eyelid tumors. The modern therapeutic approach for basal cell carcinoma (BCC) involves innovative, pathogenetically targeted local or systemic drug effects aimed at impacting the carcinogenic process. However, it is still surgery that remains a crucial aspect of the available therapeutic options. This involves microsurgical removal of the tumor within healthy tissue, followed by the subsequent coverage of resulting defects. For a successful recovery, it is essential that every surgeon practicing in the fields of aesthetic, plastic and reconstructive surgery in eyelids and lacrimal system becomes proficient in a diverse set of reconstructive techniques, and precisely plans each step in advance.

In our review we would like to describe and comment on the most common techniques used in the field of oculoplastic surgery for eyelid and lacrimal system reconstruction.The review contains numerous detailed examples of reconstructive techniques after surcical tumor excision. The goal of reconstructive management of the eyelids is to restore their function, comfort, and cosmetic appearance.This paper discusses the typical clinical characteristics and frequently employed surgical methods for eyelid tumors excisions, considering anatomical features and functionality of the eyelids.The choice of surgical procedures for eyelid tumors is determined by the tumor’s location, extent, and histology. Addressing a defect involving the medial or lateral canthus poses a unique surgical challenge.

Introduction

There have been advancements in contemporary therapeutic approaches for treating malignant eyelid tumors [1]. However, it is still surgery that remains a crucial aspect of the available therapeutic options. This involves microsurgical removal of the tumor within healthy tissue, followed by a comprehensive evaluation and the subsequent restorative coverage of resulting defects. For a successful recovery, it is essential that every surgeon becomes proficient in a diverse set of reconstructive techniques, and precisely plans each step in advance. An essential prerequisite for achieving optimal reconstruction is a solid understanding of eyelid anatomy [2]. The width of the horizontal palpebral fissure is 28–30 mm, and the vertical palpebral fissure measures 10–11 mm at its broadest locations. Eyelids can be conveniently divided into two anatomical layers: the anterior lamella and the posterior lamella. A transverse grey line is visible in the middle of each lid margin, indicating the boundary between the two lamellae [2, 3]. It is essential to accurately distinguish between defects in the anterior lamella (comprising skin and orbicularis oculi muscle), the posterior lamella (including tarsus, tarsal conjunctiva, Müller, and levator muscles), and penetrating defects (Fig. 1) [2]. A comprehensive evaluation of the defect is crucial for the successful reconstruction of the eyelid. Measurements and photographs should capture both the horizontal and vertical dimensions of the lesion. Using this information, the most suitable reconstruction technique can be selected. Small defects involving less than 30% of horizontal lid length with a vertical extent of less than 8 mm can be reconstructed through direct approximation of wound edges, using the natural stretchability of the eyelid [2, 4]. Reconstruction of a defect affecting 30% to 50% of horizontal lid length with diminished stretch ability of the remaining eyelid margins (to determine the necessary tissue for reconstruction, gentle tension is applied to the medial and lateral wound edges) requires a lateral canthotomy and cantholysis [5, 6]. For defects that extend horizontally more than 50% and less than 75% of the eyelid’s length Tenzel semicircular flap technique can be performed for reconstruction of lower and upper lid defects, with its possible extension known as McGregor flap (A-Z Plasty) [7–10]. For more extensive defects up to 75% of the eyelid’s length, advanced techniques like the Hughes flap with a pedicled tarsoconjunctival flap and Mustarde cheek rotation flap (both for lower eyelid reconstruction) and the Cutler–Beard bridge flap with a pedicled cutaneomusculoconjunctival flap and Glabellar flap are appropriate (both for upper eyelid reconstruction) [2, 4, 11–13]. Alternatively myocutaneous flaps useful for both upper and lower lid defects like Fricke s flap can be suitable [2, 5, 7, 8, 12, 14–17]. When employing a free skin graft for anterior lamella reconstruction, it is essential to reconstruct the posterior lamella with a vascularized flap. If a skin flap is accessible for the anterior lamella, the posterior lamella can be reconstructed using either a vascularized flap or a graft. It is mandatory that at least one section of the eyelid remains adequately perfused [2, 11, 13, 14, 16, 18]. In cases of extensive resection it may be necessary to reconstruct additional anatomical structures, including the lateral and medial canthus, restoring the integrity of the lacrimal duct, and addressing bone structures within the orbit or paranasal sinuses [13, 19]. Management options for recontructions of bone structures within the orbit or paranasal sinuses are outside the scope of this review.

Figure 1. The gray line (GL) serves as the demarcation between the anterior lamella (AL), which includes the skin and orbicularis oculi muscle, and the posterior lamella (PL), comprising the tarsus (T), tarsal conjunctiva (CO), Müller, and levator muscles. This line is visible on the posterior third of the eyelid’s edge, positioned ventrally to the openings of the meibomian glands (OMG). Meibomian glands (MG), orbicularis oculi muscle (OO) [2]. Reprinted with permission

Wound closure and oculoplastic reconstructions of eyelid defects

Direct wound closure

The direct closure of the lid margin can be typically carried out for smaller penetrating defects involving less than 30% of the horizontal length of the eylid. Its objective is the reconstruction of the lid margin without a notch. This method remains commonly used in trauma-related defects that do not involve big tissue loss, and holds significant importance in everyday routine reconstructive procedures (Fig. 2).

Figure 2. A. Direct closure of the eyelid margin is possible as long as the surrounding tissue is flexible enough to allow the wound edges to be brought closer together. For irregular injury, the edges of the wound are first cautiously removed through sparing excision; B. Following hemostasis, the rejoining process starts with a posterior and an intermarginal suture positioned at the eyelid’s edge, both involving the tarsus. The tarsus is secured with a minimum of two sutures; C. Subsequently, the suture is positioned at the anterior edge of the eyelid and the ends of the posterior suture are tied beneath the anterior suture to avoid contact with the cornea. Then the closure of the skin is completed [2]. Reprinted with permission

Lateral canthotomy and cantholysis

This technique can generally be performed for most penetrating lower and upper lid defects up to 50% of the horizontal lid length The most important aspect of this technique is equalization of the lash line and reconstruction of the lid margin without a notch [5, 6] (Fig. 3).

Figure 3. To perform the canthotomy, cut from the lateral canthus to the rim of the orbit using scissors needs to be done. For cantholysis the lower crus of lateral canthal tendon must be identified and cut. If combined with canthotomy, cantholysis enables the eyelid to move towards the midline, facilitating the closure of the primary defect. Author’s own graphic

Tarsomarginal grafts

Tarsomarginal grafts, following Hübner’s technique, provide a versatile solution and are applicable for reconstructing both the upper and lower eyelids defects of any size. The number of required tarsomarginal grafts necessary for reconstruction varies based on the size of the defect to be covered, ranging from one to three. Combining autologous tarsomarginal grafts with full-thickness skin flaps that provide blood supply can lead to highly favorable outcomes. Hübner propagates that the skin flap can play a role in nourishing the grafts, consequently minimizing the risk of necrosis. He suggests that this represents a significant advantage of the free tarsomarginal grafts technique. Additionally, he considers the ability to place multiple grafts alongside each other allowing for the reconstruction of larger defects to be another important benefit [20, 21]. Hübner highlights still another advantage compared to the Hughes flap technique, which results in an eyelash-free eyelid edge. In contrast, the technique he describes allows for the preservation of eyelashes in the reconstruction area, particularly in smaller eyelid defects. The drawback of this technique is the potential involvement of the opposite eye. Numerous patients are apprehensive about undergoing surgery on the unaffected opposite eye, as is the scenario with tarsomarginal grafts. Therefore, the patient should be actively involved in the decision-making process when weighing the options of tarsomarginal grafts versus the Hughes or Cutler–Beard bridge flap. Using free autologous tarsconjunctival grafts in conjunction with full-thickness skin flaps is an optimal approach when combined with the Hughes flap for the reconstruction of extensive lower eyelid defects. The disadvantage of the technique mentioned earlier is that the operated eye stays at least partially closed throughout a healing period of at least 3 to 4 weeks. Conditions such as low visual acuity in the opposite eye or monocular vision in the operated eye are considered contraindications. In these situations the use of other reconstructive techniques needs to be considered (Fig. 4–6).

Figure 4. A. Covering of a small defect in the lower eyelid using a tarsomarginal graft; B. A subciliary skin incision is created in the lower eyelid of the unaffected eye, and skin and muscle are extracted from the tarsus underneath; C. A tarsal shield containing eyelashes is removed from the unaffected eye and placed into the defect of the affected eye; D. A transposition flap is extracted from the upper eyelid of the affected eye. The skin remaining on the temporal side of the eyelid defect is dissected and saved to cover subsequent skin defects in the upper eyelid area; E. In the unaffected eye the tarsus defect is sutured, and subsequently, the lower eyelid skin is sutured in a pleated fashion to the eyelid’s edge; F. In the affected eye, the musculocutaneous transposition flap is sutured over the sutured tarsomarginal graft. Free skin grafts can be used/utilized to cover potential skin defects in the upper eyelid region [2]. Reprinted with permission

Figure 5. A, B. Possible reconstruction of an extensive lower eyelid defect using two tarsomarginal grafts from the unaffected eye. A subciliary incision is performed on the upper lid of the affected eye, and skin and muscle are extracted from the tarsus above it; D. A tarsal shield containing eyelashes is removed from the upper lid of the unaffected eye and then divided in half; E. Both halves are then fitted into the defect of the lower lid. A transposition flap is then dissected from the upper eyelid. Subsequently, the transposition flap is sutured into position to cover previously sutured tarsomarginal graft. The remaining skin on the temporal side of the eyelid defect is dissected and saved for addressing additional skin defects in the upper eyelid region; F. From the upper eyelid, the tarsal defect is sutured and the skin is then sutured in a pleated fashion to the eyelid margin [2]. Reprinted with permission

Figure 6. A. Potential reconstruction of the upper eyelid defect using three tarsomarginal grafts from all the remaining eyelids; B. In the lower eyelid of the affected eye, and in the lower and upper eyelids of the unaffected eye, a subciliary skin incision is made, and the skin and muscle are detached from the tarsus around the periphery. From each of the three normal eyelids, a tarsal shield with eyelashes is removed and placed into the defect of the affected eye. On the affected eye, the skin is dissected upward to just beneath the eyebrows. A triangular section of skin is removed from both the nasal and temporal sides of the defect and discarded; C. The tarsal defects on the three healthy eyelids are sutured. Subsequently, the upper eyelid skin is sutured tightly to the eyelid edges. On the affected eyelid, the skin flap is sutured over the three previously sutured tarsomarginal grafts [2]. Reprinted with permission

Tenzel semicircular flap

This method enables the direct closure of lower and upper lid defects that are below 75% of the horizontal lid length. Beginning at the lateral canthus as an extension of the lid line that is to be reconstructed, the incision involving both the skin and the orbicularis oculi muscle initially extends temporally upward for lower lid reconstruction or temporally downward for upper lid reconstruction following a semicircular fashion. So a semicircular shape muscle and skin flap can be undermined and dissected [7, 8]. AZ-plasty at the termination of a Tenzel flap will bring in additional tissue from the vertical temporal region, and provide horizontal tissue to the eyelid [9, 10]. Subsequently, after performing a lateral canthotomy with cantholysis, the lid can be medially mobilized to enable the closure of lid defects. After achieving minimal tension for apposing the wound edges, the flap is anchored by its deep tissues to the periosteum of the lateral orbital rim. Consequently medial and lateral wound edges can be directly closed and the lateral cathus reconstructed (Fig. 7) [7, 8].

Figure 7. Reconstruction with a semicircular flap (Tenzel) enables the direct closure of medium to larger lower and upper lid defects that are below 75% of the horizontal lid length. This technique is suitable if the temporary eyelid closure in monocular patients who need lower eyelid reconstruction in their functioning eye (using techniques like the Hughes flap or Cutler–Beard bridge flap) is unwanted. A. Following tumor removal, a lateral canthotomy with cantholysis is initially performed, along with an incision involving both the skin and orbicularis muscle. This incision follows a semicircular pattern and extends temporally; B. Semicircular shape muscle and skin flap can be undermined and dissected; C. The closure of the lid defect can be carried out directly, layer by layer. Subsequently, the lateral canthus is reconstructed through canthopexy, and the musculoskeletal flap is secured in its new position with multiple sutures [2]. Reprinted with permission

Advancement flap techniques

These special techniques can be utilized for significant defects that extend more than 50% of the eyelid’s horizontal length. Hughes tarsoconjunctival flap technique can be addressed for lower eyelid defects or, in the form of the Cutler–Beard cutaneomusculoconjunctival bridge flap, for the coverage of upper eyelid defects.

Hughes flap with a pedicled tarsoconjunctival flap

The Hughes tarsoconjunctival flap is a technique designed for the reconstruction of the lower eyelid defects larger than 50% of the eyelid’s length which do not extend much over the inferior border of the tarsal plate. It was first described by Wendell Hughes in 1937. This is a two-step procedure, where the posterior lamella of the lower lid is reconstructed using a pedicled tarsoconjunctival advancement flap derived from the conjunctiva and tarsus of the upper eyelid on the same side. This advancement flap, maintaining its blood supply, is sutured into the damaged area on the lower eyelid. The reconstruction of the anterior lamella involves using a free skin graft sourced from a different eyelid, such as the upper inner lid, preauricular, retroauricular, subclavicular, or a cutaneous advancement flap. This specific technique of reconstruction is regarded as a well-established method for lower eyelid reconstruction, particularly in cases of central lower eyelid defects involving residual tarsus on both medial and lateral sides, and it guarantees excellent functional and cosmetic outcomes. The advancement flap can also be dissected in conjunction with the Müller muscle. To reduce the elevated risk of upper lid retraction, it is advisable to separate the Müller muscle portion from the conjunctival pedicle whenever feasible. Alternatively, Müller muscle can be left intact and recessed at the second stage before advancing to the lower eyelid defect. The opening of the flap pedicle by separating the conjunctival bridge can be carried out around 2–4 weeks after the operation, if there is a well-established newly formed blood supply. To form a new eyelid margin, a slight incision should be made above the tarsus in the conjunctiva and then sutured to the skin graft or skin flap (Fig. 8, 9) [2, 11, 13, 18, 22–24].

Figure 8. Reconstruction using the Hughes tarsoconjunctival flap. A. This approach stands as one of the fundamental techniques in the field of ophthalmic plastic surgery, and is acknowledged as a well-established procedure for the reconstruction of the lower eyelid; B. A pedicled tarsoconjunctival advancement flap is separated from the conjunctiva and tarsus of the upper eyelid; C. The flap is transposed to a defect in the lower eyelid and then sutured into the lower lid to reconstruct the posteriori lamella; D. The anterior lamella is reconstructed through vertical advancement of skin and muscle or by using a free full-thickness skin graft [2]. Reprinted with permission

Figure 9. Composite of photographs illustrating reconstruction of the lower eyelid using the Hughes pedicled tarsoconjunctival flap. A. Horizontal extentension of the lower lid defect after pR0 tumor excision; B. Full thickness tarsal incision and formation of the tarsoconjunctival flap; C. Tarsoconjunctival flap turned down; D. Flap being sutured into the defect; E. Sewn in flap; F. Size of skin graft being measured; G. Covering the defect with the free skin graft; H. The pedicle between upper and lower eyelid remains in place for 3 weeks, condition immediately after eyelid separation; I. Good functional and aesthetic outcome 10 months after transection of the flap pedicle. Author’s own graphic

Cutler–Beard bridge flap with a pedicled cutaneomusculoconjunctival flap

The Cutler–Beard bridge flap is a technique designed for the reconstruction of the upper eyelid. It was first described in 1955 by N.L. Cutler and C. Beard [25]. Penetrating defects in the upper eyelid, particularly those larger than 75% of the eyelid’s length, can be addressed through a two-step procedure using full thickness advancement pedicled cutaneomusculoconjunctival flap sourced from the lower eyelid [2, 12, 24, 26, 27]. This method provides good functional and cosmetic outcomes. Compared to several rotational and advancement flap techniques this approach offers a relatively low complication alternative [24]. The dissection of the cutaneomusculoconjunctival flap from the lower eyelid initiates with a horizontal skin incision positioned 4 mm below the line of eyelashes (1 to 2 mm beneath the lower part of the tarsal plate) at the specified width. The two vertical segments of the flap are directed downward towards the conjunctival fornix. The flap is subsequently maneuvered in a cranial direction beneath the intact bridge of the lower eyelid. Complementary structures are sutured to each other in three layers in a interrupted fashion [24, 25] (Fig. 10, 11, and 12A–C) [24]. If the defect spans more than 75% of the eyelid’s width, extra tissue can be employed to enhance stabilization. Donor sclera, ear cartilage, fascia lata, hard palate, or free tarsal grafts from the contralateral upper eyelid can serve as supplementary stabilizing tissues for this repair. Without additional stabilizing tissue the likelihood of various postoperative eyelid malpositions, such as upper eyelid entropion, rises [21, 22, 24, 28–32]. 4–6 weeks following the surgery, when the development of new lymphatics and the stretching of the inverted lower eyelid flap are fully accomplished, the transection of the flap pedicle can be carried out. To achieve this, the lower eyelid bridge is pulled back using a strabismus hook. After the pedicle is cut, the upper eyelid conjunctiva is moved forward onto the lid margin by 2 mm to reduce the likelihood of corneal erosions. The flap pedicle is subsequently reattached into the lower eyelid defect, consistent with the layers [24, 25]. The most severe complication of this procedure is the necrosis of the lower eyelid bridge. The disadvanteges of this technique include lower eyelid ectropion, upper eyelid entropion, skin and lanugo hairs of the new eyelid rubbing on the cornea (the levator tends to pull the new posterior lamella more than the new anterior lamella) and lymphedema. The method is inappropriate for patients with monocular vision or infants due to the risk of amblyopia [24, 25].

Figure 10. A. Larger defects in the upper eyelid can be reconstructed using a Cutler–Beard bridge flap; B. In this regard cutaneomusculoconjunctival full-thickness flap is dissected from the lower eyelid on the same side. The incision is made 1 to 2 mm beneath the lower part of the tarsal plate. This ensures the preservation of the tarsus and prevents disruption of the inferior marginal arcade, thus preserving the vascularity of the flaps; C. The flap from the lower eyelid is subsequently drawn dorsally over the lower eyelid bridge in an upward direction; D. All three layers are then sutured into the defect area of the upper eyelid. The pedicle flap can be cut after a few weeks [2]. Reprinted with permission

Figure 11. Composite of photographs illustrating reconstruction of the upper eyelid using the Cutler–Beard bridge flap with a pedicled cutaneomusculoconjunctival flap. A. A substantial penetrating defect in the upper eyelid following the complete removal (R0 resection) of a nodular ulcerating basal cell carcinoma in an 83-year-old female patient; B. Marking of 5-millimeter horizontal skin incision, aligning with the length of the upper eyelid defect, beneath the row of eyelashes and parallel to the gray line; C. Initially, a penetrating stab incision was created at the temporal marking endpoint; D. Following the marking, a complete horizontal incision was performed, carefully preserving the unharmed lower eyelid bridge, including the lid margin, tarsus, and inferior tarsal artery; E. At the nasal extremity of the horizontal incision, a vertical cut was made, extending down to the inferior fornix; F. At the temporal extremity of the horizontal incision, a vertical cut was made, extending down to the inferior fornix; G. The U-shaped cutaneomusculoconjunctival advancement flap was held with two forceps; H. The flap was gently drawn upward in a cranial direction beneath the intact lower lid bridge; I. The gap was sealed in three layers, with each layer individually stitched into the upper eyelid defect [2]. Reprinted with permission

Figure 12. Composite of photographs illustrating satisfactory functional and cosmetic outcomes observed in postoperative assessments after surgical procedure using the Cutler–Beard bridge. A–C. A 69-year-old female patient with sebaceous carcinoma of the upper eyelid presented a 60% penetrating upper eyelid defect after R0 resection (arrow), which was addressed using the Cutler–Beard bridge flap technique without the need for additional stabilizing tissue. Three months after the surgery, the postoperative results showed satisfactory eyelid opening (B) and closure (C). D–F. In another case, a. 57-year-old male patient with sebaceous carcinoma of the upper eyelid presented a 75% penetrating upper eyelid defect after R0 resection (arrow, D), which was addressed using the Cutler–Beard bridge flap technique with additional stabilizing tissue (sclera). One year postoperatively, the postoperative results showed satisfactory eyelid opening (E) and closure (F) [2]. Reprinted with permission

Glabellar transposition flap

The initial description of the glabellar flap was provided by McCord and Wesley [21]. It includes forming an inverted “V” in the glabellar area, subsequently converting it into a “Y” shape to enable the rotation of the flap, providing tissue for the repair of the upper lid anterior lamella with medial canthal defect [33–35]. The glabellar flap (GF) presents numerous benefits, such as a close match in color and texture to the recipient site and minimal occurrence of morbidity at the donor site. One disadvantage is its tendency to bring the eyebrows closer together. Another drawback is that it fails to provide a natural depth to the medial canthus and leads to a bulky nasal bridge. This can be overcome by avoiding a too broad base to the flap between the eyebrows, and performing a meticulous thinning of the flap if needed (Fig. 13) [34].

Figure 13. Utilizing the glabellar flap for the reconstruction of the anterior lamella in the upper eyelid, specifically addressing medial canthal defects. A. Marking of the glabellar flap on the forehead above a small deep medial canthus defect; B. Undermining, dissecting the glabellar flap in the layer of subcutaneous fat, placing it without tension into the canthal defect, closing of the forehead defect and suturing the flap into the canthal defect. Author’s own graphic

The Fricke flap

The Fricke flap is a lateral forehead transposition flap with a single pedicle based on the temporal region, originally introduced by Jochim Fricke in 1829 [36]. It is applicable for the restoration of substantial defects in the lower lid, upper lid, and lateral canthal region, or to introduce a vascularized tissue to address anterior orbital defects. While some surgeons recommend it as a final alternative for periorbital reconstruction, the Fricke flap is a valuable choice for reconstructing the anterior lamella in the lateral canthus, upper, and lower lids.

This technique is very usefull in cases of lower lid defects that span the entire length of the lower lid but are relatively short in their vertical dimension, and especially beneficial in cases with monocular vision, where techniques like the Hughes or Cutler–Beard flaps, which obstruct the visual axis/that disable vision, are not preferable. It is suitable for reconstructing a substantial lower eyelid defect, providing an alternative to the more intricate dissection required for a Mustardé cheek rotation flap, which may come with the associated risk of facial nerve injury (Fig. 14) [17, 37].

Figure 14. A. The flap ought to be contoured following the curvature of the eyebrow, extending up to the medial extremity; B. A skin flap originating from the lateral aspect above the eyebrow is elevated and secured to the damaged area; C. The donor region is then closed directly. The creation of the posterior lamella can be accomplished by utilizing a Hughes tarsoconjunctival flap in reverse, or by employing a free mucous membrane graft. The separation of the flap is performed after a two-week period. Author’s own graphic

Mustarde cheek rotation flap

This method is indicated for the reconstruction of large defects of the lower eyelid up to its whole length, especially in cases with a significant vertical component extending into the cheek area. The biggest advantage of this technique is its capability to reconstruct all layers of the eyelid in a single step, making it especially well-suited for individuals with monocular vision (Fig. 15) [15, 16, 37]. For substantial resections, there might be a need to reconstruct additional anatomical structures, such as the lateral and medial canthus, ensuring the integrity of the lacrimal duct. Reconstructing the lacrimal ducts is necessary for processes involving the medial lid angle with lacrimal drainage system involvement. The choice of reconstruction method, such as bicanalicular intubation or conjunctivorhinostomy with Jones tube (CDCR), depends on the type and extent of damage [19, 38]. In the case of a lower eyelid defect involving the lower lacrimal canaliculus, simultaneous application of bicanalicular silicone intubation (Crawford Intubation System) is possible during tumor removal surgery (Fig. 16) This involves identifying the entry to the severed lower lacrimal canaliculus and inserting the stent, followed by intubation of the upper canaliculus. Under endoscopical guidance the stent is brought out into the nasal cavity. However, this procedure requires general anesthesia and the surgeon’s expertise in using both — the Crawford Intubation System and nasal endoscope. After wound healing and stent removal, the entry to the lower lacrimal canaliculus is located near or in the medial canthus. In such cases, monocanalicular intubation (e.g., Mini-Monoka) is not feasible due to the absence of the lacrimal puntctum and the inability to anchor the stent in the ampulla of the lower lacrimal canaliculus. The function of the altered anatomy of the lacrimal canaliculus is somewhat impaired afterwards [19, 38]. If the removal of the lower eyelid tumor is performed without intubation of the lower lacrimal canaliculus, and the upper canaliculus is preserved, tearing is usually not present at rest. The difference between the eyes (the healthy one and the one after the removal of the lower eyelid tumor) becomes apparent when exposed to increased irritating factors on the eye (wind, temperature changes, etc.). However, this is not an indication for conjunctivodacryocystorhinostomy, as this procedure rarely provides complete relief of tearing [39, 40]. In cases where the defect after tumor removal involves the entire medial canthus, and tearing is pronounced, consideration may be given to lacrimal bypass surgery (CDCR). The operation is performed after complete healing of the wound from tumor removal. It involves creating a connection between the conjunctival sac and the nasal cavity, using lacrimal duct prosthesis — a Jones tube. Currently, the StopLoss Jones Tube system is most commonly used, and the surgery can be performed through an external or endoscopic approach [19] (Fig. 17, 18).

Figure 15. A. Mustarde cheek rotation flap. This flap is particularly valuable for restoring the anterior lamella in larger vertical defects of the lower eyelid; B. A triangular section of skin with an acute angle is excised below the defect, where the nasal side is vertical and roughly twice as long as the length of the horizontal lid margin defect. This design enables the medial rotation of the flap. The flap is outlined on the side of the defect, reaching towards the lateral canthal region. It should subsequently take an upward curve and be extended downwards in front of the ear. Following that, the rotation flap is turned in a medial and downward direction; C. The resultant defect in the lower eyelid is less than 30% of the horizontal length of the lower eyelid. Consequently, direct closure of the wound using sutures can be performed layer by layer. In the region of the lateral canthus, the wound is closed in two layers [2]. Reprinted with permission

Figure 16. Crawford Intubation Set. Author’s own graphic

Figure 17. StopLoss Jones Tube. Author’s own graphic

Figure 18. StopLoss Jones Tube located in the medial canthus (green arrow) after DCR. Author’s own graphic

Postoperative complications

Complications may arise following any surgical procedure. Potential undesirable outcomes of surgery include postoperative bleeding, hematomas, wound infections, wound healing disorders and necrosis. Occasionally, wound healing disorders or increased wound tension may result in the dehiscence of the wound or eyelid edge. Smaller dehiscences of the lower eyelid can be allowed to undergo secondary granulation, while bigger ones can be addressed through gentle wound resurfacing with minimal wedge excision, if required, followed by re-suturing. Overlapping of wound edges, everted wound margins, asymmetries, retractions, and hypo- or hypertrophic scars can undergo surgical correction, if necessary, once the initial scar healing is fully completed. Photographic documentation before and after the surgery can be beneficial in this process.

Conclusion

The eyes serve as a central focus for facial aesthetics, making the achievement of satisfactory cosmesis in reconstruction a crucial requirement. An oculoplastic surgeon trained in the fields of aesthetic, plastic and reconstructive surgery specializing in the face, orbits, eyelids and lacrimal system is responsible for the recognition and evaluation of the occuring alterations. Surgery planning should always be customized and tailored to individual expectations of the patient. For a successful recovery, it is crucial for every surgeon to excel in diverse reconstructive techniques and meticulously plan each step in advance.

Acknowledgements

Not applicable.

Conflict of interests

Authors declare no conflict of interests.

Author contributions

P.J.G., R.R., B.F., A.L., M.N. and R.N. conceptualized, drafted, read, and approved the final version of the manuscript.

Funding

No funding.