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dysfunction or even harmful complications. As such, the following primary goals should be met in any
periorbital reconstruction: non-keratinizing epithelium should line the inside of the lid, the eyelid margin
must be well defined to avoid hair or lashes touching the eye, the reconstruction should allow for complete
eye closure and unobstructed vision with opening, and the eye should look as symmetric to the non-treated
eye as possible. The following reconstructive techniques serve as a foundation for periorbital reconstruction
[17]
to build upon and are not meant to be comprehensive .
Tenzel semicircular advancement-rotation flap
The Tenzel semicircular advancement-rotation flap is useful in repairing central lid defects that are up to
2/3 the length of the lower eyelid and was described in 1975 . An incision is marked from the lateral
[18]
canthus and extends superiorly and temporally in a curvilinear fashion. The flap is then raised in a
submuscular plane with limited use of cautery to preserve blood supply to the flap. Lateral canthotomy and
inferior cantholysis are performed. The flap is advanced medially, so that the eyelid margins can be closed
on themselves with buried vertical mattress sutures. Prior to closure, the wound edges should be squared to
ensure optimal alignment of the eyelid margins, and the closure should be tension-free. After central eyelid
reconstruction is complete, the lateral canthal angle must be reconstructed. Typically, the lateral canthal
tendon is sutured to the periosteum of Whitnall’s tubercle and then to the orbicularis oculi, transposed with
the flap to reconstruct the angle. Redundant tissue is removed, and the rest of the lateral flap is tacked down
with intradermal sutures secured to the periosteum of the orbit [19,20] .

Compared to other methods of eyelid reconstruction, the Tenzel flap is advantageous because it is a one-
stage operation, often has a less noticeable scar, has minimal donor site morbidity, and effectively prevents
lower eyelid ectropion; however, one disadvantage is the lack of lateral eyelashes after the completion of the
[21]
flap .

Fricke flap
The Fricke flap is a forehead and temple-based interpolated transposition flap that originates from above
the brow with its base lateral to the lateral canthus. It can be used to reconstruct large laterally positioned
upper or lower eyelid anterior lamellar defects. The size of the flap can vary based on the extent of the
defect, but in general, the length to width ratio should be 4:1. Furthermore, the flap should be designed to
limit the angle of the transposition to less than 90 degrees to avoid vascular compromise. When harvesting
the flap, one should avoid dissecting deeply as doing so puts the temporal branch of the facial nerve at
risk .
[22]

The Fricke flap is advantageous in some select scenarios because it is versatile enough to be used in both
upper and lower eyelid defects. It also avoids distortion of vision and can support free grafts as it is a
vascularized flap. However, its disadvantages make it a somewhat less popular option. The transposition of
forehead skin onto the periocular tissues can easily create a mismatch in texture and thickness, and the
removal of skin from the forehead will almost certainly create brow height asymmetry. The standard flap
also requires a second stage to divide the pedicle several weeks later . To circumvent some of these
[22]
disadvantages, the modified Fricke flap can be used for reconstruction of the lower eyelid. Instead of the
forehead skin, the modified Fricke flap uses lateral cheek skin that is typically raised with incisions along
RSTL and rotated medially to reconstruct the lower eyelid. The resulting defect can be closed with the
relatively relaxed cheek skin using the same principles used with cheek rotation flaps.