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Hicks et al. Plast Aesthet Res 2022;9:2 https://dx.doi.org/10.20517/2347-9264.2021.65 Page 9 of 11

In contrast with most other grafts, composite grafts used in eyelid reconstruction are designed to be under
some tension, such that adequate apposition of the eyelid to the globe is obtained postoperatively. Thus, it
may be necessary to use supportive sutures or bolsters to avoid excessive tension while the graft is healing. A
secondary canthoplasty with tarsal strip may ultimately be required for optimal results. During the closure,
accurate reapproximation of the tarsal plate and eversion of the eyelid margin are critical steps in avoiding
an irregular or notched appearance postoperatively.

First described by Callahan in 1951, one use of composite grafts for reconstruction of full-thickness eyelid
[10]
[9]
defects is the utilization of a full-thickness pentagon-shaped graft from the contralateral lid . Depending on
eyelid laxity and size of the graft, the donor defect may be closed primarily, or a lateral canthotomy may be
done to facilitate closure. In these authors’ practices, the use of such grafts is uncommon, as primary closure
often works well for small defects, and full-thickness rotation-advancement flaps work well for larger defects
and avoid donor site morbidity in the contralateral eyelid.

For the purpose of posterior lamellar reconstruction only, a free tarsoconjunctival graft may be harvested
from the upper lid. The tarsal plate is wider in the upper lid, so a graft may be taken from here, as long as
care is taken not to traumatize the upper eyelid retractors. In this case, a local flap would be utilized for
anterior lamellar coverage. A septal mucochondral composite graft may be used in a similar manner.
[11]
Utilization of this graft plus a musculocutaneous flap from the upper eyelid has been described .
Many reconstructive techniques for the eyelid result in a segment of the eyelid margin that lacks eyelashes,
which may be extremely bothersome to some patients. The use of a thin graft harvested from the eyebrow
[12]
and implanted along the eyelid margin has been described . Eyelashes are oriented parallel to one another,
are limited in length, and taper at their ends; eyebrow hairs are similar and are thus a logical choice for
replacement. The rich vascular supply of the eyelid helps ensure graft survival. The brows must be closely
analyzed to select the optimal donor site; this is often a diagonal section near the central portion of the
ipsilateral brow. The graft is approximately 3 mm in width. Meticulous incision and suturing techniques
must be used to minimize trauma to hair follicles.

SKIN AND DERMAL SUBSTITUTES
In some instances, the use of skin substitutes may be an appropriate option for or adjunct to the treatment
of wound defects. Increased research and understanding in the fields of molecular biology and tissue
engineering have led to the development of multiple skin substitute materials for use in wound care and
reconstructive procedures . Wound healing is a complex process involving many cell types, growth factors,
[13]
and extracellular matrix components. In chronically inflamed or non-healing wounds, the inflammatory
process inherent to the wound results in degradation of these components and prevention of normal
healing. Skin substitutes essentially act as a scaffold, providing various combinations of cells, growth factors,
and extracellular matrix components, depending on the specific product, with the ultimate goal of
facilitating revascularization and reepithelialization of a given wound [14,15] .

Perhaps the primary advantage of these products is the lack of donor site morbidity. Another relevant
advantage is the potential for utilization of a large amount of material, as the availability is not limited by
traditional donor site restrictions [14,15] . Conversely, there are challenges associated with product development
and refinement, including the need for substantial research and investment in biocompatibility and
application-specific optimization. In parallel with these development challenges lies the primary barrier to
widespread adoption: high cost. At this time, there is limited availability of most of these products outside of
large hospital systems [14,15] .