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Somenek. Plast Aesthet Res 2022;9:16 https://dx.doi.org/10.20517/2347-9264.2021.84 Page 9 of 10

The tarsoconjunctival flap is performed by everting the upper eyelid with a Desmarres retractor and
carefully incising the measured markings. Dissection is performed with blunt-tipped scissors, as the levator
aponeurosis is directly below this and should be left intact. Dissection is continued superiorly until there is
enough length to advance the flap into the lower eyelid defect without any tension. The flap is secured with
6-0 Vicryl suture first to the medial and lateral edges followed by the inferior edge of the defect. Care should
be taken to not include Mϋllers muscle within the tarsoconjunctival flap as the upper eyelid may retract after
flap separation. Once this is secured and the flap is in position, the anterior lamella must be reconstructed.

The options for reconstructing the anterior lamella include a full-thickness skin graft or an advancement
skin-muscle flap. The advantage of the latter is that there is an ideal color match to the surrounding tissues.
However, the advancement flap is only possible when there is sufficient local tissue present which often is
lacking with these types of defects. Skin graft donor sites commonly include the ipsilateral or contralateral
upper eyelid and pre- or post-auricular skin. The full-thickness skin graft is harvested in the usual fashion
and secured to the recipient site superiorly with 6-0 chromic gut. 6-0 silk can be used laterally and inferiorly
to also incorporate into a tie-over bolster that is typically left in place for one week to ensure graft success.

[11]
The tarsoconjunctival flap is detached approximately at 2-4 weeks after the initial reconstruction. Leaving
a small cuff of excess flap is helpful so that the location of the mucocutaneous junction is anterior to the
apex of the eyelid to provide protection to the cornea from any fine vellus hairs that are present on the skin
graft. The conjunctival edge can be sutured with 7-0 chromic gut. Erythromycin ophthalmic antibiotic
ointment is recommended twice daily for one week.

Potential short-term complications of the tarsoconjunctival flap include flap dehiscence, eyelid margin
erythema and necrosis after division. Long-term complications include upper and lower eyelid retraction,
notching of the reconstructed eyelid, ptosis to the upper eyelid, and entropion or ectropion. As an
alternative to this flap, a recent case report has demonstrated modifications of the Tenzel flap to allow the
[12]
closure of larger defects .

Canalicular repair
Canalicular injuries are commonly associated with lower eyelid avulsions. Defects that involve the upper
and lower eyelids, including the medial canthus, will frequently involve the lacrimal drainage system. An
attempt at primary reconstruction is always necessary to prevent epiphora and may involve more extensive
procedures such as conjunctivodacryocystorhinostomy. Stents that are mono or bi-canalicular are the
accepted approach to repair the canaliculi after the torn ends are identified.

CONCLUSION
Eyelid reconstruction remains one of the more challenging areas of the face to reconstruct due to its
dynamic complexity. Thoroughly understanding the anatomy will aid the surgeon as to which
reconstructive option is the best to maintain the functional and aesthetic components of the eyelid.

DECLARATIONS
Acknowledgments
Thank you to Olivia Abbatte for the talented and artistic illustrations provided for this chapter.

Authors’ contributions
The author contributed solely to the article.