Total Eyelid Reconstruction in the Anophthalmic Orbit Simplified: The Trilamellar Temporoparietal Fascia Flap

Summary:

Total eyelid reconstruction poses a challenge to the reconstructive surgeon. In the anophthalmic orbit, the reconstructive goals are more limited than in a functional, seeing eye. Eyeball protection is obviously not an issue, and the goal is to create a cosmetically acceptable autologous structure capable of retaining and accommodating an ocular prosthesis. A number of techniques have been described for the reconstruction of the total loss of both eyelids. However, reconstruction of both eyelids in the anophthalmic orbit has received less attention in the literature. A simplified technique for total eyelid reconstruction in anophthalmic orbits is described herein, with a trilamellar construct using the temporoparietal fascia flap and skin grafts. The palpebral fissure is created under local anesthesia 3 weeks after the index procedure with an acceptable cosmetic result.

Total eyelid reconstruction poses a challenge to the reconstructive surgeon. When there is a functional, seeing eye, the challenge is formidable, and no technique, to date, can replicate the finesse of movement and function of the native eyelids. In the anophthalmic orbit, the reconstructive goals are more limited. Eyeball protection is obviously not a concern (no lubrication or blinking is needed), and the goal is to create a cosmetically acceptable autologous structure capable of retaining and accommodating an ocular prosthesis. The socket has to be ample, the eyelids should be rigid enough to retain the ocular prosthesis, and the external skin coverage should blend in color and texture with the rest of the face.

A number of techniques have been described for the reconstruction of total loss of both eyelids, especially in the presence of a seeing eye,^1–3 with varied degrees of success. The reconstruction of anophthalmic, contracted orbit has also received some attention in the literature.^4,5 However, reconstruction of both eyelids in the anophthalmic orbit has received less attention in the literature, with most techniques described including prefabrication or prelamination of reconstructive flaps⁶

A simplified technique for total eyelid reconstruction in anophthalmic orbits is described herein, with a trilamellar construct using the temporoparietal fascia (TPF) flap and skin grafts. The palpebral fissure is created under local anesthesia 3 weeks after the index procedure.

CASE REPORT

A 51-year-old man presented 1 year after the traumatic loss of the right eye and both eyelids (Fig. 1), without significant comorbidities. The patient was offered anaplasty but refused this option. A single-stage reconstruction was performed using the remaining skin of the orbit as the posterior coverage of the orbital pouch and the ipsilateral TPF flap for anterior coverage (Fig. 2). The contralateral normal side was used as a size reference. Under general anesthesia, the remaining skin of the orbit was incised circumferentially, and the edges were undermined by 1 cm. The TPF flap was elevated using a zig-zag incision and tunneled to the orbital region without bone removal. A full-thickness skin graft (FTSG) was harvested from the groin region and sutured to the deep surface of the TPF flap and to the edge of the remaining posterior skin of the orbit over a bolus of antibiotic-petrolatum gauze slightly larger in size than the contralateral eyeball. The TPF was sutured to the raw surface between the undermined skin edges, and a color-matched retroauricular FTSG was harvested and sutured to the outer skin edge, over the outer surface of the TPF flap (Fig. 3). The patient was discharged in 24 hours. The double skin graft was allowed to take on both sides of the TPF for 3 weeks. No complications occurred.

Fig. 1.

A 51-year-old man with traumatic loss of the right eye and eyelids.

Fig. 2.

Sketch of the surgical procedure. A, Sagittal section of the anophthalmic orbit. B, The skin junction between normal and scarred skin is incised circumferentially. C, The trilamellar structure (TPF flap, groin, and retroauricular FTSG) is left for 3 weeks.

Fig. 3.

Intraoperative view. The TFP flap has been elevated and tunneled to the orbital region. The inner FTSG is already sutured, and the outer retroauricular FTSG lies beside, to be sutured over the TPF after insetting.

The position of the eyelid fissure was marked with the patient in the upright position, and the trilamellar construct was incised under local anesthesia, with both epithelial layers sutured. The eye prosthesis was fitted 4 weeks later. Tattooing of the gray line of the eyelashes was offered to the patient to improve cosmesis, but the patient refused it. The final cosmetic result was acceptable to the patient, although far from normal (Fig. 4).

Fig. 4.

Postoperative image at 3 years, with acceptable symmetry, good color match, and relatively good overall result.

DISCUSSION

Total eyelid reconstruction in the anophthalmic orbit is primarily a cosmetic procedure. There is no functional eye to protect, so issues such as lubrication, blinking, and emergencies do not apply. The goal is to create a stable autologous structure that resembles native eyelids as much as possible. This structure should have 3 layers: a firm connective tissue covered by outer color-matched skin and inner nonspecific skin. The need for cartilage grafts to stiffen the reconstruction has been suggested but is not uniformly considered necessary.^6,7 Acellular dermal matrix, instead of cartilage grafts, has also been reported.⁸

Many reconstructive procedures have been previously described and systematically reviewed for an orbital exenteration/anophthalmic orbit.⁹ However, when available, the pedicled ipsilateral TPF flap is an excellent source of ample, thin, and well-vascularized tissue that easily reaches the periorbital region. The construction of a 3-layered structure can be performed by prelamination (skin pregrafting) of the flap as a staged procedure or by directly skin-grafting both sides of the TPF flap in the periorbital region, as described herein. The pros and cons of prefabrication and prelamination have already been discussed in the literature.¹⁰ Given the excellent vascularization of the TPF, skin graft take is predictable, and prelamination offers no clear advantage. The inner aspect of the reconstructed eyelids in the anophthalmic orbit can be lined with keratinized stratified squamous epithelium from nonspecific skin, as neither humidity nor color match is an issue. An FTSG from the groin, as used in the technique described, is adequate. The physiological desquamation of the epithelium of the inner FTSG over the closed cavity around the gauze ball for 3 weeks does not cause any problem, so drainage is not necessary. The delay in the creation of the eyelid fissure provides safety (there is cross-circulation through the healed perimeter of the flap) and improves symmetry. Choosing a bifurcation of the superficial temporal vessels would allow immediate splitting of the flap and construction of the eyelid fissure, but probably compromise accurate and symmetrical placement. The use of scalp hair incorporated into the prefabricated TPF for eyelash reconstruction has been described in similar patients,⁵ although the parallel and graceful curvature of the eyelashes is rarely, if at all, duplicated by scalp hair.

The technique described herein is relatively simple, and the result is cosmetically acceptable. The TPF flap is familiar to most surgeons, and the planning and execution are straightforward. The rigidity of the trilamellar FTSG/TPF/FTSG construct is sufficient to retain an eye prosthesis. The technique does have disadvantages. It is not a single-stage procedure (the palpebral fissure is incised as a minor, separate procedure), although it avoids prefabrication (with the unavoidable scarring of the flap). The reconstruction is not dynamic, although in the anophthalmic orbit, this is less of a problem. In fact, this technique is indicated for eyelid reconstruction only in patients with anophthalmic orbit. The eyelashes cannot be reconstructed with this technique, although tattooing can be offered to the patient. Despite these disadvantages, the trilamellar TPF is a useful technique that could be part of the armamentarium of a surgeon considering complete eyelid reconstruction in the anophthalmic orbit.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

The patient provided written consent for the use of his image.