Principles of Eyelid Reconstruction

Is reconstruction necessary? The upper lid is essential for sight, the lower lid optional. Do not interfere with the upper lid function when using it as a donor. Reconstruction options range from laissez-faire to total eyelid reconstruction. Direct anatomical closure gives the best functional and cosmetic result through primary intention healing. Induced palpebral aperture distortion disappears through tissue expansion, within 2 months. Cantholysis has a negative effect on expansion. Undermining is unnecessary, creating additional scar planes. Directed laissez-faire is an option if full closure is impossible. Complex reconstruction involves tissue transfer. Favour periocular donor tissue over more distant sites. When planning flaps or grafts anticipate scar contraction. Measure the true defect size by pulling the wound edges together in the direction of the skin tension lines. The lid margin tolerates such tangential force well. Radial tension causes ectropion or retraction. Suture tension is lost through migration within weeks. Permanence is only achieved through scarring. Reconstruct both lid lamellae and a stable margin centrally in the all-important upper lid. Delay revision surgery by 2–12 months to allow for scar maturation and remodelling.