This article is more than 5 years old. Information may no longer be current.
Orbicularis mobilization: improved horizontal lid reconstruction technique
The procedure eliminates the need for ipsilateral lid sharing in lower eyelid reconstruction, and is also useful for other procedures.
Click Here to Manage Email Alerts
In today’s fast-paced society, sewing the upper and lower lids together for 4 to 6 weeks is considered more than a minor nuisance. In a one-eyed person, it is obviously a serious deterrent in their lives. It also can create difficulty for patients with ocular medications.
In the commonly-used Hughes technique for reconstruction of the lower eyelid (see preop photo, figure 1), a tarsoconjunctival flap is sewn into the lower lid and is covered with a free skin graft, usually from the upper lid or from behind the ear. The patient is essentially rendered blind in that eye for 4 to 6 weeks, at which time the flap and graft are severed.
Different technique
A tarsoconjunctival graft, usually harvested from the contralateral upper eyelid (figure 2c), combined with orbicularis mobilization and a free skin graft, provides a different technique for eyelid reconstruction that does not interfere with the patient’s sight.
The tarsoconjunctival graft is sewn into the defect with 6-0 or 7-0 silk sutures (figure 2d). The tarsal strips should be approximately 1 mm shorter than the actual horizontal defect to avoid ectropion or eyelid retraction. The orbicularis is undermined from the overlying skin and underlying septum orbitale at the superior margin of the defect in the form of a bipedicle flap (figure 2e, figure 3).
Relaxing incisions in the orbicularis oculi may be necessary to prevent an inferior pulling (with resultant ectropion). The rich blood supply of orbicularis oculi muscle provides an excellent vascular bed for the underlying tarsoconjunctival graft and overlying free skin graft.
Two-to-three 7-0 silk sutures can be used to attach the orbicularis approximately 1 mm inferior to the superior border of the tarsal plate (figure 2f, figure 3). The orbicularis can be sutured lower on the tarsal plate if ectropion occurs. The free skin graft is then sutured into position with interrupted 7-0 silk sutures, usually 0.5 mm inferior to the anterior-superior border of the tarsal plate (figure 2g, figure 4). A plano bandage contact lens is inserted for 2 to 3 weeks to prevent sutures from rubbing against the cornea and globe.
The postop result is comparable to that of the Hughes procedure (figure 5).
| | | |
|
| |
|
|
| | |
|
| | |
Orbicularis oculi muscle
The orbicularis oculi muscle has been used in a variety of reconstructive techniques, including myocutaneous flaps, reduction of canthal folds and modification of the Hughes procedure with repair of cicatricial ectropion as described by Doxanas.
Orbicularis mobilization can be combined with a variety of techniques in eyelid and periorbital reconstruction, such as reconstruction of the lateral canthal tendon with periosteal flaps, composite flaps, mucosal and skin grafts, large defects of the lateral canthal area, the infratemporal fossa and medial canthus. This technique is also excellent for horizontal upper eyelid reconstruction.
These kinds of techniques of eyelid reconstruction should be considered as options when a Hughes procedure or a Cutler-Beard type procedure is being offered. This technique can also be combined with a Tenzel flap for larger lesions.
For Your Information:References:
- Thomas C. Naugle Jr., MD, is clinical professor of ophthalmology, Tulane Medical School. He can be reached at 2633 Napoleon Ave., Suite 814, New Orleans, LA 70115; (504) 899-1715; fax: (504) 897-2162.
- Naugle TC, Levine MR. Free graft enhancement during orbicularis mobilization. Ophthalmol. 1995;102:493-500.
- Doxanas MT. Orbicularis mobilization and eyelid reconstruction. Arch Ophthalmol. 1986;104:910-914.