Eyelid reconstruction

By defect size (full-thickness lower lid)

< 25% lid width

• Direct closure with pentagonal wedge resection.
• Close in anatomical layers, carefully re-aligning the tarsus, grey line / lash line and skin while protecting the cornea.

25–60% lid width

• Tenzel semicircular flap — lateral semicircular advancement-rotation incorporating lateral canthotomy and inferior cantholysis. Single-stage; restores tarsus. Classically described for defects up to ~60% lid width.
• Always perform lateral canthal anchoring to prevent ectropion.

> 60% lid width

• Hughes tarsoconjunctival flap — flap of upper lid tarsus and conjunctiva advanced to lower lid; covered with anterior-lamellar skin graft or local flap. Two-stage; division at ~4–6 weeks (some series 6–8 weeks). Visual occlusion in the interim — generally avoided in young children (typically < 7–9 years) due to amblyopia risk, and used cautiously in monocular patients.
• Mustardé cheek rotation flap — large rotation of cheek skin for very large defects, often combined with tarsoconjunctival graft.

Upper eyelid (full-thickness)

< 50%

• Direct closure with pentagonal wedge.
• Tenzel modification with lateral canthotomy.

> 50%

• Cutler-Beard flap — full-thickness lower lid flap (preserving a 4 mm lower-lid marginal bridge incorporating tarsus and lash line) advanced beneath the intact lower lid margin to the upper lid defect. Two-stage; division at 6–8 weeks.
• Modified Cutler-Beard with chondromucosal graft for tarsal substitute.
• Free composite eyelid grafts for select defects.

Medial & lateral canthus

Medial canthus

• Often heals well by secondary intention if shallow — conscious planning, daily dressings.
• Glabellar V-Y flap or rhombic flap for moderate defects.
• Paramedian forehead flap for deeper defects involving lid borders.
• Protect canaliculi — stent if violated; refer to oculoplastics.

Lateral canthus

• Tenzel-type semicircular flap.
• Periosteal flap from lateral orbital rim for tarsal anchor.

Anterior lamella only (skin loss without tarsus)

• Full-thickness skin graft — best colour and texture match from contralateral upper lid (preferred), upper lid platform, retroauricular, supraclavicular.
• Local advancement, transposition or rotation flap (e.g. nasolabial for medial lower lid).
• Avoid split-thickness grafts on the lid — contracture causes ectropion.

Common pitfalls

• Ectropion from skin shortage, poor lateral canthal support, or split-thickness graft contraction. Lower lid is most susceptible.
• Lagophthalmos in upper lid reconstruction — exposure keratopathy.
• Trichiasis (lashes scraping cornea) from poor anatomical reconstruction at the lid margin.
• Failure to recognise canalicular involvement at medial canthus → epiphora.
• Bilamellar free graft → necrosis and ectropion.