Reconstruction around the eye, particularly after resection of skin cancer, is unique, as this tissue plays such an important role to vision and there is very little excess tissue to spare.
No matter the size and specific location of the defect, the principles of eyelid reconstruction remain the same. One must keep the same goals in mind: to restore anatomy, maintain the function of the eyelids — which is to protect the globe — and finally to achieve acceptable cosmesis.
Knowledge of eyelid anatomy is paramount. The eyelid must be recognized as a bilamellar structure — the anterior lamella consisting of the skin and orbicularis muscle and the posterior lamella consisting of conjunctiva, tarsal plate and Mullers muscle. When reconstructing these layers, it is important to ensure that each has appropriate blood supply. Two free grafts cannot be put on top of each other or survival is very unlikely.
When rotating flaps and grafts, be aware of the final lid function and closure. Avoid creating lagophthalmos, entropion or ectropion by oversizing grafts and tightening preexisting eyelid laxity with either a lateral canthal tendon plication or lateral tarsal strip.
When repairing defects that involve the eyelid margin, make sure sutures are not full thickness or that the tails are not rubbing against the ocular surface, which can lead to corneal abrasions, patient discomfort, and scarring of the underlying tissues. Make sure the eyelid margin is everted to prevent future lid notching.
After reconstruction, consider immobilizing the eyelid with a pressure patch for one week that acts as a cast. This will prevent the eyelid from constant movement and risk of dehiscence. Cover the wound first with antibiotic ointment. Post op treatment is minimal and includes light pain medications only (acetaminophen). Avoid narcotics that can mask bigger problems and potentially cause nausea and vomiting.