The choice of reconstructive technique for eyelid defectsafter malignant tumors was based on tumor location anddefect size after tumor excision. Treatments includeddirect closure for defects measuring less than 25%, Tenzelflap for defects measuring 25–50%, lid-sharing proceduresfor defects measuring more than 50%, skin grafts fortumors affecting the inner canthus advancement flap forouter canthus tumors, and orbital exenteration for malig-nant tumors demonstrating orbital invasion.

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INTRODUCTIONMalignant eyelid tumors include basal cell carcinoma,squamous cell carcinoma, malignant melanoma, seba-ceous carcinoma, and Merkel cell tumor. Basal cell car-cinoma can recur locally, but rarely invades the orbitand the cranial cavity. On the other hand, advancedbasosquamous and squamous cell carcinomas caninvade the orbit and, if left untreated, can cause deathby invading the cranial cavity (1). These tumors mayalso demonstrate regional lymph node metastasis. Seba-ceous carcinoma, malignant melanoma, and Merkel celltumor can metastasize to the regional lymph nodes anddistant organs (2–4). Therefore, malignant eyelidtumors should be considered life-threatening and treatedaccordingly.

The goal of treatment of malignant eyelid tumors is toremove the malignancy completely. The defect resultingfrom the excision of the tumor and tumor-free margins isoften large, and specialized surgical techniques arerequired for reconstruction of the eyelids. The defectshould be repaired in such a way that the eyelids do notexpose the globe or obstruct vision, and the cosmeticappearance is as normal as possible. In some cases, com-plete removal of a malignant eyelid tumor precludesreconstruction of the eyelids, and in these cases, exenter-ation is performed, sacrificing the globe.

This article describes surgical techniques that wehave found to be successful in the reconstruction of theeyelids after excision of malignant eyelid tumors in

KAAN GUNDUZ, MD,SIBEL DEMIREL, MD,ILHAN GUNALP, MD,BURCU POLAT, MD

R E P R I N T S :Kaan Gündüz MD, Mesa Koza Plaza 24/18, GOP 06700, Ankara, Turkey. E-mail: eyemd@ada.net.tr.

Drs. Gündüz, Demirel, Günalp, and Polat are from the Ocular Oncology Ser-vice, Department of Ophthalmology, Ankara University Faculty of Medicine,Ankara, Turkey.

The authors have stated that they do not have a significant financial interest orother relationship with any product manufacturer or provider of services dis-cussed in this article. The authors also do not discuss the use of off-label prod-ucts, which include unlabeled, unapproved, or investigative products ordevices.

Submitted for publication: 6/2/06. Accepted: 6/29/06.

Annals of Ophthalmology, vol. 38, no. 3, Fall 2006© Copyright 2006 by ASCO All rights of any nature whatsoever reserved. 1530–4086/06/38:207–212/$30.00. ISSN 1558–9951 (Online)

O R I G I N A L A R T I C L E

Surgical Approaches Used in the Reconstructionof the Eyelids After Excision of Malignant Tumors

A B S T R A C T

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various lid locations. It does not aim to discuss theresults of surgery in terms of tumor-margin-controlledsurgery and subsequent recurrence.

MATERIALS AND METHODSThe medical records of 100 consecutive cases of malig-nant eyelid tumors that underwent surgical excision andreconstruction by one of the authors (KG) betweenOctober 1998 and April 2006 at the Ankara UniversityFaculty of Medicine were retrospectively evaluated withrespect to the choice of reconstructive technique usedafter excision of eyelid malignant tumors. Differenttechniques had been used for eyelid reconstructiondepending on the tumor location and size of defect thatremained after excision of the tumor with 3–4 mmtumor-free margins on each side. In cases where tumorpositive margins were found on frozen section control,further eyelid tissue was resected to ensure a tumor-freemargin. The patients were seen at 7–10 days after thesurgery for suture removal, at 1-, 3-, and 6-month inter-vals thereafter to determine any complications related tothe surgical reconstruction technique.

Periocular malignancies were divided into three majorcategories: those with eyelid margin involvement, thosewithout eyelid margin involvement, and those withorbital involvement. Tumors that involved the eyelidmargin were subdivided into four groups according tothe involvement site, i.e., lower eyelid, upper eyelid,inner canthus, and outer canthus. Surgical techniquesused for each group are detailed below.

Lower Eyelid TumorsEyelid defects occupying less than 25% of the eyelidlength were treated with direct closure and lateral can-tholysis, whereas those involving 25–50% of the eyelidlength were treated with a lateral advancement flap(Tenzel procedure). The Tenzel procedure involves a lat-eral myocutaneous advancement flap with cantholysis(5). After the lateral canthal tendon is cut through thelateral conjunctival fornix, a curvilinear incision archingupward is created. The skin and the subcutaneous tissuesare dissected, and the ends of the lid remnants arealigned. In closing the incision, the lateral canthus mustfirst be reconstructed (5). In eyelid defects affecting lessthan 50% of the eyelid and located in the lateral half ofthe lower eyelid extending to the outer canthus, an uppereyelid advancement flap with tarsoconjunctival graftfrom the upper eyelid was used.

For tumors occupying more than 50% of the lowereyelid, Hughes tarsoconjunctival flap and skin graft

were used (6). In this technique, a tarsoconjunctivaladvancement flap from the upper eyelid is brought downto fill the lower eyelid defect. After the upper eyelid iseverted on a Desmarres retractor, a scalpel is used tomark the tarsal extent of donor tissue. The tarsoconjunc-tival flap is sutured to the respective conjunctival andtarsal surfaces of the lower eyelid defect. A free skingraft is then sutured to the defect to create the anteriorlamella of the lower eyelid. Four to six weeks after theinitial surgery, the tissue of the upper eyelid is incisedjust above the reconstructed lower eyelid edge using aconvex superior curved incision.

Upper Eyelid TumorsSmall defects affecting less than 25% of the upper eye-lid were repaired with primary closure and lateral can-tholysis when necessary. Defects measuring 25–50% ofthe upper eyelid were reconstructed using a Tenzel lat-eral advancement flap with the myocutaneous flaparched downward. For defects involving more than 50%of the upper eyelid, a Cutler-Beard flap was used (7). Inthis technique, a full-thickness lower eyelid flap is fash-ioned 4–5 mm inferior to the lower eyelid margin. Thelength of the horizontal lower eyelid incision should beequal to the defect present in the upper eyelid. A hori-zontal incision is made through the entire lower eyelid.The medial and lateral edges of the lower lid advance-ment flap are incised with sharp scissors, and the full-thickness flap is passed under the bridge of the marginof the lower eyelid. A three-layer closure of conjuncti-val, subcutaneous, and, finally, skin tissues are used toconnect the flap with the tissues at the edges of theupper eyelid defect. The bridge flap is separated 6–8weeks after initial surgery (7).

In cases with eyelid and cheek involvement, a Mus-tarde cheek rotation flap was used. In this procedure, alarge myocutaneous flap is created with the superioredge of the flap at the edge of the tragus and broughtdown vertically just in front of the ear. A medial triangleof skin and subcutaneous tissues is excised to allowsuturing of the flap to the nasal edge of the wound (8).

Inner Canthus TumorsA skin graft obtained from the retroauricular area orupper eyelid was used in the reconstruction of the defectafter excision of inner canthus tumors. The size of theskin graft was 25% larger than the defect size. The skingraft was firmly attached to the subcutaneous tissues toallow adequate vascularization of the graft. In cases withlarge medial canthus defects, a Tenzel lateral advance-ment flap was used in combination with the skin graft to

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mobilize the lower eyelid medially to fill in the defect.In selected cases in which the medial aspect of the uppereyelid was also affected, a glabellar forehead flap wasused (9). In this technique, a triangular glabellar flap isprepared. Extensive undermining of the forehead skinand subcutaneous tissues is necessary. The length of theflap is usually adjusted to be not more than four to fivetimes its width.

Outer Canthus TumorsIf the defect involved primarily the outer canthus andextended into an eyelid, an advancement flap from theother eyelid was used to close the defect. A tarsoncon-junctival graft from the upper eyelid was harvested inlarger lower eyelid defects to reconstruct the posteriorlamella. Defects in either the upper or the lower eyelidextending to the outer canthus were treated with a Ten-zel lateral advancement flap. When the lateral eyeliddefect was large, a modified Hughes tarsoconjunctivalflap procedure was used alongside the Tenzel lateraladvancement flap in the reconstruction of the posteriorlamella in lower eyelid tumors.

Tumors Without Eyelid Margin InvolvementTumors that did not involve the eyelid margin weretreated with primary closure, and a skin graft wasobtained from the retroauricular area, or V–Y rotationflap (10). In the V–Y rotation flap technique, the rotationflap is fashioned as a V, rotated in the defect, and closedas a Y.

Tumors With Orbital InvasionTumors demonstrating neuroimaging evidence of orbitalinvasion on computed tomography or magnetic reso-nance imaging were treated with eyelid-sacrificingorbital exenteration and spontaneous granulation (11).

RESULTSOf 100 patients, 54 (54%) were males and 46 (46%)were females. The mean age of the patients was 61.9years, ranging from 20 to 86 years. The tumor affectedthe lower eyelid in 36 cases (36%), inner canthus in 22cases (22%), upper eyelid in 17 cases (17%), outer can-thus in 9 cases (9%), contiguous periocular skin in 7 cases (7%), and eyelids and orbit in 9 cases (9%). Onecase included with the lower eyelid tumors had multifo-cal involvement in the upper eyelid as well. The meanlargest tumor base diameter was 2.6 cm, ranging from1.0 to 4.0 cm.

Table 1 shows the reconstructive approaches used inthe reconstruction of malignant eyelid tumors. Tenzellateral advancement flap was the most commonly usedprocedure in 27 cases (27%), followed by skin graft in16 cases (16%), primary closure in 13 cases (13%),Hughes tarsoconjunctival flap and skin graft in 12 cases(12%), and exenteration in 9 cases (9%). Table 2 showsthe breakdown classification of the reconstructive tech-nique used according to tumor location. In lower eyelidtumors, Tenzel lateral advancement flap was used in 13(13%) cases, Hughes tarsoconjunctival flap and skingraft in 12 cases (12%), primary closure in 5 cases (5%),upper eyelid advancement flap and tarsoconjunctivalgraft in 4 cases (4%), and Mustarde’s cheek rotation flapin 2 cases (2%). In inner canthus tumors, skin graft wasused in 15 cases (15%), glabellar forehead flap in 3 cases (3%), Tenzel lateral advancement flap in 2 cases(2%), and skin graft plus Tenzel lateral advancementflap in 2 cases (2%). In upper eyelid tumors, Tenzel lat-eral advancement flap was used in 10 cases (10%), pri-mary closure in 4 cases (4%), and Cutler-Beard flap in 3 cases (3%). In outer canthus tumors, Tenzel lateraladvancement flap and Hughes tarsoconjunctival flap

TABLE 1

The Breakdown Classification of the SurgicalApproaches Used in the Reconstruction of the

Eyelids After Excision of Malignant Eyelid Tumors

Number (%) Surgical approach used of patients

Tenzel lateral advancement flap 27 (27%)Skin graft 16 (16%)Primary closure 13 (13%)Hughes tarsoconjunctival flap + 12 (12%)

skin graftExenteration 9 (9%)Eyelid advancement flap + 6 (6%)

tarsoconjunctival graft Glabellar forehead flap 3 (3%)Cutler-Beard flap 3 (3%)Tenzel lateral advancement flap + 3 (3%)

Hughes tarsoconjunctival flapEyelid advancement flap 2 (2%)Skin graft + Tenzel lateral 2 (2%)

advancement graftMustarde’s cheek rotation flap 2 (2%)V–Y skin advancement flap 2 (2%)

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were used in three cases (3%), eyelid advancement flapin two cases (2%), eyelid advancement flap and tarso-conjunctival graft in two cases (2%), and Tenzel lateraladvancement flap in two cases (2%). In cases with con-tiguous periocular skin tumors not involving the eyelidmargin, primary closure was used in four (4%) cases,

V–Y skin rotation flap in two cases (2%), and skin graftin one case (1%). Nine cases (9%) with orbital involve-ment were treated with exenteration. Eyelids recon-structed with various techniques are illustrated in Figs.1–3; skin graft-Tenzel lateral advancement flap in innercanthus (Fig. 1); Tenzel lateral advancement flap in anupper eyelid (Fig. 2); and advancement flap in an uppereyelid (Fig. 3).

Histopathological examination revealed basal cell car-cinoma in 67 cases (67%), basosquamous carcinoma in10 cases (10%), squamous cell carcinoma in 14 cases(14 %), sebaceous carcinoma in 7 cases (7%), malignantmelanoma in 1 case (1%), and Merkel cell tumor in 1case (1%). At a mean follow-up of 37.8 months (range:6–60 months) complications related to the reconstruc-tive procedures included symblepharon in five cases(5%), partial ptosis in three cases (3%), notching of theupper eyelid in three cases (3%), and ectropion in twocases (2%). Loss of eyelashes was a common problemin almost all cases involving the eyelid margins.

TABLE 2

The Breakdown Classification of the SurgicalApproach Used in Eyelid Reconstruction

According to Tumor Location

Number (%)Treatment approach of patients

Lower eyelid 36 (36%)Tenzel lateral advancement flap 13 (13%)Hughes tarsoconjunctival flap + 12 (12%)

skin graftPrimary closure 5 (5%)Upper eyelid advancement flap + 4 (4%)

tarsoconjunctival graftMustarde cheek rotation flap 1 (1%)V–Y skin advancement flap 1 (1%)

Inner canthus 22 (22%)Skin graft 15 (15%)Glabellar forehead flap 3 (3%)Tenzel lateral advancement flap 2 (2%)Skin graft and Tenzel lateral 2 (2%)

advancement flapUpper eyelid 17 (17%)

Tenzel lateral advancement flap 10 (10%)Primary closure 4 (4%)Cutler-Beard flap 3 (3%)

Outer canthus 9 (9%)Tenzel lateral advancement flap and 3 (3%)

Hughes tarsoconjunctival flapEyelid advancement flap 2 (2%)Eyelid advancement flap and 2 (2%)

tarsoconjunctival graftTenzel lateral advancement flap 2 (2%)

Eyelid margin not involved 7 (7%)Primary closure 4 (4%)Mustarde’s cheek rotation flap 1 (1%)V–Y skin advancement flap 1 (1%)Skin graft 1 (1%)

Orbital involvement 9 (9%)Exenteration 9 (9%)

Figure 1––(A) A 60-year-old patient with squamous cellcarcinoma affecting the inner canthus and inferior eyelid.(B) Postoperative photograph 8 months after tumor excisionand reconstruction with skin graft and Tenzel lateraladvancement flap.

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DISCUSSIONThere are several options for the reconstruction of theeyelids after excision of malignant tumors. The choiceof reconstructive technique depends on size and locationof tumor, the surgeon’s preferences, and patient charac-teristics, such as laxity of the skin and canthal tendon.Tumors not involving the eyelid margin can be treatedwith primary closure in most cases. When the defect islarge and not amenable to primary closure, a skin graftfrom the retroauricular area or a V–Y rotation flap canbe used (12). Alternatively, the wound can be left to healby spontaneous granulation (12).

The treatment approach to tumors involving the eyelidmargin is more complex. In these cases, reconstructionof both anterior and posterior lamellae of the eyelid isrequired. The anterior lamella consists of the skin andsubcutaneous tissue, and the posterior lamella comprisesthe tarsus and the conjunctiva. The reconstruction of theanterior lamella is achieved with various skin flaps and

grafts. The reconstruction of the posterior lamella isachieved by lateral advancement flaps from the remain-ing tarsus and conjunctiva, Hughes tarsoconjunctivalflap, and tarsoconjunctival grafts. As a general principle,two grafts should not be used in the reconstruction ofthe anterior and posterior lamellae. Other combinations,including a graft and flap or two flaps, can be used.

Defects involving less than 25% of the upper or lowereyelid can be repaired with direct closure and cantholy-sis when necessary. In our experience, defects measur-ing 25–50% of the upper and lower eyelid are besttreated with a Tenzel lateral advancement flap. Fordefects involving more than 50% of the eyelid, we rec-ommend lid-sharing procedures: Cutler-Beard flap fordefects in the upper eyelid and Hughes tarsoconjunctivalflap with skin graft for defects in the lower eyelid.

If the tumor affects the inner canthus, we generallyused a skin graft from the retroauricular or the uppereyelid area. A skin graft has the versatility to be trimmedto any shape needed to fill in the defect. In cases withlarge defects in the medial canthal area, Tenzel lateral

Figure 2––(A) A 50-year-old patient with basal cell carcinomaaffecting the upper eyelid. (B) Postoperative photograph 1 year after tumor excision and eyelid reconstruction using Tenzel lateral advancement flap. Note the slight notching inthe upper eyelid margin.

Figure 3––(A) A 75-year-old patient with basal cell carcinomaaffecting the upper eyelid. (B) Postoperative photograph of thesame patient 2 months after tumor excision and eyelid recon-struction using advancement flap.

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advancement flap to mobilize the lower eyelid mediallycan be used in combination with a skin graft to fill in thedefect. A glabellar forehead flap can be used if themedial aspect of the upper eyelid is also affected.

For reconstruction in the outer canthal area, an ad-vancement flap or Tenzel lateral advancement flap isrecommended. If the defect involves primarily the outercanthus and extends into an eyelid, we used an advance-ment flap from the other eyelid to close the defect. Atarsonconjunctival graft from the upper eyelid can beused in larger lower eyelid defects to reconstruct theposterior lamella. For defects in either the upper or thelower eyelid extending to the outer canthus, a Tenzel lateral advancement flap is recommended either singlyor in combination with a modified Hughes tarsoconjunc-tival flap, the latter being used to reconstruct the poste-rior lamella in the case of larger lower eyelid defects.

In addition to the surgical techniques that we havedescribed, several other reconstructive approaches havebeen reported in the literature. Some of these techniqueshave focused on eliminating the need for prolonged clo-sure of the eyelids in lid-sharing operations as in theHughes procedure. A tarsoconjunctival pedicle flap(Hewes-Beard procedure) was used for reconstruction oflower eyelid defects instead of the Hughes procedure.With this technique, there is no need for the eyelids toremain closed for extended periods of time (13). How-ever, a recent study demonstrated that a period of sevendays does not compromise the viability of the flap inHughes procedure (14). Therefore, according to thisstudy, separation of the flap can be done at seven daysand prolonged closure of the eyelids for 4–6 weeks doesnot seem to be necessary. The Mustarde cheek rotationflap is another technique that has been be used in thereconstruction of lower eyelid and cheek defects. Thismethod is rarely used today because the Hughes tarso-conjunctival flap with skin graft or the Hewes-Beardprocedures are at least as effective as the Mustardecheek rotation flap and much simpler to perform.

For the reconstruction of medial canthus defects, aV–Y rotation flap can also be used. The flap can betaken from the glabellar area or the area inferior to themedial canthus defect (10). Other techniques for thereconstruction of medial canthal tumors, including Gor-ney’s flap procedure (15), and laissez-faire (spontaneousgranulation) approach (16, 17), are occasionally usedtoday. In Gorney’s flap procedure, a full-thickness pedi-cle flap is taken from the upper eyelid and positioned tofill in the defect in the lower eyelid. This procedure canalso be used for lateral canthus defects (15).

Neglected or inadequately treated malignant eyelidtumors have a propensity to invade the orbit. Orbital inva-

sion probably carries a worse prognosis in terms of regionallymph node and distant metastasis (18). Therefore, exenter-ation is necessary for tumor eradication in these cases (19).

In summary, the surgical preferences of the authors inthe reconstruction of eyelid tumors at different locationshave been described in this study. Successful cosmeticresults have been obtained in the reconstruction of theeyelid defect after excision of malignant eyelid tumors.Surgical techniques used alone or in combination wereprimary closure, Tenzel lateral advancement flap, skingraft, advancement flap, lid-sharing operations, includ-ing Hughes and Cutler-Beard procedures, glabellar fore-head flap, and Mustarde’s cheek rotation flap. Orbitalexenteration was necessary in malignant eyelid tumorsdemonstrating orbital invasion.

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