Fortunately for us, cosmetic surgeries of the eyelids rarely challenge us as often as these reconstructive cases.
Yesterday I performed a very challenging reconstruction of the inner corners of both eyelids. The patient had multiple attempts to reconstruct his eyelids after cancers were removed prior to visiting my office. The surgery was complicated because there was complete loss of tissue in several locations, requiring grafting.
When I describe these surgeries to my patients, I usually tell them that the eyelids are like a ham and cheese sandwich (we all have our analogies!).
Prior to undertaking eyelid reconstruction, an understanding the relationships of the various components of the eyelids is critical. To continue the ham sandwich analogy, think of it this way:
TOP BREAD SLICE = skin
HAM = muscle, the orbicularis oculi
CHEESE = the tarsal plate, which you can think of as the “cartilage” of the eyelid
LETTUCE = upper or lower eyelid retractor muscles
BOTTOM BREAD SLICE = conjunctiva, the smooth lining that coats the inside of the eyelids, which is loose enough to allow the eye to move freely
A proper eyelid reconstruction addresses all of these components. So in the case performed yesterday, the CHEESE was replaced by cartilage harvested from the ear, the BOTTOM BREAD SLICE was replaced by tissue from the inside of the lip, and the TOP BREAD SLICE was replaced by skin grafts. And along the way, to restore proper eyelid orientation and tension, wires were passed underneath the bridge of the nose and connected to both sets of composite eyelids, so that they could be directed snugly against the eyeball and maintain the appropriate tension.
After 4 hours, we arrived at a good result, and I am hopeful that we will achieve a restoration in vision afterwards!