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July - September 2006 149
Review Article

Techniques of periocular reconstruction

Vidushi Sharma, MD, FRCS; Ross Benger, FRANZCO; Peter A Martin, FRANZCO

Eyelid and periocular reconstruction is often needed in ophthalmic practice, as a result of defects created
by excision of lesions or following trauma. A variety of techniques have been described for the repair of
these defects. However, it is important to have a knowledge of the basic principles underlying all these
techniques and the advantages and disadvantages of each, so as to ensure the selection of the optimal
technique in a particular case. Different authors have popularized different techniques based on individual
preferences and experiences and a brief overview of the different techniques will be helpful to compare
them. The articles referenced in this manuscript were looked up through PubMed by feeding the keywords
‘periocular reconstruction’ and ‘eyelid reconstruction’ and then looking for relevant cross-references. In
this review, we have discussed the various techniques available and also illustrated them diagrammatically
to have a quick overview of the topic.

Key words: Cutler-Beard technique, eyelid reconstruction, hughes technique, periocular flap, periocular
reconstruction, skin flap.

Indian J Ophthalmol 2006;54:149-58

Eyelid and periocular reconstructions are frequently required
for defects due to trauma or following excision of neoplasms.
Reconstruction techniques have evolved over time and
excellent results can now be achieved with a combination of
ingenious flaps and grafts. While defects involving eyelid
margins are given a lot of attention, defects in the periocular
area are sometimes repaired, without much attention to
cosmesis. A poorly performed reconstruction or the
injudicious selection of a technique may be harmful for the
eye and may necessitate further surgical correction.1 The exact
technique to be used, depends on the defect size, location and
the elasticity of the surrounding tissues, which in turn depends
on the patient’s age. A graded approach consisting of direct
approximation, horizontally oriented advancement flaps,
rotation flaps and free skin grafts, in that order, depending on
the defect, should give good results in all cases.2 The aims should
be to achieve normal eyelid function and eye protection, with a
good cosmesis. This article discusses various techniques
commonly used for periocular reconstruction with their
advantages and disadvantages, with an emphasis on different
flaps. The articles referenced in this manuscript were looked
up through PubMed using the keywords ‘periocular
reconstruction’ and ‘eyelid reconstruction’ and then looking at
cross-references. Alternative keywords were also fed for the
commonly used techniques, such as Hughes and Cutler-Beard.
General considerations in periocular reconstruction
1. The eyelids can be divided into 2 lamellae, the anterior
Oculoplastic Unit, Sydney Eye Hospital, Save Sight Institute,
University of Sydney, Sydney, Australia; and SuVi Eye Hospital and
Research Centre, Kota, Rajasthan, India
Correspondence to Dr. Vidushi Sharma, SuVi Eye Hospital and
Research Centre, A-475, Indra Vihar, Kota, Rajasthan, India.
E-mail: svidushi@hotmail.com
Manuscript received: 4.9.05; Revision accepted: 28.11.05
skin-muscle and the posterior tarso-conjunctival lamella.
Both need to be replaced for structural integrity and
cosmesis. In general, one of these two lamellae needs to
be reconstructed as a flap to ensure adequate
vascularization and the other lamella can then be replaced
with a free graft. However, there have been attempts to
reconstruct the whole lower eyelid with a single thick flap.3
2. There are a number of natural lines in the periocular area,
which can hide surgical scars. The incisions should be
placed along the relaxed skin tension lines or the skin
wrinkle lines (which are more or less similar), to avoid
prominent scarring.4 An exception should be made to
avoid tension on free margins of the eyelids, where a
horizontal ellipse may produce ectropion on direct closure
[Figure 1].5 When scars are not placed along these natural
lines, curved scars are less conspicuous than straight scars.5
The upper lid crease can be used for most skin incisions
involving the upper eyelid.5
3. The cosmetic result depends to a large extent on the
symmetry between the two sides, which should not be
compromised.5
4. The rich vascular supply in this area provides excellent
postoperative healing, but also predisposes the patient to
greater swelling, bruising (which is not so obvious in dark
skin) and ecchymosis of the thin tissues.5 The patient
should be informed about this preoperatively.
5. Sutures should always be placed with any knots on the
cutaneous side, to avoid corneal irritation.
6. Sutures should be passed to ensure that the suture loop
is wider in the deeper layers than in the superficial layers,
to evert the edges and avoid depressed scars. This is
achieved by passing the needle perpendicular to the skin
surface and not in a tangential manner, as is often done
[Figure 1].6
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150 INDIAN JOURNAL OF OPHTHALMOLOGY
Figure 1: Principles of reconstruction. The figure on the left shows two
possible methods of excision of lesions in the periocular area. A
horizontal spindle as in A causes ectropion on closure and therefore
vertical spindles as in B are preferred even though this crosses the
natural skin crease lines in this area. The figure on the right shows two
possible ways of passing the needle for suturing of skin. A needle passed
perpendicular to the skin as in the top figure causes the deep loop BB’
to be larger than the superficial loop AA’ and therefore causes heaping
(eversion) of the skin edges on closure and prevents a sunken scar.
The figure on bottom shows the incorrect method where the needle
follows a curve while entering skin, causing BB’ to be narrower than
AA’ and leading to a sunken scar
7. Traction sutures placed on the lower or the upper eyelid
during the healing phase may be useful in avoiding lid
retraction and ectropion. Postoperative massage may also
help in this regard.
Advantages of flaps
Various types of flaps can be fashioned in the periocular
tissues. While skin and skin-muscle flaps are commonly used,
tarsoconjunctival flaps are useful in reconstruction of the
posterior lamella. The advantages of using flaps as compared
to a free skin graft for anterior lamellar reconstruction are:
a. Flaps have some degree of their own blood supply and
therefore heal faster.4
b. The color and texture is best matched by the use of adjacent
skin. The thin upper eyelid skin may be suitably replaced
by a full-thickness skin graft, but in the thicker skin of the
lower eyelid and especially the periocular regions, this
may not be a good match.2,4,5,7
c. Skin flaps do not contract as much as skin grafts.4
d. The adnexal structures have a better chance of survival in
flaps, thus contributing further to a normal appearance.5
e. Flaps avoid additional surgery at a remote site and are
easily mobilized in the relatively elastic skin of the face.
f. Flap thickness can be varied according to the defect depth,
whereas skin grafts should always be of minimal thickness
to ensure survival.8
g. Flaps can be fashioned so as to exert traction in a horizontal
direction, thus avoiding any pull on the lid margin which
can cause ectropion.8
Vol. 54 No. 3
h. The main source of blood supply to the facial skin is from
underlying muscles and therefore flaps do not have to be
based on a specific blood vessel (axial pattern flaps), but
rather can be of a random pattern.4,9 These random pattern
flaps can have a much higher length to width ratio (up to
1:6) as compared to other areas of the body, due to the
rich blood supply.6 Myocutaneous flaps have the added
advantage of greater vascularity and may sometimes
retain some muscular function.10
Despite these advantages, upper eyelid skin is best replaced
by thin skin grafts, preferably taken from the contralateral
upper eyelid. Even though flaps from the preseptal upper
eyelid skin may be advanced into marginal defects, the use of
thicker periocular flaps is inadvisable as they are bulky and
the levator may not be able to lift the resultant bulky eyelid.11
Basic types of flaps [Figure 2]
The various flaps used in this area can be divided into 5
types:
a. Sliding flap: Where the skin surrounding a simple ellipse
is undermined to close the defect.
b. Advancement flap [Figure 3 a, b, c, d and e]: The
surrounding skin is fashioned into a three sided flap,
which is dissected and advanced on its own long axis to
close the adjacent defect.4
c. Rotation flap: These flaps are commonly used in the
periocular area, where the directly adjacent skin is lifted
and rotated on itself to fill the defect.4
d. Transposition flap: In these flaps, the skin not directly
adjacent, but close to the defect, is lifted over the
intervening skin and fitted into the defect. The angle of
rotation in these flaps should not be too large, as a large
degree of rotation at the flap base may compromise blood
supply to the tip.4
e. Island flap [Figure 3f]: This flap consists of a free island of
skin and muscle, where the flap is freed from all sides,
but remains attached to a central subcutaneous pedicle;
Figure 2: Types of flaps. 1. Sliding flap. 2. Single advancement flap or U
plasty. 3. Double advancement flap or H plasty. 4a, 4b and 4c. Different
types of rotation flaps. 5. Transposition flap. 6. Island or subcutaneous
flap.
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July - September 2006 Sharma et al. Techniques of periocular reconstruction 151

a b c

Figure 3a, b, c: Demonstration of a single advancement flap or U plasty to close a medial defect of the upper lid. The nasal defect was closed with
a bilobed flap

d
Figure 3f: Demonstration of the design of an island flap. This flap is
attached on a central pedicle and can be moved to fill an adjacent
defect.

Figure 3d, e: Demonstration of the use of double advancement flap or

H plasty to close an upper lid defect.

the flap can now be considerably advanced in any

direction to fill in the defect and the flap site can be
repaired by direct closure.
Limberg rhomboid flap [Figures 4a and b, 5a
and b]
This is one of the most useful flaps and can be used in any
area of skin 12 including the periorbital area. Originally
described by Alexander Limberg in 1946, the basic concept
consists of creating a rhomboid defect and using a triangular
flap drawn in a rhomboid shape, which can be rotated into
the adjacent defect. The term ‘rhomboid’ refers to the shape
Figure 4a: The figure on top left shows the possible orientations for a
rhomboid flap. The figure on bottom left shows the infinite number of
possible orientations of a rhomboid flap in cases of circular defects.
The actual orientation to be used depends on the skin tension lines
and area of maximum skin laxity. The figure on the right shows the use
of a Limberg flap to close a medial canthal defect.
of the defect, while the flap is essentially triangular.13 However,
in the periocular area, the defects following excision of
malignancies are usually circular or oval and it has been
described that the triangular flap can be rotated into the
circular defect, without converting the defect into a
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152 INDIAN JOURNAL OF OPHTHALMOLOGY Vol. 54 No. 3

rhomboid.13 This ensures that no normal tissue is unnecessarily
excised and it allows an infinite number of possible flap
orientations rather than the original rhomboid technique,
where only 4 orientations are possible [Figure 4a].13 This does
entail fitting of a “square flap into a circular hole”, but this is
usually not a problem with the elastic periocular tissues with
undermining.13 The base of the triangle should be parallel to
the orbicularis oculi fibers, for defects above or below the
eyelids, to avoid ectropion. This flap is not useful for
excessively longitudinal defects or for those that involve a

Figure 4b: Use of a rhomboid flap.The figures on top show the rhomboid Figure 6: Bilobed flap.The figures on the left show the use of two circular
flap being used to close a rhombic defect. The figures on the bottom bilobed flaps, while the figures on the right show the use of a bilobed
show the use of the same flap to close a circular defect. flap, with the secondary flap (B) designed as a triangle, which makes
the secondary closure easier.

a a

b
b
Figure 5a, b: Demonstration of the use of a rhomboid flap to close a Figure 7a, b: Demonstration of the use of a bilobed flap to close a
circular defect just lateral to the eyebrow. defect of the medial canthus extending up to the lateral aspect of the
nose.
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July - September 2006 Sharma et al. Techniques of periocular reconstruction 153

major portion of the eyelids or the lid margin.13
Bilobed flap [Figures 6 and 7a, b]
The bilobed flap was originally described by Esser in 1918 for
reconstruction of defects of the nasal tip, which he described
as ‘a skin flap composed of two lobes, forming an angle and
with a common skin pedicle’.9,14 The proximal and distal lobes
are of the same height as the defect, but are about 20-40% less
wide than the adjacent defect9 and fashioned with the long
axis in the direction of relaxed skin tension lines, to allow
closure along these lines. 15 This flap is widely used for
reconstruction of circular defects of the nose, cheek and
forehead and has been found to be useful for medial canthal
defects as well.15 It consists of 2 adjacent transposition flaps
on a common pedicle,15 such that the first flap fills in the
original defect and the second smaller flap fills in the defect
left by the first flap. Dog ear deformities may be a problem
and need to be excised.9 The angle between the two lobes can
be varied from 30° to 120°, to take advantage of areas with lax
skin and to ensure closure of incisions along relaxed skin
tension lines.15 The pedicles should be sufficiently broad to
ensure viability of the flaps and closure should be done with
sufficient undermining to avoid tension on the suture line.15
authors have also used free tarsal grafts [Figure 9d], especially
if the anterior lamella is reconstructed by a flap rather than a
free graft and this obviates the need for a second surgery.3,22-24
When a Hughes procedure is used in combination with a free
skin graft, sutures may be passed through the partial thickness
of tarsus and through the skin graft, to ensure good apposition
of the graft to the host bed, similar to the bolsters used in skin
grafts elsewhere.25 Hughes flap and free tarsoconjunctival
grafts are very useful for reconstruction of central defects of
the lower eyelid, involving about 60-80% of the length17,26 and
can also be used for defects involving the entire eyelid, if
medial and lateral periosteal flaps are used for anchoring the
flap.27 In these large flaps, some Muller’s muscle can be left
attached to the flap to provide better vascularization.27 For
defects involving the lateral canthus, a laterally based
tarsoconjunctival transposition flap from the ipsilateral
opposite eyelid, may be used. This was originally described
by Hewes for the reconstruction of the lower eyelid and
provides a one-stage reconstruction [Figure 8b]. 28 In all
techniques which employ a tarsal flap from the upper eyelid,

Island flaps
The island flap or a subcutaneous pedicle flap for eyelid
reconstruction was described by Kazanjian in 1949.16 The
island flaps have a stalk of attachment to the underlying tissues
at the center, as opposed to the pedicled flaps which have an
attachment at the medial or the lateral end, on which they can
be rotated or transposed. The island flaps can be advanced in
any direction and are useful for covering an adjacent defect,
especially in areas like the forehead, glabella and the medial
canthus. The island flap can be smaller than the primary defect
and the site of the flap can be closed primarily or it can be
filled with another flap similar to a bilobed flap. The upper
lid preseptal skin can also be used with a central muscle
pedicle as an island flap.16 The lower border of these flaps Figure 8a: The posterior lamella of the lower lid defect is reconstructed
corresponds to the lid crease and the flap can then be passed by a tarsoconjunctival flap from the everted upper lid (area A).
through a subcutaneous tunnel into the defect.16

Tarsoconjunctival flaps and grafts

Wendell Hughes first described a tarsoconjunctival flap in
1937,17 which was based on an earlier procedure described by
Dupuy-Dutemps, who had also described the
dacryocystorhinostomy flaps.3 This flap [Figures 8a, 9 a, b and
c] has undergone many modifications since its original
description wherein: (1) the upper lid was divided into 2
lamellae at the mucocutaneous junction, (2) the posterior
lamella was advanced into the lower lid defect without
dissecting the levator or Muller’s muscle, (3) the anterior
lamella was formed by advancement of cheek skin, (4) an
eyelash transplantation from the upper lid was performed 4
weeks later and (5) finally the flap was divided 12 weeks
postoperatively.17 While conventional teaching advocated
division of the flap at 4-6 weeks, it is now recommended to Figure 8b: Hewes-Beard flap. A laterally based tarsoconjunctival flap
divide the flap at 2 weeks to allow earlier visual recovery18 is transposed into a lower lid defect involving the lateral canthus. In the
and division at 1 week has also been reported.19 In a series of original technique, an advancement flap is designed from the cheek
accidental premature dehiscence of the Hughes flap, the final skin (A). However, in our experience, this skin is seldom lax enough to
aesthetic and functional results were surprisingly good, giving give a good closure without ectropion and a transposition skin muscle
further evidence that the flap can be divided earlier.20,21 Various flap gives better results.
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154 INDIAN JOURNAL OF OPHTHALMOLOGY Vol. 54 No. 3

a b c
Figure 9a, b, c: The use of Hughes flap to reconstruct a lower lid defect. A transposition flap was used to reconstruct the anterior lamella.

Figure 9d: A tarsoconjunctival free graft used for the reconstruction of Figure 10: Cutler-Beard technique. A full thickness lower lid flap (A) is
the posterior lamella in ths elderly gentleman. The anterior lamella was fashioned from about 5 mm below the lid margin, and is passed
reconstructed using a transposition flap from the upper eyelid. underneath the intervening lower lid bridge (B) to advance into the upper
lid defect. A nasal or aural cartilage graft may be placed between the
it is crucial to leave 3-4 mm of the upper eyelid tarsus for lid two lamellae of the flap to replace tarsus. The flap is divided 6-8 weeks
margin support and to prevent upper lid entropion.17 It is also later and the reconstructed portion of the upper lid has no eyelashes.
important to dissect the levator and Muller’s muscle from the
superior border of the tarsus, to prevent postoperative upper
lid retraction and notching.17 When dividing the flap, the tarso­
conjunctiva should be cut above the skin muscle edge and the
conjunctiva can be sutured to the skin edge to provide a
smooth lid margin. However, it has been suggested that the
lid margin be allowed to heal by granulation,17 to avoid having
a chronically inflamed lid margin, as the conjunctiva blocks
the Meibomian gland openings. A reverse Hughes procedure
to reconstruct the upper eyelid has also been described, but
this normally provides only a thin 2-3 mm strip of tarsus for
reconstruction.29

Cutler-Beard technique [Figures 10 and 11]

The Cutler-Beard technique or the bridge flap was described
in 195530 and is used for large defects of the upper eyelid such
as sebaceous carcinoma of the upper lid, which is considerably
more common than other lid tumors in India.31 It uses a full
thickness (cutaneo-myo-conjunctival) flap of the lower eyelid,
which usually does not contain any tarsal plate, as its superior
border is placed 5 mm below the lower eyelid margin to
preserve the marginal vascular arcade. After 6-8 weeks, the
flap is divided at the level of the desired upper lid margin
and the pedicle of the flap is repositioned into the donor lower
lid.32 Potential complications include bridge necrosis, lower
eyelid ectropion, poor upper eyelid contour, as well as
Figure 11: Cutler-Beard flap used to reconstruct a defect of the upper
eyelid.
retraction and cicatricial entropion of the upper eyelid.32 The
absence of any tarsus in the original technique, compromises
the structural integrity of the upper eyelid and the posterior
lamella without tarsus contracts over a period of time,
producing entropion.32,33 Wesley and McCord described the
use of preserved donor sclera between the two lamellae of the
Cutler-Beard flap.34 However, the use of donor sclera is not
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July - September 2006 Sharma et al. Techniques of periocular reconstruction
universally favored due to reports of sloughing of the eyelid
and concerns with slow virus transmission and shrinkage.33
Ear and nasal cartilage11 have been used and it is reported
that the prolonged edema and shrinkage seen with scleral
grafts, can be avoided with the use of ear cartilage.32,35 In cases
where there is at least 3 mm of residual tarsus in the upper
lid, it can be advanced into the marginal defect.36,37 Such
defects are seen following trauma or Moh’s excision and not
following excision of malignancies without pathological
control, as the whole width of tarsus is generally sacrificed
in the absence of any method, to know the width of tarsal
involvement. A free tarsal graft from the contralateral upper
lid36,38 or rotation of a vertical strip of tarsus in the horizontal
direction has also been described, to replace the posterior
lamella;39 the anterior lamella can then be replaced either with
a myocutaneous flap from surrounding skin or as an
advancement flap from the lower eyelid, in a modified
Cutler-Beard fashion.35
Tenzel’s flap
Tenzel flap is a semicircular skin-muscle flap, a type of
advancement-rotation flap which is fashioned from the skin
beyond the lateral canthus and can be used for both the upper
and lower eyelid [Figure 12a].40 The vertical extent should not
cross the eyebrow for inferior eyelid defects and the flap
should stay within the orbital margin or the arc defined by
the eyebrow.40 The upper or the lower crus of the lateral canthal
tendon is divided at the orbital rim through a lateral
canthotomy performed under the flap and the flap is rotated
into the adjacent defect.40 The lateral attachment of the orbital
septum should also be divided to allow free rotation.40 The
diameter of the flap ranges from 10 to 20 mm.40 The flap is not
always circular and the horizontal or the vertical dimension
may be greater than the other, depending on the defect.40 The
effectivity of Tenzel flap can be further enhanced by use of a
Z-plasty at the end of the flap, which recruits more tissue from
the vertical temporal area, to provide horizontal tissue to the
Figure 12a: Tenzel flap. A semicircular flap (B) is designed within the
lateral orbital rim to replace the lower lid defect. The defect can be
converted into a triangular defect, but this is not essential. A canthotomy
and cantholysis allows the remaining lateral portion of the lid (A) to be
advanced into the defect, and the resultant defect in the lateral lid is
now closed by the flap. The same technique can be used for defects of
the upper lid, where the flap is designed with an inferior convexity.
155
Figure 12b: McGregor flap. This is a modification of the Tenzel flap,
where a Z plasty at the end of the incision provides extra length of
tissue to close the defect.
eyelid [Figure 12b]. This extension into the temporal area with
Z-plasty is known as McGregor flap and is useful for both the
upper and the lower eyelid.41
Glabellar flap [Figure 13]
The glabellar flap was first described by McCord and
Wesley42 and involves an inverted V incision in the median
forehead area between the eyebrows, which is partly closed
as a Y and the rest of the flap is rotated into the adjacent
medial canthal defect. It can also be seen as a combination of
a V-Y and a rhomboid flap. A small area may have to be
excised at the tip, to achieve a comfortable fit of the flap into
the defect.42 In an excellent review, the construction of the
flap has been described in a step-wise manner.43 The width
of the initial V fills the height of the defect and the height
fills the width. The initial V therefore, should be constructed
to take into account not only the horizontal size of the defect
(which corresponds to the height of the V), but also the depth
of the medial canthus (which will require a greater height of
the V) and the height of the defect, which will necessitate a
broader base of the V.43 The apex of the V can be shifted from
the midline towards the side of the defect and the angle of
the V should be between 45°-60°, as a larger angle makes a
cosmetically unacceptable bulky flap on the root of the nose,
while a narrow angle compromises blood supply. 43 The
advantages of the glabellar flap are, that it is a relatively quick
procedure, has a good vascular supply and can also be used
for deep defects as it is a thick flap. The disadvantages are,
that it does not give a natural depth to the medial canthus,
results in a bulky nasal bridge and draws the eyebrows
together.42 Some patients may later need surgical debulking
of the nasal bridge, as the size of the flap is considerable,
compared to the defect. 15 Scar contracture may cause
webbing. It also results in prominent scars that cross the
relaxed skin tension lines of the forehead. In patients with
continuous eyebrows or synophrys, continued hair growth
in the flap is a cosmetic disadvantage.42 This flap is best used
for small defects above the medial canthal tendon. As the
defect becomes larger or more inferior, there is considerable
tension at the nose where the flap is rotated, giving
unsatisfactory results.15
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156 INDIAN JOURNAL OF OPHTHALMOLOGY Vol. 54 No. 3

lacrimal structures, which may not function properly in the

Figure 13: The use of a glabellar falp to close a medial canthal defect.
Tripier flap
event of an eyelid malposition, even if they are structurally
intact. A contracted scar may lead to webbing. Direct closure
is hardly ever possible or desirable. Bilobed flaps, skin
advancement flaps, rhomboid flaps44 and small V-Y flaps or
combinations of these, provide best results.42 A larger or more
inferior defect can be closed by a combination of a glabellar
flap with a nasolabial island flap [Figure 14a and b]15 or a
nasolabial V-Y advancement flap.47 It has also been shown that
small circular central defects at the medial canthus, especially
those less than 1.5 cms in diameter and those distributed
equally above and below the medial canthal tendon, may heal
well by secondary intention (laissez-faire), specially in older
patients with thin skin, giving excellent cosmetic results and
a natural concave appearance. 5,7 Medially based
myocutaneous transposition flaps from the upper lid are also
described.48 It is also necessary to reconstruct the medial
canthal tendon and the lacrimal structures, if injured. Full-
thickness skin grafts were traditionally used, but in addition

Tripier first described the use of an innervated myocutaneous

flap in the form of a bipedicle flap (with lateral and medial
pedicles) from the upper lid, for reconstruction of a lower lid
defect in 1889.44 The advantage is that it contains muscle fibers
and therefore provides some bulk as well as increased
vascularity. However, it is debatable whether it actually
provides muscle function, as originally described by Tripier.44

Fricke flap
Fricke flap was first described by Jochim Fricke in 1829.45 It is
a laterally-based, mono-pedicle transposition flap raised above
the eyebrow, which can be used for reconstruction of the upper
or lower eyelid. It is now uncommonly used. It is useful for
shallow defects of the lower lid, which involve almost the
entire eyelid length.45 A Hughes procedure may be technically
difficult in these cases and a Mustarde flap entails very wide
dissection and sacrifice of normal tissues, to convert the Figure 14a: Use of a combination of techniques to repair a large defect
original defect into a V.45 Asymmetrical brow height following of the medial canthus. This defect was closed with a combination of a
the procedure is a major disadvantage, but this can be reduced Hughes flap, an island flap and a glabellar flap. The white arrow shows
to some extent by a rigorous postoperative downward the medial canthal tendon and the black arrow shows the angular vein.
massage of the eyebrow.45

Periosteal flaps
Periosteal flaps are very useful for reconstruction of large
eyelid defects or those placed extremely laterally or medially.46
In defects where there is no residual tarsus, the tarsal graft or
flap can be sutured to periosteal flaps fashioned from the
adjacent periosteum and the base of the flap is placed at the
site of the desired position of the canthal tendons.27 The flaps
should be sufficiently wide to provide strong attachment and
a width of about 4 mm throughout the length of the flap is
recommended.27 The disadvantage includes some blunting of
the canthal angles, especially laterally.46 Care should be taken,
not to place a free skin graft directly over a periosteal flap, as
periosteal flaps have poor blood supply.46

Medial canthal defects

Figure 14b: Use of a combination of techniques to repair a large defect
The medial canthus is one of the most difficult areas to of the medial canthus. This defect was closed with a combination of a
reconstruct, as skin here is in short supply. The region also Hughes flap, an island flap and a glabellar flap. The final result of the
has a natural concavity which is cosmetically important and defect shown in Fig 14a.
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July - September 2006 Sharma et al. Techniques of periocular reconstruction
to other disadvantages of skin grafts such as poor color and
texture match, they are especially problematic in slightly deep
defects, where the skin graft does not fill the defect and
postoperative contraction of the graft produces distortion of
tissue contours.15 When marking a flap for a medial canthal
defect, it is preferable to take skin from the root of the nose or
forehead. If inferior nasolabial skin is advanced, care should
be taken to avoid lower lid ectropion on closure.
In conclusion, there are a variety of techniques available
for periocular reconstruction. Usually, when there are many
options to achieve the same purpose, it indicates that none of
them is satisfactory. However, in the case of eyelid
reconstruction, knowledge of various techniques is needed,
as different procedures may be required, depending on the
location and size of the defect.
References
1. Bajaj MS, Sethi A. Complicated eyelid reconstruction after an
unusual glabellar flap repair. Acta Ophthalmol Scand 2000;78:599­
600.
2. Harris GJ, Garcia GH. Advancement Flaps for Large Defects of
the Eyebrow, Glabella, Forehead and Temple. Ophthal Plast
Reconstr Surg 2002;18:138-45.
3. Porfiris E, Christopoulos A, Sandris P, Georgiou P, Ioannidis A,
Popa CV, et al. Upper eyelid orbicularis oculi flap with
tarsoconjunctival island for reconstruction of full-thickness lower
lid defects. Plast Reconstr Surg 1999;103:186-91.
4. Patrinely JR, Marines HM, Anderson RL. Skin flaps in periorbital
reconstruction. Surv Ophthalmol 1987;31:249-61.
5. Bowman PH, Fosko SW, Hartstein ME. Periocular
Reconstruction. Semin Cutan Med Surg 2003;22:263-72.
6. Tyers AG, Collin JR, editors. Colour atlas of ophthalmic plastic
surgery, Churchill Livingstone: Edinburgh; 1995. p. 255-307.
7. Moy RL, Ashjian AA. Periorbital reconstruction. J Dermatol Surg
Oncol 1991;17:153-9.
8. Harris GJ, Perez N. Anchored Flaps in Post-Mohs Reconstruction
of the Lower Eyelid, Cheek and Lateral Canthus Avoiding Eyelid
Distortion. Ophthal Plast Reconstr Surg 2003;19:5-13.
9. Golcman R, Speranzini MB, Golcman B. The bilobed island flap
in nasal ala reconstruction. Br J Plast Surg 1998;51:493-8.
10. Elliot D, Britto JA. Tripier’s innervated myocutaneous flap 1889.
Br J Plast Surg 2004;57:543-9.
11. Scuderi N, Ribuffo D, Chiummariello S. Total and Subtotal Upper
Eyelid Reconstruction with the Nasal Chondromucosal Flap: A
10-Year Experience. Plast Reconstr Surg 2005;115:1259-65.
12. Turan T, Kuran I, Ozcan H, Bas L. Geometric Limit of Multiple
Local Limberg Flaps: A Flap Design. Plast Reconstr Surg
1999;104:1675-8.
13. Teske SA, Kersten RC, Devoto MH, Kulwin DR. The modified
rhomboid transposition flap in periocular reconstruction. Ophthal
Plast Reconstr Surg 1998;14:360-6.
14. Iida N, Ohsumi N, Tonegawa M, Tsutsumi K. Simple method of
designing a bilobed flap. Plast Reconstr Surg 1999;104:495-9.
15. Sullivan TJ, Bray LC. The bilobed flap in medial canthal
reconstruction. Aust NZJ Ophthal 1995;23:42-8.
16. Porfiris E, Kalokerinos D, Christopoulos A, Damilakos P,
Ioannidis A, Georgiou P. Upper Eyelid Island Orbicularis Oculi
Myocutaneous Flap for Periorbital Reconstruction. Ophthal Plast
Reconstr Surg 2000;16:42-4.
17. Rohrich RJ, Zbar RI. The Evolution of the Hughes
Tarsoconjunctival Flap for Lower Eyelid Reconstruction. Plast
157
Reconstruct Surg 1999;104:518-22.
18. McNab AA, Martin P, Benger R, O’Donnell B, Kourt G. A
prospective randomized study comparing division of the pedicle
of modified Hughes flaps at two or four weeks. Ophthal Plast
Reconstr Surg 2001;17:317-9.
19. Leibovitch I, Selva D. Modified Hughes flap: Division at 7 days.
Ophthalmology 2004;111:2164-7.
20. Bartley GB, Messenger MM. The dehiscent Hughes flap:
outcomes and implications. Trans Am Ophthalmol Soc
2002;100:61-5.
21. Bartley GB, Messenger MM. Outcome of tarsoconjunctival flap
dehiscence after eyelid reconstruction. Am J Ophthalmol
2002;134:627-30.
22. Stephenson CM, Brown BZ. The use of tarsus as a free
autogenous graft in eyelid surgery. Ophthal Plast Reconstr Surg
1985;1:43-50.
23. Leibovitch I, Selva D, Davis G, Ghabrial R. Donor site morbidity
in free tarsal grafts. Am J Ophthalmol 2004;138:430-3.
24. Leone CR Jr, Van Gemert JV. Lower lid reconstruction using
tarsoconjunctival grafts and bipedicle skin-muscle flap. Arch
Ophthalmol 1989;107:758-60.
25. Putterman, AM. Bolster for the Tarsoconjunctival Flap-Skin
Graft. Ophthal Plast Reconstr Surg 2002;18:466-7.
26. Hughes WL. A new method for rebuilding a lower lid. Arch
Opthalmol 1937;17:1008.
27. Maloof A, Ng S, Leatherbarrow B. The Maximal Hughes
Procedure. Ophthal Plast Reconstr Surg 2001;17:96-102.
28. Hewes EH, Sullivan JH, Beard C. Lower eyelid reconstruction
by tarsal transposition. Am J Ophthalmol 1976;81:512-4.
29. Mauriello JA Jr, Antonacci R. Single tarsoconjunctival flap (lower
eyelid) for upper eyelid reconstruction (“reverse” modified
Hughes procedure). Ophthalmic Surg 1994;25:374-8.
30. Cutler Nl, Beard C. A method for partial and total upper lid
reconstruction. Am J Ophthalmol 1955;39:1-7.
31. Sihota R, Tandon K, Betharia SM, Arora R. Malignant eyelid
tumors in an Indian population. Arch Ophthalmol 1996;114:108-9.
32. Carroll RP. Entropion following the Cutler-Beard procedure.
Ophthalmology 1983;90:1052-5.
33. Kadoi C, Hayasaka S, Kato T, Nagaki Y, Matsumoto M, Hayasaka
Y. The Cutler-Beard bridge flap technique with use of donor
sclera for upper eyelid reconstruction. Ophthalmologica
2000;214:140-2.
34. Wesley RE, McCord CD Jr. Transplantation of eyebank sclera in
the Cutler-Beard method of upper eyelid reconstruction.
Ophthalmology 1980;87:1022-8.
35. Hsuan J, Selva D. Early division of a modified Cutler– Beard
flap with a free tarsal graft. Eye 2004;18:714-7.
36. Jordan DR, Anderson RL, Nowinski TS. Tarsoconjunctival flap
for upper eyelid reconstruction. Arch Ophthalmol 1989;107:599-603.
37. Irvine F, McNab AA. A technique for reconstruction of upper
lid marginal defects. Br J Ophthalmol 2003;87:279-81.
38. Patrinely JR, O’Neal KD, Kersten RC, Soparkar CN. Total Upper
Eyelid Reconstruction With Mucosalized Tarsal Graft and
Overlying Bipedicle Flap. Arch Ophthalmol 1999;117:1655-61.
39. Kersten RC, Anderson RL, Tse DT, Weinstein GL. Tarsal
rotational flap for upper eyelid reconstruction. Arch Ophthalmol
1986;104:918-22.
40. Tenzel RR, Stewart WB. Eyelid reconstruction by the semicircle
flap technique. Ophthalmology 1978;85:1164-9.
41. Khan JA, Garden VS. Combined Flap Repair of Moderate Lower
Eyelid Defects. Ophthal Plast Reconstr Surg 2002;18:202-4.
42. Meadows AE, Manners RM. A Simple Modification of the
 [Downloaded free from http://www.ijo.in on Friday, March 23, 2018, IP: 139.47.3.210]
158 INDIAN JOURNAL OF OPHTHALMOLOGY Vol. 54 No. 3

Glabellar Flap in Medial Canthal Reconstruction. Ophthal Plast
Reconstr Surg 2003;19:313-5.
43. Maloof AJ, Leatherbarrow B. The glabellar flap dissected. Eye
2000;14:597-605.
44. Ng SG, Inkster CF, Leatherbarrow B. The rhomboid flap in
medial canthal reconstruction. Br J Ophthalmol 2001;85:556-9.
45. Wilcsek G, Leatherbarrow B, Halliwell M, Francis I. The ‘RITE’
use of the Fricke flap in periorbital reconstruction. Eye
2005;19:854-60.
46. Weinstein GS, Anderson RL, Tse DT, Kersten RC. The use of a
periosteal strip for eyelid reconstruction. Arch Ophthalmol
1985;103:357-9.
47. Yildirim S, Akoz T, Akan M, Cakir B. The use of combined
nasolabial V-Y advancement and glabellar flaps for large medial
canthal defects. Dermatol Surg 2001;27:215-8.
48. Jelks GW, Glat PM, Jelks EB, Longaker MT. Medial Canthal
Reconstruction Using a Medially Based Upper Eyelid
Myocutaneous Flap. Plast Reconstr Surg 2002;110:1636-43.

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