Perspective

Key Issues When Reconstructing Extensive Upper

Eyelid Defects With Description of a Dynamic,
Frontalis Turnover Flap
Christopher M. Stewart, F.R.A.N.Z.C.O.*, Lee Teak Tan, F.R.C.Ophth.*, David Johnson, F.R.C.S.(Plast.),
Jonathan H. Norris, F.R.C.Ophth.*
*Oxford Eye Hospital, and Department of Plastic and Reconstructive Surgery, John Radcliffe Hospital, Oxford
University Hospitals NHS Trust, Oxford, United Kingdom

total upper eyelid reconstruction are relatively limited, although

Abstract: Reconstruction of full thickness, total upper eyelid
defects represents a significant challenge in terms of recreating
an upper eyelid which has acceptable cosmesis and a degree
of dynamic function. Options include bridging, eyelid-sharing
techniques (e.g., Cutler-Beard), or nonbridging techniques such
as an anterior lamella-based flap combined with a posterior
lamella free graft or a sandwich flap. The success of these
techniques depends on the size of the defect, postoperative
cosmesis and whether or not the upper eyelid still has a degree of
dynamic function to avoid ptosis and exposure keratopathy. The
authors present an innervated frontalis turnover flap supporting
anterior and posterior lamella grafts as a reconstructive
solution for an extensive upper eyelid defect. This technique is
cosmetically acceptable, preserves local tissues, and maintains
a degree of dynamic function, which keeps the patients eye
comfortable and does not adversely affect visual acuity.
(Ophthal Plast Reconstr Surg 2016;32:249251)
A CASE EXAMPLE
several techniques have been described. A number of key issues
are to be considered in this case; first reconstruction of an exten-
sive full thickness defect with no levator muscle may lead to
poor dynamic function of the eyelid which in turn may compro-
mise the visual axis of the patient or cause corneal breakdown
due to lagophthalmos. This is particularly important as potential
future radiotherapy may further exacerbate any dry eye leading
to additional corneal exposure concerns. Corneal exposure is a
particular concern in patients with a reduced Bells reflex. This
patient has involvement of not only the upper eyelid but also the
both the medial and lateral canthi as well as 50% of the lower
eyelid; this limits the use of certain recognized options, such as
the bridging, eyelid sharing flaps.
Recurrent disease is always a concern and our reconstruc-
tion should preserve as much local tissue as possible in order to
provide secondary options should there be a tumor recurrence.
The use of laterally based flaps could potentially damage facial
nerve fibers resulting in further lagophthalmos from paralysis
of orbicularis oculi. Finally, this gentleman has frontal baldness.
Any primary surgery to the forehead will result in cosmetically
visible scarring which we would ideally like to avoid.

A 79-year-old male, with a poor Bells reflex, presents

with a locally invasive squamous cell carcinoma involving the
left upper eyelid. A wide local full thickness excision with 5-mm
margins was performed resulting in an extensive full thickness
defect extending to the brow (Fig.1).

WHAT ARE THE KEY ISSUES WHEN

CONSIDERING RECONSTRUCTION OF THIS
DEFECT?
Reconstruction of full thickness, total upper eyelid
defects can be challenging in terms of restoring a functioning
eyelid with reasonable cosmesis.14 Good quality outcomes of

Accepted for publication April 16, 2016.

Christopher M. Stewart is a Chief author, literature review; Lee Teak Tan
is a Minor author, literature review; David Johnson is an Operating surgeon,
supervision/authorship of manuscript preparation; Jonathan H. Norris is an
Operating surgeon, supervision/authorship of manuscript.
The declaration of Helsinki was adhered to by all authors, at all times,
in all aspects of this case including treating the patient and writing for
publication. FIG. 1. The tissue defect requiring reconstruction following
The authors have no financial or conflicts of interest to disclose. wide local excision. The defect involves the whole upper eyelid
Address correspondence and reprint requests to Christopher M. Stewart, (anterior and posterior lamella, superior fornix) extending to the
F.R.A.N.Z.C.O., Oxford Eye Hospital, Level LG1 West Wing, John Radcliffe inferior brow, superior conjunctival fornix and both medial and
Hospital, Headley Way, Oxford OX3 9DU, United Kingdom. E-mail: lateral canthi. Only 2/3 of the lower eyelid remains. The levator
cstmac@hotmail.com muscle/aponeurosis has been resected and is unable to be used
DOI: 10.1097/IOP.0000000000000721 in the reconstruction.

Ophthal Plast Reconstr Surg, Vol. 32, No. 4, 2016 249

Copyright 2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
 C. M. Stewart et al. Ophthal Plast Reconstr Surg, Vol. 32, No. 4, 2016

WHAT ARE THE STANDARD OPTIONS FOR

RECONSTRUCTION OF THIS EXTENSIVE
DEFECT?
Extensive upper eyelid defects can be reconstructed
either of 2 ways. The first option uses bridging, eyelid shar-
ing which mobilize tissue layers in a composite manner from
the ipsilateral lower eyelid into the defect.1 Examples include
the Cutler-Beard5 and the Mustarde eyelid switch proce-
dure,6 both of which require a secondary procedure to divide
the flap and sacrifice tissue from the lower eyelid. The second
option includes nonbridging techniques which rely on either
an anterior lamellar flap supporting a posterior lamellar graft
or bilamellar grafts supported by a sandwich flap and have
the advantage of no second stage procedure or occluded eye.1
Examples of distal periocular flaps which can be used to recon-
struct the anterior lamella include the Fricke flap,7,8 paramedian FIG. 2. The frontalis turnover flap is reflected over the defect.
forehead flap,9 and islandised superficial temporal artery flap.10 It measures 5.5cm 3cm.
The posterior lamella can be reconstructed with a tarso-con-
junctival graft from the contralateral upper eyelid11 or other sub-
stitutes such as hard palate mucoperiosteum12 and nasal-septal Reconstruction of the lateral canthus and lateral lower
chondromucosa.13 The sandwich flap technique originally eyelid was performed using a periosteal flap reflected from
based on orbicularis oculi reconstructs the anterior lamella with the lateral orbital rim. The lower eyelid was advanced medi-
a full thickness skin graft, not a flap.14 Potential disadvantages ally to complete the lower eyelid reconstruction. A Frost suture
of nonbridging techniques include lagophthalmos, exposure was placed in the upper eyelid and was removed at day 4
keratopathy, upper eyelid retraction, marginal entropion, and postoperatively.
bulky flaps.2 Reasonable cosmesis can often be achieved, but
poor functional results are common (ptosis, lagophthalmos).4 If OUTCOME
the defect is significant multiple flaps may be required. Ten months postoperatively, the patients vision remains
Jean et al.3 first described a single stage frontalis flap 6/12, unchanged from preoperative measurements. There is
based on a sandwich technique for total upper eyelid recon- mild punctate staining of the inferior cornea with 2mm of lag-
struction. Notable advantages were good cosmesis, nonbulky ophthalmos on gentle closure, but the eye remains comfortable.
flap, a degree of dynamic function, no lagophthalmos or expo- The technique provided 4mm of dynamic eyelid excursion
sure keratopathy, and preservation of local tissues. The case (Figs.3, 4) through the contraction of the frontalis muscle when
described, however, involved a subtotal defect with only 75% of the patient attempts to raise the brow. There is no loss of brow
the upper eyelid excised, preserving medial and lateral canthi as elevation or sensation.
well as functional levator muscle/aponeurosis.
CONSIDERATIONS FOR THIS TECHNIQUE
WHAT OPTION DID WE CHOOSE?
This flap relies on preserving the facial nerve innervation
We opted for a modification of the technique described of frontalis. If the flap is reflected too inferiorly frontalis func-
by Jean et al.3 We aimed to preserve the innervation of the fron- tion may be compromised. An anatomical study by Ishikawa15
talis muscle to provide dynamic movement to the flap given that concluded that the temporal branch of the facial nerve enters
the levator muscle had been resected. frontalis no higher than a point 4cm above the lateral canthus
The patient was positioned supine under general anesthetic. and our flap creation was based around this by incising and
Subcutaneous local anesthetic (lignocaine 2% with adrenaline reflecting above this point. There is also small risk of inducing
1:200000; Astra Zeneca, London, UK) was infiltrated. The fronta-
lis muscle was accessed through the superior margin of the defect.
Dissection was performed in the subcutaneous plane superiorly
using a Colorado-needle diathermy (Stryker, Kalamazoo, MI,
USA) over the anterior surface of frontalis muscle, with the aid
of a light-pipe retractor (B Braun Melsungen, Germany). A stab
incision was made through skin at the insertion of the Galea into
frontalis. The Galea was incised horizontally and further dissection
was performed with Metzenbaum scissors in the sub-Galeal plane
inferiorly. The frontalis flap including Galea was incised medially
and laterally to the width of the defect. The lateral incision stopped
4.5cm above the orbital rim to preserve innervation and the flap
was reflected inferiorly at this point (Fig.2).
The posterior lamella and superior fornix were recon-
structed using a combination of free tarsal graft (from the contra-
lateral upper eyelid) and buccal mucosa which were sutured to the
posterior frontalis flap surface using absorbable sutures (6-0 Vicryl;
Ethicon, West Somerville, NJ, USA). The anterior lamella was
reconstructed using a full thickness skin graft harvested from the FIG. 3. Eyelid closure. Approximately 2mm of lagophthalmos
neck and quilted to the anterior frontalis flap surface. is present.

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 Ophthal Plast Reconstr Surg, Vol. 32, No. 4, 2016 Innervated Frontalis Turnover Flap
FIG. 4. Eyelid open. Approximately 4mm of dynamic excursion is
present when compared with the closed position. The visual axis is
clear and the patients forehead (not shown) is still able to function
dynamically. Fluorescein staining of the cornea under cobalt blue
light demonstrates some inferior punctate erosions.
areas of forehead paraesthesia when raising the flap as the
supraorbital nerve sends branches through frontalis to supply
the overlying skin.16
WHAT ARE THE BENEFITS OF CHOOSING
THIS OPTION?
This option confers several advantages over traditional
upper eyelid reconstructive techniques and addresses our key
issues outlined earlier. This technique preserves the neuro-
vascular pedicle of frontalis creating a muscular flap which is
able to support anterior and posterior lamella grafts while also
providing a degree of upper eyelid excursion. Building on the
advantages described by Jean et al.,3 this modification allows
reconstruction of larger defects with no useful levator complex
providing reasonable cosmesis and limited dynamic function
(4mm eyelid excursion). Local tissues are preserved to deal
with secondary recurrences and the only secondary scar is
a small paramedian stab incision. We acknowledge that there
is a small degree of lagophthalmos but this complication is
commonly seen in most reported techniques for upper eyelid
reconstruction.2 One could argue that when performing a more
standard technique (for example a forehead flap), a secondary
brow suspension could be used to provide eyelid lift. In our
experience, the success of brow suspension surgery can often
be limited after significant reconstructive surgery. This is pri-
marily due to the inherent thickening of the flaps and inevitable
scar tissue, which tends to lead poor dynamic function. Brow
2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. 251
Copyright 2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
suspension surgery would also require a second procedure and
could potentially provide a path for tumor spread should there
be a recurrence of the malignancy.
CONCLUSION
Complete upper eyelid reconstruction is complex
with variable outcomes. Whilst we acknowledge that this is a
single case, we believe that this technique certainly should have
a place in the oculoplastic surgeons armamentarium due to a
number of described benefits.
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