Graft transplantation in eyelid reconstruction is perhaps the most commonly used procedure in routine clinical settings. Various tissues can be transplanted to complete the eyelid reconstruction. Both lamellae can be restored with grafts; however, the anterior lamella is the most common segment that tends to be repaired. As a basic rule, grafts should be used when there is an adequate vascular bed to enhance post-transplanted survival. Grafts can also be used in irradiated tissues when needed; however, these types of grafts generally need to be associated with local flaps to enhance the vascularization and guarantee graft survival. Radiotherapy on engrafted areas could cause ulceration or delay the wound healing. Commonly used techniques combine a non-vascularized graft for one lamella with a vascularized flap for the other.
As mentioned above, usually only one lamella can be reconstructed with a graft, but techniques to reconstruct both have also been described. Kakizaki et al reported bilamellar graft reconstruction with orbicularis muscle mobilization between grafted areas (“sandwich flap”), first described by Doxanas in 1986. The orbicularis oculi muscle provides an excellent blood supply to grafted tissues in these cases, in addition to enhancing the mobility of the reconstructed lid. In 2020, Bortz et al published a clinical series in which full-thickness lid defects were restored using free tarsal grafts for the posterior lamella and free skin grafts for the anterior lamella. The authors reported this method as an alternative to the “classic” Hughes flap for lower eyelid reconstruction, especially when the occlusion of the eye could be a problem (vision deficit, elderly patients, etc). The evidence reported by Tenland et al led the authors to propose this type of reconstruction. The study showed that tarsoconjunctival (TC) tissue survival does not seem to be dependent on a conjunctival flap, and thus free TC grafts or composite grafts might be considered as viable alternatives.
Posterior lamella grafts
Grafts or flaps are viable options for posterior lamellar reconstruction. Grafts include conjunctival or TC grafts, hard palate (or palate) graft, cartilage (auricular or nasal septal) grafts, mucoperichondrium grafts, dermis fat grafts (DFGs), venous grafts (VGs), galea or pericranium grafts, mucosal membrane (buccal or labial) grafts, and temporalis fascia grafts. For lower eyelid reconstruction, for example, single or tandem composite skin muscle TC eyelid grafts from the upper lids or contralateral lower lid may be an option.
TC grafts: TC grafts are an excellent choice for posterior lamellar reconstruction considering that this structure reflects the features of a normal eyelid. Tarsal grafts alone, taken from the healthy eyelid, can be used in association with local flaps for anterior lamella reconstruction. TC grafts and flaps are essential components of eyelid reconstruction since these alternatives provide anatomically similar tissues for the inner layer of reconstructed eyelids. First described in 1918 by Blaskovics for lower eyelid reconstruction, autogenous TC grafts have found widespread use, as described by Hughes, Leone et al, and several others in the literature[21,22]. Hawes et al proposed guidelines for the use of TC flaps and grafts to repair lower eyelid defects.
Free grafts are preferred in most cases in which the defect is from one-third to three-quarters of the eyelid length. TC flaps are advantageous when the defects are large (entire lower eyelid loss) and when poor healing can be expected. Usually, this type of reconstruction is completed by a local flap for the anterior lamella and is not limited only to the lower eyelid. Yazici et al recently described the association of a TC graft with a bilobed local flap for the upper eyelid. Bengoa-González et al described the use of the graft to complete and modify the Cutler-Beard technique for the upper eyelid. The TC graft gives stability to the new upper eyelid, avoiding retraction caused by scarring. From a technical point of view, it is fundamental to also avoid complications in the donor site, which usually heals spontaneously by secondary intention. Almost 3-4 mm of tarsus must be maintained to allow donor eyelid stability, and Müller’s muscle should be conserved. To avoid entropion or ectropion to reconstructed eyelid, the tarsal graft should be snug and no wider than the smallest dimension of the defect. Figure 1 shows an example of our patient that underwent left lower eyelid reconstruction after tumor excision using a TC graft (from the left upper eyelid) for the posterior lamella and a local flap for the anterior one.
Figure 1 A patient that underwent left lower eyelid reconstruction after tumor excision using a tarsoconjunctival graft (from the left upper eyelid) for the posterior lamella and a local flap for the anterior one.
A: Basal cell carcinoma of left lower eyelid with preoperative markings; B: Lid after surgical removal; C: Postoperative reconstruction with Tenzel flap + tarsoconjunctival graft from the left upper eyelid; D: Clinical presentation 2 wk after surgery.
Hard-palate mucoperiosteal grafts: Hard-palate mucoperiosteal (HPM) grafts, described for the first time by Siegel in 1985, can be used to replace the posterior lamella due to the ability of this graft to provide structural support and mucosal lining. HPM may be considered the optimal choice for reconstructing the posterior lamella of the eyelids because it has similar histological composition and texture to the tarsoconjunctiva, and an adequately sized graft can easily be acquired[26,27]. HPM tends to be one of the preferred choices for most lower eyelid reconstructions in routine clinical settings. The use of HPM in upper eyelid reconstruction is controversial because hard-palate mucosa is composed of keratinized, stratified squamous epithelium, which can irritate the cornea, especially when the defect is adjacent to the middle part of the cornea[9,28]. Despite this, excellent results without complications have been reported in studies when used in upper eyelid posterior lamellar reconstruction[28,29].
The reconstruction of the anterior lamella requires the use of flaps. Palatal mucosal grafts provide good structural support to the eyelid. This is essential for the inferior eyelid, especially when the graft is combined with a heavy flap such as the Mustardé or the orbito-nasogenien flap. The graft is and remains stiff. The shrinkage is minimal, thus providing a stable, free eyelid margin and limiting ectropion or entropion. Limits of this technique, in addition to the aforementioned corneal irritation, are the described pain and delayed healing at the donor site observed when periosteum is included in the graft.
Auricular and nasoseptal cartilage grafts: Auricular and nasoseptal cartilage can also be useful alternatives when considering graft tissues for reconstructive surgery[28,31,32]. In some cases, this graft may prove to be too thick and too stiff to match with the eye convexity, thus needing to be thinned without compromising the supportive strength. Ear cartilage is useful because it is easy to harvest and fabricate, has suitable flexibility, and provides adequate support. The spherical surface fits well with the shape of the external bulbar surface. Chondromucosal grafts from the nasal septum consist of highly supportable tissue. Caution must be taken when harvesting a chondroseptal graft to avoid damage to the remaining mucosa surrounding the vast perforation. Considering this tissue is composed of hyaline cartilage, it lacks softness and flexibility. This may result in difficulty with fabrication and unsuitable contact with the bulbar conjunctiva. In addition, the harvestable size is limited. The use of alar or triangular cartilage provides a thinner but smaller sized sample, with good adaptability in eyelid reconstruction but raises the problem of donor site morbidity. Suga et al published in 2016 a comparison between ear and nasal septum grafts. The study reported that both tissues provide good options for reconstructing an inner layer of the lower eyelid. The authors stressed that the main difference lies on postoperative outcomes at the donor site. Ear cartilage tends to have lower complication rates, while harvesting nose grafts can cause important septal perforation and vast bleeding.
Another option for cartilaginous reconstruction of the posterior lamella of the lower eyelid is a scapha chondrocutaneous graft, first proposed by Yanaga and Mori. Further studies reported by Uemura et al described interesting results with the use of this graft combined with a local propeller flap. The scapha cartilage graft is an interesting alternative because it has a thin coat of skin and is round and soft with a shape similar to that of the lower lid. This tissue can provide a good fit with the eye globe and can be harvested quickly without severe complications.
DFGs: DFGs can provide useful replacement tissue for eyelid and orbit reconstruction. The DFG is composed of a dermis button, obtained by removing the overlying epidermis with the underlying subcutaneous fat. The dermis provides stiffness, additional surface area, and a scaffold. Moreover, the dermis helps with vascularization and decreases fat tissue atrophy. This tissue can be flat or domed shaped. This graft option tends to be considered primarily for socket reconstruction in the context of anophthalmia, either congenital or acquired. Secondary indications are eyelid reconstruction, socket contraction, eyelid contraction (used as spacer), or implant exposure.
VGs: Barbera et al first proposed VGs as a reconstructive possibility in 2008. The study reported that VGs obtained by propulsive venous vessels are the most suitable for this type of surgical reconstruction because of the tissue thinness, texture, and anatomical structure. Moreover, due to the properties of elasticity, smoothness, and concavity, the venous graft conforms to the globe without inducing a chronic inflammatory reaction on the bulbar conjunctiva or on the cornea. Scevola et al showed that VG is a good technique for palpebral reconstruction because it is safe, fast, and easily reproducible when compared with a chondroseptal graft.
Galea and pericranium grafts: Galea and pericranium grafts represent a secondary choice in eyelid reconstruction. These tissues represent a reconstructive possibility in cases of severe periocular trauma, wide tumor resections, or in socket reconstruction. Ibáñez-Flores et al published a series of cases in which pericranium grafts were used. The authors concluded that pericranial grafts provided a sufficient amount of tissue to cover large defects, thus providing appropriate substitutional volume without painful postoperative healing.
Buccal mucosa graft: Buccal mucosa graft is a good lining option. Oral mucosa has similar biological properties to conjunctiva, thus making it a viable alternative to restore the ocular surface. This tissue, however, lacks structural integrity and tends to be too weak and small to support the lower eyelid. Moreover, postoperative shrinking can be substantial during the follow-up period, thus it should be used in combination with cartilage[43,45]. It is important to note that buccal mucosa graft harvesting and postoperative healing tend to be rather painful for most patients.