2 Stage Reconstruction of Simultaneous Subtotal Full Thickness Upper and Lower Eyelid Defects With a Single Hard Palate Graft Covered with Advancement Orbicularis Occuli Myocutaneous Flaps

            Simultaneous loss of both the lower and upper eyelids is a devastating injury. Most of the techniques previously described to reconstruct this defect involve mucosal advancement for lining, cartilage grafts for support, and forehead, cheek or distant skin for cover of both eyelids.

            This paper describes a 2 stage method of simultaneous reconstruction of subtotal full thickness upper and lower eyelid defects (fig 1 and 2). In the first stage, lining and support are reconstructed with a single large hard palate graft spanning both eyelid defects (fig 3). The graft is sutured to remnants of the canthal ligaments or tarsal plates, as well as to the remnant of the levator muscle. The hard palate graft is covered by the remaining orbicularis occuli muscle of the upper lid which is sewn to the remaining orbicularis occuli muscle of the lower lid. The skin over the orbicularis muscle of the upper lid is then sewn to the skin over the orbicularis muscle of the lower lid (fig 4).

             In the second stage, the skin, orbicularis muscle and hard palate graft are divided where the normal eyelid separation occurs. The raw area created in the upper and lower lids is covered with a single buccal mucosal graft spanning both upper and lower eyelid raw margins as well as the raw margin of the lateral commissure of the eyelids (Fig 5). The patient in Fig 1 is seen 1 year post op forcing his eyelids shut in figure 6, showing good orbicularis closing function. He is then shown looking forward (fig 7), and upward (fig 8), demonstrating good levator function.

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