Periosteal Strips

Description

Strips of deep temporalis fascia and periosteum pedicled near the orbital rim are useful for replacement of the lateral tarsus and conjunctiva (4,5). The strip is oriented at a 45 degree angle from the lateral orbital rim either in a superior direction for lower lid defects or in an inferior direction for upper lid defects. The inner surface of the periosteal strip will re-epithelialize from the bordering conjunctiva. The anterior lamella is reconstructed with musculocutaneous flaps for full-thickness defects.

Indications

Periosteal strips may be used for lateral posterior lamella defects involving up to 60% of the upper or lower lid margin. They may also be used under a semicircular flap (Tenzel) for improved lateral fixation of the eyelid.

Advantages

This is a one-staged reconstruction that uses nonvital, easily harvested tissues. The location of the pedicle provides good lateral support for the reconstructed eyelid. The upper and lower eyelids may be reconstructed simultaneously with properly designed flaps.

Disadvantages

The periosteum is less rigid than the tarsus making eyelid margin malposition and entropion more likely. This is a nonepithelial surface and a foreign body sensation is present until re-epitheliazation occurs (by 1 month postoperatively). Periosteal flaps have insufficient vascularity to nourish full-thickness skin grafts and should be covered with skin flaps.

Semicircular (Tenzel) Flap |

Description I

A Tenzel flap is a musculocutaneous rotation flap extending from the lateral canthus c

(Fig. 4). The flap can be marked approximately 22mm vertically (upwards to recon- ^

d struct the lower eyelid and downwards to reconstruct the upper eyelid), and 18 mm in >3 horizontal direction. This should not extend further lateral than the end of the eyebrow. Cantholysis frees the flap to rotate medially, allowing the free eyelid margin to o be closed. The new lateral canthus is fixed to the lateral orbital rim with dermal- ยง periosteal sutures.

Figure 4 A Tenzel flap used to reconstruct an extensive defect of the medial lower eyelid margin.

Indications

A Tenzel flap is indicated for central or medial defects of the eyelid affecting up to 60% of the eyelid margin. For excessively large defects, the posterior lamella should also be reconstructed to stabilize the eyelid margin (using tarsus, hard palate, nasal septum, ear cartilage, or periosteum).

Advantages

The primary advantage of the Tenzel flap is that it advances normal eyelid tissue to the center of the lid, leaving flap tissue in a less conspicuous area near the lateral canthus.

Disadvantages

If this flap is used to repair excessively large defects, a greater amount of unsupported tissue results in the lateral lid, potentially resulting in eyelid malposition including entropion or ectropion. Eyelid malposition including entropion or ectro-pion may occur when the posterior lamella is not reconstructed.

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