Lower Eyelid Reconstruction: A New Classification Incorporating the Vertical Dimension

Sir: We read with great interest the article by Alghoul and colleagues entitled “Lower Eyelid Reconstruction: A New Classification Incorporating the Vertical Dimension” (Plast Reconstr Surg. 2019;144:443–455).1 The article reports a retrospective review of outcomes for lower eyelid reconstruction with consideration of vertical dimension. This study indicates significantly higher rates of postoperative retraction and poor aesthetic outcome in patients with complex pretarsal and preseptal defects, which they have classified as type IV. We agree that the rhetoric of horizontal defect size to determine closure technique is slightly outdated and feel the algorithm proposed provides a useful guide to reconstruction. However, we would like to put forward a couple of perspectives. First, healing by secondary intention, the “laissez-faire” approach, has been widely used with excellent periocular wound healing and aesthetic outcome.2,3 The complications noted are ectropion and retraction,4 similar to those reported by Alghoul and colleagues. In our experience, we find secondary intention healing useful, particularly in “type IA and IB” and some “type II” defects. It may be further advantageous in selective cases in which reconstructive options may be limited, due to unavailability of ipsilateral or contralateral eyelid donor tissue or insufficient tarsoconjunctival transfer to cover the full extent of the defect. Second, regarding direct closure of defects greater than a quarter of the eyelid length, the limit set in traditional textbooks appears arbitrary, perhaps due to perceived limitation of the elasticity of the eyelid. Thaller et al.5 recently reported outcomes of direct closure under tension of relatively larger defects. The prospective case series performed direct closure on eyelid defects ranging from 29 percent to 108 percent of the horizontal palpebral aperture,6 with mean horizontal and vertical defect sizes measuring 16.4 mm (range, 4 to 26 mm) and 12.6 mm (range, 4 to 32 mm), respectively. Results showed comparable palpebral apertures (vertical and horizontal planes) between the operated and nonoperated eyes, with high patient satisfaction on postoperative function and cosmesis. Direct closure of such defects often requires extreme tension with consequent temporary lid margin distortion, upper lid ptosis, and upward globe displacement. However, the displaced globe exerts the steady and sustained force necessary for eyelid expansion.5,6 Thaller et al.6 hypothesize that the eyeball forms a natural tissue expander that governs expansion and reformation of tissue margin. For this reason, direct closure is performed without any relaxing incisions or lateral cantholysis to maintain the intercanthal tension. The vectors for closure should be directed between the medial and lateral canthi or perpendicular to the Langer lines in the periocular region. The main advantages of direct closure in the context of defects with a large vertical component are uniform tissue thickness, lack of donor-site morbidity or skin hair contact with the ocular surface associated with skin grafts, continued presence of lashes and meibomian glands (allowing one-stage surgery), and faster rehabilitation in most cases.5,6 Finally, a hybrid of direct closure and secondary intention healing can be useful in cases of large defects with insufficient laxity of the neighboring tissues that does not permit direct closure. The so-called directed laissez-faire approach is performed with strategic placement of deep sutures to direct the healing, respecting the above-mentioned vectors. This allows for significant reduction of both the horizontal and vertical components of the defect. In the case series by Shankar et al.,4 26 percent underwent other reconstruction methods; in particular, a combination of directed laissez-faire showed equally effective clinical outcomes. In summary, there is a need for a paradigm shift in terms of assessment and management of eyelid defects. Direct closure and the directed laissez faire approach are both simple and viable techniques that should be considered for reconstruction of periocular defects beyond the limits described in the traditional oculoplastics teaching, and therefore warrant consideration in the proposed algorithm. DISCLOSURE There are no direct benefits to the research participants or study authors.