The Vertical Tarsotomy Technique: Serial Tarsotomies Enable Direct Closure of Moderate-to-Large Full-Thickness Eyelid Defects

BACKGROUND: Direct closure of eyelid defects is traditionally limited to small defects of less than a third of the horizontal eyelid length due to concern regarding distortion of the palpebral aperture and risk of eyelid malposition. We describe a simple, reproducible technique using serial vertical full-thickness tarsotomy incisions to lengthen the residual eyelid. This facilitates direct closure of larger defects, avoiding the need for Tenzel, Macgregor, and in selected cases, even Hughes flaps. METHODS: Single-center retrospective case series of patients undergoing eyelid reconstruction following periocular tumor excision. Serial vertical full-thickness tarsotomies were performed in the residual tarsus to increase eyelid length and facilitate direct closure. Patient demographics, tumor characteristics, defect size, reconstructive techniques, and complications were recorded. RESULTS: Ten patients were included with a mean age of 78.5 years (range 65-93). Six (60%) patients were female, and basal cell carcinoma accounted for 90% of tumors. The lower eyelid was involved in 80% of cases. Defects ranged from one-third to two-thirds of the horizontal eyelid length, with the majority (70%) involving more than half of the eyelid. Additionally, internal lateral cantholysis was performed in 8 cases, and direct closure was achieved in all cases. Mean follow-up was 8.1 (range 5-17) months. Postoperative complications occurred in 3 patients, including corneal irritation requiring temporary bandage contact lens wear (n = 1) and mild ectropion (n = 2). There were no cases of wound dehiscence or sight-threatening complications. CONCLUSION: Serial vertical tarsotomies represent a unique technique to increase eyelid length and facilitate direct closure of moderate-to-large eyelid margin defects. This approach offers favorable functional and aesthetic outcomes and may represent a new reconstructive option in the management of full-thickness eyelid defects.