A stepwise approach to pediatric periocular reconstruction

Periocular reconstruction in children presents a different challenge from that in adults and requires a different approach to reconstructive planning to achieve success.¹ For example, children have much less tissue laxity than adults do, so there is less surrounding tissue to borrow. When an ophthalmologist does need to transfer adjacent tissue, the tissue is usually tighter and less elastic, making it harder to stretch across a defect.²

Furthermore, any reconstruction that looks good now may look completely different as the child’s eyelids, face, and underlying bony structures continue to develop. Therefore, I consider pediatric periocular reconstruction to be an evolving process rather than a one-time procedure.

Understanding the defect

I find it helpful to divide pediatric periocular defects into broad categories, each of which requires the consideration of different variables: 1) congenital abnormalities; 2) defects secondary to trauma; and 3) defects secondary to lesions or malignancies.

With congenital periocular defects, a child is born with absent or abnormal tissue, so the surgeon has to plan for more tissue borrowing or tissue movement during reconstruction. When dealing with periocular tissue defects secondary to trauma, tissue is usually not missing but rather lacerated or folded onto itself. Careful consideration must be given to identifying and reconstructing the missing tissue, with a particular emphasis on preventing scar formation. In cases of defects secondary to lesions or malignancies, surgeons may have to intentionally remove significant amounts of periocular tissue, which will then need to be replaced, necessitating close follow-up as the child develops.

The size and depth of the defect also help determine the complexity of the reconstruction. A superficial defect involving the skin or muscle is much easier to address than a full-thickness eyelid defect or one that extends to the bony orbital rim. In extreme cases, such as when patients have total loss of the eye and orbital structures, a multidisciplinary team including otolaryngologists, neurosurgeons, and pediatric plastic surgeons should be consulted to ensure both the bony and soft-tissue defects are appropriately addressed.

Rebuilding the eyelid: Planning in layers

The eyelid contains 2 major sections: the anterior lamella, composed of skin and the orbicularis oculi muscle, and the posterior lamella, composed of conjunctiva and the tarsus, which provides the eyelid with rigidity and shape.³ Both sections must be accounted for when performing an eyelid reconstruction.

The first goal is to rebuild the posterior lamella to restore the eyelid’s structural integrity and provide proper scaffolding for the anterior lamella. Then, the surgeon seeks to restore the anterior lamella to ensure appropriate functioning and appearance of the eyelid. Careful attention must be paid to restoring the anterior and posterior lamella to prevent scarring and upper- and lower-eyelid retraction, which can cause downstream complications, including exposure keratopathy, if not properly addressed.⁴

Beyond the eyelid itself, it is important to consider the medial and lateral canthal attachments, which tether the eyelids to the bone. The canthal structures act like a belt on a pair of pants, enabling the eyelid to appropriately “hug” the globe. Critically, the medial canthus also contains the nasolacrimal system.⁵ Damage to the nasolacrimal system can cause excessive tearing,⁶ so this needs to be carefully accounted for in any reconstruction. It is also important to protect the supratrochlear and supraorbital neurovascular bundles, which lie near the eyebrow, to prevent vascular or neurological symptoms that could arise from their damage.

Matching the technique to the defect

If possible, I try to perform primary closure on any pediatric periocular defect. If I am able to close the wound without having to add tissue or alter the surrounding anatomy, I anticipate a positive outcome. However, it is critical to avoid closing the wound under undue tension, as this increases the risk of wound dehiscence, scar formation, and eyelid retraction.⁷ If enough tissue has been lost that primary closure would create significant tension, surgeons need to consider the use of surrounding tissue, facial flaps, or skin grafts.

Although both local flaps and skin grafts can be used for periocular reconstruction,⁸ these approaches pose additional challenges when performed in pediatric patients due to their having less redundant tissue and less skin elasticity than adults. Surgeons also must consider cosmesis, because creating a noticeable facial scar could have greater implications for a child during their developmental years than for an adult.

To replace the anterior lamella, a surgeon might consider adjacent tissue transfer from the surrounding face, semicircular or glabellar flaps, or full-thickness or split-thickness skin grafts from various sites on the body.⁹ To replace the posterior lamella, a surgeon might consider free tarsal grafts from the other eyelid, acellular dermal matrix grafts, mucous membrane grafts, and amniotic membrane grafts.

The primary advantage of facial flaps, compared with skin grafts, is that these flaps usually have their own blood supply. The skin quality is usually similar to that of the eyelid, and the skin color of the final result usually matches the surrounding tissue.

The primary advantage of amniotic membrane grafts, compared with mucous membrane grafts, is that they can substitute for lost conjunctiva without requiring the harvest of mucosal tissue from a donor site, such as the mouth. They also contain anti-inflammatory and antiscarring properties,¹⁰ which can assist in healing and provide positive cosmetic outcomes. Whenever I can safely and effectively use amniotic membrane or another biological substitute for repairing a periocular defect, I tend to lean in that direction.

In my practice, I typically use cryopreserved amniotic membranes, as opposed to dehydrated ones, as they better preserve the biological properties of the amnion.¹¹ I usually employ 2 different forms of amniotic membrane: thinner grafting sheets and thicker, umbilical cord–derived tissue. The thinner sheets are useful for covering the corneal surface or conjunctiva, particularly on the bulbar side, whereas the umbilical cord–derived tissue is more robust and easier to suture to the surrounding tissues, making it better for fornix-based and palpebral conjunctival reconstructions. However, it should be noted that the amniotic membrane is not a perfect substitute, and these patients still require careful monitoring for early signs of inflammation and symblepharon formation.

It is naturally much harder for pediatric patients to comply with postoperative instructions, and it can be much harder to adequately examine them in a clinic setting. As such, I am typically more aggressive when reconstructing periocular defects in children and take extra preventive steps, such as temporarily suturing the eye closed so the child cannot manipulate the tissues or using a symblepharon ring to prevent conjunctival adhesions.

Thinking beyond the surgery

Some of the most important parts of any pediatric surgery happen outside of the operating room. In particular, it is vital to have a conversation with the patient’s family regarding expectations and wound management. I like to tell patients that periocular reconstruction is a marathon, not a sprint—results and healing can take months. The ultimate goal of any periocular reconstruction is to protect the eye and preserve eyelid and facial functionality; however, parents also need to understand that their child’s eyelids, face, and bony structures are all going to change as they grow and that these changes can affect the surgical outcome.

Close follow-up in these cases is also important, and when examining a pediatric patient who has undergone a periocular reconstruction, I not only look for early complications such as tissue tethering, scar formation, and exposure keratopathy, but also watch to see how the reconstruction develops alongside their physical growth.

Conclusion

Guiding a patient through a pediatric periocular reconstruction can be a long journey, but by approaching the process in a thoughtful, stepwise manner, surgeons can give the children who need their help their best chance at achieving optimal visual and cosmetic outcomes.

Christopher Dermarkarian, MD

E: [email protected]

Dermarkarian is an oculofacial plastic and orbital surgeon as well as an associate professor of ophthalmology in the Oculofacial and Orbital Surgery Division at the Duke Eye Center in Durham, North Carolina. Dermarkarian reports affiliations with ArgenX and Bryn Mawr Communications.

References

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