Bridging Structure and Biology in Eyelid Reconstruction

In clinical practice, the spectrum of eyelid defects can span from superficial anterior lamellar losses to large full-thickness defects, either of which may involve multiple aesthetic units. The most common defects involve eyelid skin alone, which tend to be the most straightforward to repair, but once the eyelid margin is involved the reconstruction becomes more challenging. The eyelid margin harbors structures essential for ocular protection and tear film distribution, including the glands that produce the lipid layer of tear film (1). Protecting the integrity of these structures during reconstruction is critical to achieving a good outcome.

Successful repair of an eyelid defect depends on a fine balance of structural restoration, functional preservation, and aesthetic harmony. The repair must consider not only the size and location of the defect, but also the tension lines, the presence of concomitant inflammation, the blood supply, the availability of donor tissue, and the patient’s inherent healing capacity. Modern reconstructive planning therefore integrates traditional surgical principles with a deeper understanding of tissue biology, and has increasingly integrated the use of engineered biologic materials, especially for defects that require both structural scaffolding and modulation of inflammation.

Principles of eyelid reconstruction

Despite the diversity of eyelid defects, four guiding principles consistently shape my own reconstructive approach: 1) replace the missing tissue; 2) support the reconstruction structurally so that gravity, functional tension, and pre-existing laxity do not distort the eyelid; 3) ensure adequate blood supply; and 4) ensure sufficient stem/progenitor cell availability. It’s important to note that burns, trauma, and cicatrizing disorders can diminish patients’ reserve of stem cells and increase the risk of scarring and delayed or poor healing (2).

Local flaps remain a cornerstone of reconstruction for many small- to medium-sized defects, largely because they have the advantage of providing their own blood supply, but also because the skin type is usually a good match for the recipient site. However, flap design must avoid distortion of adjacent structures, and donor site repair must also be considered. For larger defects, or when there is insufficient surrounding tissue, the use of skin grafting becomes a very viable option. Split-thickness skin grafts offer a theoretically unlimited supply and may be used as temporary coverage, but their high contraction rate often limits their role for definitive reconstruction (3).

The role of engineered tissue substitutes

In many complex cases, particularly in patients with burns, ongoing inflammation, or cicatrizing disease, immediate use of autologous tissue may not be ideal because it uses up a limited supply of autologous tissue with a high risk of graft failure. In these situations, the surgeon must balance the need for temporary coverage of the defect with the need to preserve limited native tissue for future stages of the repair. Engineered tissue substitutes have emerged as valuable adjuncts in such cases, and a variety of artificial skin matrices exist that provide effective structural scaffolds to facilitate epithelial migration. However, most of these skin substitutes lack anti-inflammatory or anti-scarring properties.

It has been my experience that cryopreserved ultra-thick umbilical cord amniotic membrane (UC-AM) offers both structural and biological benefits (4). UC-AM retains a dense matrix enriched with heavy chain hyaluronic acid complexes and other biomolecules known to reduce fibrosis, modulate TGF-β pathways, and improve the wound-healing microenvironment (5). These biologic features give UC-AM a unique dual role: it acts as a matrix for epithelialization and provides an anti-inflammatory, anti-scarring milieu.

Clinical evidence supporting cryopreserved umbilical cord amniotic membrane in periocular reconstruction

In a recent case series published in Ophthalmic Plastic and Reconstructive Surgery, my colleagues and I evaluated cryopreserved UC-AM as a skin substitute in patients with periocular skin loss due to burns or trauma, which are notoriously challenging defects to reconstruct with traditional methods alone. In this cohort, the cryopreserved UC-AM performed exceptionally well. The membrane provided stable coverage with minimal contraction, and the healing environment appeared more favorable compared to typical outcomes with split-thickness grafts or temporary dressings (6). The biologic activity of cryopreserved UC-AM likely contributed to its success, facilitating a prolonged presence on the wound bed, reducing inflammation, and supporting epithelial ingrowth.

These findings align with broader literature reporting the advantages of amniotic-derived tissues in ocular surface reconstruction, where both regular and ultra-thick amniotic membrane have long been recognized for promoting regeneration while reducing scar formation (7, 8). The ability of cryopreserved UC-AM to bridge the gap between structural graft and biologic therapy makes it a uniquely powerful tool for eyelid reconstruction.

Successful use of cryopreserved UC-AM requires meticulous intra- and post-operative management. Intraoperatively, the membrane should be thoroughly hydrated prior to placement and secured with sutures, as fibrin sealants alone lack the tensile strength required to maintain a stable position on mobile periocular tissue. I typically use 7-0 or 8-0 polyglactin sutures (Vicryl®). Bandaging should use non-adherent dressing; alternatively, the graft can be left dry. Post-operatively, patients need to be counseled to set their expectations for the wound’s appearance over the weeks following surgery: the UC-AM will gradually desiccate, forming a firm, sometimes “scab-like” surface; underneath this layer, the re-epithelialization will steadily progress. Although this may look unseemly to some patients, we must advise them not to manipulate or wash this surface, as it can disrupt the healing process. It is not necessary to place antibiotic ointment on the graft – on the contrary, petrolatum- and oil-based dressings and ointments can sequester the biologicals released by the UC-AM graft.

It is important to note that I usually combine local flaps with cryopreserved UC-AM grafting to optimize results, making sure to respect the aesthetic units, address tension, and provide sufficient blood supply to the reconstructed area.

Conclusion

Eyelid defect reconstruction continues to evolve to better integrate new regenerative therapies into existing surgical principles. While local flaps and autologous grafts are important tools, cryopreserved ultra-thick UC-AM provides a meaningful advancement, offering a biologically active scaffold that supports healing in cases where traditional methods alone may be insufficient. As clinical experience and research continue to expand for eyelid reconstruction, cryopreserved UC-AM is poised to play an increasingly important role in achieving functional, stable, and aesthetically harmonious outcomes.