Transforming the lower eyelid longitudinal incision direction to conceal the closure line: Longitudinal incision horizontal closure

Small lower eyelid marginal lesions are commonly treated with full-thickness pentagonal excision.1Verhoekx J.S. Soebhag R.K. Weijtens O. et al.A single- versus double-layered closure technique for full-thickness lower eyelid defects: a comparative study.Acta Ophthalmol. 2016; 94: 257-260Google Scholar Repairing the resulting wedge defect (Fig 1, A) using primary closure or local flap reconstruction inevitably results in a longitudinal wound closure line perpendicular to the lower eyelid margin and poor cosmetic results. Concealing the vertical closure line in the lower eyelid is challenging. To achieve an inconspicuous wound closure line, we perform longitudinal incision horizontal closure, which transforms a vertical longitudinal incision to a horizontal incision close to the lower eyelid margin. After full-thickness pentagonal block excision, we add a secondary incision parallel to the lower eyelid edge near the eyelashes on both sides of the defect (Fig 1, B). Then, we gently open the secondary incision with fine scissors and blunt dissection, undermining inferiorly to harvest adequate skin and release tissues deep to the orbicularis muscle (Fig 1, C). Using 6-0 absorbable suture, we longitudinally suture the wedge defect in the posterior lamella (conjunctiva, tarsus, and partial orbicularis muscle) (Fig 1, C) and adjust the eyelid margin to obtain seamless alignment. Next, we lift the prepared relaxed skin upward to cover the defect and posterior lamellar vertical closure line. Finally, we trim excess skin along the horizontal incision. If necessary, the secondary incision is extended to the lateral canthus. The final horizontal incision is closed using 6-0 sutures under minimal tension, successfully transforming the incision (Fig 1, D). A full-thickness melanocytic nevus involving the left lower eyelid margin (Fig 2, A) was removed with pentagonal block excision. By transforming the closure line direction, the incision was successfully hidden, with good cosmetic effects (Fig 2, B and C).