Eyelids contain specialized structures that protect eyes from the external environment. They also provide a protective tear film on the anterior surface of the eyes during blinking.2 Eyelid injuries are frequently encountered, presenting in both outpatient department (referred from Ophthalmology, General Surgery etc.) and emergency department. Eyelid injuries are on the rise due to increased incidence of road traffic accidents, workplace accidents and assaults and can lead to both functional and aesthetic deformities as well as corneal complications. Eyelid injuries often pose a challenge to reconstructive efforts due to the multiple complex anatomical structures that are in close proximity to each other. A restoration of normal anatomical structure is vital for optimum functional and aesthetic outcome after trauma.1 A clear distinction should be made between partial thickness and full thickness defects for optimal reconstruction.3 Ideally eyelid injuries need to be repaired within 12 to 24 hours of injury, but delay can arise due to general condition of the patient or financial status and can lead to complications.4 Simple eyelid injuries are repaired by the ophthalmology team or the trauma team in emergency department in our institution while complex eyelid defects are referred to the plastic surgery department from ophthalmology and general surgery department. Inadequate or incomplete eyelid repair can result in complications such as entropion, ectropion, trichiasis, and epiphora, which significantly impair a patient’s quality of life. Understanding the factors contributing to eyelid trauma and its epidemiological characteristics is essential for effective prevention and to maximise surgical and therapeutic potential. So, one must explore the different flap based technique to have the optimum result in eyelid trauma management. Although ocular trauma is widely studied, research specifically addressing eyelid injuries remains limited. Eyelid injuries in India, often from road traffic accidents, account approximately 25% of ocular trauma cases, with an incidence of ~1–3 per 100,000 annually, requiring targeted approach5 .The aim is to study the various reconstructive procedures employed in the management of the eyelid defects and its outcome..

This is a retrospective observational case series study for a period of 14 years (2011-2025) in a tertiary care hospital in Upper Assam, including patients who were all admitted and managed under the Chief author to maintain the consistency in functional and aesthetic surgical approach with his team. Those cases who presented with isolated eyelid injury with anatomical and functional tissue loss were taken in this study and hence globe rupture, other facio-maxillary tissue loss including bony fracture were excluded from this study. The main objective is to evaluate study outcomes in various reconstructive procedures undertaken for eyelid defects. The other variable outcome included the aesthetic outcome, and final outcome in terms of functional approach and anatomical integrity. Inclusion criteria: Patients with eyelid defects resulting from trauma were included in the study. Exclusion criteria: Unwilling to participate in the study, previously existing eyelid pathology, globe rupture, and or with bony fracture. Data Collection After obtaining written informed consent, all patients underwent a comprehensive clinical evaluation, including detailed medical history and physical examination. The following parameters were documented: • Demographic details (age, sex) and socio-economic status • Mechanism of injury (e.g., road traffic accident, workplace mishap) • Laterality of injury (left or right eye) • Anatomical location of the defect (upper eyelid, lower eyelid, or both including canthal region) • Types of reconstructive procedure undertaken All patients underwent ophthalmology evaluation to evaluate other associated ocular and canalicular injuries. Patients with punctum and canalicular injuries are treated by the ophthalmology team. Two cases of punctal lacerations and canalicular injuries (along with eyelid injury) were repaired. One patient was treated with Mini Monoka stent. The canalicular part of the eyelid is often susceptible to laceration in both direct mode and indirect mode of injury, making localisation of the injury difficult. For which application of viscoelastic substance with a cannula or bowman’s lacrimal probe becomes beneficial. Direct anastomosis with the lacerated parts of canaliculi also provides benefit. There were no cases of epiphora during the follow up period. Wounds were thoroughly cleansed with normal saline to check and remove foreign bodies and identify normal anatomical structures such as tarsus, orbital septum, gray line, anterior lash line and posterior margin before debridement of unhealthy and dead tissue. Preoperative assessment included detailed evaluation of the size, percentage of tissue loss, extent, and anatomical location of the eyelid defects to guide reconstructive planning. Reconstructive procedures were chosen in such a way that they maintain the anatomical integrity of eyelids along with proper aesthetic and functional results6. Defects were classified as involving the upper eyelid, lower eyelid, or both including canthal region. Associated facial or orbital injuries, bony injuries were categorized differently and were excluded. We consider isolated eyelid injuries only to explore the research potential .After debridement of unhealthy tissues and thorough irrigation with normal saline, the reconstructive procedure was planned, taking into consideration the availability of local tissues. For larger and complex defects, use of single flap or combination of flaps was preferred for proper aesthetic and functional result. Reconstruction was done with correct anatomical orientation. Orbital septum repair was done whenever necessary. Gray line repair was done with 5-0 non-absorbable suture and tarsus with 6-0 absorbable suture. Both the anterior and posterior lamellae were repaired with absorbable sutures in muco-muscular fashion. Haemostasis was checked and achieved in all cases and mini drain was used whenever required and removed on 3rd or 4th post-operative day. Sutures were usually removed on 7th-10th day after the procedure. Follow up were done up to 1 year at appropriate interval. In the initial post-operative period, local application of Neomycin ointment was advised. In post wound healing period, gentle scar massage was advised followed by application of Silicon gels to make the scar soft and supple. Use of sunglass was advised as a protective measure.

The study consists of 25 patients, who attended emergency and outpatient department of the study hospital. DEMOGRAPHICS: The studies showed most of the patients are males (88%) as compared to only (12%) females Table 1 SEX NUMBER PERCENTAGE (%) MALE 22 88 FEMALE 3 12 AGE INCIDENCE: Most of the injuries fall in the age group of 30-39 years (40%), followed by the age group of 20-29 years (28%) Table 2 AGE (YEARS) NUMBER PERCENTAGE 10-19 1 4 20-29 7 28 30-39 10 40 40-49 1 4 50-59 6 24 LATERALITY OF EYELID INJURY: The study showed that the right eye (68%) is affected more than the left eye (32%) Table 3 SIDE NUMBER PERCENTAGE (%) LEFT 8 32 RIGHT 17 68 ANATOMICAL LOCATION: From the study, it is found that the lower eyelid (44%) is involved equally as the upper eyelid (44%), with only 12% involving both upper and lower eyelids Table 4 LOCATION NUMBER PERCENTAGE (%) UPPER EYELID 11 44 LOWER EYELID 11 44 BOTH UPPER AND LOWER EYELIDS 3 12 MECHANISM OF INJURY: The study showed that workplace mishaps (60%) is the most common mechanism of injury followed by Road traffic accident (32%) Table 5 MECHANISM NUMBER PERCENTAGE (%) WORK PLACE MISHAPS 15 60 ROAD TRAFFIC ACCIDENTS 8 32 BULLET INJURY 1 4 OTHERS 1 4 RECONSTRUCTIVE PROCEDURE: Most of the eyelid injuries are repaired by advancement of local tissue flap (36%). Repair of other injuries are tailored as per the injury as shown in the table below. Table 6 PROCEDURE NUMBER PERCENTAGE (%) Tenzel flap 4 16 Advancement flap from local tissue 9 36 NasoJugal flap 2 8 NasoJugal flap + Mustarde like cheek advancement flap 1 4 NasoJugal + Tenzel flap 1 4 Naso-jugal + local advancement flap 2 8 Cutler- Beard flap 1 4 Primary repair 3 12 Cheek advancement flap 2 8

This retrospective observational study, conducted over 14 years (2011–2025) at a tertiary care hospital in Upper Assam, analysed 25 patients with post-traumatic eyelid defects, providing valuable insights into the epidemiology, aetiology, and reconstructive approaches for such injuries. The findings highlight several key trends and align with existing literature while offering context-specific observations relevant to resource-limited settings. The study revealed a significant male predominance, with 88% of patients being male compared to 12% female. This gender disparity is consistent with prior research, which attributes higher male involvement to increased exposure to occupational risks, outdoor activities, and behavioural factors such as risk-taking. For example, Kumar J et al in a prospective interventional study of 110 patients with eyelid and peri-orbital injuries (2020) found a male: female ratio of 2.23, noting that 69.09% were males and 30.90% were females.4 The predominance of males in our study may also reflect the regional context, where many patients were farmers, a profession with high exposure to workplace mishaps, which accounted for 60% of injuries. The age distribution showed that the majority of injuries occurred in the 20–39-year age group, with 40% in the 30–39-year range, followed by 28% in the 20–29-year group. This aligns with the findings of Awidi et al., who noted that 52% of eyelid laceration cases occurred in adults aged 21–60 years, reflecting the heightened risk in young, working-age individuals due to active lifestyles and occupational hazards.7 In developing regions like Upper Assam, where road traffic accidents (32%) and workplace mishaps (60%) were the leading causes of injury, the productive age group’s exposure to vehicular travel and manual labour likely contributes to this trend. The predominance of farmers in the cohort further underscores the occupational risks associated with agricultural work, such as machinery-related injuries. Due to the close proximity of tea garden worker population to this tertiary care hospital, many patients were referred from various tea garden hospitals and therefore this study has a unique value representing the nature of injuries from this cohort of tea garden community. A notable finding was the higher incidence of right-sided eye injuries (68%) compared to the left eye (32%). This observation is partially supported by a study in IOSR Journals, which reported 50.9% right-sided and 47.27% left-sided involvement in eyelid trauma cases.4The reasons for right-sided predominance remain speculative but may relate to factors such as handedness, directional exposure during trauma, or occupational positioning. For instance, right- handed individuals may expose their right side more during work-related activities. However, the small sample size in our study limits definitive conclusions, and further research with larger cohorts is needed to explore this pattern. Anatomically, the study found equal involvement of the upper and lower eyelids (44% each), with only 12% of cases affecting both. This distribution differs slightly from some literature, where lower eyelid injuries are often reported as more common due to their anatomical vulnerability. The equal distribution in our study may reflect the diverse mechanisms of injury, particularly workplace mishaps, which can affect both eyelids depending on the trauma’s nature and direction. The involvement of both eyelids in 12% of cases underscores the complexity of certain injuries, often necessitating advanced reconstructive techniques. The reconstructive approaches employed in this study were tailored to the defect’s size and location, emphasizing a defect-based strategy. For both upper and lower eyelid defects, if the defect size is less than 25%, usually repair with primary closure is the choice of management. For defects of size more than 25%, standard operative procedures like Tenzel flap, Cheek advancement flap, Naso-jugal flap, Cutler-Beard flap for anterior lamellar defect and Nasal chondromucosal graft, advancement of conjunctival flap with placement of auricular cartilage graft for posterior lamellar defect were performed to achieve optimal functional and aesthetic outcomes. 8 Repair with advancement flap from local tissue were the most common techniques (36%), reflecting their suitability for smaller defects. For larger or more complex defects, flaps such as Tenzel (16%), Naso-jugal (8%), Cheek advancement (8%), and Cutler-Beard (4%) were used. In 4 cases, there were difficulties in reconstruction using a single flap due to the complexity of the tissue defects. Hence, a tailored reconstruction using various flap combinations like Mustarde like cheek advancement flap with NasoJugalflaps (1) and Tenzel with NasoJugal flaps (1),Naso-jugal with local advancement of tissue (2) for better cosmetic and functional result was adopted. This aligns with established reconstructive principles, where defects involving the lateral lower eyelid are often managed with Mustarde or Tenzel flaps, and medial lower eyelid defects are addressed with Naso-jugal flaps8. In the defect of posterior lamella specially for lower eyelid , depending upon the type of defect reconstructive procedures like simple advancement of conjunctival flap , nasal chondromucosal graft, advancement of conjunctiva flap with placement of auricular cartilage graft for tension free closure were done. It gives a good structural stability, aesthetic outcome, prevent ectropion along with proper functional outcome10,11. The preference for simpler techniques like repair with advancement of local tissue in resource-limited settings highlights their efficacy and accessibility, while the use of flap combinations for complex cases demonstrates the need for individualized surgical planning to achieve optimal functional and aesthetic outcomes. Complications such as ectropion, entropion, lagophthalmos, and trichiasis were anticipated but minimal in this study. A few patients experienced incomplete eye closure in the immediate postoperative period, which resolved with proper scar management, indicating effective surgical techniques and postoperative care. The absence of major complications further supports the efficacy of standard reconstructive techniques in achieving good outcomes, even in a resource constrained environment. The study’s findings emphasize the importance of timely intervention, ideally within 12–24 hours of injury, to minimize complications and optimize outcomes. Coordination with ophthalmology department was critical, particularly for assessing associated ocular or canalicular injuries, ensuring a multidisciplinary approach. Further scope of this study can be attributed to cater a larger population size to overcome the limitation including its single-centre design, small sample size, and exclusion of other injury mechanisms like burns etc. We also suggest the need for larger, multicentre studies to validate these findings and explore a broader range of aetiologies with respect to ethnicity, tea garden population and other available local variables.

In conclusion, this study underscores the effectiveness of tailored, defect- based reconstructive strategies for traumatic eyelid injuries. The predominance of workplace mishaps and road traffic accidents as causes, along with the high incidence among young adult males, highlights the need for targeted preventive measures in occupational and road traffic safety. The successful use of standard flap techniques and primary repair methods supports their continued relevance in reconstructive surgery. Each case of eyelid injury requires tailor based individual approach according to the situation to achieve the maximum anatomical, functional and aesthetic outcome. Future research should focus on larger cohorts and longer follow-up for more refine and advance techniques to improve the outcomes for eyelid trauma management.

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