Structural Deficit-Guided Reconstruction of an Extended Lower Eyelid–Bicanthal Defect

Background/Objectives: Extended lower eyelid defects involving both lamellae and canthal supports require restoration of lining, support, vascularized coverage, and horizontal stability. We describe a two-stage reconstruction guided by structural deficits and available autologous tissues. Methods: A 63-year-old man underwent staged excision with frozen-section margin control for conventional-type basal cell carcinoma involving almost the entire right lower eyelid. A lengthened septal chondromucosal graft restored posterior support and lining. A right transtemporal midface lift and a near-margin bipedicled upper eyelid orbicularis myocutaneous flap provided anterior coverage. Six months later, the lateral pedicle was divided, the graft was contoured and fixed transosseously to the lateral orbital rim, and the medial pedicle tunnel was revised. Results: All transferred tissues survived. At final follow-up, MRD2 measured 4.61 mm on the reconstructed side and 4.12 mm contralaterally (difference, 0.49 mm); palpebral fissure height measured 6.02 and 5.92 mm, respectively (difference, 0.10 mm). Lower scleral show and the residual gap during forceful closure were 0 mm. The absolute lateral canthal height difference was 1.45 mm preoperatively, 4.14 mm after stage 1, 0.45 mm after stage 2, and 1.58 mm at final follow-up. At 4 years, globe apposition was maintained without ectropion, entropion, retraction, or graft exposure; magnetic resonance imaging showed no recurrence. Conclusions: This case illustrates a potentially transferable process: define structural and functional deficits first, then match each reconstructive objective to suitable patient-specific tissues.