Repair of large full thickness lower lid defect following mass excision using Modified Hughes procedure

Abstract

Objective: To highlight a case of lower lid repair using Hughes procedure. Case Report: 70 year old male presented with painless, firm looking growth on left lower eyelid for 2 years. A pentagonal shaped lid excision done involving whole extent of the mass along with 2 mm of surrounding healthy looking tissue. Large posterior laminar horizontal defect was repaired with a Hughes tarsoconjunctival flap prepared by undermining the tarsus and conjunctiva upto the levator aponeuros in superior fornix and inferiorly leaving at least 4 mm of tarsus for lid stability. This bridge flap was advanced to the lower lid defect and sutured to the remnants of tarsus of lower lid to form posterior lamella. Anterior lamella was repaired with an appropriately sized full thickness skin graft taken from upper lid. A second stage surgery was done after 6 weeks to excise the bridge. With the help of a grooved director, which was slid underneath the flap anterior to the cornea, the flap was divided using a blade. Conjunctiva sutured to the lower eyelid margin. Results: Post op showed excellent graft uptake. During follow up visits there were good lid movements, no exposure keratitis. There was no lid retraction or lagophthalmos. Conclusion: This case highlights that management for a large lid defect using Hughes Procedure gives a successful outcome in terms of graft uptake and stability. Anterior lamella repaired from upper eyelid skin gives superior results as it is easily available and matches the host site in color and skin characteristics