Reply Re: "Successful Free Bilamellar Eyelid Grafts for the Repair of Upper and Lower Eyelid Defects in Patients and Laser Speckle Contrast Imaging of Revascularization".

Abstract

To the Editor: Thank you for taking an interest in our article on free bilamellar eyelid grafts. We agree that clinical experience gained over the years and previous studies should be taken into account. We acknowledge that the principle in repairing full-thickness eyelid defects is to combine a vascularized flap with a free graft, to provide an adequate blood supply to the reconstructed tissues. However, our results are rather clear; namely that a free bilamellar eyelid graft has been found to survive without vascular support. The reason for graft survival, despite a lack of perfusion, may be that the periocular region is such a well-vascularized region, known to be forgiving to reconstructive surgery. There are indeed studies reporting failures, as mentioned by Dempsey and Mawn. However, our grafts were small, and the width less than 1 cm. The use of free composite grafts is well known from other specialties, for example, a free composite graft from the outer ear, without any vascularized flap, may be used in the repair of a nasal wing defect. We agree that most of the patients in our cohort were fairly healthy. Due to the limited number of patients included in the study, we were not able to draw any conclusions regarding the effects of impaired microcirculation, due, for example, to years of smoking, cardiovascular disease, diabetes, obesity, or poor diet. A larger study would be needed to perform subgroup analyses to determine whether the survival of a bilamellar autograft is affected in higher-risk populations. There are potential benefits of using a bilamellar autograft, such as avoiding a second surgery and occlusion of the visual axis, especially in patients with poor vision in the contralateral eye. However, there are possible disadvantages, such as lack of vertical lifting during healing, not being able to adjust the final position of the lower lid margin during a second surgery, and potential distress of the patient having to undergo surgery not only on one eyelid but both. We do not advocate the use of free bilamellar autografts in all patients, only in selected cases. The surgical approach may be tailored to the individual patient, taking into account the size of the graft needed and the patient’s health status, such as smoking and diabetes, which might affect the microcirculation. Future studies will be needed to investigate which factors should be taken into consideration. Finally, we would like to point out that the Hughes tarsoconjunctival grafting technique was developed long before modern laser-based techniques were available for the measurement of microvascular perfusion. New technology makes it possible to monitor perfusion and to refine and optimize our surgical procedures.