Eyelid Defects Research Articles

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".

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.

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

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

Squamous cell carcinoma during long term hydroxyurea treatment: A case report.

BackgroundHydroxyurea (HU) is a ribonucleotide diphosphate reductase inhibitor that interferes with the S phase of cell replication and inhibits DNA synthesis, with limited or no effect on RNA or protein synthesis. The cutaneous side effects of hydroxyurea treatment are diverse and frequent. Squamous cell carcinoma is one of the most challenging side-effect.Case presentationThe authors report the case of a healthy 59-year-old woman on long-term therapy with Hydroxyurea 500 mg daily for essential thrombocytosis, presented with a painless slow-growing lesion of the jaw that had persisted and increased in size for six months, the appearance of the lesion is correlated to the administration of the hydroxyurea treatment. Clinical examination revealed a large nodular lesion 4 × 4 cm with irregular borders of the right cheek, infiltrated into underlying tissue, the lesion extending to the free border of the right lower eyelid without sensory disturbances or diplopia. The surgery was indicated. The surgical procedure had the aim of the restoration of the anatomic landmarks after a large excision of the tumor and reconstruction of full-thickness eyelid defect with a local flap under general anesthesia.ConclusionMaxillofacial surgeons must be aware of the side effects of hydroxyurea including facial cancer, ulceration, etc. Rigorous follow-up of patients on hydroxyurea is required.

Using Buccal Mucosa and Auricular Cartilage With a Local Flap for Full-Thickness Defect of Lower Eyelid.

Reconstruction of full-thickness eyelid wounds is challenging. In this case, using buccal mucosa to repair the conjunctival surface of the lower eyelid defect maintain the function of the conjunctival surface, reduce the damage to the original ocular surface environment. Using autologous auricular cartilage as the skeleton of the eyelid defect, provided better support for the flap, and the site had a good esthetic appearance after surgery. Using skin flap to repair the skin surface of the lower eyelid defect, the eyelid defect can be repaired and good clinical results can be obtained.

Porcine Urinary Bladder Extracellular Matrix for Treatment of Periocular Skin Defects.

To describe the experience of 4 oculoplastic surgeons with porcine bladder matrix for periocular anterior lamella and donor site skin defects either as stand-alone treatment or in conjunction with other reconstructive procedures. The authors hypothesized that defect size and location influence the requirement for additional matrix treatments or ancillary procedures. Following the Institutional Review Board approval, the authors conducted a retrospective review of 17 patients treated with porcine bladder matrix at 2 oculoplastic practices between 2016 and 2018. Powdered matrix was applied to the skin defect and overlaid with a matrix sheet. Subsequent rounds of matrix treatment or other reconstructive procedures were performed as necessary. Defect size and location were correlated to the number of ancillary matrix treatments or surgical procedures via univariate analysis. Twenty-five sites (21 primary and 4 donor) in 17 individuals (8-95 years, M = 58.8 years, 10 males) were treated with porcine bladder matrix. All wounds healed successfully. Additional matrix treatments were administered at 5 sites. Ancillary procedures were performed for 7 sites. Upper lid involvement and larger defect size tended to require additional ancillary procedures (p = 0.006), while lower eyelid and other periocular defects required fewer procedures (p < 0.001). Porcine bladder matrices are useful adjuncts to healing periocular anterior lamella defects in various settings. Such repairs are useful in nonsurgical candidates, but must take into account varying levels of complexity based on lesion location. Smaller defects are more conducive to application of matrices as stand-alone treatment, while larger or upper eyelid defects often require additional procedures.

Reconstruction of Large Upper Eyelid Defects Using the Reverse Hughes Flap Combined With a Sandwich Graft of an Acellular Dermal Matrix.

To investigate the usefulness of the reverse Hughes flap procedure combined with a sandwich graft of an acellular dermal matrix for reconstruction of large full-thickness defects of upper eyelids after cancer excision. Clinical data were obtained from patients who underwent upper eyelid reconstruction using a reverse Hughes flap combined with a sandwich graft of an acellular dermal matrix (AlloDerm) as a tarsal substitute. The tarsoconjunctival flap of the donor lower eyelid was mobilized to reconstruct the posterior lamella, and acellular dermal matrix was grafted onto the tarsoconjunctival flap. A skin-orbicularis muscle flap superior to the defect was advanced to cover the acellular dermal matrix graft, followed by application of lid crease formation sutures to prevent postoperative entropion. The tarsoconjunctival pedicle was divided 3-8 weeks after the surgery. Six patients with sebaceous carcinoma were included, and all had ≥70% full-thickness upper eyelid defects after tumor excision. After a median follow-up of 40 months (range 6-62 months), all 6 showed satisfactory functional and cosmetic outcomes. Tumor recurrence, exposure keratopathy, upper eyelid entropion, persistent use of bandage contact lenses, lower eyelid deformity, and dermal matrix-related complications were not observed by the last follow-up. Reverse Hughes flap combined with a sandwich graft of an acellular dermal matrix as a tarsal substitute was successful in reconstructing large upper eyelid defects. Acellular dermal matrix graft and lid crease formation sutures enhance marginal stability and prevent postoperative entropion of the reconstructed upper eyelid.

Lateral sliding flap for one-step reconstruction of medium-sized eyelid defects

Background/purpose: To report the results of our clinical study on the efficacy of a ‘Lateral Sliding Flap’: A one-step technique for lower or upper eyelid reconstruction. Methods: Retrospective analysis of a consecutive case series of patients treated with a ‘Lateral Sliding Flap’ following tumour removal by horizontal block excision. In this technique a (medium-sized) defect of up to 50% of the eyelid was reconstructed by disinsertion of the lateral canthus, medial advancement of the lateral (remaining) (full-thickness) eyelid and a laterally-based horizontal skin-muscle advancement flap, followed by canthal fixation. We recorded the operating time and evaluated the postoperative eyelid apposition, lid contour, complications and frequency and type of re-operation. The outcome was scored (according to four grades (excellent/good/fair/ poor) of lid apposition and contour. Results: Seven consecutive patients, all treated by one oculoplastic surgeon in one year, were included. Six were female, one was male. Five had lower eyelid defects, two had upper eyelid defects of 40-50% of the horizontal width. The average age was 67,9 years, ranging from 52 to 85 years. The mean postoperative follow-up time was 31 months, ranging from 21-43 months. The average duration of the reconstruction was 31 minutes (ranging from 25 to 38 minutes). The outcome was excellent in 3 patients, good in 3 patients and fair in one patient. (Some) lash loss may be encountered. No complications such as flap ischemia of necrosis were noted. No re-operation was required. Conclusion: The ‘Lateral Sliding Flap’ is an efficaceous, one-step technique for reconstruction of defects of up to 50% of the lower or upper eyelid. With the technique a normal eyelid margin is created at the level of the cornea for optimal visual function and comfort. Compared to Tenzel’s semicircular rotation flap, the ‘lateral sliding flap’ results in a shorter vertical scar and “Hidden” horizontal scars in the relaxed skin tension lines.

Ideal esthetic and functional full-thickness lower eyelid “like with like” reconstruction using a combined Hughes flap and swing skin flap technique

A goal in ideal lower eyelid reconstruction is to achieve not only an esthetic recovery of the shape of the eyelid but also to obtain satisfactory eyelid function without damage to the corneal surface. In this report, we introduce our "Like with Like" reconstruction technique using a combined Hughes flap and swing skin flap. The Hughes flap is a tarsoconjunctival pedicled flap from the upper eyelid, and the swing skin flap is a kind of transposition flap based on the orbicularis muscle pedicle. Eight patients who had more than 25% of the lower eyelid affected by a full-thickness defect were included. There were five men and three women, and the average age was 68.4years old. All patients had undergone wide tumor excision of the lower eyelid due to a malignant tumor and had also had primary two-stage eyelid reconstruction with a combined Hughes flap and swing skin flap. The average reconstructive time was 1:20, and no postoperative severe complications such as flap necrosis or wound dehiscence were observed. The follow-up period was an average of one year, and there were no functional problems such as ectropion, lower eyelid retraction, lid margin hypertrophy, lacrimation disorder, or corneal problems observed in any cases. Esthetically, no reconstructed eyelid bulging or asymmetry in the lid margin was observed in any of the cases. Combining the Hughes flap and skin swing flap technique might be the best choice for a full-thickness lower eyelid defect with regard to the esthetic and functional results.

Orbicularis Bi-Pedicle flap: A single-staged surgical technique for the reconstruction of large and shallow, upper or lower eyelid defect

Aims: To evaluate the usefulness of orbicularis bi-pedicle flap, a simple surgical technique to reconstruct shallow, upper or lower eyelid defects with loss of more than two-thirds of the lid tissue. Materials and Methods: This prospective interventional study was conducted at a two tertiary referral centers in Lahore, Pakistan from Jan 2011 - Dec 2018. 17 consecutive cases were included: 4 primary, 9 with recurrent tumour and 4 secondary cases with an excised tumour and eyelid defect. The upper lid was affected in 6 cases and lower lid in 11 cases. The median age of patients was 62 years (range 45 - 71 years), with 9 female and 8 male patients. The posterior lamella was reconstructed by mobilising forniceal conjunctiva while donor sclera was used to replace the tarsus. To reconstruct anterior lamella, orbicular bi-pedicle flap was mobilised, covered by a free skin graft. Post-operative follow-up was after 1, 2 weeks and then after 1, 3, 6 months and 1 year. At each visit, functional, aesthetic, visual outcome and patient satisfaction was assessed. Results: Patient satisfaction was 100%. Lagophthalmos in 3 cases (27%), 2 mm lid retraction in 2 cases (18%) following upper lid reconstruction. No complication noted after lower lid reconstruction. Conclusions: Orbicularis bi-pedicle flap is a simple, single-staged technique, with short learning curve and minimal complications. It is particularly useful in single-eyed patients. Keywords: Lid reconstruction, Lid tumor excision, Lid margin defects, Orbicularis bipedicle flap.

A modified method for upper eyelid reconstruction with innervated orbicularis oculi myocutaneous flaps and lower lip mucosal grafts

BackgroundNumerous reports have described methods for repairing full-thickness upper eyelid defects using lower eyelid tissue. To avoid sacrificing the lower eyelid and thereby prevent lower eyelid sagging or dysfunction, we used innervated orbicularis oculi myocutaneous flaps harvested from the upper eyelid for upper eyelid reconstruction. MethodsWe modified a method reported by Moschella and Cordova for repairing full-thickness upper eyelid defects using innervated bipedicled orbicularis oculi myocutaneous flaps mobilized from the upper eyelid and labial mucosal grafts. First, we avoided the use of a Fricke flap, which is used in the original method to repair the myocutaneous flap donor site, since it can cause asymmetry of the eyebrows on both sides. Second, reconstruction of the double-fold eyelid was performed with buried sutures in the myocutaneous flap in secondary surgery, since the double eyelid fold of the original method is not necessary or is too wide for Asian people. Functional and cosmetic outcomes were assessed by six evaluators using postoperative photographs. ResultsSix patients with malignant upper eyelid tumours underwent repair of upper eyelid defects by our modified method. Donor sites of the myocutaneous flaps were repaired with a medial forehead flap in one patient with Merkel cell carcinoma, a lateral orbital flap in one patient with sebaceous carcinoma, and a two-stage skin graft in two patients with sebaceous carcinoma and basal cell carcinoma, respectively. The two remaining patients (one with sebaceous carcinoma and the other with basal cell carcinoma) required no donor site repair. Functional and cosmetic outcomes were good or excellent in most cases. ConclusionOur modified method for repairing full-thickness upper eyelid defects using innervated orbicularis oculi myocutaneous flaps resulted in optimal eyelid function and support, with morphologically satisfactory results including bilateral symmetry. This method provides a useful alternative to conventional methods of upper eyelid reconstruction.

Tail flap for eyelid reconstruction: An alternative to the Tenzel flap

Purpose: To describe a technique of eyelid reconstruction with the tail flap method and also to evaluate the post-surgical outcome in a group of patients. Methods: This was a prospective case series study on nine patients who had undergone an eyelid reconstruction with the tail flap method. The study had been conducted from July 2014 to July 2019. The follow-up continued for six months to one year. Results: A total of nine patients with ten eyelid defects, 2 (22%) patients had unilateral eyelid coloboma, 1 (11%) had lower lid defect associated with Treacher-Collins syndrome,1 (11%)with bilateral upper eyelid coloboma, only one eyelid undergone lid reconstructive surgery associated with craniofacial anomalies,1 (11%) with Juvenile xanthogranuloma of the left upper eyelid,1(11%) with Basal cell carcinoma in the right upper lid, 3(34%) with Meibomian gland carcinoma 2 in lower eyelid and 1 in upper lid undergone lid reconstructive surgery with triangular flap. Among nine patients, a total of ten eyelid defects were repaired with the triangular flap technique, 5 (50%) in the upper eyelid and 5 (50%) in the lower eyelid. The eyelid defects were completely repaired with tail flap in all patients. All patients were evaluated preoperatively and postoperatively. The cosmetic outcomes of surgical intervention were excellent in 5(50%) cases, good in 3(30%) cases, fair enough in 2(20%) cases. Conclusions: Tail flap is an alternative surgical method to the well-established Tenzel flap in eyelid reconstruction. Keywords: Tail Flap; Tenzel Flap; Eyelid Defect; Lid reconstruction

Reconstruction of a Large Oncologic Defect Involving Lower Eyelid and Infraorbital Cheek Using MSTAFI Flap.

An oncologic defect that includes both the lower eyelid and the infraorbital cheek often results in complex reconstructive problems because its reconstruction involves 2 distinct tissue types and cosmetic subunits. Herein, we first present a novel combination of modified supratrochlear artery forehead island flap and advancement rotation cheek flap enables reconstructing a large oncologic defect of lower eyelid and infraorbital cheek. Although discoid lupus erythematosus affects the skin, the patient had achieved a satisfying color match and an acceptable aesthetic restoration without tumor recurrence. This novel flap has shown to be feasible, reliable, and advantageous alternative to the repair of such defects.

Reconstruction of total upper eyelid defects using a myocutaneous advancement flap and a composite contralateral upper eyelid tarsus and hard palate grafts

Reconstruction of total upper eyelid defects using a myocutaneous advancement flap and a composite contralateral upper eyelid tarsus and hard palate grafts

A deviant behaviour of squamous cell carcinoma of eyelid: Rare case report

Squamous cell carcinoma (SCC) is a malignant tumour of the squamous cell layer of the epidermis accounting for about 9.2% of all eyelid malignancies. We report a case of a 45 year old female patient presented with itching, sticky discharge and swelling over the right upper eyelid (RUL) for 20 days. Initially, it was diagnosed as a case of blepharitis of Right Eye and antibiotic eye ointment and lubricants were prescribed. And 2 months later she presented with a mass over the same site. Past history of trauma, burn and chronic exposure to sunlight was absent. Examination revealed a mass of 1.25cm -1.50cm width &amp; 1cm - 1.25cm in height approximately, shape was irregular &amp; firm in consistency. Eyelid margin contour was lost with loss of eyelashes. Other ocular structures were within normal limits. No associated lymphadenopathy was noted. Incisional biopsy of the mass was suggestive of moderately differentiated SCC. Wide excision of the mass was done. Full thickness defect of the upper eyelid was reconstructed with Cutler - Beard technique. : Wide variation at presentation, delay in diagnosis and high propensity to recur with risk of perineural spread leads to difficulty in management. Therefore, any suspicious lesion eyelid lesion should be excised and biopsied.

Total or subtotal replacement of tarsal plate by novel silicone plate for upper eyelid reconstruction in malignant tumors

Purpose:To evaluate the cost, safety, surgical outcome, and efficacy of modified Cutler–Beard eyelid reconstruction utilizing a novel silicone plate as a tarsal plate replacement in the repair of 60% to 100% eyelid defects following the excision of large malignant tumors.Methods:A prospective, noncomparative, interventional study of 30 eyes was done over 3 years. Fourteen patients were female, and 16 patients were male. In all the cases, a silicone plate, the synthetic, artificial tarsal plate, was utilized for a total or subtotal replacement of the tarsal plate. The created defect was measured in mm (length and width) and later expressed in percentage. Pre- and postoperative action of levator palpebrae superioris (LPS) was measured. Pre- and postoperative measurements of the margin-to-margin reflex distance (MRD1) were noted.Results:Preoperative LPS action was 1.23 ± 1.35 mm, whereas postoperative LPS actions at the end of 1 week and 18 months were 11. 8 ± 0.88 mm and 13.53 ± 0. 73 mm, respectively. Preoperative MRD1 was − 3.0 ± 1.144 mm, whereas postoperative MRD1 values at the end of 1 week and 18 months were 2.18 ± 0.27 mm and 4.16 mm ± 0.35, respectively. The mean created defect after the removal of the tumor was 87.3% ±11.10. The mean length of the silicone plate implanted in this study was 27.53 ± 2.48 mm. The follow-up period for the study participants was 18 months.Conclusion:The synthetic novel silicone plate was successful as a tarsal plate replacement. A second surgical site for ear cartilage harvesting is avoided. Cadaver transfer of Achilles tendon carries the risk of transmission of communicable diseases, for example, hepatitis B and HIV. Silicone is an inert, nonreacting, and tissue-tested material, thus eliminating the possibility of graft rejection. This material is readily available and cost-effective. The novel silicone plate is considered to be the most promising alternative material as a tarsal replacement in the future generation.

Total and Near Total Composite Lower Eyelid Defect Reconstruction with Glabella Flap: An Excellent Option with Limited Donor Site Availability

Background/Objective: Traumatic loss of the lower eye lid is usually combined with the paucity of adjacent flaps to reconstruct composite defects. We describe the use of Glabellar flaps with composite or cartilage graft to reconstruct total or near total composite lower eyelid defects and its outcome.&#x0D; Material and Methods: This case series was done from January 2017 to December 2019. Patients of either gender, with unilateral post traumatic partial or full thickness lower eyelid defect of 75% eyelid loss or more and Glabellar flap as only remaining option to reconstruct the anterior lamella were included. Patients with medial, lateral canthi, upper eyelid and injuries to orbital contents were excluded. The outcome was assessed on follow-up by the presence of epiphora, ectropion, lagophthalmos, obstruction of vision, graft infection/ extrusion, lower lid retraction, donor site scarring and the need for flap debulking.&#x0D; Results: 12 patients were operated for lower eyelid defects. 2 (16.7%) patients had total loss of eyelid, while 10 (83.3%) had near total loss, 7 (58.3%) patients presented with partial thickness loss of the eyelid, while rest presented with full thickness loss. 1 patient (8.3%) presented with epiphora, similarly 1 (8.3%) had obstruction of vision in down gaze and 1 (8.3%) had conjunctivitis. None had any other complaint.&#x0D; Conclusion: Glabellar flap together with composite or cartilage graft is an excellent option to reconstruct total or near total composite lower eyelid defects.

All-in-One Lower Eyelid Reconstruction after Skin Malignancies Removal: Combined Modified Tenzel Flap &amp; Palatal Mucosal Graft

Lower eyelid reconstruction for defects greater than 50% is a much discussed topic in literature. The aim of this paper is to present an “all-in-one” surgical technique based on the combination of modified Tenzel flap and palatal mucosal graft to restore the anatomical integrity. In our paper we present a case report of 64 years old patient admitted in Maxillo-Facial Surgery Unit of Polyclinic Federico II of Naples in January 2020. He was affected by lower eyelid basal cell carcinoma, measuring 1.5 cm in diameter. He was treated removing full-thickness neoplasia, leaving a surgical gap of 2 cm. Reconstruction was performed using modified Tenzel flap to cover the skin gap and a palatal graft for the reconstruction of the tarsal region structural integrity. This "all-in-one" technique can handle full thickness eyelid defects with the advantage of respecting the dual layer eyelid structure without the need of a secondary surgical step. Moreover, has shown excellent results for both the preservation of eyelid competency and the low complications rate like ectropion and lagophthalmos.

Reconstruction of giant full-thickness lower eyelid defects using a combination of palmaris longus tendon with superiorly based nasolabial skin flap and palatal mucosal graft

Reconstruction of a full-thickness lower eyelid defect is challenging. We aim to use palmaris longus tendon to improve clinical outcomes in eyelid reconstruction. We generated a novel “three-layer structure” tissue by combination of palmaris longus tendon with superiorly-based nasolabial skin flap and palatal mucosal graft and applied in eyelid reconstruction surgery in 34 patients with significant full-thickness lower eyelid defects. The satisfaction scores were assessed in each patient to evaluate their cosmetic and functional outcomes in follow-up visits. The mean follow-up period was 15 months (range, 6-24 months). Satisfactory results were obtained in 100% patients. No patients reported deformities, obvious scars at the donor sites, or abnormalities of hand function on the surgical side. Our results demonstrated that the three-layer structure incorporating palmaris longus tendon for the reconstruction of giant full-thickness defects in lower eyelid is an effective procedure with satisfactory long-term results.

Клинико-цитологический анализ приживления различных вариантов сложносоставных лоскутов при реконструктивной блефаропластике рубцовых дефектов век

Клинико-цитологический анализ приживления различных вариантов сложносоставных лоскутов при реконструктивной блефаропластике рубцовых дефектов век

Rzadka izolowana wrodzona szczelina powieki górnej z tłuszczakiem powieki – opis przypadku

Congenital eyelid defects mainly include unilateral or bilateral ptosis of epicanthic folds or atresia of the tear ducts. Eyelid defects can also be associated with cleft facial defects as described by Tessier. These defects are rare especially if they are isolated. The eyelid fissure, depending on its size, may cause a functional problem related to incomplete protection of the eye against drying out, or an aesthetic problem, which is particularly important in the psychological development of a child. The reconstruction of the upper eyelid with restoration of its full continuity is a prerequisite for improving the appearance and comfort of life of the growing child.