Full-thickness Eyelid Defects Research Articles

The Switch Flap in Eyelid Reconstruction

Purpose: Full-thickness eyelid defects are conventionally reconstructed by either a Hughes flap or a Cutler-Beard bridge flap. The switch flap is an alternative method and is not very widely practiced. The author has used this method for repair of large full-thickness eyelid defects and describes her experience with the use of this technique. Method: Eight cases of large full-thickness eyelid defects resulting from excision of tumours such as basal cell carcinoma (bcc), squamous cell carcinoma (scc) and sebaceous gland carcinoma (sgc) were taken for repair using the switch flap technique. The technique involves switching a full-thickness flap on a pedicle to fill a defect from lower lid to upper or vice versa. The pedicle is divided in three weeks. The recipient lid is reconstructed by direct closure and the donor lid by direct closure with or without cantholysis or sliding flap, or it is left to heal by second intention. The patients were followed up frequently in the first few weeks according to need, at six months, and then every year for five years before discharge. At these visits, contour of lid, condition of wound, cornea and donor site were examined for infection, dehiscence, corneal ulcer, notching, trichiasis, and recurrence. The preoperative and postoperative photographs were also compared. Results: Out of the eight cases of eyelid defects, one was from squamous cell carcinoma, three were from sebaceous gland carcinoma, and four were from infiltrative basal cell carcinoma. Using the switch flap technique, the defects resulting from their excision were completely covered in all cases. The main complication was a corneal ulcer in cases 1 and 3 where the flap had crossed the central cornea. A bandage contact lens was inserted until the division of the flap. The main morbidity was the blurred vision until the flap is divided, especially in the cases of reduced vision in the other eye. At about 4–6 weeks post flap division, the recipient and donor sites have healed completely, even when the donor lid was left to heal by second intention (case 4). There was no trichiasis, notching or notable deformity, and the morbidity was minimal. A comparison between preoperative and postoperative photographs shows satisfactory results with the switch flap technique. Conclusion: The author has found the switch flap technique very useful for reconstruction of large full-thickness eyelid defects resulting from tumour excision as this method results in complete repair of defects with a full-thickness flap, tarsus, lid margin and eyelashes and without causing notable deformity at the donor site. The switch flap can successfully replace the Hughes flap technique and Cutler-Beard technique for repair of large eyelid defects.

Sliding Tarsal Flap for Reconstruction of Large, Shallow Lower Eyelid Tarsal Defects

To describe a novel technique for reconstructing shallow, full-thickness defects of the lower eyelid. Twelve patients with shallow, full-thickness lower eyelid defects after Mohs excision of eyelid malignancies were treated with this technique. The posterior lamella was reconstructed by obliquely incising the residual tarsus to create medial and lateral tarsal flaps. These flaps were obliquely overlapped to tighten the eyelid and reconstruct a tarsus approximating normal height. The anterior lamella defect was then reconstructed by using local flaps or free grafts in a conventional manner. Eyelid defects ranged from 25 to 40 mm horizontally and 20 to 35 mm vertically, with tarsal defects ranging from 18 to 27 mm horizontally and 2 to 3.5 mm vertically. A stable eyelid margin with good aesthetic appearance was achieved in all patients. Two patients had mild eyelid retraction not requiring intervention, and one had lower eyelid entropion 9 months after surgery. Sliding tarsal flaps are an effective technique for reconstruction of this type of defect. The advantages of this approach are its simplicity, utilization of preserved tissue, and avoidance of the morbidity associated with more complex procedures.

Reconstruction Following Subtotal Full-Thickness Upper Eyelid Resection with Preservation of the Lid Margin

Purpose: To describe a modification of a technique for upper eyelid reconstruction previously described by Patrinely et al. Methods: Radical excision of a large adenoid cystic carcinoma of the upper eyelid resulted in a subtotal full-thickness eyelid defect with preservation of 2 mm of eyelid margin. Reconstruction was performed with a free transconjunctival graft of maximum size from the contralateral upper eyelid, an overlying bipedicled skin-orbicularis oculi muscle flap and a free skin graft. Results: With this one-step technique, a good cosmetic and functional result could be obtained. Conclusion: If the eyelid margin can be spared, reconstruction of even very large upper eyelid defects with a modification of the technique reported by Patrinely et al. may yield a good result.

Secondary Tarsoconjunctival Flap After Previous Lower Eyelid Hughes Repair

To describe a secondary, two-stage eyelid-sharing tarsoconjunctival flap advancement technique for the repair of full-thickness lower eyelid defect, using the remaining upper eyelid marginal tarsus that was spared in a previously performed Hughes procedure. A computerized database search was performed on all cases of Hughes repair of the lower eyelid performed over a 10-year period (1995 to 2005) to identify patients who required a secondary tarsoconjunctival flap repair. In two cases of tumour recurrence at the lower eyelid margin, an eyelid-sharing, two-stage tarsoconjunctival flap repair of the lower eyelid using the remaining 4 mm of marginal tarsus that was spared in the original Hughes procedure was performed. Case reports of these 2 patients are presented together with their postoperative results. The incidence rate of the described secondary tarsoconjunctival flap procedure was 2 cases per 240 cases (0.8%) of primary Hughes procedure performed over a 10-year period. The postoperative courses in the 2 patients were uncomplicated with excellent surgical results at 6 months' follow-up. The secondary tarsoconjunctival flap advancement procedure is an effective reconstructive technique for the repair of the full-thickness lower eyelid defect in an eyelid that has already undergone a previous Hughes repair.

The Use of Composite Lid Graft and the Adjacent Temporal Myocutaneous Tissue with Orbicularis Muscle Mobilization for Full-Thickness Total and Subtotal Upper Lid Reconstruction

Purpose: To evaluate the use of a lateral full-thickness upper eyelid graft and the adjacent myocutaneous tissue in the temporal area with mobilization of the orbicularis muscle as a single-stage procedure for reconstruction of full-thickness total and subtotal upper eyelid defects. Methods: Twelve patients with extensive basal cell carcinoma were included. In seven patients, the tumor involved the inner canthus and at least the medial one-fourth of both upper and lower eyelids. In five patients, the tumor involved more than two-thirds of the upper eyelid. Following resection of the tumor with a safety margin, a 16-mm graft from the normal upper eyelid and its adjacent myocutaneous tissue in the temporal area was used in reconstruction of the defect in the upper eyelid, without affecting the function or the esthetic appearance of the donor upper eyelid. In all cases, the remaining orbicularis in the recipient bed was mobilized as a bipedicle flap, advanced inferiorly and sutured to the graft. Results: All the grafts have taken. The functional and esthetic results in both donor and recipient upper eyelids were acceptable during a follow-up period of 6–50 months. In 8 patients (67%), the cilia of the composite lid portion of the graft have only partially taken. Conclusion: This single-stage procedure with a single donor site may represent a simple alternative to more complicated procedures described for total full-thickness upper eyelid reconstruction or subtotal reconstruction associated with medial lower eyelid defects.

Pyoderma gangrenosum of the ocular adnexa: A rare condition with characteristic clinical appearances

Purpose To describe the clinical characteristics of periocular pyoderma gangrenosum and to highlight features that may encourage early diagnosis of this extremely rare condition. Design Retrospective, noncomparative, interventional case series. Participants and methods Four patients with periocular pyoderma gangrenosum were treated in the Orbital Unit at Moorfields Eye Hospital over the course of a decade. Main outcome measures Presenting clinical features, therapy, and outcome. Results Four patients (female) between the ages of 56 and 75 years (mean, 65 years; median, 64 years) sought treatment for slowly evolving, painful, unilateral blue-gray swellings of the pretarsal tissues of the lower (1 case), upper (1 case), or both eyelids (2 cases). The swelling progressed to frank tissue necrosis and loss of full-thickness eyelid, with patchy sparing of the lid margin or lashes; in some cases, there was a very distinctive preservation of the pretarsal marginal artery across full-thickness eyelid defects. The lid loss characteristically involved the lateral one third of the lower eyelid (3 of 4 lids), the central part of the upper eyelid (3 of 4 lids) and, in one case, extending into the postseptal tissues in the inferotemporal quadrant of the orbit. In 3 patients, the pyoderma, often associated with a positive serum rheumatoid factor (three of three cases where measured), responded well to systemic immunosuppression and eyelid repair was undertaken during the quiescent phase. In a single patient, relapsing disease led to loss of the eye as a result of involvement of the globe and deep orbital tissues. Conclusions Although an extremely rare condition, periocular pyoderma gangrenosum has a typical clinical appearance, and early recognition and immunosuppression will reduce the ocular morbidity.

Eyelid reconstruction using a hard palate mucoperiosteal graft combined with a V-Y subcutaneously pedicled flap

Full-thickness eyelid defects after tumour ablation require the reconstruction of two layers, the anterior and posterior lamellae. Eyelids were successfully reconstructed after removal of malignant tumours in four patients using a hard palate mucoperiosteal graft combined with a curved V-Y subcutaneously pedicled flap. Although there have been some reports of hard palate mucosal grafts for reconstruction of the posterior lamella, the graft is not sufficiently rigid to support the reconstructed eyelid without the aid of supporting materials such as cartilage grafts. The hard palate mucoperiosteal graft seems to be rigid enough to support the reconstructed eyelid without the use of cartilage or other supporting materials. The subcutaneously pedicled V-Y advancement flap is useful for reconstruction of the anterior lamella in partial eyelid defects. We used it with a modified curved design to allow easy advancement and to make postoperative scars inconspicuous.

One-stage reconstruction of full-thickness lower eyelid defects using a subcutaneous pedicle flap by a palatal mucosal graft: Nakajima T, Yoshimura Y. Br J Plast Surg 49:183, 1996

One-stage reconstruction of full-thickness lower eyelid defects using a subcutaneous pedicle flap by a palatal mucosal graft: Nakajima T, Yoshimura Y. Br J Plast Surg 49:183, 1996

One-stage reconstruction of full-thickness lower eyelid defects using a subcutaneous pedicle flap by a palatal mucosal graft: Nakajima T, Yoshimura Y. Br J Plast Surg 49:183, 1996

One-stage reconstruction of full-thickness lower eyelid defects using a subcutaneous pedicle flap by a palatal mucosal graft: Nakajima T, Yoshimura Y. Br J Plast Surg 49:183, 1996

One-stage reconstruction of full-thickness lower eyelid defects using a subcutaneous pedicle flap lined by a palatal mucosal graft

The authors previously reported a subcutaneous pedicle flap pivoting on the lateral canthus to reconstruct the skin of a whole eyelid as an aesthetic unit. A palatal mucosal graft was added to line the conjunctival side of the flap to make a one-stage reconstruction of the full-thickness eyelid . Although it is becoming popular to use the palatal mucosa as a conjunctival substitute, there are very few reports on the one-stage reconstruction of the eyelid. Two patients with total defects of the lower eyelid resulting from resection of malignant skin tumours have been treated using this technique. The functional and aesthetic results have been excellent in both cases.

Single Tarsoconjunctival Flap (Lower Eyelid) for Upper Eyelid Reconstruction ("Reverse" Modified Hughes Procedure)

We present a two-stage reconstruction of partial or total full-thickness upper eyelid defects. In the first stage, a single tarsoconjunctival flap from the donor lower eyelid reconstitutes the posterior lamella, and a full-thickness skin graft reconstructs the anterior lamella. In the second stage, 5 to 8 weeks later, the skin tarsoconjunctival flap is severed. The single tarsoconjunctival flap we describe is analogous to the modified Hughes reconstruction for full-thickness lower eyelid defects and thus may be termed a "reverse" modified Hughes procedure. In the lid-sharing Cutler-Beard procedure, the popular alternative, the full-thickness lower lid is advanced into the upper eyelid defect. Our procedure provides greater stability due to the increased amount of vertical tarsus in the reconstructed eyelid. Also, in our procedure, the tarsoconjunctival flap is incised 1.5 to 2 mm from the lower eyelid margin rather than the 4 to 6 mm necessary to preserve the marginal artery in the Cutler-Beard procedure. With a follow up ranging from at least 6 months to over 2 years, the only complications among the 10 patients in our series were pyogenic granuloma at the edge of the donor lower eyelid, and mild, medial upper eyelid blepharoptosis. There were no cases of cicatricial entropion of the upper eyelid, a known complication of the Cutler-Beard procedure.

Irradiated homologous aorta in eyelid reconstruction. Part 1: Technique and animal research.

Reconstruction of full thickness eyelid defects requires the correction of posterior lamella (tarsus, conjunctiva) and anterior lamella (skin, muscle). Various tarsal substitutes--conchal and nasal cartilage, banked sclera, hard palate, irradiated homologous tarsal plates, periosteum, temporalis fascia, and composite grafts from the opposite eyelid--have been used for posterior lamellar replacement over the years. Eyelid-sharing procedures and full thickness flaps have also been described. At times, because of extensive tissue loss, the eyelid reconstruction can be particularly challenging because of the shortage of tissue. We describe a new posterior lamellar technique using irradiated homologous aorta. The experimental surgical procedure in rabbits, the clinical response, and the histological fate of the donor aorta are described in Part 1 followed by our experience with four patients in Part 2.

Island chondro-mucosal flap and skin graft: a new technique in eyelid reconstruction

We report a new technique of large full thickness eyelid defect reconstruction using an axial island chondro-mucosal flap from the lateral aspect of the nose and a full-thickness skin graft. The flap is harvested undermining the skin and the subperiosteal plane and taking a strip of upper lateral cartilage and nasal mucosa. It is transposed to reconstruct the tarso-conjunctival plane of the missing eyelid and the skin defect repaired with a skin graft. The donor defect is repaired by direct closure. Satisfactory results were obtained in 3 patients. In our opinion, the technique is a reliable choice when dealing with large full thickness defects of the upper eyelid, and, in selected cases, of the lower eyelid.

Irradiated Homologous Tarsal Plate Banking

Reconstruction of full thickness eyelid defects requires the correction of both posterior lamella (tarsus, conjunctiva) and anterior lamella (skin, muscle). Tarsal substitutes including banked sclera, nasal cartilage, ear cartilage, and periosteum can be beneficial for posterior lamellar repair, while anterior lamellar replacement, including skin grafts, pedicle flaps, advancement flaps, etc., is important to cover the posterior reconstructed portion. At times, due to extensive tissue loss, the eyelid reconstruction can be particularly challenging. We have found an alternative posterior lamellar reconstructive technique utilizing irradiated homologous tarsal plate that can be particularly useful in selected cases of severe tissue loss. The experimental surgical procedure in monkeys and the histological fate of the implanted tarsus is described in Part I, and followed in Part II by our experience with this tissue in six human patients.

Irradiated Homologous Tarsal Plate Banking

Reconstruction of full thickness eyelid defects requires the correction of both posterior lamella (tarsus, conjunctiva) and anterior lamella (skin, muscle). Irradiated homologous tarsal plate provides a structured framework for the lid reconstruction, and is incorporated nicely into the normal lid anatomy.

Lower Eyelid Reconstruction

At the recent meeting of the American Academy of Facial Plastic and Reconstructive Surgery in Washington, DC, Theodore Staahl, Modesto, Calif, presented a method for reconstruction of the lower eyelid. He proposes a new technique for reconstruction of full-thickness lower eyelid defects, such as those occurring after excision of a basal or squamous cell carcinoma of the free margin of the lower eyelid. Modifying a technique used by Segal for ectropion repair, he develops a skin-muscle flap from the upper eyelid, being sure to maintain at least an 8-mm pedicle of muscle laterally. This bipedicled flap is swung inferiorly. The lining of the flap is created by a composite upper lateral nasal cartilage-plus-mucosa graft. The curve and thinness of this graft closely mimic the tarsal plate. The flap and graft are joined to the superior margin, and the rest of the flap and graft are sutured in place. The advantages

Tarsoconjunctival flap for upper eyelid reconstruction.

Reconstruction of large, full-thickness upper eyelid defects is a challenge to the ophthalmic plastic surgeon. Ideally, the defect should be reconstructed with tissues similar or identical to those that have been lost. We present a procedure similar to the Hughes tarsoconjunctival flap technique for lower eyelid reconstruction. However, our technique was used for upper eyelid reconstruction. A remnant of tarsus at least 3 mm wide must be available to be advanced inferiorly in the upper eyelid. We have performed this procedure on 13 patients over ten years (1977 to 1987) with good to excellent results.

Fricke supraorbital flap for reconstruction of total lower eyelid defects

Split or full thickness eyelid defects resulting from tumor destruction or surgical excision present a dilemma for plastic and reconstructive surgeons. Full thickness eyelid replacement requires composite grafting of the skin, together with tarsal support of its substitute and mucosa. The flap described by Fricke in 1829 was used for reconstruction of anterior lamella in six lower eyelid defects. In three of our cases chondromucosal grafts taken from nasal septum were utilized for posterior lamella repair. The results have been satisfactory from a functional and cosmetic standpoint.

Reconstruction of the eyelids following resection for carcinoma

Full-thickness eyelid defects are created in the resection of eyelid carcinomas. These eyelid colobomas can be satisfactorily reconstructed with remaining eyelid tissue in the majority of cases. Procedures are described for resection of varying portions of the eyelids.

Reconstruction of the Eyelids Following Resection for Carcinoma

Full-thickness eyelid defects are created in the resection of eyelid carcinomas. These eyelid colobomas can be satisfactorily reconstructed with remaining eyelid tissue in the majority of cases. Procedures are described for resection of varying portions of the eyelids.