Large Full-thickness Eyelid Defects Research Articles

Reconstruction of Full-Thickness Eyelid Defects Following Tumor Resection: The Bucket Handle Modification.

To describe a modified approach for full-thickness lower eyelid defect reconstruction. This is a retrospective review of 5 patients with large full-thickness lower eyelid defects after tumor resection requiring reconstruction. For these lower eyelid defects, a lateral-based or superior-based tarsoconjunctival pedicle flap from the upper eyelid was used to rebuild the posterior lamella. In all cases, the anterior lamella was supplied from an adjacent myocutaneous flap in a bucket handle configuration. Data collection included tumor type and location, size of eyelid defect, presence of canalicular involvement, postoperative eyelid position, patient satisfaction, and complication rates. Five eyelids of 5 patients underwent Mohs micrographic excision of basal cell carcinoma followed by reconstruction with a bucket handle flap. Age range was 68 to 96 years old (mean of 81y). Five patients presented with lower eyelid involvement. The defect size ranged from 80% to 100% of the eyelid. Three patients had canalicular involvement and required bicanalicular nasolacrimal stent placement. After reconstruction, all patients showed good eyelid apposition to the globe with excellent esthetic outcome. No revision procedures were done. Average follow-up time was 13 months (range of 8 to 21mo). The bucket handle flap for full-thickness eyelid reconstruction is a simple technique that allows for preservation of all anatomical layers of the anterior lamella. This technique shows promising functional and esthetic outcomes.

The Cutler-Beard flap for upper eyelid reconstruction: Surgical indications revisited.

To present the long-term outcome of the Cutler-Beard two-stage technique in patients with large full-thickness upper eyelid defects after tumor excision. The medical records of 24 patients with large full-thickness upper eyelid defects reconstructed with the Cutler-Beard technique from January 2000 to January 2021 were retrospectively reviewed. All the defects involved ≥ 60% of the horizontal length of the upper eyelid and extended vertically for at least 15 mm from the eyelid margin. Patients with follow-up < 24 months were excluded. Long-term postoperative complications, functional outcome, and patient's satisfaction at the end of the follow-up were evaluated. Patients' age ranged from 36 to 88 (mean 66.0 ± 10.7 years) and 58.3% were females. Seven patients (29.2%) had had previous eyelid surgeries. The most common diagnosis was basal cell carcinoma (62.5%), followed by sebaceous gland carcinoma (12.5%), squamous cell carcinoma (8.3%), and Merkel cell carcinoma (8.3%). The mean duration of follow-up was 53.0 ± 16.9 months. Eleven patients (45.8%) developed upper eyelid entropion: 9 were treated conservatively with a therapeutic contact lens, 2 patients required a third operating stage. Most patients achieved a satisfactory functional and aesthetical outcome at the end of the follow-up. Although non-bridging techniques are usually favored to reconstruct large upper eyelid defects, the Cutler-Beard bridge flap is a valuable technique in case of large horizontal defects where the vertical gap is greater than 15 mm. Further surgical steps are rarely necessary; however, alternative techniques should be considered following excision of highly malignant tumors.

Management of Full-Thickness Lower Eyelid Defect After MOHS Procedure and Mustard Flap

Introduction : Large full-thickness eyelid defects are considered a challenging case. This study reports how to manage the reconstruction of eyelid defect in a case with a history of carcinoma cell basal of the eyelid, which is removed with MOHS procedure and mustard flap reconstruction but full-thickness of more than 50% defect of the lower eyelid remains.&#x0D; Case Illustration : A 67 years old woman was referred from the dermatology and venereology clinic with a history of eyelid cancer operation, 13 days prior. The patient's chief complaint was the left lower eyelid felt pulled down. Examination revealed a left lower eyelid full-thickness defect of more than 50% and ectropion at the lateral side. An 8 mm lagophthalmos without corneal exposure was present. The reconstruction was done with a lips mucosa graft to form posterior lamella, at the medial side anterior lamella was formed by the glabellar flap, and at the lateral side was formed by a skin graft due to lack of the anterior lamella from the mustard flap previously.&#x0D; Discussion : Eyelid reconstruction aims to provide adequate globe protection. The principle management of reconstruction in full-thickness eyelid defects horizontally of more than 50% can’t be done by an anterior flap (mustard) only because it's unstable and the eyelid can be retracted. The reconstruction must consist of the anterior and posterior lamella which have to be tight to the periosteum.&#x0D; Conclusion : One step procedure for large defects of the lower eyelid after cancer removal can be done with considering the proper plan of reconstruction technique.

Periosteal flaps allow for single stage reconstruction of larger full thickness eyelid defects: a retrospective study.

Full-thickness lower eyelid defects after Mohs micrographic surgery are frequently referred out to oculoplastic surgery for reconstruction. Reconstructive options include wedge closure with or without canthotomy/cantholysis and tarsoconjunctival sliding flaps. Defects > 50% of the eyelid margin have traditionally required the two-stage Hughes flap, leaving the patient with monocular vision for 3-6weeks until pedicle division. To demonstrate single-stage periosteal flaps performed by dermatologic surgeons can result in safe, functional, and cosmetically acceptable repairs for large full thickness eyelid defects, an institutional review board-approved retrospective study of repairs performed by two dermatologic surgeons between January 2017 and July 2021 at the University of Minnesota. Patient demographics, operative notes, and follow-up notes were reviewed. Defect and follow-up photographs were scored using a visual analogue scale to assess aesthetic results. Ten cases were included in the analysis. Six patients were male and the average age was 62years old. 8/10 were basal cell carcinoma and 2/10 were melanoma. The mean defect was 9.5cm2, with a range of 1-24cm2. The median cosmetic score was 85.8 ± 10.7. There were no serious complications reported. Mohs micrographic surgeons can safely and successfully reconstruct large, full thickness eyelid defects by periosteal flap.

Neurotized Free Platysma Flap for Functional Eyelid Reconstruction: A Cadaveric Study of Anatomical Feasibility.

Conventional reconstructive options for large full-thickness eyelid defects are limited to static local flaps without replacing the missing orbicularis. The authors' aim is to delineate the platysma neurovascular anatomy for innervated functional eyelid reconstruction. Fourteen fresh latex-injected heminecks were dissected. The locations where neurovascular structures entered the platysma muscles were expressed as the percentage distance ± SD from the sternocleidomastoid muscle mastoid insertion to manubrium origin. The superior thyroid, facial, and lingual vessels were the major pedicles in eight of 14 (57.1 percent), four of 14 (28.6 percent), and one of 14 specimens (7.1 percent), respectively. In one specimen (7.1 percent), both the superior thyroid and facial vessels supplied a major pedicle. Venous drainage generally mirrored arterial inflow but was redundant, with 43 percent and 14 percent of flaps also with major contributions from the external jugular and anterior jugular veins, respectively. Neurovascular pedicles entered the platysma 28 to 57 percent caudal to the sternocleidomastoid muscle mastoid insertion, between 0.5 and 4.8 cm anterior to the medial sternocleidomastoid muscle border. Although variability exists, platysma neurovascular pedicles enter at predictable locations between 28 and 57 percent of the distance from the mastoid insertion of the sternocleidomastoid muscle, therefore making free platysma transfer a feasible option for eyelid reconstruction.

Repair of a Full-thickness Eyelid Defect With a Bilamellar Full-thickness Autograft in a Porcine Model (Sus scrofa).

It has been demonstrated the pedicle of a tarsoconjunctival flap advancement does not appear to supply the flap itself and the vascularization of the remaining eyelid/tear film is thought to offer adequate nourishment for survival of the flap; as such, a swine model was constructed to assess the viability of a bilamellar autograft for repair of large full-thickness eyelid defects. Full-thickness defects of varying sizes were created in each lower eyelid of 4 Yorkshire/Yorkshire crossed swine. The defects were then closed with a full-thickness ipsilateral graft from the upper eyelid. Large full-thickness defects were then created in the upper and lower eyelids of 8 Yorkshire/Yorkshire crossed swine and closed with bilamellar autografts from the contralateral eyelids. The subjects were then monitored postoperatively and assessed clinically for graft viability at postoperative days 1, 7, and 30. At the conclusion of the 30-day postoperative monitoring period, necropsy was performed and histopathologic analysis utilized to assess cell morphology and vessel ingrowth of the graft sites. In total, 28 full-thickness bilamellar grafts were constructed and examined. At the conclusion of the postoperative monitoring period, 27 of the grafts were deemed clinically viable and vascular ingrowth was determined to be equivalent to unaffected eyelid sections by histopathologic analysis. One case of postoperative hematoma was noted in the failed graft. One case of postoperative wound dehiscence required subsequent surgical repair. No clinically significant notching of the graft sites was noted. No cases of wound infection, corneal decompensation, or forniceal shortening were identified. This analysis demonstrates the viability of a full-thickness bilamellar autograft as a surgical alternative in the repair of large full-thickness eyelid defects in a porcine model. The postoperative outcomes are consistent with the recent literature. Additional studies need to be performed to assess the procedure's clinical utility in human subjects before incorporation into clinical practice.

Surgical Feasibility of Curtler-Beard Reconstruction for Large Upper Eyelid Defect.

To report long-term surgical outcomes of Cutler-Beard reconstructive surgery in patients with large full-thickness upper eyelid defects following malignant tumor excision. The medical records of 5 consecutive patients with full-thickness upper eyelid defects following tumor resection who underwent Cutler-Beard surgery were reviewed retrospectively between April 2005 and November 2018. Surgical procedure comprises 2 stages: first, complete tumor resection followed by bridged full-thickness lower eyelid advancement flap; second, separation of the closed eyelid with eyelid margin repair 7 to 9 weeks later. Postoperative anatomical, functional and cosmetic outcomes, and complications were evaluated during follow-up at 22 to 77 months. Patients were in the age group of 49 to 75 years, including 3 (60%) females and 2 (40%) males. Three of the 5 patients (60%) exhibited sebaceous cell carcinoma and 2 (40%) showed squamous cell carcinoma. Three patients (60%) underwent Cutler-Beard surgery after recurrence of primary carcinoma following previous operation. Three patients underwent revision surgery with entropion, 2 underwent correction for wound dehiscence and 1 was treated with symblepharon lysis. No serious or permanent ocular complications were observed during the operation or follow-up with the patients. The procedure resulted in good aesthetic quality and acceptable sequelae at the donor site. Cutler-Beard procedure for the reconstruction of large and full-thickness upper eyelid defects is an effective procedure with satisfactory long-term results, although a few patients may require minor revision surgery.

Long-Term Outcomes of Acellular Dermal Allograft as a Tarsal Substitute in the Reconstruction of Extensive Eyelid Defects.

To report the long-term outcomes of using acellular dermal allograft (ADA) as a tarsal substitute for reconstruction of large full-thickness eyelid defects where ipsilateral or contralateral eyelid donor tissue was either not available or tarsoconjunctival transfer was insufficient to cover the full extent of the defect. A retrospective review of a consecutive series of 10 patients between May 2003 and April 2012. Main outcome measures were anatomical and functional outcomes and complications. The study cohort included 4 males and 6 females with a mean age of 48.1 years (range 31-64 years). Indications for reconstruction were extensive full-thickness eyelid defects (upper or lower or both) resulting from tumor excision (n = 6), traumatic eyelid defect (n = 2), electrical burn (n = 1), and eyelid necrosis (n = 1). The mean postoperative follow-up was 84.3 months (range 33-164 months). The reconstructive procedure included a variety of techniques using ADA as the posterior lamellar graft. Overall, 7 patients achieved excellent anatomical, cosmetic, and functional results. Reoperation was required in 3 patients (for postoperative upper lid retraction, upper lid entropion, and lower fornix reconstruction) despite acceptable initial results. There were no intraoperative complications, postoperative allergic or immunologic rejection associated with the use of allograft, nor any long-term sequelae. The extensive upper and lower eyelid defects with large vertical component can be successfully repaired using ADA as a tarsal substitute. The results of our study with long-term follow-up indicate excellent functional and cosmetic outcomes with minimal morbidity.

Longevity results of modified Hughes procedure in reconstructing large lower eyelid defects.

PurposeThe purpose of this study was to evaluate the longevity results of modified Hughes procedure in reconstructing large lower eyelid defects.BackgroundThe modified Hughes procedure was used to reconstruct large full-thickness lower eyelid defects. Meanwhile, the functional results indicated that ocular surface health in the treated eyes may be affected.Patients and methodsNoncomparative, case series retrospective study was designed after obtaining the approval of the institutional review board at the Ophthalmology Department, Menoufia University, Egypt, where the results of cases who underwent surgery with the modified Hughes procedure during a 7-year interval were evaluated.ResultsEleven patients (seven males and four females) in the age range 59–77 years (mean age 67±5 years) were identified. The follow-up ranged from 12 months to 48 months. Cosmetic, functional, and postoperative results were analyzed.ConclusionDespite the favorable cosmetic results of the Hughes tarsoconjunctival flap, the procedure has its own limitations. The results indicated that it does affect the functions and tear film stability in the treated eyes.

Modified Hughes procedure for reconstruction of large full-thickness lower eyelid defects following tumor resection.

BackgroundTarsoconjunctival flap advancement, or the Hughes procedure, is among the techniques of choice for reconstructing full-thickness lower eyelid defects so as to restore normal anatomy and function with the best possible cosmetic outcome. The purpose of this study is to report the outcome of a series of patients treated with a modified Hughes procedure following malignant tumor removal.MethodsThis retrospective study included 45 consecutive cases of modified Hughes procedures performed between January 2013 and October 2015. During Hughes flap creation an incisional plane was chosen in all cases, which left Müller’s muscle attached to the superior tarsal margin, while disinserting the levator aponeurosis. All cases were grouped according to the horizontal length of the lower lid defect to be reconstructed, as well as to the type of anterior lamella reconstruction (free graft vs. inferiorly based advancement flap). Grouped data were compared for the rate of surgical success, defined as achievement of normal lid function and satisfactory cosmesis without needing further surgical interventions, and for the frequency of specific complications.ResultsSurgical success was achieved in 39 cases (87 %). The remaining cases required additional surgery for minor complications including lower-lid ectropion (4 %), pyogenic granuloma (4 %), or lower lid margin hypertrophy (2 %). Donor-site complications were not detected apart from one case of mild entropion with focal trichiasis. No case of premature flap rupture was seen. Neither the horizontal length of the lower lid defect (p = 0.489), nor the type of anterior lamella reconstruction (p = 0.349) significantly affected the surgical success. Particularly, there was no increased onset of lower-lid ectropion among patients receiving an advancement flap.ConclusionsThe modified Hughes procedure remains a well-suited technique for reconstructing lower eyelid defects involving up to 100 % of the horizontal lid length. Leaving Müller’s muscle attached to the Hughes flap might prevent premature flap dehiscence without increasing the frequency of upper lid retractions in turn. Whether using a free skin graft or a skin-muscle advancement flap for anterior lamella reconstruction, seems to be insignificant for the functional-aesthetical outcome.

Internal Cantholysis for Repair of Moderate and Large Full-Thickness Eyelid Defects

To determine the safety and efficacy of internal cantholysis for closure of larger full-thickness eyelid defects. Retrospective review of a consecutive case series. Eighteen patients (18 eyelids) underwent internal cantholysis for repair of a moderate or large full-thickness eyelid defect during the study period. Retrospective review of a consecutive case series of all patients undergoing transconjunctival lateral cantholysis for repair of moderate and large full-thickness eyelid defects between October 2008 and November 2010. Moderate was defined as ≥ 14 mm in horizontal length, and large was defined as ≥ 20 mm in horizontal length. Charts were reviewed for patient demographics; indication for surgery; defect size, type, and location; other concomitant repair; follow-up interval; and complications. Eighteen patients (18 eyelids) underwent internal cantholysis for repair of a moderate or large full-thickness eyelid defect during the study period. Average patient age was 73 years (range, 45-94 years), and there were 10 male and 8 female patients. Average defect size was 19.0 mm (range, 14-25 mm). Average follow-up interval was 4.6 months (range, 1-12 months). Complications included eyelid margin notch (3 cases), persistent canthal dystopia (3 cases), trichiasis (2 cases), pyogenic granuloma (2 cases), eyelid margin nodule (1 case), lower eyelid elevation of 1 mm (1 case), and mild resolving medial lagophthalmos (1 case). No patient requested or required further surgery on the operated eyelid for any reason during the study period. Internal cantholysis allows for closure of moderate and large full-thickness eyelid defects. Complications are acceptable in light of the morbidity of other therapeutic options, such as semicircular flap or shared eyelid flap procedures.

Dry Eye Symptoms in Patients after Eyelid Reconstruction with Full-Thickness Eyelid Defects: Using the Tomey TG-1000 Thermographer

Background: Large full-thickness eyelid defects are conventionally reconstructed by either a Hughes flap or Cutler-Beard bridge flap. Since the structure of the eyelid and its components are necessary for the tear film production and stability, we investigated the outcome after eyelid reconstruction focusing on dry eye symptoms using a new thermographic device, the TG-1000. Methods: Seventeen eyes of patients formerly treated with Hughes flaps (n = 16) and a Cutler-Beard bridge flap (n = 1) were compared to untreated healthy eyes (n = 17) regarding the functional and aesthetic outcome. The follow-up ranged from 3 to 63 months (mean 24.88 ± 17.86). Results: There was no significant difference in Schirmer’s test, break-up time and ocular surface temperature (p > 0.05) between patients after full-thickness eyelid reconstruction and a control group. Eleven patients had minor postoperative complications such as notching of the lid margin (11/17), epiphora (1/17), superficial punctate keratitis (6/17), trichiasis (2/17) and a mild tendency to eversion of the lid margin (6/17). More than 75% of the patients rated their postoperative aesthetic outcome as good or even excellent. Conclusion: The new TG-1000 device is a simple and quick tool for screening of dry eye. This study shows that tarsoconjunctival grafts offer good aesthetic and functional outcome with sufficient tear film composition and stability.

Myocutaneous Pedicle Flap Combined with a Free Skin Graft for Upper Eyelid Reconstruction

Purpose: Repair of large upper eyelid defects can be accomplished by both 1-stage and 2-stage techniques some of which are complicated and time consuming. I here present a simple 1-stage technique for upper eyelid reconstruction.Methods: The records and the peroperative and postoperative photographs of two patients who underwent reconstruction of large full-thickness upper eyelid defects after tumor removal were reviewed. The posterior lamella was reconstructed with lip mucosa in one patient and with a hard palate graft in the other. The anterior lamella was reconstructed with a myocutaneous pedicle flap from the remaining upper eyelid with its base medially or laterally. The resulting skin defect under the eyebrow was covered by a free skin graft from the contra lateral upper eyelid.Results: In both patients the flap healed without necrosis or any other complications. In the case where the posterior lamella was reconstructed with lip mucosa the cosmetic appearance was excellent, and the cornea remained unaffected throughout the postoperative period. In the case where a hard palate graft was used the cosmetic appearance was good, but the corneal epithelium developed an edema and a soft contact lens was needed. The visual acuity was 20/20 and 20/40, respectively, 3 months postoperatively.Conclusion: Large upper eyelid defects can successfully be reconstructed by a pedicle flap from the infra brow area, which subsequently is covered by a free skin graft.

Free Tarsal Graft Combined With Skin Transposition Flap for Full-Thickness Lower Eyelid Reconstruction

We present the surgical outcome in a series of 4 patients with large full-thickness eyelid defects after basal cell carcinoma excision. The patients underwent reconstructive eyelid surgery using autogenous free tarsal grafts combined with a skin transposition flap from the upper eyelid. Two female and 2 male patients ranging in age from 44 years to 85 years were treated. In all 4 cases, posterior lamellae were reconstructed using a free tarsal graft, and the outer lamella was developed with a transposition skin flap from the upper eyelid. The skin flap provided adequate vascular support in all cases. Follow up of 10 months to 20 months showed a good outcome in all patients. Reconstruction of full thickness eyelid defects after extensive tumor excision requires reforming of the anterior and posterior lamella. Whereas the Hughes or Cutler Beard techniques for eyelid reconstruction require a 2-step approach with occlusion of the eye for at least 1 week, reconstruction with a free tarsal graft is a 1-stage procedure and does not entail eye occlusion. Autogenous tarsus as a free graft proves to be a simple procedure for posterior lamella substitution in lower eyelid surgery, especially in combination with a skin transposition flap from the upper eyelid.

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.