Tarsal Flap Research Articles

Modified Hughes Tarsoconjunctival Flap Procedure for Lower Eyelid Defect

Introduction : Hughes procedure of tarsoconjunctival flap is a method of choice in reconstructing full thickness inferior eyelid defect that involves >50% of eyelid margin to restore anatomical integrity, function, and cosmetic of the eyelid. The modified Hughes procedure includes sparing of the marginal upper lid tarsus and removal of the levator muscle aponeurosis from the tarsoconjunctival flap.This article reports 2 patients who underwent modified Hughes procedure after basal cell carsinoma excision.
 Case Illustration : Two patients underwent inferior eyelid reconstruction using modified Hughes procedure. After wide excision of the tumor, tarsoconjunctival flap was made to reconstruct posterior lamella of the eyelid. Subsequently, anterior lamella of the eyelid were reconstructed using full thickness skin graft and advancement flap, respectively. Both patient then underwent second surgery, tarsus flap release, 6-8 week after the first surgery.
 Discussion : A tarsoconjunctival flap from the upper eyelid replaces the posterior lamella, whereas a skin graft, a skin flap, or a skin-muscle flap restores the anterior lamella. After surgery, tarsal flap apposition, skin flap/graft, and stitches were intact. After tarsus flap release, wound healing was good. Tumor biopsy showed basal cell carcinoma.
 Conclusion : Modified Hughes procedure is a treatment of choice in reconstructing full thickness inferior eyelid defect involving >50% of eyelid margin. Full thickness skin graft and advancement flap to reconstruct anterior lamella of the eyelid is choosen after considering skin color and texture similarity and laxity of eyelid and cheek.

Hinged tarsal flap: A novel technique for canthal tendon reconstruction.

Reconstruction of the medial canthal region is challenging due to the complex regional anatomy. Options to reconstruct a medial canthal tendon sacrificed during tumour removal is limited. We present a novel surgical technique where hinged tarsal flap serves to substitute the canthal tendons. This is a retrospective consecutive case series of five patients that underwent canthal reconstruction using this novel technique between May and December 2020. Electronic patient records and medical photograph database were reviewed. Patient demographics, co-morbidities, location and histology of the lesion, size of the resultant defect, reconstructive technique and post-operative complications were noted. All patients had good eyelid stability with no malposition, lagophthalmos or exposure keratopathy. No or minimal distraction of the eyelid from the globe, good cosmetic outcomes and no troublesome watering was reported. No wound dehiscence, no sight loss and no further surgical intervention was warranted. Multiple techniques have previously been described to reattach the medial canthal tendon with silk or supramid sutures. Transnasal wiring, stainless-steel screw and mini-plate fixation are also described, but carry a high risk of complications and are unfamiliar amongst most oculoplastic surgeons. Our technique is quick and simple and utilises autogenous tissue without breaching the periosteum which acts as a natural barrier to tumour infiltration.Refashioning the canthal tendon aids to lengthen the remaining eyelid stump, reducing the horizontal length required to reform the newly constructed eyelid and facilitates the reconstruction.

Lower eyelid margin reconstruction: results of five different techniques

ABSTRACT Purpose This retrospective study was performed to examine surgical results of five different techniques for lower eyelid margin reconstruction after Mohs surgery: primary closure, semicircular flap, dermal matrix graft, sliding tarsal flap, and tarsoconjunctival flap. Methods Medical records were reviewed in 178 patients undergoing surgery between 2005 and 2020. Outcomes were evaluated (photographic review) by three oculoplastic observers masked to procedure type, both with and without knowledge of the eyelid defect. Results All patients achieved a good-excellent functional result and 90.4% were asymptomatic after surgery. Tarsoconjunctival flaps were associated with greater need for subsequent interventions (p < .001) and anterior lamellar deformities (p < .001). Semicircular flaps had a higher incidence of lateral canthal deformity (p < .001), but less eyelash disruption than other flap/graft techniques (p < .001). Mean cosmetic ratings (defect masked) were similar for dermal matrix grafts, semicircular, and sliding tarsal flaps; with each grading higher than tarsoconjunctival flaps (p ≤ .05). Among patients with 9–15 mm wide defects, results were better for semicircular and sliding tarsalflaps, than dermal matrix grafts (p ≤ .005) and tarsoconjunctival flaps (p ≤ .02). Conclusions All patients achieved a good-excellent functional result and 87.1% a good-excellent cosmetic result. The semicircular flap was effective for repairing medium sized wounds that could not be closed primarily, creating a continuous lash line, although with a higher incidence of lateral canthal deformities. The sliding tarsal flap was effective for shallow wounds of varying widths. The single-staged dermal matrix graft provided similar results as the tarsoconjunctival flap. Subsequent interventions were more frequent after the tarsoconjunctival flap than other methods.

Correction of eyelid retraction using a half-thickness tarsal flap for lengthening of the eyelid following ptosis surgery

Various surgical procedures for correction of upper eyelid retraction have been reported, many of which have had favorable results. However, most of these reports are concerned with the correction of upper eyelid retraction in patients with thyroid ophthalmopathy, and few have focused on upper eyelid retraction caused by overcorrection during ptosis surgery. Corrective surgery for upper eyelid retraction resulting from ptosis surgery is often difficult because of the extensive irregular contracture caused by scar tissue. However, as this is a repeat surgery following ptosis surgery, it is important to ensure good postoperative evaluation indices, particularly favorable symmetry, appropriate palpebral fissure width, appropriate crease height, and natural-looking parabolic eyelid margins. Here, we report the lengthening of the upper eyelids using a half-thickness tarsal flap to address upper eyelid retraction secondary to ptosis surgery. By using a half-thickness tarsal flap, the anatomy of the levator insertion onto the tarsal plate is retained, so that good eyelid contour can be obtained, and the results are quantitatively reproducible. Therefore, this technique can be considered for the treatment of upper eyelid retraction and has a potentially wide range of applications. Level of Evidence: Level V, therapeutic study.

Anterior tarsal flap rotation combined with anterior lamellar reposition in the repair of cicatricial upper eyelid entropion.

This study aimed to share the results of patients who underwent anterior tarsal flap rotation combined with anterior lamellar reposition because of cicatricial upper eyelid entropion, and to determine the effectiveness and reliability of this surgical technique. Fifteen eyes of 11 patients (2 right eyes; 5 left eyes; and 4 bilateral eyes) on whom we performed anterior tarsal flap rotation surgery combined with anterior lamellar reposition because of cicatricial entropion were included in this study. The medical records of the patients were analyzed retrospectively, and the causes of cicatricial entropion as well as the preoperative and postoperative ophthalmic examination findings were recorded. Normal anatomical appearance and function of eyelid were considered to have been achieved. The mean age was 59.81 ± 18 years. The mean follow-up period was 21.72 ± 14 months (range, 5-43 months). The causes of cicatricial entropion were postoperative cicatrices development due to multiple electrolyzes for trichiasis and/or distichiasis in 7 eyes, trachoma in 6 eyes, and trauma in 2 eyes. Irritation and watering were detected in all patients preoperatively, whereas corneal opacity and erosion were detected in 10 patients and epithelial erosion was detected in one patient. Full anatomical and functional success was achieved for all patients. Anterior tarsal flap rotation combined with anterior lamellar reposition in the repair of cicatricial entropion was found to be an effective and reliable alternative surgical procedure.

Treatment of eyelid basal cell carcinoma with Mohs micrographic surgery

Objective To investigate the efficacy of Mohs micrographic surgery in the treatment of eyelid basal cell carcinoma. Methods The data of 12 cases with lower eyelid basal cell carcinoma were collected and retrospectively analyzed. All cases underwent Mohs micrographic surgery combined with one stage repair of eyelid defect. The repair methods included sliding, rotation flap, free skin graft and upper eyelid tarsal conjunctival flap repaired surgery. Postoperative eyelid shape, function and tumor recurrence were observed 6 months-3 years after surgery. Results After surgery the skin incision of 9 cases retained tarsus intraoperatively was good.The sliding flap, rotation flap and free skin graft were all survived.Among them 2 cases of rotation flap were in the form of mild elevation in early time, they became flat and level 3 months afer surgery.The color of free skin graft appeared light firstly, then became pigmentation deposit, it gradually returned to normal 6 months later. The tarsals were rosy and survived well after 3 months in 3 cases of full-thickness eyelid underwent resection. All the patients achieved satisfied appearance of the eyelids, the wound was healed, conjunctiva and cornea were not exposed. No recurrence occurred. Conclusion Mohs micrographic surgery combined with the reconstruction of eyelid is effective and safe for the treatment of eyelid basal cell carcinoma. Key words: Basal cell carcinoma, eyelid; Mohs micrographic surgery

Observation on the efficacy of Hughes operation for the repair of the full-thickness lower eyelid defect

Objective To observe the efficacy of Hughes operation for the repair of the full-thickness lower eyelid defect. Methods A retrospective case series review of patients with lower eyelid malignant tumor who underwent surgical repair of full-thickness eyelid defect from February 2005 to April 2015 was made.There were 24 eyes of 24 cases of the lower eyelid defect ranged from 50% to 80%.Hughes operation was used to repair the posterior lamellar, the local flap or free graft were fashioned to repair the anterior defect.The pedicle was divided and the eyelid margin was repaired at 3-6 months postoperatively. Results All patients were followed up for 6 to 36 months after operation.The tarsal conjunctival flap, local flap or free graft were survived.The contour of all upper and lower eyelids was satisfactory after the pedicle divided.No eyelid margin deformity or upper eyelid retraction was observed.The movement of upper eyelid was normal.Palpebral fissure could closed completely.There was only 1 case with squamous carcinoma recurred in eyelid.The complications with lower eyelid entropion in 2 patients, they were corrected surgically; while mild lower lid retraction happened in 4 patients, they didn’t have surgical repair. Conclusion Hughes operation for the repair of full-thickness lower eyelid defect is effective, the eyelid is achieved favorable functions and cosmetic results. Key words: Hughes operation; Eyelid tumor, malignant; Eyelid defect, full-thickness, lower lid

Lower Eyelid Reconstruction with Combined Sliding Tarsal and Rhomboid Skin Flaps.

To report results in patients undergoing lower eyelid reconstruction following Mohs surgery using a combination of surgical techniques, the rhomboid skin flap and a sliding tarsal flap. An IRB approved, retrospective case series of patients undergoing surgery between April 2007 and October 2014. Outcomes include establishment of a functional eyelid, quality of postoperative eyelid margin contour, and postoperative complications. During the study period, sliding tarsal flaps were used to repair marginal lower eyelid defects in 32 patients. Coexisting anterior lamellar defects were repaired with a modified rhomboid skin flap in 24 patients, a full thickness skin graft in 4 patients, and combined skin graft and rhomboid flaps in 4 patients. The average width of the marginal defects was 11.3 mm (range: 7-19 mm). Reconstruction resulted in a functional lower eyelid in all patients, the majority having an excellent cosmetic result (n = 20). Minimal contour abnormalities were present in 9 patients, while 3 patients developed a noticeable notch following surgery. Patients repaired with a rhomboid flap were more likely to have isolated postoperative misdirected lashes (5/24) than those repaired using a skin graft with or without a flap (0/8). Combined sliding tarsal and modified rhomboid skin flaps are an effective method of repairing superficial defects of the lower eyelid margin. This tissue-preserving technique maintains the ability to perform subsequent upper eyelid tarsoconjunctival flaps and lateral canthal procedures should a future need arise. Isolated misdirected lashes and minor contour abnormalities are the most common complications of the procedure.

The Usage of a Conjunctival Flap to Improve Retention of Boston Type 1 Keratoprosthesis in Severe Ocular Surface Disease

Purpose: The Boston keratoprostheses type 1 devices (KPro) are utilized in cases unfavorable to penetrating keratoplasty. The prognosis remains guarded in cases of ocular surface disease due to risk of tissue necrosis. We describe a novel surgical approach using a conjunctival flap with a delayed opening to improve retention.Methods: In three patients with advanced cicatrizing conjunctivitis, a Type 1 keratoprosthesis was stabilized using a full tarsal conjunctival flap. Three months postoperatively, an opening was created in the flap overlying the optical portion of the device.Results: All patients had no device related complications over a mean follow-up period of 17.7 months (range 15-21 months) and vision remained excellent at better than 20/200 for all patients.Conclusions: Utilization of a tarsal flap either primarily as part of a two stage modified technique or secondarily in cases of tissue necrosis and impending device extrusion might maximize retention of the type 1 KPro.

Successful Management of Upper Eyelid Laceration in a Dromedary Camel (Camelus dromidarius)

A female dromedary camel was presented with clinical signs of lacerated left upper eyelid, profuse lacrimation due to continuous irritation of avulsed large, edematous tarsal flap. In order to correct the thwarted vision, continuous irritation and profuse lacrimation, a decision was made to repair the avulsed part of the lacerated eyelid under deep sedation and local infiltration. Obligation of proper surgical techniques and maintenance of adequate postoperative measures rewarded with uneventful recovery.

Free lateral tarsal flap transfer for repair of skin defects of the hand

Objective To explore the clinical efficacy of repairing hand skin defect by free lateral tarsal flap transfer.Methods Lateral tarsal flap free transplantation based on the lateral tarsal artery was carried out to repair skin defects of the hand in 35 cases.The size of flap ranged from 4 cm × 3 cm to 8 cm × 4 cm.Results All skin flaps survived.The follow-up time was 6 to 18 months.The flaps showed good texture and color match with no bulkiness.The sensory recovery was good and hand function was satisfactory.Conclusion The free lateral tarsal flap has a relatively consistent vascular pedicle.The flap is easy to dissect,thus is a useful option to repair small and medium size skin defects in the hand. Key words: Surgical flaps; Hand injuries; Lateral tarsal flap

Surgical Technique: Repair of Forefoot Skin and Soft Tissue Defects Using a Lateral Tarsal Flap With a Reverse Dorsalis Pedis Artery Pedicle: A Retrospective Study of 11 Patients

Various authors have proposed flaps to reconstruct traumatic forefoot skin and soft tissue defects, especially with exposure of tendon and/or bone although which is best for particular circumstances is unclear. The indications for the technique were a forefoot defect area of no more than 8-cm × 8-cm and a well-preserved lateral tarsal (LT) donor site. The injured tendons were repaired using tendon grafts. The free dorsalis pedis flap was outlined by centering it on the cutaneous branch of the LT artery and tailoring it to the size of the wound, allowing 0.5-cm margins in length and width. The flap was rotated around the plantar perforating branch of the dorsalis pedis artery (DPA) to cover the forefoot defect. The lateral dorsalis pedis cutaneous nerve was anastomosed with the recipient plantar nerve stump. The donor site was covered with an inguinal, full-thickness skin graft. Traumatic forefoot skin and soft tissue defects with exposure of the tendon and/or bone involving 11 feet in 11 patients (mean age, 32 years) were covered using a LT flap with a reversed DPA pedicle. Three patients with forefoot defects underwent emergency repair within 8 hours of injury, whereas eight patients required delayed repair. All patients were followed up for at least 6 months (mean, 13 months; range, 6-24 months). All flaps survived uneventfully, except for two that had superficial marginal necrosis or severe venous insufficiency. All skin grafts covering the donor sites survived and all wounds healed. None of the patients had restricted standing or walking at followups. The two-point discrimination was 4 mm to 10 mm at 6 months postoperative. The mean hallux-metatarsophalangeal-interphalangeal scale score was 93 points (range, 87-98 points). Our observations suggest the LT flap with a reversed DPA pedicle is a reasonable option for repair of traumatic forefoot skin and soft tissue defects with exposure of tendon and/or bone but a well-preserved LT donor site and is associated with minimal morbidity.

Multiple flaps based on one pedicle from the foot to repair multiple skin defects of the hand

Objective To introduce the clinical outcomes of using multiple flaps based on one pedicle from the foot for repairing multiple skin defects of the hand.Methods Eight cases with a total of 19 wounds of the hand were treated with multiple flaps based on one pedicle from the foot.The lateral flaps from the first and second toes based on first plantar metatarsal artery were used to repair 12 wounds in 5 cases.Lateral tarsal flap and the first and second toes lateral flaps based on dorsalis pedis artery were transferred to repair 3 wounds in 1 case.Foot dorsum flap and big toe pulp flap pedicled on dorsalis pedis artery were used to repair 4 wounds in 2cases.Results All 19 flaps in 8 cases survived.Postoperative follow-up periods ranged from 3 to 36 months.Flap appearance was lifelike.Two-point discrimination was 5 to 11 mm.Sweat function recovered.Primary healing of skin grafts was achieved at the donor sites. Conclusion Transfer of multiple flaps based on one pedicle from the foot is an ideal method to repair multiple defects of the hand.It simplifies the surgical procedure and shortens the operation time.Flap selection should be based on the type and area of the injury. Key words: Surgical flaps; Microsurgery; Hand injuries

Donor site repair of great toe-nail flap in finger reconstruction surgery

struction surgery Objective To explore methods of donor repair of the great toe-nail flap in finger recon- Methods From December 1998 to December 2010, various kinds of flaps were used in 511 donor sites to repair the great toe-nail flaps, including： 32 dorsal pedal artery flaps; twenty-four first dorsal metatarsal artery flaps; twenty-one second dorsal metatarsal artery flaps; forteen anterior malleolar flaps; seventeen medial tarsal artery flaps; seventy-nine lateral tarsal artery flaps; one hundred and six plantar metatarsal flaps, seventy-nine flaps from second toe; fifteen flaps from mid/lower leg and 124 freed flaps. Results After postoperative 6 months to 11 years of follow-up, repaired donor sites of great toe-flaps all survived successfully, with ideal outlook and function. Conclusion There are many kinds of methods for donor site repair of the great toe-nail flap, and each kind of method has its own advantages and disad- vantages. Among these flaps, plantar pedal artery flap and free groin flap are amony the best ones. Key words: Great toe-nail flap ; Transplantation ; Finger ; Reconstruction ; Microsurgery

Microsurgical repair for soft tissue defects at the foot and ankle

Objective To explore surgical application of local and free flaps for repair of soft tissue defects at the foot and ankle. Methods Between March 2008 and March 2010, 28 cases of soft tissue defects at the foot and ankle were treated in our department. They were 21 males and 7 females with a mean age of 34. 0 years (range, 6 to 62 years) . Thirteen cases were caused by a traffic accident, 11 cases by machine crush, 2 cases by falling, one by chronic ulcer and one by burning. A local or free flap was used in the repair as an emergency or secondary treatment for all the 28 cases, mainly according to the severity of the soft tissue defects at the foot and ankle. The anterolateral thigh flap was used in 10 cases, the sural neurovascular flap in 8 cases, the medial supramalleolar flap in 4 cases, the lateral tarsal flap in 3 cases, the medial plantar flap in 2 cases and the latissimus dorsi flap in one case. The survival and healing of all the flaps were evaluated postoperatively. Results All the cases were followed up for 4 to 24 months postoperatively, with a mean time of 14 months. Distal flap necrosis occurred in 2 cases and edge necrosis in 2. The necroses were cured after dressing, anti-infection management and skin grafting. The rest were all successful at primary repair, with a good contour, texture and elasticity. The patients had restored their foot and ankle function and walked normally. Conclusions Application of a local or free flap for repair of soft tissue defects at the foot and ankle should depend on the location, size and severity of the injury. For heel and ankle defect repair, sural neurocutaneous flap, medial plantar flap, lateral supramalleolar flap or lateral tarsal flap can be used. A free flap, such as anterolateral thigh flap or latissimus dorsi flap, is the first choice for patients with an extensive open injury. The lateral tarsal flap has an advantage in repair of minor forefoot defects. Key words: Foot injuries; Surgical flaps; Skin transplantation

Repair of soft tissue defect on dorsum of the hand with free dorsalis pedis flap

Objective To evaluate the clinical outcomes of repairing soft tissue defect on dorsum of the hand by free dorsalis pedis flap transfer. Methods Ten cases of soft tissue defects on dorsum of the hand were treated. Dorsalis pedis flap including the superficial peroneal nerve was harvested and transferred to cover the defects. In one of the 10 cases, the 3rd and 4th toe extensor tendons were also included in the flap. In the other case, the second toe was transferred simultaneously to reconstruct the middle finger. The sizes of the harvested flaps ranged from 5 cm x 4 cm to 21 cm 12 cm. Results All 10 flaps survived. Postoperative vascular crisis occurred in 1 ease. Surgical exploration revealed venous thrombosis. The flap survived after resection of the thrombotic site and vascular re-anastomosis. Postoperative follow up period was 6 to 24 months. In 9 eases the flaps were not bulky. The texture and color of the skin were near normal. Partial recovery of pain, temperature and touch sensation was observed. In 1 ease the skin was dark and hard. Necrosis of skin grafts at the donor site with exposed tendons was seen in 3 cases. One case healed secondarily after dressing change; one was treated by transferring medial fascial flap from the lower leg; one case was repaired with medial tarsal island flap. Conclusion Composite dorsalis pedis flap is an ideal mehed to repair defects of skin, tendon and nerve on dorsum of the hand. Key words: Flaps; Hand injuries; Transplantation; Repair

A technique for posterior lamellar reconstruction of upper-eyelid marginal defect

We report a technique for a posterior lamellar reconstruction of upper-eyelid marginal defects under general anaesthesia. The technique included a tarso-conjunctival muscular flap with double horizontal incisions and quantification in eyelid closure. An 83-year-old female presented with a left upper-eyelid marginal sebaceous carcinoma of 4 × 5 mm. A 5-mm safety margin was set for excision of the tumour. A 3-mm high tarsus remained after removal of the tumour. The tarso-conjunctival muscular flap, including Muller’s muscle and the levator aponeurosis, was then formed into an oblong shape. The distal tarsal flap was fixed to both sides of the original tarsus. Two horizontal incisions, the distal one set from the lateral side, were formed to elongate the flap. The incisions were extended until the upper-eyelid margin remained stable after a forcible eyelid closing under finger force. Anterior lamellar reconstruction was performed with a vertical advancement flap with Burrow’s triangles. After closing the wound with two additional sutures to reform the skin crease, three tarsorrhaphy sutures were set. These were removed a week later. The upper eyelid then opened appropriately and closed without lagophthalmos, and the curvature was within a permissible range. A posterior lamellar tarso-conjunctival muscular flap with double horizontal incisions and quantification with eyelid closure using finger force were useful for reconstructing a posterior lamellar defect under general anaesthesia.

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

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

Lateral tarsal artery flap with dorsal lateral cutaneous nerve to close forefoot cutaneous defect

目的 探讨前足皮肤缺损的修复及感觉功能恢复的方法. 方法 在足背外侧设计以足背动脉为蒂的跗外侧动脉皮支穿出点为中心的逆行皮瓣修复前足皮肤缺损,用足背外侧皮神经与跖底神经吻合,足外侧供区用腹股沟全厚皮打包植皮.结果 17例跗外侧动脉皮瓣及植皮全部成活,感觉、外形良好、不需要二期整形. 结论 跗外侧动脉皮瓣逆行转移修复前足皮肤缺损,皮瓣薄、有神经支配、解剖位置恒定。

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.