Upper eyelid defect by dog bite reconstructed by an ipsilateral advanced tarsoconjunctival flap with skin graft

A technique for reconstruction of a traumatic upper-eyelid marginal defect utilizing a local tarsoconjunctival advancement flap with a skin graft is presented. A 22-year-old woman was bitten by a dog, resulting in a full-thickness loss of approximately the central half of her left upper eyelid. Debridement was performed under topical anaesthesia followed by one-stage upper eyelid reconstruction. The residual tarsal plate was used as a tarsoconjunctival advancement flap to reconstruct the posterior lamella of the defect. Skin from the posterior aspect of the left ear was grafted onto the reconstructed posterior lamella with two setting tarsorrhaphy sutures. One month postoperatively, the patient had an excellent cosmetic result with appropriate upper eyelid height and curvature, although cilia were not transplanted. The technique described offers a one-stage procedure with a simple surgical method providing on appropriate cosmetic and functional result.     

Total upper eyelid reconstruction

Total upper eyelid reconstruction is required infrequently and is a challenge following trauma or the removal of eyelid for tumor. The vertical forehead flap can provide the external lamella with a mucous membrane graft lining its posterior surface. Two cases of total upper eyelid reconstruction using this method are presented and discussed. Received: 10 August 1998 / Accepted: 19 November 1998     

Fricke supraorbital flap for reconstruction of total lower eyelid defects

Summary 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.     

Monopolar cautery for graft cartilage sculpting in reconstructive eyelid surgery.

We describe a technique for using the monopolar cautery to sculpt ear cartilage to prepare it for use as a graft to reconstruct or support the posterior lamella of the eyelid in oculoplastic procedures. We have used this simple, rapid, and predictable technique in 16 patients with excellent results.     

Total upper and lower eyelid replacement following thermal burn using an ALT flap--a case report.

Upper and lower eyelid unilateral full thickness reconstruction in a patient with no available adjacent tissues because of burns or trauma sequelae is a surgical challenge. A case of severe thermal burn with unilateral complete defect of both upper and lower eyelids is reported, together with the surgical technique of reconstruction. The patient was a 65-year-old man who sustained deep burns of the head and neck with upper airway burns after falling into a fireplace. After tracheostomy and acute resuscitation, he underwent escharectomy and coverage of his head and neck burns with split thickness skin grafts and with full thickness skin grafts to the eyelids. There was incomplete take of the skin grafts to the upper and lower left eyelids. In these areas, infection and loss of the tarsum and subsequent eyelid retraction led to exposure keratitis and blurred vision. After healing and respiratory rehabilitation, he was referred to our microsurgical unit for upper and lower eyelid reconstruction. A free forearm flap was first considered, but the Allen test was negative. Therefore, a free anterolateral thigh (ALT) flap was chosen to provide skin eyelid coverage. The flap was harvested including fascia and centred on one perforator. The levator muscle stump and conjunctiva from both upper and lower cul-de-sacs were dissected and advanced. Flap vessels were anastomosed to the superficial temporal artery and vein. The conjunctiva and the fascia replaced the new inner upper and lower lamella. To our knowledge, this is the first report of the use of a perforator flap, the ALT flap, in full thickness reconstruction of both upper and lower eyelids and may be a reliable option in such selected and challenging situations.     

The sanctity of the upper lid in lower eyelid reconstruction questioned. A modification of a lid sharing procedure with a long-term follow-up

Sharing techniques using the upper eyelid to reconstruct the lower one have been criticised for causing distortion of the normal upper lid leading to corneal exposure and possible visual disturbance, and for creating second-rate lids. A modification of previously described tarsoconjunctival flap techniques is described which minimises the known complications of earlier methods. A flap of conjunctiva alone is mobilised from the upper eyelid and covered with a full thickness skin graft. A second minor procedure to divide the flap from its donor site is necessary 2 weeks later. Forty-three patients over a 25-year period have undergone total lower eyelid reconstruction with this modified technique and are reviewed with some illustrative cases. Total or subtotal lower eyelid reconstruction is most commonly performed following tumour resection and only occasionally to correct congenital or traumatic defects. The surgical techniques available still cause controversy (Byrd, 1983). An upper lid sharing technique has been criticised for possibly causing a shortened or distorted normal lid (Mustardé, 1981). A modification of this method is described which has been used for over 25 years and has reduced the morbidity of the procedure, leading to acceptable cosmetic and functional long-term results.     

Total upper and lower eyelid reconstruction using deltopectoral flap

Total upper and lower eyelid unilateral full thickness reconstruction is a surgical challenge. A case of right orbital haemangioma with unilateral complete defect of total upper and lower eyelids with right orbital exenteration is reported, together with the surgical technique of reconstruction. Patient was a 24-year-old female who underwent right orbital exenteration with total upper and lower eyelid excision for orbital haemangioma presented after 3 weeks of the above procedure. In the first stage split thickness skin grafting is used to resurface orbital cavity raw area followed by staged reconstruction of total upper and lower eyelid reconstruction using pedicle deltopectoral flap. This reconstruction provided stable eyelid reconstruction to retain ocular prosthesis with concealed and minimal donor area. After reconstruction patient underwent rehabilitation with ocular prosthesis, now the patient is satisfied with cosmetically acceptable results.KEY WORDS: Deltopectoral flap, total eyelid reconstruction, total upper and lower eyelid reconstruction with DP flap     

Lower eyelid reconstruction preserving symmetry of bilateral palpebral fissure

Summary A method for lower eyelid reconstruction is reported. The lower lid defect is reconstructed with a composite flap including skin and orbicularis oculi muscle from the ipsilateral upper eyelid. To cover the donor eyelid defect, a composite graft (skin and the orbicularis oculi muscle) is taken from the contralateral upper lid. The width of the graft is half of that of the flap so that the resulting contour of the bilateral palpebral fissures is symmetrical. The donor scar is invisible being placed in the natural lid fold. The color and texture match of the reconstructed lower lid is excellent. This is a simple technique which can be done as an outpatient.     

Reconstruction of an inner layer defect of the upper eyelid with avulsion of the superior levator palpebrae muscle and orbital fat

The authors report a successful reconstruction of the total upper eyelid in conjunction with the gliding surface of the extraocular muscles. A 21-year-old woman sustained an inner layer defect of her right upper eyelid together with avulsions of the superior levator palpebrae muscle and the superior orbital fat. Her right superior rectus muscle was exposed, and no orbital fat was seen in the space between the muscle and the orbital roof. To preserve eye movement, a gliding surface between the superior rectus muscle and the orbital roof had to be reconstructed. Total upper lid reconstruction was performed using a radial forearm flap with a hard palate mucosal graft. The gliding surface was reconstructed with an adipofascial flap obtained from the forearm. Despite lack of levator function, the patient could raise her eyelid approximately 5 mm by using only the superior rectus muscle without frontalis suspension.     

眶脂肪保留和眼轮匝肌瓣悬吊法整复睑袋畸形

目的预防睑袋整复术后出现下睑凹陷和巩膜过多显露等并发症。方法术中沿眶下缘松解眶隔,释放出眶脂肪,将其充填眶下缘凹陷,并设计下睑眼轮匝肌瓣,用以缩紧悬吊松弛下垂的下睑肌肉与皮肤。结果从１９９６年９月至１９９７年５月,共以此法整复睑袋畸形３０例。２６例得到３～８个月随访,除１例因一侧眼轮匝肌瓣固定不牢致下睑轻度外翻外,其余均获满意效果。结论此法既可有效地矫正睑袋畸形,又可避免术后出现下睑凹陷和巩膜过多显露状况,同时具有颊提升效果,可使全中面部变得年轻化。     

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.     

Histological evaluation of grafted hard palate mucosa in the reconstruction of the upper eyelid.

We have used a hard palate mucosal graft for reconstruction of the posterior lamella of the eyelid and in only one case was replacement required because of discomfort and pain. The stratum corneum of the hard palate mucosa may have been the cause.     

眶脂肪保留和眼轮匝肌瓣悬吊法整复睑袋畸形

目的 预防睑袋整复术后出现下睑凹陷和巩膜过多显露等并发症。方法 术中沿眶下缘松解眶隔,释放出眶脂肪,将其充填眶下缘凹陷,并设计下睑眼轮匝肌瓣,用以缩紧悬吊松驰下垂的下睑肌肉与皮肤。结果 从1996年9月至1997年5月,共以此法整复睑袋畸形30例。26例得到3－8个月随访,除1例因一侧眼轮匝肌瓣固定不牢致下睑轻度外翻外,其余均获满意效果。结论 此法既可有效地矫正睑袋畸形,又可避免术后出现下睑凹陷和巩膜过多显露状况,同时具有颊提升效果,可使全中面部变得年轻化。     

瘢痕皮瓣修复上睑皮肤瘢痕性缺损

目的：探讨局部瘢痕皮瓣修复上睑皮肤瘢痕性缺损的效果。方法：烧伤、感染后的瘢痕疙瘩所致上睑皮肤瘢痕性缺损10例;采用保留瘢痕皮肤的瘢痕内剥除塑形手术方法,同时松解复位外翻的眼睑,术后曲安奈德瘢痕内注射2～5次。结果：除1例皮瓣坏死改善不明显外,其余病例瘢痕疙瘩和睑外翻完全矫正。随访3～12月,无复发,重睑形态良好。结论：瘢痕皮瓣是修复上睑皮肤瘢痕性缺损的良好办法。     

Hemi-orbicularis oculi switch flap for upper eyelid defects.

BACKGROUND: The technique chosen to reconstruct anterior lamellar defects of the upper eyelid requires careful consideration. We modified pre-existing techniques used to reconstruct anterior lamellar defects after tumour resection and have called this procedure a hemi-orbicularis oculi switch flap. METHODS: This musculocutaneous flap is elevated with underlying orbicularis and its base abuts the anterior lamellar defect. The flap, which is half the height of the defect, is elevated and inset to cover the defect. Then, taking into consideration the extensibility of upper eyelid skin, the remainder of the defect and the donor site are closed directly. RESULTS: Five patients with basal cell carcinoma, haemangioma, and xanthoma of the upper eyelid were treated by this method. All flaps survived and complications were minimal. Aesthetically and functionally good results were obtained by this method. CONCLUSIONS: We have developed a surgical method for the reconstruction of anterior lamellar defects of the upper eyelid. The proposed method is technically simple and safe and provides consistent results for a potentially wide variety of upper eyelid tumours.     

Optimal care for eyelid contraction after radiotherapy: case report and literature review

Radiotherapy represents a major problem in facial surgery. Orbital and periorbital radiation therapy causes a contraction of the soft tissues. Scarring with ectropion is the most severe complication, with shrinking of the anterior lamella, skin dystrophy, muscle atrophy, and alteration of the remaining soft tissues. Goals for reconstruction include correction of distorted orbitofacial tissues and the restoration of orbital structures. The management of these patients is not standardized. We suggest systematically using a combined approach of surgery and lipofilling to restore the orbital deformity and dystrophy, respectively. For this purpose, we present the case of a 65-year-old woman with asymmetry of the orbital regions and severe lower eyelid cicatricial ectropion due to multiple radiation treatments in childhood for an extensive cavernous hemangioma of the right side of the face. We performed a reconstructive procedure using a tarsal strip technique in association with contralateral upper eyelid graft to correct the extensive retraction of the right lower eyelid and lid asymmetry. Subsequently, the patient underwent lipofilling to correct the post-radiotherapy dystrophy. Skin texture, softness, and elasticity greatly improved with further symmetrization. The combined treatment with surgery and lipofilling can significantly improve the functional and cosmetic outcome of shortened and dystrophic eyelids with a successful result with regard to post-radiotherapy retraction.     

Functional lip reconstruction with a radial forearm free flap combined with a masseter muscle transfer after wide total excision of the chin

Total lower lip reconstruction was accomplished by combining a radial forearm free flap with a masseter muscle transfer. The patient, who had T4 carcinoma, had the entire lower lip resected including the depressor anguli oris muscle. A radial forearm flap was used to reconstruct the lower lip lining and the floor of the oral cavity. The right and left masseter musculofascial flaps were elevated and transferred in the medial-superior direction, and the peripheral margins of the flaps were sutured together. The lateral margins of the flaps were then sutured to the orbicularis oris muscle of the upper lip. Good sphincter function was obtained more than 1 year after the operation, electromyography revealed almost normal mobility of the transferred masseter muscles, and no sagging of the masseter muscle sling was observed. This procedure appears to be effective for the reconstruction of sphincter function of the lower lip after wide excision of the entire chin.     

双瓣法在睑袋成形术中的应用

目的探讨采用皮瓣和肌瓣法（简称双瓣法）行睑袋成形术的操作方法和临床效果。方法对36例采用下睑成形术切口人路,分别形成皮瓣和肌瓣,在皮肤和眼轮匝肌表面与眶隔之间进行分离,直达眶下缘凹陷部,术中充分剥离松解弓状缘眼轮匝肌,特别是泪槽处眶下缘骨膜面的眼轮匝肌,将眶隔脂肪释放,缝合固定于眶下缘下方骨膜面上,行睑颊沟填充。然后设计眼轮匝肌瓣,将眼轮匝肌瓣上提和缝合固定,提升面中部使下睑区域达到年轻化效果。结果36例术后未出现血肿和下睑退缩现象。所有患者术后经3～18个月随访,均未出现睑外翻及面神经损伤等并发症。结论双瓣法既能矫正睑袋畸形,又能有效提升面颊部,达到面中部年轻化的效果,是一种较好的睑袋切除术式。     

应用扩张预制黏膜衬里皮瓣修复眼睑缺损

目的 探讨眼睑全层缺损修复的新方法。方法 在额部扩张皮瓣的内面移植口腔黏膜，待黏膜成活后与皮瓣一起转移至眼睑部，分层缝合。4个月后行上、下睑裂分开，安装义眼。结果 修复后的外形较好，恢复了部分功能。结论 在扩张后的皮瓣内预制黏膜衬里皮瓣是修复眼睑全层缺损的一种较好的可行方法。     

岛状鼻中隔软骨粘膜瓣修复眼睑结膜和睑板缺损

目的 介绍岛状鼻中隔软骨粘膜瓣修复眼睑结膜和睑板缺损的解剖学基础和3例临床实践。方法 根据解剖研究结果,设计以鼻懵基底动脉和神经为蒂的岛状鼻中隔软骨粘膜瓣,通过眶下区皮下隧道移转到眶区,修复缺损眼睑的结膜和睑板,结果 1998年至今共治疗3例,术后软骨粘膜瓣完全成活,无并发症发生。结论 岛状鼻中隔软骨粘膜瓣血运丰富,易成活,可提供足量的组织用以修复上、下睑或上和下眼睑结膜睑板的缺损,血管神经蒂长,移转灵活,使通过常规方法不能或难以修复的眼睑缺损得以修复,供区隐蔽,无明显继发畸形。