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     

Eyelid reconstruction with a composite radial forearm palmaris longus tendon flap.

We performed reconstruction with a composite radial forearm palmaris longus tendon flap in patients with wide defects of upper or lower eyelids. In one upper eyelid reconstruction, a palmaris longus tendon was fixed to the frontal muscle to make it possible to open the eye. In the lower eyelid reconstruction, the tendon was fixed to both the medial palpebral ligament and the lateral orbital rim to support the flap. In wide upper and lower eyelid reconstruction with a forearm flap, it is convenient to utilise the palmaris longus tendon to support the flap.     

Total upper eyelid reconstruction by single staged malar-cheek flap

We report a case of total upper eyelid reconstruction by a new technique after excision of an eyelid tumour. The eyelid was reconstructed by a horizontal, laterally based flap from just under the lower eyelid combined with a chondro-mucosal graft from the nasal septum. Surgical outcome was an excellent aesthetically reconstructed eyelid, which was mobile and properly gliding on the globe to achieve complete eye closure.KEY WORDS: Eyelid tumour, sebaceous carcinoma, upper eyelid reconstruction     

Surgical reconstruction of eyelids

Tumors of the eyelid region are a special entity within the tumors of head and neck. Their early recognition and histologic classification helps to avoid extensive and destructive surgery, which is particularly challenging with regard to the surgical repair of those defects. In 58% of the patients with eyelid tumors treated at Fachklinik Hornheide between 2002 and 2006, a malignant neoplasia was diagnosed. In eyelid surgery, particular principles need to be observed. Provided those guidelines are strictly observed, even extensive defects of the upper or lower eyelid can be repaired in an aesthetically acceptable manner. When reconstructing a lower eyelid, not only restoration of the original structure of the margin of the lower eyelid including the ciliary edge is aimed at but also stabilization of the eyelid especially in reconstruction of the lateral angle of the eye. Static reconstruction is not sufficient in many cases with extensive defects of the upper eyelid. It is necessary not only to replace skin, mucosa, and tarsus, but also to restore mobility and function of the upper eyelid to enable complete eyelid closure to protect the cornea. In the current study, the experience with various techniques of eyelid reconstruction and their functional and aesthetic implications are presented and discussed.     

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.     

Transconjunctival upper blepharoplasty: a safe and effective addition to facial rejuvenation techniques

Transconjunctival techniques for eyelid rejuvenation are now well accepted in the lower eyelid. Transconjunctival upper blepharoplasty is a relatively new technique for which overall experience has been limited. Since October 1998, the authors performed 42 bilateral transconjunctival upper blepharoplasties on patients undergoing facial and eyelid rejuvenation. They describe the essential anatomy and technique of the procedure. The CO2 laser is used concomitantly for treating fine rhytids and tightening loose upper eyelid skin. This procedure is an effective method of removing medial upper eyelid fat with minimal complications.     

应用局部皮瓣修复上睑全层缺损一例报告

目的探讨局部皮瓣修复上睑全层缺损的价值。方法2007年3月,对一例狗咬伤所致的右侧上睑全层缺损进行急诊局部皮瓣修复手术。结果术后随访45d,右侧上睑外形满意,功能良好。结论应用局部皮瓣急诊修复眼睑全层缺损,术后效果满意,可避免Ⅱ期手术和睑缘缝合。     

Eyelid sebaceous carcinoma. A case report with literature review

Sebaceous carcinoma of the eyelids is a rare malignancy of which most cases require extensive excision followed by usually complete eyelid reconstruction. We report a case developed from the Meibomius glands of the lower eyelid. Complete excision was achieved by removing the entire eyelid 'en bloc'. Reconstruction was with a composite, chondromucosal septal graft layered on an upper eyelid, musculocutaneous, transposition flap based on a lateral pedicle. After a brief review of the relevant literature, the advantages and disadvantages of the various methods of complete lower eyelid reconstruction are discussed.     

Eyelid reconstruction with acellular human dermal allograft after chemical and thermal burns

OBJECTIVE: To evaluate the efficacy of eyelid reconstruction with acellular dermal allograft in patients with eyelid defect after chemical and thermal burns. METHOD: Eyelid reconstruction was performed in 15 eyelids of 13 patients during the period of June 2001-October 2004 by a single senior surgeon (Chen). Among them five patients had thermal burns, and eight patients had chemical burns. The acellular dermal allograft was used as a tarsus substitute that was sutured into the place between the levator aponeurosis in upper lid or retractor in lower eyelid and the remaining tarsus. RESULTS: After a mean follow-up of 9 months, satisfactory function and cosmesis were obtained. No implant rejection or severe complications were observed. CONCLUSION: Acellular dermal allograft may be used safely as a posterior lamellar spacer graft after chemical and thermal burns; the allograft appears to be biocompatible and does not aggravate the inflammation in the injured eyelid.     

Bipedicle Orbicularis Oculi Flap in the Reconstruction of the Lower Eyelid Ectropion

Background Lower eyelid ectropion is conventionally reconstructed with a local flap or full-thickness skin graft. However, scar contracture and recurrence of ectropion often occur. This article describes an effective surgical technique for lower eyelid ectropion repair using a bipedicle orbicularis oculi muscle or myocutaneous flap from the upper eyelid. Methods This study prospectively analyzed collected data on the bipedicle orbicularis oculi muscle or myocutaneous flap from the upper eyelid in reconstruction of lower eyelid ectropion between 1995 and 2004. The flap was used in 12 eyelid procedures for the correction of lower eyelid ectropion, in 10 cases with traumatic ectropion, and in 1 case with bilateral congenital ectropion. In these cases, a strip of orbicularis oculi muscle or a myocutaneous flap from the upper eyelid with two pedicles attached in the medial and lateral canthus was advanced to the lower eyelid to suspend the eyelid and repair the skin defect. Results No problem of flap viability was encountered in any of the patients, and all healed well. Deformities were corrected, and evaluation showed satisfactory function and appearance during 0.5 to 6 years (average, 2 years) of follow-up evaluation. Eyelid malposition and bulkiness of the lower eyelid occurred in the early stages, but disappeared gradually about 3 months after the operation. There was no flap contraction, recurrent deformity, or significant donor site morbidity in the follow-up period. The incision scars were almost invisible. Conclusions The application of bipedicle orbicularis oculi muscle or a myocutaneous flap from the upper eyelid in reconstruction of lower eyelid ectropion is effective and reduces postoperative morbidity.     

异体巩膜移植替代睑板重建眼睑

目的 探讨异体巩膜移植替代睑板重建眼睑的临床效果。方法 1986年5月～2001年1月对45例部分眼睑缺损患者，采用异体巩膜替代睑板行眼睑重建。其中男31例，女14例，上睑18例，下睑27例；累及上或下眼睑内眦都9例，外眦都7例，眼外伤22例，眼睑肿瘤23例。眼睑缺损不超过眼睑总长度的1／2。术后观察重建眼睑的外观、功能及并发症。结果 45例移植异体巩膜行眼睑重建均获成功。术后随访11～38个月，平均19．7个月。重建的眼睑完整，双侧眼睑长度及高度差值均小于2mm。眼睑开闭及上提功能基本正常，对视功能无影响。结论 异体巩膜是替代睑板行眼睑重建的理想材料。     

A dynamic reconstruction of the upper eyelid with a reversed orbital septum flap

We used the reversed orbital septum for reconstruction both of an upper eyelid defect and movement caused by resection of Meibomian carcinoma. The surface of the orbital septum cosmetically had an appearance similar to normal mucosa. This reconstruction was made dynamic by the connection of the orbital septum with levator aponeurosis. The skin defect was closed with surplus skin as a skin-muscle flap. All materials required for this new method were obtained from the recipient's upper eyelid tissues, except for ear cartilage, so that its texture was natural and donor sacrifice was minimal. This procedure requires surplus skin, some area of orbital septum, and connection of the orbital septum with levator aponeurosis. We believe this new procedure provides a good dynamic reconstruction of the upper eyelid.     

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。     

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.     

Experience in upper eyelid reconstruction with the Cutler-Beard technique

Reconstruction of full-thickness upper eyelid defects has to supply a movable lid with perfect corneal protection, good aesthetic quality, and acceptable sequelae at the donor site. The Cutler-Beard procedure, a full-thickness cutaneoconjunctival inferior eyelid advancement flap, is a reliable method for reconstruction of total or partial upper eyelid defects. Especially in older individuals, the skin of the donor site is loose and provides sufficient tissue to stretch. Color and texture of the donor matches the recipient site perfectly. Destabilization or ectropion of the donor site, the lower lid, and retraction or entropion of the recipient site, the upper lid, are the main complications. Therefore, a modification of the classic technique should be considered by implantation of an enforcing inlay in the reconstructed lid (eye bank sclera, fascia lata, ear cartilage), especially in reconstruction of extended defects of the upper lid.     

A combined flap reconstruction for full-thickness defects of the medial canthal region.

The medial canthus is an aesthetically and functionally important area. Adequate consideration of the local anatomy is essential when reconstructing this area. We developed a combined flap technique with a simple combination of standard flaps for the treatment of extensive defects of the nose and upper and lower eyelids, including full-thickness medial canthus defect. In our technique, a median forehead island flap is used for the nasal region, the anterior surface of the eyelid is reconstructed along aesthetic unit, and the posterior surface is reconstructed with a palatal mucoperiosteal graft. A cheek flap is then used for the reconstruction of the lower eyelid. When reconstructing a small defect of the upper eyelid, the upper eyelid is advanced, while a V-Y advancement flap within the upper eyelid is used for a large defect. To reconstruct the acute angle of the medial canthus, a 0.3 mm titanium wire was passed through the tip of the tarsal plate of the upper and lower eyelids to be reconstructed and was fixed in the perforated nasal bone on the affected side. Using this technique, the acute angle of the medial canthus is well preserved after surgery, and is located symmetrically with its counterpart on the intact side. Our technique provides good reconstructive results and should serve as a valid alternative for the reconstruction of this area.     

Reconstruction of the levator function and conjunctiva using an inferiorly based orbital septal flap for subtotal full-thickness defects of the upper eyelid: two cases of ocular sebaceous carcinoma

Without using the lower eyelid, functional reconstruction of the tarsoconjunctival layer is challenging for subtotal full-thickness defects of the upper eyelid. In 2 cases of ocular sebaceous carcinoma, the levator function and conjunctiva were reconstructed using the inferiorly based orbital septal flap and conchal cartilage graft. The raw surface of the orbital septal flap was epithelialized within 14 days postoperatively. The new upper eyelid with a stable lid margin could open and close properly. Our surgical procedures may be available in the case that the lower eyelid is not usable.     

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.     

眼睑恶性肿瘤切除术后自体硬腭黏膜移植眼睑再造

目的 眼睑恶性肿瘤切除术后采用自体硬腭黏膜替代眼睑后层进行眼睑再造，并对其临床效果进行评价。方法1998年1月～2003年10月，对18例（18眼睑）患者行眼睑恶性肿瘤切除术后，局部旋转移位皮瓣或游离皮瓣联合自体硬腭黏膜替代眼睑后层的眼睑再造术。其中男10例，女8例，年龄35～67岁。18例均为重度眼睑缺损，其中眼睑全部缺损12例，2／3眼睑缺损6例。眼睑基底细胞癌10例，睑板腺癌6例，眼睑鳞状细胞癌2例。结果18眼睑术后外观及功能基本恢复正常，闭合完全，无内外翻。术后随访6个月～4年，平均3年2个月，眼睑形态及功能保持稳定，无植片感染及挛缩，无免疫排斥反应，无肿瘤复发。结论自体硬腭黏膜代替眼睑后层作眼睑恶性肿瘤切除术后的眼睑重建术，是一种简便易行、取材方便、术后并发症少、临床效果满意的眼睑再造术，硬腭黏膜优于传统的眼睑后层替代材料。     

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.