Reconstruction of large upper eyelid defects with a free tarsal plate graft and a myocutaneous pedicle flap plus a free skin graft

Purpose: To review and present the results of a one-step method employing a free tarsal plate graft and a myocutaneous pedicle flap plus a free skin graft for reconstruction of large upper eyelid defects after tumour surgery.Methods: This was a retrospective case-series of 8 patients who underwent reconstruction of the upper eyelid after tumour removal. The horizontal defect involved 50–75% of the lid (3 pts.), more than 75% (3 pts.), and more than 75% plus the lateral canthus (2 pts.). The posterior lamella was reconstructed with contralateral upper eyelid tarsal plate. The anterior lamella was reconstructed with a laterally based myocutaneous pedicle flap in 7 patients, leaving a raw surface under the brow which was covered with a free skin graft. In 1 patient with little skin left under the brow, the anterior lamella was reconstructed with a bi-pedicle orbicularis muscle flap together with a free skin graft.Results: All patients healed without necrosis, did not suffer from lagophthalmos, achieved reasonable cosmesis, and did not need lubricants. In one patient, a contact lens was necessary for three weeks because of corneal erosion. One patient still needs a contact lens 3 months after excision to avoid eye discomfort.Conclusion: Large upper eyelid defects can be reconstructed with a free tarsal plate graft and a laterally based myocutaneous pedicle flap in combination with a free skin graft. Two-step procedures can probably be avoided in most cases.     

Levator aponeurosis sandwich flap for reconstruction of upper eyelid defect

A 72-year-old woman suffered from a sebaceous gland carcinoma on her left upper eyelid. The tumour was 13 × 5 mm without metastasis. The tumour was excised with a 5-mm safety margin, resulting in a large, full-thickness defect in which almost all of the tarsal plate, approximately half of the orbicularis oculi muscle, and part of the levator aponeurosis were lost. Reconstruction of the upper eyelid was successfully performed with a levator aponeurosis sandwich flap, upon which the posterior lamella was covered by a free tarsal graft with medial and lateral periosteal flaps, and a skin graft from the contralateral upper eyelid for the anterior lamella. No lagophthalmos was demonstrated after the operation. Six months postoperatively, there was no tumour recurrence, no ocular complications, and good cosmetic results.     

Levator Aponeurosis Sandwich Flap for Reconstruction of Upper Eyelid Defect

A 72-year-old woman suffered from a sebaceous gland carcinoma on her left upper eyelid. The tumour was 13 × 5 mm without metastasis. The tumour was excised with a 5-mm safety margin, resulting in a large, full-thickness defect in which almost all of the tarsal plate, approximately half of the orbicularis oculi muscle, and part of the levator aponeurosis were lost. Reconstruction of the upper eyelid was successfully performed with a levator aponeurosis sandwich flap, upon which the posterior lamella was covered by a free tarsal graft with medial and lateral periosteal flaps, and a skin graft from the contralateral upper eyelid for the anterior lamella. No lagophthalmos was demonstrated after the operation. Six months postoperatively, there was no tumour recurrence, no ocular complications, and good cosmetic results.     

The cutaneomarginal eyelid graft

Purpose: To assess the effectiveness of the cutaneomarginal graft.
Methods: The cutaneomarginal graft consists of eyelid margin tissue with anterior lamella skin. The tarsal plate is resected following harvesting of a wedge of eyelid tissue. The graft is used to repair eyelid defects following excision of neoplasms which spares the posterior lamella. The graft is principally used at the lateral most part of the lower eyelid following Mohs surgery. A case series of five patients are reviewed to assess the effectiveness of the technique.
Results: All patients achieved a satisfactory result following grafting and there were no donor site complications.
Conclusions: The cutaneomarginal graft is an effective means of repair, although with limited indications.     

Treatment of upper eyelid entropion. Lid split surgery and fibrin sealing of free skin transplants

The repair of severe upper eyelid entropion with trichiasis was reported early in ophthalmological literature; a historical review of the main operative techniques is provided. The aim of treatment is to bring the eyelashes away from the lid margin. Recent procedures use an upward transposition of the anterior lamella, which is performed by a lid split technique. The free anterior tarsal surface must be covered by a free, autologous skin graft or mucous-membrane graft to stabilize the free lid margin and to prevent the tarsal plate from shrinking. A fibrin-sealing method is used for the fixation of the graft on the tarsus, thus making sutures unnecessary. The anterior tarsal surface is covered by the fibrin-glued transplant, which prevents the posterior lamella from shrinking and does not allow the lashes to descend to the lid margin again. The results of using this new method on seven patients are presented.     

Superiorly hinged blepharoplasty flap for reconstruction of medial upper eyelid defects following excision of xanthelasma palpebrum

This paper documents an interventional case series which describes a novel technique for reconstructing large medial upper eyelid skin defects following excision of xanthelasma palpebrum. All visible upper eyelid xanthelasma is excised and a superiorly hinged blepharoplasty skin flap is created with a classic skin crease and lateral blepharoplasty incision, the latter acting as an effective 'back-cut' to allow medial advancement of the flap into the defect. Excess triangles of skin are excised and the flap is sutured without tension into the defect in a conventional manner. The patients selected were patients with medial upper eyelid skin defects not amenable to direct closure following surgical excision of xanthelasma. The main outcome measures were the upper eyelid aesthetic and functional outcome, postoperative complications and need for revisionary surgery. In our study seven patients with bilateral medial upper eyelid xanthelasma excised and reconstructed with this technique were identified. Good aesthetic outcome and high patient satisfaction without functional compromise was achieved in all patients at the last follow-up visit. Patient age ranged from 30–52 years old. Follow up ranged from 8 to 18 months. In conclusion, the superiorly hinged blepharoplasty skin flap is a novel and simple technique for the reconstruction of skin defects that are not amenable to direct closure following xanthelasma excision. It avoids the complications of skin grafting and non-surgical ablative methods, particularly in dark-skinned patients.     

Sliding tarsal flap for reconstruction of large, shallow lower eyelid tarsal defects

PURPOSE: To describe a novel technique for reconstructing shallow, full-thickness defects of the lower eyelid. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.     

Entropion of the upper eyelid--surgical aspects

At the end of the 19th century several surgical procedures for the treatment of upper eyelid entropion were described. At that time this type of entropion was much more common than it is today. The goal of treatment is to evert the lashes away from the lid margin. This can be accomplished by tightening the anterior lamella combined with a tarsal wedge resection, or by an upward transposition of the lid skin after splitting the upper lid apparatus. The resulting free anterior tarsal surface must be covered by a free graft to prevent tarsal shrinking. The latter would soon cause a recurrence. After upward transposition of the anterior lamella, the excised skin is very suitable for covering the free tarsal surface. A fibrin sealing method is used to fix the graft on the tarsus, thus making sutures unnecessary. Good results, primarily with regard to function, can be achieved with these methods.     

异种脱细胞真皮基质联合邻位皮瓣修复眼睑全层缺损的临床观察

目的 观察异种脱细胞真皮基质联合邻位皮瓣Ⅰ期修复眼睑恶性肿瘤切除术后眼睑全层缺损的临床疗效.万法 35例(35眼)眼睑恶性肿瘤患者,其中基底细胞癌21例,睑板腺癌13例,鳞状细胞癌1例;累及上睑者12例,累及下睑者23例.所有患者均行术中冰冻并根据冰冻结果确定切缘,肿物切除后眼睑有不同程度全层缺损.取异种脱细胞真皮基质替代结膜睑板组织,根据皮肤缺损大小做邻近滑行或转位皮瓣修补眼睑缺损.术后观察皮瓣及口腔修复膜愈合情况、有无眼睑闭合不全及睑球粘连.结果 随诊半年,异种脱细胞真皮基质已完全溶解,被爬行结膜上皮覆盖,皮瓣愈合良好、无一例皮瓣坏死.其中28例患者术后恢复良好,无眼睑闭合不全及睑内、外翻.4例患者出现轻度眼睑闭合不全,均无暴露性角膜炎.3例患者出现轻度睑球粘连.结论 异种脱细胞真皮基质可替代睑板结膜组织,联合邻位皮瓣治疗眼睑恶性肿瘤切除术后的眼睑全层缺损有较好的临床疗效,可减少患者因取口唇黏膜或行二次眼睑重建的痛苦.     

Myotarsal flap – a versatile entity for lower eyelid reconstructions

The purpose is to present a new surgical technique using myotarsal (MT) flap for reconstruction of small to subtotal full thickness defects - up to 8 mm in height - of lower eyelids, without needing concomitant supplementary procedures. MT flap consists of a 3 mm tarsal strip with attached levator complex. It does not have conjunctival lining or pedicle. Versatility of the flap extends to correction of mild to severe ptosis, and retraction of upper eyelids. This is a retrospective personal series of 163 patients, who underwent surgical reconstruction with MT flap overlaid with quilted skin graft (modified myotarsal flap) after excision of malignant tumours of lower eyelid. Surgery was on day case basis under LA. Patients were assessed for aesthetic and functional outcome, and complications. No patient had any complication. Assessment of outcome included corneal and ocular surface health and protection, eye closure, tear secretion, and lid contours. These were aesthetically and functionally satisfactory. Histology confirmed complete tumour clearance, and clinical diagnosis. There was no recurrence of tumour. An astounding, new, unique and original observation of the study is that cornea and ocular surface remained undamaged throughout, despite absence of conjunctival lining of MT flap. This goes against all current tenets of oculoplasty. Use of the modified MT flap is a safe, versatile, and effective procedure yielding satisfactory aesthetic and functional results for reconstruction of the lower eyelid.     

Operation nach Hughes und damit kombinierte Verfahren

Background

The Hughes procedure is a standard and widely used technique for lower eyelid reconstruction. This paper presents the results of 55 patients who underwent reconstruction of the anterior and posterior lamella with the Hughes procedure at the University eye clinic in Salzburg between 2002 and 2012.

Patients and methods

This study included 55 patients who underwent lower eyelid reconstruction performed with the Hughes procedure including a full skin graft. In 95?% of patients (52/55) this method was performed after tumor resection. The defect size of the lower lid was at least 10 mm horizontally and ranged between 10 and 15 mm. Of the patients three were treated with a combined Hughes and Tenzel procedure whereas in five cases the Hughes procedure was combined with an autologous tarsoconjunctival flap of the contralateral upper lid and a local full skin rotational flap.

Results

In 42 out of 55 patients both the eyelid function as well as the restoration of good cosmesis could be achieved. In 6 out of the remaining 13 patients suffering from minor complications, the function and cosmesis were restored after secondary minor surgery or additional conservative treatment. For six patients, further reconstructive surgery was necessary and one experienced a major complication in the form of a recurrence of basal cell carcinoma necessitating exenteration.

Conclusions

The Hughes procedure is a well-suited technique for eyelid reconstruction of shallow defects extending beyond 10 mm horizontally and involving up to 100?% of the eyelid. The latter require a combined procedure such as the Hughes procedure and an autologous tarsoconjunctival flap and skin graft.     

The ‘over-the-top’ modified Cutler–Beard procedure for complete upper eyelid defect reconstruction

Purpose: To describe the ‘Over-the-Top’ Modified Cutler Beard Procedure (OTTMCB) for complete upper eyelid defect reconstruction

Methods: This is retrospective case note review of four patients that underwent the OTTMCB procedure. This two-stage procedure comprises the replacement of the posterior lamella with a free tarsal graft from the contralateral upper eyelid, and the anterior lamella with a lower lid skin flap over the lower eyelid margin which is divided 2–4 weeks later.

Results: The procedure was undertaken for four patients with 75–90% upper eyelid defects from tumour excision surgery. One patient had post-operative dehiscence requiring debridement and resuturing and further reconstructive surgery 18 months later to improve the cosmesis and lagophthalmos. The other three patients had good functional and cosmetic outcomes.

Conclusions: The OTTMCB procedure replaces the anterior and posterior lamellae of the upper eyelid with ‘like-for-like’ tissues. It avoids some of the drawbacks of the original and other variations of the Cutler–Beard procedure and achieves a good cosmetic outcome.     

Total lower lid reconstruction:clinical outcomes of utilizing three-layer flap and graft in one session

METHODS: Seventeen patients with total or near total lower eyelid defect were included. The defects were reconstructed in three layers. Posterior lamella was reconstructed by using tarsoconjunctival free graft from the ipsilateral upper lid and periosteal flap from lateral orbital rim. Mobilization of residual orbicularis muscle provided a rich blood supply; and the anterior lamella was reconstructed by skin flap prepared from upper lid blepharoplasty as a one-pedicular or bipedicular bucket handle flap.RESULTS: The cause of lower eyelid defect was basal cell carcinoma in 15 patients and trauma in two of them. No intraoperative and postoperative complication occurred. Patients were followed from 10 to 15mo postoperatively. Cosmetic results were favorable in all patients and we had acceptable functional results. Thickness of the reconstructed tissue was a concern in early postoperative period.CONCLUSION:Three-layer lower lid reconstruction in one session is an effective technique for total lower lid reconstruction with minimal complications and acceptable functional and aesthetic outcomes and can be considered as a safe alternative for the preexisting techniques.     

“Sandwich Block” for Eyelid Reconstruction

Purpose: To report on a one-stage technique for eyelid reconstruction with preservation of the eyelid margin.

Design: Prospective study.

Methods: Five patients with small-to-intermediate full-thickness lower eyelid defects (n?=?3) and upper eyelid defects (n?=?2) after tumor excision. Defect size ranged from 5 to 7?mm vertically and from 7 to 12?mm horizontally. For eyelid reconstruction, a full-thickness pentagonal graft from the opposite lid was sutured into the full-thickness defect after removal of the orbicularis oculi muscle from the graft. The orbicularis muscle flap from the recipient eyelid was mobilized and brought in for vascular supply between tarsus and skin of the graft. The outcome after surgery was assessed using a subjective scoring system with 4 subsequent grades.

Results: At 1 week postoperatively, adequate viability of the grafts was noted in all patients. After a mean follow-up of 13 months (range 3–33 months) the cosmetic and functional outcome was adequate in 1 case, good in 2 cases, and excellent in 2 cases.

Conclusion: Reconstruction of small to intermediate full-thickness defects of both lower and upper eyelid with the “sandwich block”-technique is associated with a good functional and cosmetic outcome.     

Tarsal switch procedure for the surgical rehabilitation of the eyelid and socket deficiencies of the anophthalmic socket.

PURPOSE: To describe a tarsal transfer procedure, which we have named the "tarsal switch," to correct the eyelid malpositions and camouflage the socket defects of acquired anophthalmos. METHODS: The technique consists of an upper eyelid tarsectomy, with transfer of the autologous tarsoconjunctival graft to the posterior lamella of the lower eyelid. RESULTS: The operation was performed in 21 anophthalmic patients. In 16 patients with eyelid malpositions, excellent results (within 1 mm of the fellow eye) were attained in 100% of the patients with ptosis, and in 88% of patients with lower eyelid retraction. In the remaining 5 patients, orbital volume loss with secondary implant migration, inferior prosthetic displacement and eyelid asymmetry predominated. In these patients the anophthalmic orbital defects and eyelid asymmetry were masked well. Patient satisfaction was high and complications were few during an average follow-up interval of 16 months. CONCLUSION: The tarsal switch procedure is useful in managing the eyelid malpositions and masking the orbital deficiencies of the anophthalmic socket.     

Rekonstruktion des medialen Lidwinkels Verfahren, Probleme und Ergebnisse

BACKGROUND: Histologically controlled excision of medial canthal eyelid tumors often creates large skin defects, which may be closed by various reconstruction techniques. PATIENTS AND METHODS: To obtain information about indications for surgery, complications, and esthetic and functional results we analyzed 39 of our patients who underwent surgery in this area between August of 1995 and January 1998. RESULTS: Four small defects were closed primarily. A free full-thickness skin graft was used in 15 patients with a medium-sized defect, and 18 patients with large defects were handled by a local rotation or transposition flap. Granulation was left to occur spontaneously in two patients in poor general health. No tumor recurrences were seen. The functional and esthetic results were good. After 3 months free transplants and rotational flaps had healed in well. Increased scarring with mild medial ectropion was seen in five patients with rotation flaps. Patients who were left to spontaneous granulation required a more intensive and longer local treatment. CONCLUSIONS: For the reconstruction of medial canthal defects after tumor excision, free skin transplants were used for small to medium, and rotation flaps for large defects. These are successful procedures with good functional and esthetic results. Spontaneous granulation is an acceptable therapeutic alternative for patients in poor general health.     

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.     

Pedicled lower lid-sharing flap for full-thickness reconstruction of the upper eyelid

Purpose

To explore the clinical effect of the pedicled lower lid-sharing flap for full-thickness reconstruction of the upper eyelid.

Methods

From 2009 to 2013, 13 upper eyelids with meibomian gland carcinoma (13 patients, age range 52–78 years) were excised, and immediately reconstructed with a pedicled lower lid-sharing flap used for full-thickness upper eyelid defects (up to two-thirds of the eyelid width). Traditionally, the flap is divided after 3 to 4 weeks, and the recipient site closed directly.

Results

During a 1–18-month follow-up period, no recurrence, lagophthalmos, hypertrophic scar, or bulky appearance was noted in any of the patients. Aesthetic results for the upper eyelid were obtained for all patients.

Conclusions

We conclude that the pedicled lower lid-sharing flap is a safe and reliable method for reconstruction of full-thickness upper eyelid defects. This procedure not only enables eyelid closure for eye protection, but also directly improves the aesthetic appearance of the face. After second-stage surgery, a stable eyelid margin and lashes with good blood supply and an acceptable cosmetic appearance with regard to symmetry of eyelid height, contour, tarsal show, and skin fold were achieved.     

Reconstruction of the upper eyelid with flaps and free grafts after excision of Basal cell carcinoma

Purpose: To describe a reconstructive technique of the superior eyelid with flaps and free grafts after excision of a basal cell carcinoma. Methods: Single case report of a 79-year-old woman who presented to our hospital with a basal cell carcinoma of the upper eyelid margin with initial erosion. Results: A large and full-thickness excision of the carcinoma was performed. The reconstruction technique should be customized to the individual patient. In this case, the use of a full-thickness tarsal graft from the contralateral upper eyelid, followed by an ipsilateral bipedicled flap and finally by a skin graft, was an effective surgical procedure, performed in one stage, without complications, and with good functional and esthetic results. Conclusions: Malignant neoplasms represent the leading cause of plastic reconstruction in the orbital region. Surgical techniques must be individualized for each patient and for each type of carcinoma. Reconstructive techniques with free grafts and flaps yield excellent results in the orbital region, particularly when some advice and a few fundamental rules are followed, namely accurate hemostasis of the receiving graft bed by moderate use of diathermy, careful suturing of the edges, and application of a compressive dressing for at least 4 days. Postoperative complications are very rare.     

Irradiated homologous tarsal plate banking: a new alternative in eyelid reconstruction. Part II. Human data

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.