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.     

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.     

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.     

带蒂肌皮瓣加游离睑板结膜瓣重建眼睑

目的 总结用带蒂肌皮瓣加游离睑板结瓣一期修复眼睑全导的缺损的手术。方法 取同侧或对侧游离睑板结膜瓣作睑后层替代物，同侧睑周带蒂肌眼瓣复盖睑后层替代物重建眼睑。结果 本组６例均获得满意的功能重建和可接受的外貌。结论 带蒂肌上瓣加游离睑板结膜瓣是修复眼睑全层缺损的较好方法。     

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.     

转移皮瓣修复眼眶组织巨大缺损

目的:观察几种不同类型转移皮瓣修复眼眶组织巨大缺损的临床效果,探讨眼眶组织巨大缺损的修复技巧。方法:回顾性分析16例被恶性肿瘤广泛破坏眼睑、眶周皮肤、眶内球旁组织及眼球的患者。行控制性或扩大切除肿瘤后,利用眶周健康组织形成转移皮瓣进行修复缺损区,供皮处缺损区取上臂内侧或腹部全厚游离皮片修复。观察术后6mo皮瓣存活情况,分析与皮瓣存活有关的术式及皮瓣类型。结果:患者16例中接受控制性切除肿瘤的患者12例12眼,扩大切除肿瘤者4例4眼;缺损区采用额部或额顶部轴型皮瓣修复10例10眼,皮下蒂皮瓣4例4眼,反转皮瓣2例2眼;术后接受放射治疗12例12眼,未接受放射治疗4例4眼,随访至术后6mo,所有皮瓣均存活。结论:转移皮瓣是修复眼眶组织巨大缺损的安全、有效方法。     

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.     

Medpor下睑插片修复中重度下睑缺损的疗效观察

目的：观察下睑恶性肿瘤切除术后采用Medpor下睑插片植入在修复中重度下睑缺损中的效果。

方法：选取下睑恶性肿瘤切除术后患者19例19眼,采用Medpor下睑插片植入替代睑板联合滑行结膜瓣和带蒂皮瓣移植,修复下睑全层缺损行眼睑再造术。

结果：眼睑外观修复及功能恢复满意,对眼球无刺激,对视功能无影响,术后随访6～36mo,植入物无吸收、移位、排斥及感染,肿瘤无复发。

结论：Medpor下睑插片替代睑板植入修复中重度下睑缺损简便易行,术后并发症少,是一种理想的睑板替代物。     

The use of tarsus as a free autogenous graft in eyelid surgery

This is a report of the use of autogenous tarsus as a free graft in 121 eyelid surgical procedures. Seventy-three operations were for reconstruction of full-thickness defects and 30 were for repair of eyelid retraction. The remainder were for repair of cicatricial entropion, symblepharon, distichiasis, and irregularity of the eyelid margin. No grafts failed. There were three complications to a donor eyelid. It is believed that donor eyelid complications are less likely when the graft is harvested so as to include the upper tarsal margin. The free autogenous tarsal graft was found to be effective in repairing a variety of eyelid defects.     

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.     

Total upper eyelid reconstruction with mucosalized tarsal graft and overlying bipedicle flap

Total or near-total upper eyelid reconstruction with a mucosalized tarsal graft and overlying bipedicled myocutaneous flap was performed on 12 patients. This technique offers several advantages over other reconstructive methods: (1) the opportunity for immediate visual rehabilitation through a single-staged procedure without obscuration of the visual axis, (2) preservation of eyelid blinking and closure by relocation of functional orbicularis muscle, (3) excellent eyelid contour, and (4) use of tissue physiologically similar to that removed. The technique and clinical results are presented herein.     

风筝皮瓣修复眼睑前层及中面部皮肤缺损

目的 评价风筝皮瓣修复合并或不合并中面部皮肤缺损的眼睑前层缺损的疗效.方法 自2008年1月至2010年3月,以面部皮下组织为蒂,设计"风筝"皮瓣,联合或不联合硬腭黏膜移植,修复合并或不合并中面部皮肤缺损的眼睑缺损共10例.眼睑前层或和中面部皮肤缺损面积为(1.2～6.5)cm2、(0.7～4.0)cm2.其中下眼睑中央水平方向4/5、垂直方向完全全层缺损合并颧颊部皮肤缺损1例,下睑内侧水平方向1/2、垂直方向完全全层缺损、下泪小点下泪小管缺损合并中面部皮肤缺损1例,下睑水平及垂直方向均完全全层缺损合并下泪小点及下泪小管缺损1例,上下睑水平方向完全、垂直方向1/3全层缺损合并上下泪小点泪小管缺损1例,下睑中央水平方向4/5、垂直方向完全全层缺损合并颧颊部皮肤缺损1例,全上眼睑前层及颞部皮肤缺损1例,下睑内侧水平方向1/3、垂直方向1/5前层缺损1例,上下睑中央水平方向2/3、上睑垂直方向1/3,下睑垂直方向2/3全层缺损1例,上下睑内侧1/3前层及内呲内侧皮肤缺损合并上下泪小点缺损1例,外眦外侧前层及颞部皮肤缺损1例.结果 皮瓣均无张力修复缺损,皮瓣及硬腭黏膜均全部成活,眼睑外形、功能完全恢复.结论 风筝皮瓣是修复眼睑缺损及面部皮肤缺损的良好方法.

Abstract：

Objective To evaluate the effect of rehabilitating the anterior 1amella of eyelids and midfacial skin defects with kite flap.Methods From January 2008 to March 2010,with or without combination of a hard palate mucosal grafts,the kite flap on a subcutaneous pedicle have been used to repair defect in the anterior lamella of eyelids and midfacial skin in 10 patients.The area of the defect in the anterior lamella of eyelids and midfacial skin ranged from(1.2～6.5)×(0.8～4)cm.Among them,defects span central 4/5 in horizontal direction and complete in vertical direction in full-thickness lower eyelid and partes zygomatica skin in 2 patient,medial 1/2 in horizontal direction and complete in vertical direction and puncta and canaliculus in full-thickness lower eyelid and midface skin in 1 patient,complete lower eyelid and inferior puncta and canaliculus in 1 patient,complete in horizontal direction and 1/3 in vertical direction and puncta and canaliculus both in full-thickness upper and lower eyelids in 1 patient,complete anterior layer of upper eyelid and temples skin in 1 patient,medial 1/3 in horizontal direction and 1/5 in vertical direction in the anterior lamella of lower eyelid in 1 patient,central 2/3 in horizontal direction and 1/3 in vertical direction in full-thickness upper eyelid,and central 2/3 in horizontal direction and 2/3 in vertical direction in full-thickness lower eyelid in 1 patient,medial 1/3 of anterior lamella and puncta and canaliculus both in upper and lower eyelid and inside skin of medial canthus in 1 patient,outside skin of outer canthus and temples skin in 1 patient.Results All flaps and hard palate mucosal grafts were survived.All defects were repaired without tention.The cosmetic appearance and function of eyelids rehabilitated.Conclusions The kite flap provides a competitive method for repairing the anterior lamella of eyelids and facial skin defects.     

Donor site morbidity in free tarsal grafts

PURPOSE: To determine if harvesting free tarsal grafts from the upper eyelids is associated with significant morbidity. DESIGN: Prospective case series. METHODS: Consecutive patients managed with free tarsal grafts by three of the authors (D.S., D.G., R.G.) over a 4-year period. RESULTS: Ninety-one eyelids in 75 patients were operated on using the free tarsal graft for various eyelid pathologies. Mean follow-up period was 14.83 +/- 8.45 months (range, 4 to 42 months). Contour peaking in donor upper eyelid appeared in two eyelids (2.2%), lash ptosis in four eyelids (4.4%) of three patients, and donor site infection in one eyelid (1.1%). Four patients (5.3%) complained of a transient ocular discomfort. There were no cases of postoperative changes on the eyelid height, entropion, or keratopathy in the donor site eye. Most of the donor site complications were mild or transient and required no further surgery. In three patients who underwent subsequent surgery to treat preexisting ptosis or retraction of the donor eyelid, the results were less predictable and further procedures were required. CONCLUSION: Free tarsal grafts harvested from the upper eyelids, with preservation of at least 4 mm of the tarsal plate inferiorly, do not lead to significant donor site morbidity. However, subsequent procedures to alter the position of the donor eyelid may be less predictable.     

异体睑板移植修复眼睑缺损

目的 修复21眼因各种原因所致的部分或全层眼睑缺损。方法 采用低温保存的异体睑板移植替代瞪板,内层行结膜转移或唇粘膜移植。外层应用邻近带蒂皮瓣或游离显效5眼,改善2眼,失败1眼,术后效果与血运 的好坏和移植片的大小有关。结论 采用低温保存的异体睑板修复眼睑缺损,排斥反应轻,疗效佳。是替代睑板的理想材料。     

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 I. Technique and animal research

Reconstruction of full thickness eyelid defects requires the correction of both posterior lamella (tarsus, conjunctiva) and anterior lamella (skin, muscle). Tarsal substitutes including banked sclera, nasal cartilage, ear cartilage, and periosteum can be beneficial for posterior lamellar repair, while anterior lamellar replacement, including skin grafts, pedicle flaps, advancement flaps, etc., is important to cover the posterior reconstructed portion. At times, due to extensive tissue loss, the eyelid reconstruction can be particularly challenging. We have found an alternative posterior lamellar reconstructive technique utilizing irradiated homologous tarsal plate that can be particularly useful in selected cases of severe tissue loss. The experimental surgical procedure in monkeys and the histological fate of the implanted tarsus is described in Part I, and followed in Part II by our experience with this tissue in six human patients.     

Transplantation of Eyebank Sclera in the Cutler — Beard Method of Upper Eyelid Reconstruction

A modification of the Cutler-Beard, or bridge flap, technique for upper eyelid reconstruction using donor sclera for tarsal replacement was performed in 26 patients with follow-up ranging from eight months to nine years. Because the flap advanced from the lower lid normally contains little or no tarsus, donor sclera is inserted between the conjunctiva-lower lid retractor and the skin-muscle layers and is fixed medially and laterally to the tarsal remnants and to the levator aponeurosis superiorly in order to provide substance and stability to the upper lid. Use of donor sclera for tarsal replacement has provided a more normal appearance and greater stability to the reconstructed upper lid. No infection, shrinkage, or rejection has occurred.     

Lower eyelid reconstruction by tarsal transposition.

We reconstructed the lower eyelids of 13 patients using a tarsoconjunctival flap from the upper eyelid. The laterally based pedicle flap permitted a one-stage repair without prolonged occlusion of the eye. The technique was best suited to lesions involving the lateral aspect of the lower eyelid, but can be applied to lesions of the central and medial eyelid. The functional and cosmetic results were equal or superior to tarsoconjunctival advancement flaps.     

A technique for the reconstruction of lower eyelid marginal defects

Objectives

To report on a new one‐step technique for the reconstruction of lower eyelid marginal defects.

Method

Retrospective case series of 5 patients with lower eyelid basal cell carcinomas abutting the eyelid margin. In all patients, the tumour was radically excised with a 3‐mm clear cutaneous margin and a 2‐mm tarsoconjunctival margin under frozen section control. Defect size ranged from 12 to 22 mm horizontally and from 8 to 9 mm vertically. For eyelid reconstruction, the 2‐mm residual lower lid tarsus was advanced superiorly on a conjunctival pedicle and sutured into the posterior lamella defect. The anterior lamella was reconstructed with orbicularis muscle advancement and a free skin graft from the ipsilateral upper eyelid.The outcome following surgery was assessed using a subjective scoring system with 4 subsequent grades (poor, adequate, good, excellent).

Results

At 1 week postoperatively, adequate viability of the grafts was noted in all patients. One patient developed transient punctate epithelial keratopathy. After a mean follow‐up of 10 months (range 1 to 21 months) the outcome was “poor” in 0 patients, “adequate” in 0 cases, “good” in 1 case and “excellent” in 4 cases.

Conclusion

Reconstruction of small to large lower lid marginal defects with local tarsoconjunctival flap advancement combined with orbicularis muscle advancement and free skin graft is associated with a good functional and cosmetic outcome and limited donor‐site morbidity.Basal cell carcinomas account for approximately 90% of eyelid tumours and most frequently involve the lower eyelid.¹ Several techniques can be used to reconstruct lower lid marginal defects (table 1​1).). We present a one‐step technique to repair lower lid marginal defects in patients with cutaneous tumours abutting the lower lid margin. In this technique, the posterior lamella is reconstructed by advancing the residual lower lid tarsus on a conjunctival pedicle, as described by Irvine and McNab for the upper eyelid.⁷ The anterior lamella is reconstructed by orbicularis muscle advancement and a free skin graft, as recently reported by our group.⁵Table 1 Alternative surgical techniques for the repair of lower eyelid marginal defects