Modified Hughes flap

Reconstruction of Upper Eyelid Defects Secondary to Malignant Tumors with a Newly Modified Cutler-Beard Technique with Tarsoconjunctival Graft

Purpose

We describe a modification of Cutler-Beard's technique, using a contralateral tarsoconjunctival graft, in patients who underwent excision of large malignant tumors of the upper eyelid.

Methods

This is an interventional retrospective review (clinical study) of ten cases, with age range from 64 to 86 years (mean: 71.2 years ± 6.49) with malignant upper eyelid tumors, operated by the same surgeon (AB-G), between 2011 and 2016. The resulting defects were reconstructed using a modification of Cutler-Beard's technique. A tarsoconjunctival graft was harvested from the contralateral upper eyelid, with an extra 3 mm of conjunctiva from the superior edge of tarsus and was attached to the upper eyelid defect, different from that previously described. Follow-up ranged between 24 and 60 months (mean: 41.6 ± 9.87). Functional, cosmetic outcomes and postoperative complications were evaluated.

Results

No upper eyelid retraction, eyelid margin entropion, or graft retraction was observed in any of the cases. All of the patients were satisfied with the aesthetic result.

Conclusion

This technique allows us to safely inset a suitable graft on the ocular surface, with sufficient blood supply, resulting in a stable margin and good contour.

Large Eyelid Defect Repair Using a Free Full-Thickness Eyelid Graft

Large eyelid full-thickness defects are traditionally repaired using flaps with a blood-supplying pedicle, for the reconstruction of the anterior or posterior lamella or both. This is a 2-stage procedure involving occlusion of vision in the affected eye for 4–8 weeks, as the flap pedicle is not divided until vascularization is deemed adequate. However, the importance of using a flap with a pedicle to ensure adequate perfusion of the graft has recently been questioned.

Eyelid reconstruction using the "Hughes" tarsoconjunctival advancement flap: Long-term outcomes in 122 consecutive cases over a 13-year period

This article evaluates the complications and long term functional and cosmetic outcomes of tarsoconjunctival advancement flaps for repairing a range of lower eyelid defects in a large cohort of consecutive cases. A retrospective series of 122 consecutive cases of eyelid reconstruction using tarsoconjunctival-advancement flaps was conducted at Waikato Hospital, or Hamilton Eye Clinic, New Zealand. All cases of lid reconstruction using tarsoconjunctival-advancement flaps between January 1, 2001 until April 3, 2014 were included for analysis. All patients provided written consent for surgery and the study complied with New Zealand Health and Disability Ethics Committee guidelines and the Declaration of Helsinki. Data were collected on patient demographics, lesion histology, defect size, adjuvant surgical procedures required for reconstruction, surgical and postoperative complications, cosmesis and patient satisfaction. Patients requiring lower eyelid reconstruction were predominantly male (56%) and basal cell carcinoma was the most common pathology (>80%). Male gender was associated with larger tarsoconjunctival-advancement-flap width (P-value = 0.0432), larger maximum flap width (20 vs 15 mm), and required on average more adjuvant procedures for reconstruction (1.80 vs 1.48, P-value = 0.02). Mean duration to flap division was 37 days and decreased over the duration of the study. Complicated cases were associated with shorter duration to flap division. Mean follow-up was 7 months, complications were observed in 14% with revision required in 4%. Tarsoconjunctival flap reconstruction of the lower lid is suitable for a range of defect sizes and produces excellent functional and cosmetic outcomes. Complications are relatively infrequent and may be associated in some cases with decreased duration to flap division.

[Glaucoma attack following Hughes tarsoconjunctival flap: what should be done?]

PURPOSE

The aim of this article is to present a case of acute glaucoma arising in a closed eye 10 days after lower eyelid reconstruction by Hughes tarsoconjunctival flap technique and to discuss clinical strategies to avoid this complication.

CASE REPORT

A 61-year-old hyperopic patient presented with a basal cell carcinoma of the lower eyelid. After 2-step tumor resection eyelid reconstruction was performed by Hughes tarsoconjunctival flap technique but 1 week later the patient presented with headache and pain in the contralateral eye. Acute glaucoma was diagnosed and successfully treated (mannitol, aceatazolamide i.v., topical pilocarpine and iridotomy). Some days later the patient came back with relapsed headache and pain in the closed eye. Although the intraocular pressure (IOP) could not be measured acute glaucoma of the right eye as well was suspected and the patient was treated again with mannitol and acetazolamide. As the pain resolved under this therapy the closed eyelid was not opened at this time but the lid reopening was performed at the regular time point (4 weeks postoperatively).

CONCLUSIONS

To the best of our knowledge this is the first published case of an acute glaucoma arising in a topically uncontrolled treatable eye with sutured eyelids. The risk of insufficient treatable acute glaucoma should be included in the patient informed consent when planning eyelid reconstruction by Hughes tarsoconjunctival flap technique. The case supports experimental research efforts to establish techniques of transpalpebral IOP measurement.