Avoiding the Hughes flap in lower eyelid reconstruction

Equivalence in Color-coded Duplex Sonography Parameters before Complex Microsurgery

Background

Color-coded duplex sonography (CCDS) is a widely proposed noninvasive diagnostic tool in microsurgery. CCDS has been applied to lower extremity salvage cases to define appropriate blood flow velocity criteria for achieving arterial success in diabetic foot and complex microsurgery cases. This study aimed to compare the success ratio of free flaps when using CCDS versus cases where CCDS was not used.

Methods

We included complex microsurgery cases from 2019 to 2021. These cases were subsequently categorized into two groups: group A consisted of cases where CCDS parameters were applied, whereas group B comprised cases where CCDS was not performed at all.

Results

The study encompassed 14 cases (11 men and three women). The age range varied from 23 to 62 years, with an average age of 42. Using CCDS analysis and planning demonstrated improved outcomes in comparison with cases where CCDS was not performed, albeit without statistical significance (P = 0.064).

Conclusions

The application of CCDS proves to be beneficial in the realm of microsurgery. Although not achieving statistical significance, our data imply that CCDS utilization holds promise for enhancing microsurgical procedures.

Surgical Strategies for Eyelid Defect Reconstruction: A Review on Principles and Techniques

Reconstruction of eyelid defects, especially the posterior lamella, remains challenging because of its anatomical complexity, functional considerations, and aesthetic concerns. The goals of eyelid reconstruction include restoring eyelid structure and function and achieving an aesthetically acceptable appearance. An in-depth understanding of the complex eyelid anatomy and several reconstructive principles are mandatory to achieve these goals. Currently, there are multiple surgical treatment options for eyelid reconstruction, including different flaps, grafts, and combinations of them. This comprehensive review outlines the principles of reconstruction and discusses the indications, advantages, and disadvantages of currently available surgical techniques. We also propose our clinical thinking for solving specific clinical questions in eyelid reconstruction and offer perspectives on new potential methodologies in the future.

Pillar tarsoconjunctival flap: An alternative approach for the management of refractory corneal ulcer

PURPOSE

To report the effectiveness of the surgical procedure of the tarsoconjunctival flap (FTC) in patients with severe ocular surface impairment refractory to previous conventional treatments.

METHODS

A retrospective, noncomparative, consecutive case series.

RESULTS

Pillar tarsoconjunctival flap (PTCF) was performed in eight eyes of eight patients. Three patients had neurotrophic corneal ulcer (NCU), three had exposure keratopathy and two had corneal melting. Seven of them had satisfactory postoperative results, showing total corneal re-epithelialization that lasted throughout the postoperative follow-up (mean 10.33 ± 2.65 months [SD], range 6 to 12 months). Mean time for the re-epithelization was 11.28 ± 8.97 days [SD] (range 4 to 30 days).

CONCLUSION

This study suggest PTCF is a valid alternative to tarsorrhaphy in cases of persistent epithelial defect (PED) or NCU resistant to conventional treatments. Notwithstanding, prospective comparative trials comparing PTFC with conventional and/or novel therapies in PED or NCU are needed to corroborate these findings.

Reconstruction of giant full-thickness lower eyelid defects using a combination of palmaris longus tendon with superiorly based nasolabial skin flap and palatal mucosal graft

Reconstruction of a full-thickness lower eyelid defect is challenging. We aim to use palmaris longus tendon to improve clinical outcomes in eyelid reconstruction. We generated a novel "three-layer structure" tissue by combination of palmaris longus tendon with superiorly-based nasolabial skin flap and palatal mucosal graft and applied in eyelid reconstruction surgery in 34 patients with significant full-thickness lower eyelid defects. The satisfaction scores were assessed in each patient to evaluate their cosmetic and functional outcomes in follow-up visits. The mean follow-up period was 15 months (range, 6-24 months). Satisfactory results were obtained in 100% patients. No patients reported deformities, obvious scars at the donor sites, or abnormalities of hand function on the surgical side. Our results demonstrated that the three-layer structure incorporating palmaris longus tendon for the reconstruction of giant full-thickness defects in lower eyelid is an effective procedure with satisfactory long-term results.

Angular artery island flap for eyelid defect reconstruction

Eyelid reconstruction is a challenging surgical procedure because of the special function and structure of the eyelids. There are various useful techniques which can be used to reconstruct eyelid defects. In this report, the authors aimed to present the clinical results of angular artery-based island flap for the repair of the full thickness eyelid defects. This presented series consists of eight patients with full-thickness eyelid defects. Oncologic resection was the reason for all of them. Five of the patients had lower eyelid defects and the other three had upper eyelid defects. Nasojugal angular artery-based axial flap was used in reconstruction in all patients. The inferior limit of the flap was the alar rim level in order to make the flap totally axial. A tunnel was created under the orbicularis oculi muscle in cases where the medial portion of the eyelids was left intact and healthy. Septal chondromucosal graft was used to repair posterior lamella of the eyelid. The follow-up period of the cases was from 12 months to 22 months, with a mean follow-up period of 16 months. There was only one patient with reconstructed upper eyelid needed flap defatting. There was no ectropion or wound healing problem observed during the follow-up period. This presented series shows that angular artery-based axial flap and septal chondromucosal graft combination is a simple and safe technique for both upper and lower eyelid full-thickness defect reconstruction. The donor site of this flap heals with an inconspicuous scar concealed in the nasojugal area.

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.

Outcomes after surgical resection of lower eyelid tumors and reconstruction using a nasal chondromucosal graft and an upper eyelid myocutaneous flap

INTRODUCTION

Surgical excision of large malignant lower eyelid tumors may cause important full-thickness eyelid defects. The reconstruction of such defects must restore the physiologic function of the eyelid and also re-establish an acceptable aesthetic result.

MATERIALS AND METHODS

We report the outcomes of full-thickness excision of tumors extending over half of the horizontal lid length, followed by reconstruction using a nasal chondromucosal graft (coming from the ipsilateral ala of the nose) and an upper eyelid myocutaneous flap. Histological analysis of the specimen identified the tumor type and surgical margins for each patient.

RESULTS

A total of 25 patients were operated using this reconstruction technique between March 2009 and June 2015: 17 basal cell carcinomas, 3 spindle cell carcinomas and 5 conjunctival melanomas (out of which 2 were associated with lentigo maligna). Mean duration of follow-up after surgery was respectively 36, 41 and 17 months for each of these 3 tumor types. We found a single local tumor recurrence and this was a basal cell carcinoma in a xeroderma pigmentosum patient. After surgery, none of the patients had lagophthalmos or ocular surface complications. Only 4 patients had a 1mm scleral show postoperatively; 3 other patients developed a small retraction of the eyelid after adjuvant radiotherapy and a 1mm scleral show occurred.

CONCLUSION

In malignant tumors, complete surgical excision with histological margins adapted to tumor type prevents local recurrence in most cases. Our repair strategy of nasal chondromucosal graft and skin-muscle flap for large inferior eyelid defects provides good functional and aesthetic results.