Double Mucosal and Myocutaneous Island Flap

Lateral eyelid island flap for reconstruction of large central and medial full-thickness defects of the lower eyelid

Introduction

To report our experience with lateral eyelid island flaps for reconstruction of large central and medial full-thickness defects of lower eyelid.

Methods

Retrospective case series of patients with large central and medial full-thickness lower lid defects repaired with medial transposition of the lateral lower lid combined with a temporal myocutaneous flap. Preoperatively the authors collected demographic data, etiology and percentage of the defects. Postoperatively the lids were assessed for flap viability and lower eyelid margin position and contour.

Results

The sample was comprised of 10 patients (5 females) with a mean of age 60.10 (SD 13.75) years. The defects ranging from 50% to 75% of the lid width resulted from excision of eight basal cell carcinomas, one (10%) malignant schwannoma and one (10%) squamous cell carcinoma. The median follow-up was 1.58 years (IQR 2.58). Flap ischemia was not observed in any eyelid. One mild ectropion was observed in just one lid. All patients were satisfied with the esthetic results.

Conclusions

Medial transposition of the lateral lower lid island flap combined with horizontal myocutaneous advancement flap is an excellent one-stage procedure that avoids the drawbacks of the two-stages procedures

Eyelid Reconstruction: An Algorithm Based on Defect Location

ABSTRACT

Eyelid reconstruction is a complex topic. This review looks at articles from 1990 to 2018 on eyelid reconstruction that had at least 10 patients and a mean 6 month follow-up. The authors present the results of our findings and propose an algorithm to guide the surgeon in choosing the best technique based on location, size, and lamella. Defects less than 1/3rd of the upper or lower eyelid may be closed primarily. Anterior and posterior lamella defects of the lower eyelid greater than 1/3rd in size should be reconstructed with a double mucosal and myocutaneous island flap. Those greater than 50% in size should be recreated with a Tripier flap for the anterior lamella and conchal chondroperichondral graft for the posterior lamella. For total lid reconstruction, a Fricke flap is best for the anterior lamella and the tarsoconjunctival free graft/lateral orbital rim periosteal flap is best for the posterior lamella. Full-thickness defects between 1/3rd and 2/3rd in size of the upper eyelid should be reconstructed with a myotarsocutaneous flap and those greater than 2/3rd should be reconstructed with a Cutler-Beard flap for the anterior lamella and auricular cartilage for the posterior lamella. For the medial canthal region, the island pedicle and horizontal cheek advancement flap is recommended for the anterior lamella and a composite upper lid graft for the posterior lamella. For the lateral canthal region, a bilobed flap is recommended for the anterior lamella and a periosteal flap for the posterior lamella.

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.

Repair of 50-75% full-thickness lower eyelid defects: Lateral stabilization as a guiding principle

Introduction:

Repair of large defects of the lower eyelid can be difficult. A common procedure performed to address these defects is a Hughes flap. This procedure has a number of disadvantages: The eye is closed postoperatively, a second stage is required, and the edge of the flap is often erythematous. The purpose of this paper is to describe a one-stage procedure for the repair of large full-thickness defects of the lower lid as an alternative to a Hughes flap.

Materials and Methods:

This is a retrospective study of patients who underwent the described procedure. The procedure employs lateral stabilization of the posterior lamella with a periosteal strip, medial transposition of the lateral posterior lamella for central and medial defects, and a myocutaneous advancement flap to stabilize the anterior lamella.

Results:

A total of 38 patients underwent the procedure to reconstruct full-thickness defects of the lower lid ranging from 50% to 75%. All patients underwent previous Mohs excision of a skin cancer. The average follow-up was 5.6 months. Eleven patients (29%) had postoperative sequelae, but only two patients (5%) required additional treatment.

Conclusion:

Lateral stabilization with a periosteal strip and myocutaneous advancement flap is an excellent one-step procedure that avoids many of the complications seen with the Hughes procedure and is comparable to other techniques used for the reconstruction of subtotal, full-thickness lower lid defects.

Double Lateral Flap: A New Technique for Lower Eyelid Reconstruction Alternative to the Tenzel Procedure

BACKGROUND

The final esthetic result is a common concern of patients with eyelid tumors, especially young patients and those with tumors affecting the medial edge of the lower eyelid.

METHODS

The procedure herein described combines two lateral flaps: one tarsoconjunctival and the other from the periosteum. The first step is removal of the tumor lesion. Preseptal dissection is then performed through a subciliary incision on both the lateral and medial halves of the eyelid up to the orbital rim. Next, the lateral canthal tendon, lateral attachment of the orbital septum, capsulopalpebral fascia, and conjunctiva are cut. This allows the medial displacement of the tarsoconjunctival flap, which is sutured to the defect area. The second flap, a periosteal strip, is used to reconstruct the tarsus and lateral canthal tendon, providing firm support for the posterior lamella. The orbicularis muscle is anchored to the orbital rim, and the skin of the lower eyelid is directly sutured to the subciliary incision and periosteal strip.

RESULTS

The author successfully carried out this procedure on nine patients. None of the patients developed ocular irritation or postoperative epiphora.

CONCLUSIONS

The defects that can be repaired by this technique are equivalent in size to those repaired by the Tenzel procedure. Unlike the semicircular flap procedure, this technique allows eyelid reconstruction with no vertical scarring and a smaller lateral incision, and it ensures soft contact between the palpebral rim and surface of the eyeball. This procedure confers an attractive eyelid appearance that may be crucial for some patients.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Extensive full-thickness eyelid reconstruction with rotation flaps through "subcutaneous tunnel" and palatal mucosal grafts

AIM

To reconstruct the extensive full-thickness defects of eyelids is a challenge for the plastic surgeon because of their complex anatomy and special functions. This article presents and discusses an improved surgical technique in which the orbicularis oculi myocutaneous flap is rotated through a "subcutaneous tunnel" in conjunction with a palatal mucosal graft employed for lining.

METHODS

Data from 22 eyes with extensive full-thickness eyelid defects from various causes between 2009 and 2013 were analyzed in this study. After the different layers of eyelid were separated completely, a temporally based orbicularis oculi myocutaneous flap was designed following fishtail lines and was mobilized, leaving the base of the pedicle intact with a submuscular tissue attachment. The flap was then rotated through a "subcutaneous tunnel" to the defect, and the donor site was closed primarily. Posterior lamellar reconstruction was performed with a mucosal graft harvested from the hard palate.

RESULTS

All the flaps were survived without any healing problems. There was no corneal irritation, flap contraction, or significant donor-site morbidity in the follow-up period. The incision scars were almost invisible. The defects were repaired completely, and the evaluations showed satisfactory function and appearance.

CONCLUSION

This technique is an improved single-stage operation and can be applied to repair large, full-thickness eyelid defects from various causes. With our method, the functional and aesthetic results can be obtained in either the upper or lower eyelids.

Oncologic surgery of the eyelid and orbital region

Oncologic surgery of the eyelid and orbital region is a challenge in dermatologic surgery. This region presents difficulties and possible complications that do not exist at other sites, including ectropion, epiphora, corneal exposure, keratitis, conjunctivitis, and lagophthalmos. Adequate oncologic surgery associated with the best possible functional and cosmetic result requires extensive knowledge of the anatomy, innervation, and blood supply of the eyelid and anatomy of the lacrimal apparatus. We present examples of reconstructive surgical techniques that can be used after the excision of tumors of the upper or lower eyelid, with descriptions of the different flaps and grafts employed in our department in recent years. We also review the surgical techniques according to the site and size of the lesions.

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

AIM

To report the clinical outcomes of utilizing a three-layer flap and graft in reconstruction of the lower lid 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.

Reconstruction of lower eyelid retraction or ectropion using a paranasal flap

BACKGROUND

This report aims to describe a paranasal flap technique for reconstruction of lower eyelid retraction and ectropion.

METHODS

After the contracture of the lower eyelid skin or conjunctiva had been thoroughly released, the ipsilateral upper pedicle paranasal flap was designed according to the size of the lower eyelid skin wound. After dissection of the flap, the subcutaneous tissue of the flap was trimmed according to the depth of the wound, the flap was rotated to cover the defect, and an anchor was fixed to the distal aspect of the outer canthus. The secondary defect of the donor area was sutured directly.

RESULTS

In this study, 67 patients with lower eyelid defects resulting from correction of eyelid retraction and ectropion were reconstructed using paranasal flaps between April 2004 and October 2009. The sizes of the paranasal flaps ranged from 0.6×2.2 to 1.5×3.5 cm. At the follow-up assessment, the patients could close their eyes easily and completely without lagophthalmos, and neither the upper lips or the nasal ala showed any anatomic deformities. The features of the paranasal flaps, such as skin color, texture, and contour of the repaired tissue, were a good match with the surrounding skin. The suture lines of the donor areas were sheltered well.

CONCLUSIONS

Paranasal flaps were used for effective reconstruction of lower eyelid retraction or ectropion, with achievement of good eyelid function and a good color, contour, and texture match with the surrounding skin. Overall, the functional and cosmetic results were satisfactory.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

An evidence-based approach to the treatment of nonmelanoma facial skin malignancies

The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications, with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented.