The cutler-beard bridge flap technique with use of donor sclera for upper eyelid reconstruction

Clinical Outcomes and Prognostic Factors in Eyelid Malignancy: A 17-Year Retrospective Analysis of Surgical Management and Reconstruction Techniques

PURPOSE

To assess clinical outcomes in patients undergoing surgical excision and eyelid reconstruction for malignancies.

METHODS

This 17-year retrospective study (2004-2021) analyzed patients with malignant eyelid tumors who underwent excision and reconstruction. Data on tumor type, size, location, surgical techniques, complications, and prognostic factors for recurrence were evaluated.

RESULTS

A total of 152 patients underwent surgical excision and reconstruction for eyelid malignancies. Basal cell carcinoma was the most common (52.6%), followed by sebaceous cell carcinoma (32.2%). Direct lid closure was the most frequent reconstructive method. Postoperative complications, including ectropion, entropion, and canalicular obstruction, were minimal but required additional surgery in some cases. Recurrence occurred in 13 patients. Lymph node involvement (odds ratio, 21.291; p = 0.004) and positive intraoperative frozen margins (odds ratio, 7.083; p = 0.018) were significant risk factors for local recurrence.

CONCLUSIONS

Surgical excision and reconstruction are effective treatments for eyelid malignancies, with techniques tailored to tumor size, location, and extension to ensure proper lid function. Lymph node involvement and positive intraoperative frozen margins are key predictors of local recurrence.

A 10/14 French silicone urinary catheter with inflatable balloon used as novel expansion device in lid reconstruction surgery

PURPOSE

To describe the surgical technique using a 10/14 French silicone urinary catheter as a novel tissue expander for repair of defects after removal of eyelid tumors. This device recruits additional tissue by tissue expansion for repair of large eyelid defects.

METHODS

A prospective noncomparative, interventional case study was conducted over a period of 3 years in which 30 patients were enrolled. All the 30 patients were selected for upper or lower lid Tenzel rotational flap after removal of large malignant tumor, using the tissue expander.

RESULTS

A 10/14-French silicone urinary catheter was placed in the periocular region and expanded by graded inflation with normal saline to a total volume of 10 or 14 ml, respectively, over a period of 3 days. On the fourth day before the planned surgery, the catheter balloon was deflated and a modified Tenzel rotational flap was performed to close the defect. Postoperative blink reflex was preserved. There were no cases of wound dehiscence. There was a significant reduction of incision length in upper and lower lid reconstruction with modified Tenzel flap reconstruction.

CONCLUSION

This approach allows for temporary tissue expansion, permitting the closure of large eyelid defects, typically not possible with a conventional Tenzel flap. This also provides excellent functional outcomes without closing patients' eyelids (which limits vision for weeks to months) as is typical of other reconstructive modalities (e.g. Cutler Beard procedure). The device is cost-effective and readily available. The authors believe it is an excellent alternative in the developing world where access to more expensive options is limited.

Surgical excision of eyelid tumors and subsequent ophthalmoplastic reconstruction

In recent years new modern therapeutic concepts have been developed in the treatment of malignant eyelid tumors; however, surgical restoration remains an important component of the therapeutic options addressed, which include microsurgical tumor excision into healthy tissue and subsequent coverage of the defects. An ophthalmic surgeon experienced in oculoplastic surgery is responsible for the recognition and evaluation of the existing alterations and planning a procedure together with the patient that meets the patient's expectations. The planning of surgery must always be individualized and fit the initial findings. Depending on the defect size and localization, different coverage strategies are available to the surgeon. To ensure successful reconstruction, every surgeon should master a wide range of reconstructive techniques.

[Surgical excision of eyelid tumors and subsequent ophthalmoplastic reconstruction]

In recent years new modern therapeutic concepts have been developed in the treatment of malignant eyelid tumors; however, surgical restoration remains an important component of the therapeutic options addressed, which include microsurgical tumor excision into healthy tissue and subsequent coverage of the defects. An ophthalmic surgeon experienced in oculoplastic surgery is responsible for the recognition and evaluation of the existing alterations and planning a procedure together with the patient that meets the patient's expectations. The planning of surgery must always be individualized and fit the initial findings. Depending on the defect size and localization, different coverage strategies are available to the surgeon. To ensure successful reconstruction, every surgeon should master a wide range of reconstructive techniques.

Total or subtotal replacement of tarsal plate by novel silicone plate for upper eyelid reconstruction in malignant tumors

Purpose

: To evaluate the cost, safety, surgical outcome, and efficacy of modified Cutler-Beard eyelid reconstruction utilizing a novel silicone plate as a tarsal plate replacement in the repair of 60% to 100% eyelid defects following the excision of large malignant tumors.

Methods

: A prospective, noncomparative, interventional study of 30 eyes was done over 3 years. Fourteen patients were female, and 16 patients were male. In all the cases, a silicone plate, the synthetic, artificial tarsal plate, was utilized for a total or subtotal replacement of the tarsal plate. The created defect was measured in mm (length and width) and later expressed in percentage. Pre- and postoperative action of levator palpebrae superioris (LPS) was measured. Pre- and postoperative measurements of the margin-to-margin reflex distance (MRD1) were noted.

Results

: Preoperative LPS action was 1.23 ± 1.35 mm, whereas postoperative LPS actions at the end of 1 week and 18 months were 11. 8 ± 0.88 mm and 13.53 ± 0. 73 mm, respectively. Preoperative MRD1 was - 3.0 ± 1.144 mm, whereas postoperative MRD1 values at the end of 1 week and 18 months were 2.18 ± 0.27 mm and 4.16 mm ± 0.35, respectively. The mean created defect after the removal of the tumor was 87.3% ±11.10. The mean length of the silicone plate implanted in this study was 27.53 ± 2.48 mm. The follow-up period for the study participants was 18 months.

Conclusion

: The synthetic novel silicone plate was successful as a tarsal plate replacement. A second surgical site for ear cartilage harvesting is avoided. Cadaver transfer of Achilles tendon carries the risk of transmission of communicable diseases, for example, hepatitis B and HIV. Silicone is an inert, nonreacting, and tissue-tested material, thus eliminating the possibility of graft rejection. This material is readily available and cost-effective. The novel silicone plate is considered to be the most promising alternative material as a tarsal replacement in the future generation.

Surgical Feasibility of Curtler-Beard Reconstruction for Large Upper Eyelid Defect

PURPOSE

To report long-term surgical outcomes of Cutler-Beard reconstructive surgery in patients with large full-thickness upper eyelid defects following malignant tumor excision.

METHODS

The medical records of 5 consecutive patients with full-thickness upper eyelid defects following tumor resection who underwent Cutler-Beard surgery were reviewed retrospectively between April 2005 and November 2018. Surgical procedure comprises 2 stages: first, complete tumor resection followed by bridged full-thickness lower eyelid advancement flap; second, separation of the closed eyelid with eyelid margin repair 7 to 9 weeks later. Postoperative anatomical, functional and cosmetic outcomes, and complications were evaluated during follow-up at 22 to 77 months.

RESULTS

Patients were in the age group of 49 to 75 years, including 3 (60%) females and 2 (40%) males. Three of the 5 patients (60%) exhibited sebaceous cell carcinoma and 2 (40%) showed squamous cell carcinoma. Three patients (60%) underwent Cutler-Beard surgery after recurrence of primary carcinoma following previous operation. Three patients underwent revision surgery with entropion, 2 underwent correction for wound dehiscence and 1 was treated with symblepharon lysis. No serious or permanent ocular complications were observed during the operation or follow-up with the patients. The procedure resulted in good aesthetic quality and acceptable sequelae at the donor site.

CONCLUSIONS

Cutler-Beard procedure for the reconstruction of large and full-thickness upper eyelid defects is an effective procedure with satisfactory long-term results, although a few patients may require minor revision surgery.

Posterior lamellar reconstruction: a comprehensive review of the literature

The aim of the review is to describe the different techniques and materials available to reconstruct the tarsoconjunctival layer of the eyelid; to analyze their indications, advantages, and disadvantages. We searched the Cochrane, PubMed, and Ovid MEDLINE databases for English articles published between January 1990 and January 2017 using variations of the following key words: "posterior lamella," "eyelid reconstruction," "tarsoconjunctival," "flap," and "graft." Two reviewers checked the abstracts of the articles found to eliminate redundant or not relevant articles. The references of the identified articles were screened manually to include relevant works not found through the initial search. The search identified 174 articles. Only a few articles with a therapeutic level of evidence were found. Techniques for the posterior lamellar reconstruction can be categorized as local, regional, and distant flaps; tarsoconjunctival, heterotopic, homologous, and heterologous grafts. Several techniques and variations on the techniques exist to reconstruct the posterior lamella, and, for similar indications, there's no evidence of the primacy of one over the other. Defect size and location as well as patient features must guide the oculoplastic surgeon's choice. The use of biomaterials can avoid possible complications of the donor site.

A primary study of poly(propylene fumarate)-2-hydroxyethyl methacrylate copolymer scaffolds for tarsal plate repair and reconstruction in rabbit eyelids

Eyelid reconstruction includes anterior lamella reconstruction and posterior lamella reconstruction. As an important skeletal component of the posterior lamella, tarsal plates repair is the key issue for eyelid reconstruction. Presently, neither traditional surgery nor autograft/allograft has achieved satisfactory repair effects. Poly(propylene fumarate)-co-2-hydroxyethyl methacrylate (PPF-HEMA) networks with mass ratios of 1 : 0.5, 1 : 1 and 1 : 2 were synthesized and used as the tarsal substitute in this study. Their chemical compositions, swelling ability, and mechanical properties were characterized. Porous scaffolds were fabricated by a gelatin particle leaching method. The in vitro studies of cytotoxicity on human dermal fibroblasts (HDFs) and degradation demonstrated that PPF-HEMA scaffolds did not have noticeable cell cytotoxicity and their degradation rates correlated with the ratio of PPF to HEMA. The PPF-HEMA networks, with mass ratios of 1 : 1 and 1 : 2, and an ADM control were implanted in rabbits with tarsal plate defects for in vivo biocompatibility and degradation behavior evaluation. PPF-HEMA scaffolds provided satisfactory repair results with mild tissue response and biocompatibility to fibroblast growth and fibrous capsulation compared to the ADM control. The tissue compatible and biodegradable PPF-HEMA networks with elastic mechanical properties were proven to be a suitable candidate for tarsal repair.

Upper Eyelid Coloboma Repair Using Accessory Preauricular Cartilage in a Patient With Goldenhar Syndrome: Technique Revisited

We present an unusual case of upper eyelid coloboma repair in a patient with Goldenhar syndrome. We describe the use of a modified Cutler-Beard flap with concurrent inlay graft using cartilage from a preauricular appendage. This technique provides the benefits of autologous tissue, while minimizing donor site morbidity and reducing the risk of upper eyelid retraction.

Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure

PURPOSE

The Cutler-Beard procedure is a commonly used technique to reconstruct large upper eyelid defects. Eyelid retraction and entropion are common complications. To prevent these problems, the authors modified the traditional Cutler-Beard procedure with secondary placement of an autologous tarsoconjunctival graft.

METHODS

This is a retrospective review of 2 patients with large upper eyelid defects necessitating upper eyelid reconstruction. The initial stage is unaltered. At the time of flap division, a tarsoconjunctival graft from the contralateral upper eyelid is sutured to the posterior surface of the newly constructed upper eyelid. Two patients underwent this procedure, and follow up was 4 and 23 months, respectively. Patients developed no postoperative complications, including entropion or retraction.

CONCLUSIONS

This modification to the Cutler-Beard operation is a technically simple procedure that can restore a more anatomically correct eyelid and can prevent subsequent entropion or retraction. This technique is unique, offering 3 major advances: first, placing the graft at the second surgical stage; second, replacing the tarsus and conjunctiva with like tissue; and third, preserving a lip of conjunctiva to cover the edge of the newly reconstructed upper eyelid.

Unilateral giant coloboma of the upper eyelid associated with other congenital anomalies (33 years follow-up of surgical repair)

PURPOSE

To describe a case of congenital unilateral giant coloboma and its successful surgical repair with 33 years of follow-up.

CASE REPORT

A 6-year-old boy presented with a congenital unilateral giant coloboma of the right upper eyelid associated with madarosis of the eyebrows, microphthalmos, dystopia of the hair, and coloboma of the apex of the nose. The patient underwent surgical repair of the multiple anomalies in different steps.

DISCUSSION

A multiple-step, two-layer technique for the reconstruction of the right upper eyelid was performed in a 6-year-old boy with congenital unilateral giant coloboma associated with multiple ocular and facial anomalies. After 33 years of follow-up, the cosmetic results are excellent, although it has not been possible to preserve the visual function of the right eye, which had to be enucleated.