Purpose

The Hughes tarsoconjunctival flap is a well-established technique for reconstruction of full-thickness lower eyelid defects, but typically requires temporary occlusion of the visual axis, limiting its use in elderly or monocular patients. This study evaluates modified techniques that preserve the visual axis through partial pedicle division and explores expanded indications, including its use in cicatricial conjunctival disease and chronic eyelid retraction

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Methods

This multicentre case series included nine eyes of nine patients treated by two surgeons (JHN, RM). Indications for a Hughes flap included reconstruction following skin cancer surgery (n=6), cicatricial ectropion (n=2) and traumatic cicatrical entropion (n=1). A superiorly based upper eyelid tarsoconjunctival flap was used to reconstruct the posterior lamella, with anterior lamellar reconstruction using myocutaneous advancement flaps or full-thickness skin grafts. The conjunctival pedicle was partially divided intraoperatively to preserve the visual axis, leaving a narrow medial or lateral bridge. In six cases, the pedicle was retained long term to provide lateral canthal support. Outcomes included functional results, patient tolerability and complications

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Results

All patients achieved satisfactory anatomical and functional outcomes. There were no cases of donor-site morbidity, premature flap dehiscence, surgical site infection, or lower eyelid ectropion. The retained conjunctival pedicle was well tolerated in all cases and contributed to improved lower lid support where maintained. Visual axis preservation was successfully achieved in all patients, three of whom were monocular

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Conclusion

Modified Hughes flap techniques allow preservation of the visual axis and improved tolerability, particularly in elderly or monocular patients. Furthermore, retention of the conjunctival pedicle for structural support broadens the use of this technique to correct eyelid retraction where standard interventions prove unsuccessful; making this technique a very useful and simple tool in the armamentarium of the Oculoplastic surgeon

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Additional Authors

First name	Last name	Base Hospital / Institution
Simerdip	Kaur	Queen Victoria Hospital NHS Foundation Trust
Raman	Malhotra	Queen Victoria Hospital NHS Foundation Trust
Jonathan	Norris	Oxford University Hospitals NHS Foundation Trust

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