You Don’t Have to Hughes It: Lower Eyelid Reconstruction with Free Tarsal Graft and Myocutaneous Flap
Author: Harry Marshak
Base Hospital / Institution: Eisenhower Medical Center
Video presentation
Abstract ID: 25-172
Purpose
Large full-thickness lower eyelid defects often require a Hughes tarso-conjunctival flap and skin graft. This requires visual occlusion for several weeks and a second stage procedure to incise the conjunctival flap. Direct closure of large defects with Tenzel type flaps create difficulty in anchoring the lateral eyelid to the orbital rim, leading to horizontal shortening of the fissure, lateral canthal dystopia or ectropion. The technique presented here involves closure of lower eyelid defects by mobilizing the lateral eyelid combined with a Tenzel myocutanous flap and a free tarsal graft placed laterally to connect the lateral native tarsus to the lateral orbital rim. This allows for a one stage reconstruction and good reformation of the lateral canthal angle. This technique can be performed on defects up to at least 15mm.
Methods
A Tenzel myocutaneous rotational flap is created by incising the skin along a curvilinear line extending lateral from the lateral canthus. The inferior canthal tendon is incised. The flap is undermined in the pre-periosteal plane. The myocutaneous flap and lateral eyelid are advanced medially. The medial and lateral cut edges of tarsus are sutured together with 6-0 vicryl partial thickness sutures. The orbicularis is closed over the tarsus with 6-0 vicryl buried sutures. The margin is reformed with two 6-0 vicryl sutures. The skin is closed with 5-0 plain interrupted sutures.
The distance from the lateral edge of the lower eyelid to the lateral orbital rim is measured. A 4mm wide section of superior tarsus measuring this length is excised from the upper eyelid and placed in the newly created posterior defect in the lateral lower lid. The graft is sutured to the lateral edge of native tarsus with two 6-0 vicryl partial thickness sutures. The lateral edge of the graft is sutured to the periosteum of the lateral orbital rim with two 5-0 vicryl sutures.
The rotated myocutaneous flap is sutured to the periosteum lateral to the lateral orbital rim with 4-0 Monocryl sutures. The flap is sutured to the superior border of the tarsal graft with 6-0 vicryl buried sutures. The lateral angle is reformed by passing a 5-0 vicryl suture through the lateral aspect of the upper lid and the corresponding portion of the rotated flap, the tarsal graft and the periosteum. The lateral canthal wound and donor sites are closed with 4-0 Monocryl buried sutures. The skin of the lateral canthus and donor site is closed with 5-0 plain running suture. No traction sutures were used.
Results
72 patients underwent this technique for reconstruction after skin cancer excision with Mohs surgery or frozen sections. Primary defects measured between 10-20mm (average=13mm) and were located centrally or medially. All patients had good healing of the flap and graft. Patients overall had good cosmesis. 3 patients developed lateral canthal dystopia requiring revision. One patient developed notching of the eyelid margin.
Conclusion
Closure of large full-thickness lower eyelid defects with myocutaneous flap and free tarsal graft provides one stage closure with good functional results and cosmesis.
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