Lower eyelid reconstruction with Hughes’ tarsoconjunctival flap







Table 40.1

Indications for surgery





Reconstruction of large full thickness defects of the lower eyelid


Table 40.2

Preoperative evaluation

















Size and dimensions of lower eyelid defect
Involvement of proximal canalicular system
Eyelid laxity
Prior eyelid, facial surgery or trauma
Evaluation of donor site for full thickness skin graft (upper eyelid, pre-/retroauricular, supraclavicular, inner arm)
Visual function of both eyes (monocular status)
History of smoking/tobacco use


Introduction


Total defects of the lower eyelid often result from wide excision of lower eyelid malignancies such as melanoma, squamous cell carcinoma, basal cell carcinoma and Merkel cell carcinoma. The resultant defects can encompass the entire lower eyelid and may involve the proximal lacrimal drainage system. Reconstruction of these defects is guided by the goal of reconstructing the bi-lamellar nature of the lower eyelid and lacrimal system if needed.


The size of the defect and degree of lower eyelid laxity dictate the reconstructive options. Small lower eyelid defects of less than 33% or slightly larger defects with significant lower eyelid laxity may be repaired by direct closure ( Chapter 37 ). An adjunctive lateral canthotomy and cantholysis can be performed to yield an additional 2–3 mm of laxity needed to close defects primarily. Larger defects greater than 50% can be closed with a semicircular flap ( Chapter 39 ). Lower eyelid defects greater than 80% usually require reconstruction with a tarsoconjunctival flap with full thickness skin graft or a Mustardé rotational flap for the anterior lamella ( Chapter 41 ).


Wendell Hughes originally described reconstruction of the lower eyelid using an upper eyelid tarsoconjunctival flap that was split at the eyelid margin. The anterior lamellar deficit was supplied by advancement of the cheek. At 3 months postoperatively, the flap was divided and inset. Hughes’ original tarsoconjunctival flap was complicated by upper eyelid retraction and entropion after division of the pedicle. Today, most surgeons perform a modification of Hughes’ original description by raising a tarsoconjunctival flap at least 4 mm from the eyelid margin and reconstructing the anterior lamella with a full thickness skin graft or adjacent pedicle-based flap. Preservation of the inferior 4 mm of the tarsus along with the eyelid margin maintains structural support of the upper eyelid. The blood supply for the full thickness skin graft is derived from the tarsoconjunctival flap of the upper eyelid and this can be augmented with an adjacent orbicularis flap. The tarsoconjunctival pedicle is typically separated at 4–6 weeks after the initial operation. Patients should be strictly advised to stop smoking.


In patients who are monocular, with the seeing eye on the reconstructed side, a Hughes’s tarsoconjunctival flap will effectively render the patient blind until the pedicle is severed. A non-eyelid sharing procedure such as a free tarsal graft with adjacent tissue flap, for example as a semicircular flap or Mustardé, may be more appropriate. Likewise, children under the age of 8 should undergo non-eyelid sharing procedures to minimize risk of occlusion amblyopia.




Surgical Technique





Figures 40.1A–D


Marking of tarsal plate

This patient has a full thickness lower eyelid defect greater than 80% including the inferior canaliculus after excision of a basal cell carcinoma ( Figure 40.1A ). If a scalloped wound is present after Mohs micrographic excision, the edges are squared off to create a rectangular defect. The Hughes’ tarsoconjunctival flap is a suitable technique for the reconstruction of the posterior lamellar defect in this case. For reconstruction of the inferior canalicular system, refer to Chapter 62 for silicone stent placement using the pigtail catheter. Prior to reconstruction, the upper tarsal plate is everted with a Desmarres retractor and evaluated for vertical and horizontal adequacy ( Figure 40.1B ). On average, the tarsal plate is 12 mm in height, as in this case. In patients with multiple or recurrent periocular neoplasms, prior tarsal splitting procedures may have been previously performed without the patient’s knowledge. This patient has a virgin tarsal plate. Local anesthetic consisting of 1% lidocaine, 1 : 200,000 epinephrine and 0.25% bupivacaine is given transcutaneously. A 4 mm mark is made from the central eyelid margin and extended horizontally to encompass the estimated size of the lower eyelid defect ( Figures 40.1C and 40.1D ). Leaving the inferior 4 mm of the tarsal plate and keeping the eyelid margin intact significantly minimize the risk of postoperative eyelid malpositions.

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May 16, 2019 | Posted by in Reconstructive surgery | Comments Off on Lower eyelid reconstruction with Hughes’ tarsoconjunctival flap

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