Superiorly Based Tarsoconjunctival Advancement (Hughes, Landholt, Köllner) Flap for Reconstruction of The Lower Eyelid
M. A. CALLAHAN
This is one of the oldest, time-tested flaps for eyelid reconstruction. It will result in a reconstructed eyelid of excellent color match, thickness, and function (1, 2, 3, 4, 5) (Fig. 15.2). The tarsoconjunctival flap for lower eyelid reconstruction supplies the deficient lower lid with conjunctiva for lining and tarsus for structural support. This posterior lamella flap should be combined with a free skin graft (or skin flap) to create the new anterior lamella of the lower lid.
Note that, as originally described, the upper eyelid was split along the gray line. Because of associated complications, this flap achieved a bad reputation. It is no longer performed as originally described, and even Dr. Hughes warns against splitting the upper eyelid (6).
Application of this technique is limited, in that the vertical height of the upper lid tarsal plate measures 10 to 12 mm, and if more than 7 mm of this tarsal plate is removed, the upper lid may itself become crippled and deformed. Therefore, this technique is most useful for repair of lower lid defects that are no more than 5 to 7 mm in vertical height. The best results are obtained when the horizontal extent of the defect is less than the distance from the inner to outer canthus. If necessary, however, the technique can be used to reconstruct the entire margin of the lower lid.
Defects of the lower lid that extend horizontally the full length of the lid and vertically to the inferior orbital rim are better repaired by the bipedicle or bucket-handle flap (Tripier) technique, as described in Chapter 17. When the lower lid defect exceeds 7 mm vertically and half the horizontal lid length has been resected, the Tenzel semicircular flap gives excellent results. The Tenzel flap also can be used in certain patients in whom a tarsoconjunctival flap is contraindicated.
When all the lower lid must be removed, including the base of the lid past the inferior orbital rim, the Mustardé cheek rotation flap, as described in Chapter 13, provides the best cosmetic and functional result.
Since the lids are closed for a significant period of time, this flap is not advisable when the patient has corneal or retinal disease that needs attention or when the lids cover the only seeing eye.
Figure 15.1 illustrates resection of a lower lid tumor well below the lower lid tarsal plate, leaving a 5- to 7-mm vertical defect. Two 4-0 silk sutures are placed along the upper lid margin, being careful to avoid the lash follicles, to evert the lid and expose the inner tarsal surface (Fig. 15.2B). The sutures are anchored to the drapes with hemostats. A horizontal mattress “tension” suture is placed across the lower lid defect to hold the wound edges in position temporarily, so that the width of the tarsoconjunctival flap can be estimated. The tension of the suture should be adjusted to approximate that of the normal lid. Alternatively, the width of the tarsoconjunctival flap can be estimated before the malignant lesion of the lower lid is resected.