[Hughes' operation and combined procedures]

The Köllner Tarsoconjunctival Flap for Lower Eyelid Reconstruction: Historical Perspective and Surgical Outcomes of 140 Cases

PURPOSE

While Wendell Hughes popularized the tarsoconjunctival flap for lower eyelid reconstruction, most modern procedures are derived from the technique described by Köllner in 1911. This study reviews the history, techniques, and outcomes of a large series of patients treated with a modified Köllner flap.

METHODS

In this observational cohort study, medical records and photographs were reviewed in patients undergoing surgery between 2005 and 2020. Patient demographics, complications, secondary interventions, and outcomes were evaluated.

RESULTS

Marginal defect size ranged from 12 to 41 mm among the 140 study patients. Ancillary procedures included lower eyelid conjunctival flaps (n = 64) and septal orbicularis flaps (n = 68). The anterior lamella was reconstructed with skin grafts (n = 86), flaps (n = 10), or combined flaps/grafts (n = 44). Pedicle division was performed 23 to 84 days after primary repair. Subsequent interventions included steroid injection (n = 10), cryotherapy (n = 10), marginal erythema treatment (n = 9), and upper eyelid retraction repair (n = 6). Tearing (6.5%) and dryness (10%) were the most common postoperative symptoms, with most patients (78.6%) being asymptomatic. A good-excellent functional outcome was achieved in 94.3% and cosmetic outcome in 85.0% of cases. Defects <30 mm in width (P = 0.0001), defects not involving a canthus (P = 0.0158), and upper eyelid skin graft donor sites (P = 0.0001) were associated with better outcomes.

CONCLUSIONS

The Köllner tarsoconjunctival flap is an effective technique to repair moderate-large lower eyelid defects, with the majority of patients achieving good-excellent cosmetic and functional outcomes. Factors associated with a poorer result include marginal eyelid defects ≥30 mm in width, defects involving a canthus, and non-upper eyelid skin graft donor sites. Most patients are asymptomatic after surgery.

Polarization and Distribution of Tumor-Associated Macrophages and COX-2 Expression in Basal Cell Carcinoma of the Ocular Adnexae

PURPOSE

Basal cell carcinoma (BCC) is a locally invasive skin tumor which can be subdivided into a circumscribed nodular and an invasive fibrosing subtype. There is increasing evidence that macrophages play an important role in interacting between tumor cells and their microenvironment, thereby affecting not only the invasive potential but also the patients' prognosis. Thus, we wanted to compare these two BCC variants with regard to tumor-related inflammation, COX-2 expression, distribution, and polarization of tumor-associated macrophages.

MATERIAL AND METHODS

30 BCCs (nodular: n = 15; fibrosing: n = 15) of the ocular adnexae were investigated by histopathology and immunohistochemistry. The grade of inflammation was evaluated on hematoxylin and eosin stains (score: 0-3). Immunohistochemical stains for CD68 (macrophages), Ki67 (proliferative activity), and COX-2 as well as immunofluorescence stains for CD68 and CD163 (to distinguish M1 and M2 macrophage subtypes) were performed. SPSS was used for statistical analysis.

RESULTS

Fibrosing BCCs were predominantly located on the lower lid, while nodular BCCs showed a broader distribution (p = 0.013). The fibrosing BCC subtype was associated with a higher degree of inflammation (p < 0.001) and revealed a higher COX-2 immunoreactivity than nodular BCC (p = 0.012). COX-2-positive cells were predominantly located on the infiltrating edge of the tumor. Macrophage polarization was balanced regarding M1 and M2 macrophage subtypes. There was no difference in macrophage number (p = 0.389) or polarization (p = 0.161) between nodular and fibrosing BCC.

CONCLUSIONS

The findings indicate that COX-2 represents a factor for invasion of BCC. Macrophage polarization did not play a major role for aggressive behavior. However, other inflammatory components than tumor-associated macrophages seem to be involved in tissue destruction and thereby an invading growth pattern since fibrosing BCC revealed a significantly more intense inflammatory reaction in the surrounding tissue.

Longevity results of modified Hughes procedure in reconstructing large lower eyelid defects

PURPOSE

The purpose of this study was to evaluate the longevity results of modified Hughes procedure in reconstructing large lower eyelid defects.

BACKGROUND

The modified Hughes procedure was used to reconstruct large full-thickness lower eyelid defects. Meanwhile, the functional results indicated that ocular surface health in the treated eyes may be affected.

PATIENTS AND METHODS

Noncomparative, case series retrospective study was designed after obtaining the approval of the institutional review board at the Ophthalmology Department, Menoufia University, Egypt, where the results of cases who underwent surgery with the modified Hughes procedure during a 7-year interval were evaluated.

RESULTS

Eleven patients (seven males and four females) in the age range 59-77 years (mean age 67±5 years) were identified. The follow-up ranged from 12 months to 48 months. Cosmetic, functional, and postoperative results were analyzed.

CONCLUSION

Despite the favorable cosmetic results of the Hughes tarsoconjunctival flap, the procedure has its own limitations. The results indicated that it does affect the functions and tear film stability in the treated eyes.

Modified Hughes procedure for reconstruction of large full-thickness lower eyelid defects following tumor resection

Background

Tarsoconjunctival flap advancement, or the Hughes procedure, is among the techniques of choice for reconstructing full-thickness lower eyelid defects so as to restore normal anatomy and function with the best possible cosmetic outcome. The purpose of this study is to report the outcome of a series of patients treated with a modified Hughes procedure following malignant tumor removal.

Methods

This retrospective study included 45 consecutive cases of modified Hughes procedures performed between January 2013 and October 2015. During Hughes flap creation an incisional plane was chosen in all cases, which left Müller’s muscle attached to the superior tarsal margin, while disinserting the levator aponeurosis. All cases were grouped according to the horizontal length of the lower lid defect to be reconstructed, as well as to the type of anterior lamella reconstruction (free graft vs. inferiorly based advancement flap). Grouped data were compared for the rate of surgical success, defined as achievement of normal lid function and satisfactory cosmesis without needing further surgical interventions, and for the frequency of specific complications.

Results

Surgical success was achieved in 39 cases (87 %). The remaining cases required additional surgery for minor complications including lower-lid ectropion (4 %), pyogenic granuloma (4 %), or lower lid margin hypertrophy (2 %). Donor-site complications were not detected apart from one case of mild entropion with focal trichiasis. No case of premature flap rupture was seen. Neither the horizontal length of the lower lid defect (p = 0.489), nor the type of anterior lamella reconstruction (p = 0.349) significantly affected the surgical success. Particularly, there was no increased onset of lower-lid ectropion among patients receiving an advancement flap.

Conclusions

The modified Hughes procedure remains a well-suited technique for reconstructing lower eyelid defects involving up to 100 % of the horizontal lid length. Leaving Müller’s muscle attached to the Hughes flap might prevent premature flap dehiscence without increasing the frequency of upper lid retractions in turn. Whether using a free skin graft or a skin-muscle advancement flap for anterior lamella reconstruction, seems to be insignificant for the functional-aesthetical outcome.