Surgical Strategies for Eyelid Defect Reconstruction: A Review on Principles and Techniques

Acellular Fish Skin Grafts for Treatment of Periocular Skin Defects

PURPOSE

To describe the outcomes of acellular fish skin grafts for repair of periocular anterior lamella skin defects after Mohs surgery for skin cancers.

METHODS

Following the institutional review board approval, we conducted a retrospective chart review of patients treated with acellular fish skin grafts between January 2022 and December 2023. Indication was to repair defects after Mohs excision of basal cell carcinoma and squamous cell carcinoma. Demographics, smoking and diabetes status, diagnosis, defect location, graft size, and complications were evaluated. Outcomes were analyzed using the scar cosmesis assessment and rating scale.

RESULTS

Six patients (3 females and 3 males) with a mean age of 60.8 (range 44-80) had Mohs surgery for basal cell carcinoma (4) and squamous cell carcinoma (2). Location of defects included eyebrow (3 cases), lateral nasal wall (1 case), lower eyelid (1 case), and medial lower eyelid/nasal wall (1 case). Defect size ranged from 8 × 10 mm to 30 × 40 mm. Two patients had more than 1 application of xenograft. One patient developed a mild cicatricial ectropion. No other postoperative complications were seen, and all had good wound healing and cosmetically acceptable results.

CONCLUSIONS

In this pilot study, acellular fish skin xenografts are shown to be promising skin graft substitutes in patients with Mohs defects and decrease the need for autologous skin harvesting or allogenic skin donation.

Modified Mustardé and Superolateral Periosteal Flaps for Full-Thickness Defects of Medial and Central Lower Eyelid: A Case Series

BACKGROUND

Reconstructing full-thickness defects involving 50% to 75% of the horizontal length of the lower eyelid after medial and central full-thickness block resection can be challenging. As a disadvanatge, 1-stage reconstructions may require a free graft reconstruction of the posterior lamella. In addition, 2-stage reconstructions are associated with several complications, including erythema, and the eye must be temporarily closed after surgery.

METHODS

The present study describes a single-surgeon retrospective case series. Five patients diagnosed with basal cell carcinoma underwent wide full-thickness block resection with optimal excision margins (3-5 mm). Subsequently, 1-stage reconstruction was performed using the modified Mustardé flap, incised using the transconjunctival approach. This flap comprised the skin, muscle, tarsus, and conjunctival flap raised from the lateral canthus through a lateral cantholysis procedure, and then extended to the lateral cheek. The flap was medially transposed to cover the medial and central lower eyelid defect. The superolateral periosteal flap was harvested from the superolateral orbital rim attached to the lateral border of the tarsus of the modified Mustardé flap. The lateral forniceal conjunctiva was released from the retractor and advanced superiorly to cover the inner surface.

RESULTS

The study included 3 men and 2 women, with a mean age of 71 years (range, 62-90 years). Histological evaluations confirmed tumor-free margins in all cases. The average follow-up duration was 20 months (6-60 months), with no tumor recurrence. None of the patients developed long-term complications, such as ectropion, entropion, lagophthalmos, trichiasis, symblepharon, erythema, wound dehiscence, or flap necrosis. All patients had minimal scarring, and no secondary surgical interventions were necessary.

CONCLUSIONS

This case series demonstrates the efficacy of the combined modified Mustardé and superolateral periosteal flaps in 1-stage reconstruction of full-thickness defects involving 50% to 75% of the horizontal length of the medial and central lower eyelid without compromising functional and aesthetic outcomes.

Bioengineering autologous cartilage grafts for functional posterior lamellar eyelid reconstruction: A preliminary study in rabbits

The reconstruction of posterior lamellar eyelid defects remains a significant challenge in clinical practice due to anatomical complexity, specialized function, and aesthetic concerns. The ideal substitute for the posterior lamellar should replicate the native tarsoconjunctival tissue, providing both mechanical support for the eyelids and a smooth surface for the globe after implantation. In this study, we present an innovative approach utilizing tissue-engineered cartilage (TEC) grafts generated from rabbit auricular chondrocytes and a commercialized type I collagen sponge to reconstruct critical-sized posterior lamellar defects in rabbits. The TEC grafts demonstrated remarkable mechanical strength and maintained a stable cartilaginous phenotype both in vitro and at 6 months post-implantation in immunodeficient mice. When employed as autografts to reconstruct tarsal plate defects in rabbits' upper eyelids, these TEC grafts successfully restored normal eyelid morphology, facilitated smooth eyelid movement, and preserved the histological structure of the conjunctival epithelium. When applied in bilayered tarsoconjunctival defect reconstruction, these TEC grafts not only maintained the normal contour of the upper eyelid but also supported conjunctival epithelial cell migration and growth from the defect margin towards the centre. These findings highlight that auricular chondrocyte-based TEC grafts hold great promise as potential candidates for clinical posterior lamellar reconstruction. STATEMENT OF SIGNIFICANCE: The complex structure and function of the posterior lamellar eyelid continue to be significant challenges for clinical reconstructive surgeries. In this study, we utilized autologous auricular chondrocyte-based TEC grafts for posterior lamellar eyelid reconstruction in a preclinical rabbit model. The TEC grafts exhibited native cartilaginous histomorphology and comparable mechanical strength to those of the native human tarsal plate. In rabbit models with either tarsal plate defects alone or bilayered tarsoconjunctival defects, TEC grafts successfully restored the normal eyelid contour and movement, as well as supported preservation and growth of conjunctival epithelium. This is the first study to demonstrate autologous TEC grafts can be employed for repairing tarsal plate defects, thereby offering an alternative therapeutic approach for treating posterior lamellar defects in clinic settings.

Surgical reconstruction of medial eyelid defects using margin transposition, tarsal graft, and periosteal strip

PURPOSE

Surgical reconstruction of medially located lower eyelid defects can be challenging. The Hughes procedure, considered the standard for reconstruction in such cases, often falls short in terms of cosmetic outcomes. An alternative approach that combines medial transposition with a tarsal graft and periosteal strip has shown promise. Here, we aim to demonstrate the cosmetic advantages of medial transposition of a preserved temporal lower eyelid over other techniques.

METHOD

We conducted a retrospective study involving seven well-documented patients who underwent the procedure described below. The study was approved by the University's Ethics Committee.

RESULTS

All patients were followed up for one year. Lower eyelid defects spanned 50-80% of their total length, situated in the central third of the eyelid or the central to medial portion. Postoperative complications were minimal, with all patients exhibiting good cosmetic, functional, and anatomical outcomes at follow-up.

CONCLUSION

The absence of eyelashes is well tolerated if it is lateral, but when the defect is medial, medial transposition could be a good alternative to the familiar Hughes surgical intervention.

Polymers and Biomaterials for Posterior Lamella of the Eyelid and the Lacrimal System

The application of biopolymers in the reconstruction of the posterior lamella of the eyelid and the lacrimal system marks a significant fusion of biomaterial science with clinical advancements. This review assimilates research spanning 2015 to 2023 to provide a detailed examination of the role of biopolymers in reconstructing the posterior lamella of the eyelid and the lacrimal system. It covers the anatomy and pathophysiology of eyelid structures, the challenges of reconstruction, and the nuances of surgical intervention. This article progresses to evaluate the current gold standards, alternative options, and the desirable properties of biopolymers used in these intricate procedures. It underscores the advancements in the field, from decellularized grafts and acellular matrices to innovative natural and synthetic polymers, and explores their applications in lacrimal gland tissue engineering, including the promise of 3D bioprinting technologies. This review highlights the importance of multidisciplinary collaboration between material scientists and clinicians in enhancing surgical outcomes and patient quality of life, emphasizing that such cooperation is pivotal for translating benchtop research into bedside applications. This collaborative effort is vital for restoring aesthetics and functionality for patients afflicted with disfiguring eyelid diseases, ultimately aiming to bridge the gap between innovative materials and their clinical translation.

Post-oncological full-thickness eyelid defect reconstruction: An aesthetical overview

Purpose of the current study was to introduce a new detailed aesthetical subunit (ASU) involvement chart to localize the defect configuration on the eyelids, and, to evaluate the aesthetical and functional outcomes of the post-oncological full-thickness eyelid defect reconstruction surgery by using a modified aesthetical rating guideline. Medical records of subjects who were diagnosed with a primary malignant full thickness eyelid tumor involving the eyelid margin and underwent full-thickness eyelid defect reconstruction surgery between April 2016 and May 2022 were retrospectively reviewed. Age, sex, pathological diagnosis, follow-up time, the ASU of the eyelid involvement, and surgical methods used to reconstruct the anterior and posterior lamella were examined from medical records. The reconstructed eyelid photos were scored according to the modified aesthetical rating guideline to analyze the aesthetical and functional outcomes of the surgeries. A total of 31 subjects were included to the study, and the overall mean aesthetical score was 3.5. Seventeen subjects with aesthetical scores greater than 3.5 were included in the more aesthetically pleasing (AP) group, and 14 subjects with aesthetical score less than 3.5 were included in less AP group. Anterior lamella repair was mainly performed using myo-cutaneous flaps in the more AP group and multiple flap combinations in the less AP group (P: 0.13). Posterior lamella reconstruction was performed using tarso-conjunctival tissue in both groups. In more AP group, tissue scarring, lash line disruption, eyelid thickness, and retraction or ectropion scores were significantly higher when compared with less AP group (P:0.03, P:0.03, P:0.02, and P:0.01, respectively). Subjects with fair eyelash color were significantly more common in more AP group (P: 0.009). The ASU involvement chart and outcomes of the current study may aid novice surgeons to determine which method will provide the best result for an individual patient for full-thickness eyelid defect repair and may offer some insight into the different surgical techniques used for repairing similar wounds.

Use of biomaterials in the reconstruction of posterior lamellar eyelid defects: a systematic review and meta-analysis

Eyelid defects can occur secondary to tumours, trauma, burns, and congenital factors. Among the most challenging aspects of eyelid reconstruction is the rebuilding of a tarsal substitute due to its delicate and multi-layered tissue composition. Attempts to use biomaterials for posterior lamellar reconstruction are intended to provide an alternative to traditional autograft reconstructions. In this review, we aimed to assess the types of biomaterials used for the reconstruction of the posterior lamella associated with eyelid defects and the associated clinical outcomes. A literature search was conducted on Pubmed, Prospero, Dynamed, DARE, EMBASE, and COCHRANE databases. A total of 15 articles fulfilled the inclusion criteria, and 129 patients with 142 eyelids reconstructed, using artificial grafts, were included in the review. Acellular dermis allograft (AlloDerm®, LifeCell) (n = 49) was the most common artificial graft used. A meta-analysis was performed, which demonstrated a pooled success rate of artificial grafts of 99% (95% CI 96-100, p = 0.05; I2 = 40%, total complications seen 39% (95% CI 96-100, p = 0.05; I2 = 40%) and re-operation rates of 5.6% (n = 8). The biomaterials used demonstrated an overall success rate of 99%, which is similar if not greater than that reported with the use of traditional autograft reconstruction techniques, with similar complications and fewer re-operations than autografts. This suggests that clinicians should consider the clinical use of artificial grafts for posterior lamellar reconstruction.