Reconstruction of periorbital defects following malignant tumour excision: A report of 50 cases

Periosteal flaps allow for single stage reconstruction of larger full thickness eyelid defects: a retrospective study

Full-thickness lower eyelid defects after Mohs micrographic surgery are frequently referred out to oculoplastic surgery for reconstruction. Reconstructive options include wedge closure with or without canthotomy/cantholysis and tarsoconjunctival sliding flaps. Defects > 50% of the eyelid margin have traditionally required the two-stage Hughes flap, leaving the patient with monocular vision for 3-6 weeks until pedicle division. To demonstrate single-stage periosteal flaps performed by dermatologic surgeons can result in safe, functional, and cosmetically acceptable repairs for large full thickness eyelid defects, an institutional review board-approved retrospective study of repairs performed by two dermatologic surgeons between January 2017 and July 2021 at the University of Minnesota. Patient demographics, operative notes, and follow-up notes were reviewed. Defect and follow-up photographs were scored using a visual analogue scale to assess aesthetic results. Ten cases were included in the analysis. Six patients were male and the average age was 62 years old. 8/10 were basal cell carcinoma and 2/10 were melanoma. The mean defect was 9.5 cm2, with a range of 1-24 cm2. The median cosmetic score was 85.8 ± 10.7. There were no serious complications reported. Mohs micrographic surgeons can safely and successfully reconstruct large, full thickness eyelid defects by periosteal flap.

Reconstruction of Medial Canthal Ligament With Autogenous Fascia Lata Graft

BACKGROUND

An eyelid malignant tumor invading the medial canthus is a serious eyelid disease that requires extensive resection and complex destruction. The medial canthus ligament is especially difficult to repair because its reconstruction often requires special materials. In this study, we described our reconstruction technique using autogenous fascia lata.

METHODS

Data from 4 patients (4 eyes) who had medial canthal ligament defects after Mohs resection of eyelid malignant tumors were reviewed from September 2018 to August 2021. The reconstruction of the medial canthal ligament using autogenous fascia lata was performed in all of the patients. If combined with the upper and lower tarsus defects, autogenous fascia lata was split into 2 branches to repair the tarsal plate.

RESULTS

The pathologic diagnosis was basal cell carcinoma in all patients. The mean follow-up time was 13.6±3.51 months (range, 8-24 mo). There was no tumor recurrence, infection, or graft rejection. All patients achieved good eyelid movement and function and were satisfied with their medial angular shape and cosmetic contour.

CONCLUSIONS

Autogenous fascia lata is a good material to repair medial canthal defects. It is easy to take and effectively maintains eyelid movement and function with satisfactory postoperative effects.

Feasibility, comparability and outcomes of three acquainted facial island flaps for periorbital defects reconstruction

Severe coloboma of ocular malignant neoplasms post-resection poses a reconstructive challenge to surgeons. To compare the practicability, manipulability and outcomes of temporal (myocutaneous) flaps (TFs), forehead (supratrochlear artery/supraorbital artery) flaps (FFs) and buccal (facial artery) flaps (BFs) for periorbital defects reconstruction, a retrospective case series was conducted and evaluated between March 2014 and March 2021. Patient demographics and clinical parameters including age, gender, pathological diagnosis, operative methods, flap selection, operation time, aesthetic satisfaction and follow-up period were collected. The differences in complications were compared and assessed of the three flaps, including flap survival, venous congestion and donor site healing. Totally, 68 patients who underwent periorbital reconstructive operations because of common ocular malignant tumours were reviewed in this study. As for aesthetic satisfaction, a score more than "moderately dissatisfied" was obtained in 21 patients with TFs (95.5%), and of which the scores in FFs group were 12 cases (60%) and 16 cases with BFs reconstruction (61.5%) (P < .05). Severe microvascular complications underwent re-exploration operation occurred in one patient with FFs (1.5%) (P > .05). Notable flap necrosis was observed in two patients with BFs repair (2.9%) and in one case with FFs repair (1.5%), with no statistical difference between the three flap selections (P > .05). Moderate venous congestion occurred in one patient with TFs (1.5%), which was fully meliorated non-surgically. The three familiar facial island flaps are considered as minor trauma and time-saving process for reconstructing the extensive periorbital defects with comparable ranks of complications.

Advancements in the repair of large upper eyelid defects: A 10-year review

PURPOSE

The reconstruction of large (>50%) upper eyelid margin defects can be technically challenging, with multiple approaches described in the literature. We sought to review the recent literature for new techniques or modifications to existing techniques.

METHODS

We conducted a Pubmed search for technique papers on the reconstruction of large upper eyelid defects published within the past ten years with a minimum of four patients.

RESULTS

We identified ten articles, and divided them into techniques that use a bridging flap from the lower eyelid and those that do not. The number of upper eyelids repaired in each article ranged from 4 to 17. Most techniques could be considered either a modification of the Cutler-Beard technique or a novel anterior lamella flap laid over a graft for the posterior lamella. Postoperative complications included upper or lower eyelid cicatricial retraction, trichiasis, entropion, and lagophthalmos.

CONCLUSIONS

Surgeons continue to innovate for this challenging reconstructive surgery. Overall, the trend was to use a graft, most commonly tarsoconjunctiva from the contralateral upper lid, to replace the posterior lamella, and a skin flap, from the lower eyelid or from the adjacent periorbital area, to replace the anterior lamella. Bridging techniques utilized the skin; the skin, orbicularis, and conjunctiva; or a tarsoconjunctival flap from the lower eyelid. Non-bridging techniques generally used a tarsoconjunctival or substitute graft for the posterior lamella, and a skin flap for the anterior lamella.

Complications in facial Mohs defect reconstruction

PURPOSE OF REVIEW

To review the recent literature in regards to complications after reconstruction of Mohs defects, outline common pitfalls and to discuss the literature on avoiding complications as outlined per aesthetic subunit.

RECENT FINDINGS

Complications in facial Mohs reconstruction commonly consist of infection, wound necrosis and dehiscence, hematoma and suboptimal scarring. However, site-specific complications such as hairline or eyebrow distortion, eyelid retraction or ectropion, nasal contour abnormality, alar retraction, nasal valve compromise, significant facial asymmetry or even oral incompetence must also be considered.

SUMMARY

A successful reconstruction mimics the premorbid state and maintains function. The use of perioperative antibiotics, sterile technique, meticulous hemostasis, subcutaneous dissection and deep sutures to minimize wound tension should be considered for all Mohs reconstructions. Cartilage grafting can minimize nasal deformity and obstruction. Reconstruction near the lower eyelid should employ periosteal suspension sutures to minimize downward tension and lid retraction. Perioral complications, such as microstomia and oral incompetence, typically improve with time and therapy. Always consider secondary procedures such as dermabrasion, steroid injection, scar revision and laser resurfacing to help optimize aesthetic outcome.

Total Upper Eyelid Reconstruction with Modified Cutler-Beard Procedure Using Autogenous Auricular Cartilage

INTRODUCTION

Malignant tumour in upper lid is a surgical challenge to oculoplastic surgeon. Full thickness defect created after removal of large tumour promptly treated with modified cutler beard procedure using autogenous auricular cartilage. Surgical procedure is two staged: In first stage, removal of the tumour followed by full thickness flap repaired; In second stage, opening the closed lid with lid margin repair. Post-operatively, there is good anatomical, functional and cosmetic restoration of the eyelid similar to the other eye.

AIM

To evaluate the efficacy of the modified Cutler-Beard procedure using autogenous ear cartilage for tarsal plate reconstruction in the repair of 70-100% upper eyelid defects.

MATERIALS AND METHODS

This is a prospective, interventional case series of 16 patients over a period of three years. Patients with upper eyelid defects, secondary to removal of tumour, greater than or equal to 70% were included. Of these patients, those with lymph node involvement, distant metastasis, lower eyelid involvement, corneal infiltration or intra-orbital extension were excluded. FNAC was done in all the cases. Created defect was measured in mm (length and width) and later expressed in percentage. Pre and Post-operative measurement of Levator Palpebrae Superioris (LPS) was done. Pre and Post-operative measurement of Margin to Reflex Distance (MRD1) were also noted.

RESULTS

Upper eyelid recreation was successful in all patients without complications. Pre-operative LPS action ranged from 0-4 mm, while post-operative LPS action was 12-14 mm. Pre-operative MRD1 ranged from -4 millimeters to -1 mm, while post-operative MRD1 was +3 to +4 millimeters. The follow-up period ranged from six months to two years. Every patient had a successful upper eyelid reconstruction.

CONCLUSION

The modified Cutler-Beard procedure using an autogenous auricular cartilage graft is an effective procedure for repair of large upper eyelid defects, with acceptable functional and cosmetic results. Furthermore, it is particularly useful in resource-poor areas, due to lower cost than other available options.

Switch Flap for Upper Eyelid Reconstruction-How Soon Should the Flap Be Divided?

BACKGROUND

The results of a cohort of patients treated at one institution for upper eyelid reconstruction with the switch flap method after a defect due to excision of malignant tumor were reviewed.

METHODS

A retrospective data file review of all patients who had undergone total upper eyelid reconstruction with the switch flap method was conducted at the Saga University Hospital between April 2000 and October 2014. The follow-up lasted for varying periods during which the preoperative and postoperative photographs were compared as well.

RESULTS

A total of 10 patients with upper eyelid tumors, that is, 7 sebaceous carcinoma, 2 squamous cell carcinoma, and 1 basal cell carcinoma, underwent reconstructive surgery. With the switch flap technique, the defects resulting from tumor excision were completely covered in all cases. The mean of defect widths after tumor excision (A) was 18.8 mm (range, 15-25 mm), the mean of widths of switch flaps (B) was 13.3 mm (range, 8-22 mm), and the mean of B/A ratios was 0.69 (range, 0.5-0.88). When the switch flap was divided at 7 to 14 days, there was no flap loss, trichiasis, or corneal ulcer.

CONCLUSION

Our protocol managed to make flaps with a B/A ratio of 0.5-0.7, and the flaps were divided at 7 to 14 days after surgery, the timing of which was much earlier than in the conventional method, lessening the possibility of complications.

Eyelid reconstruction following excision of cutaneous malignancy

PURPOSE

With advancing age, cutaneous malignancy around the eye becomes more prevalent. Different kinds of malignant tumors of the eyelid have features particular to their subtype, and a diagnosis should be obtained before definitive treatment if possible. The aim of treatment is total tumor eradication with the smallest recurrence risk, using the most cost-effective method that is acceptable to the patient. Reconstruction of periocular defects following excision of eyelid malignancy can present difficulties, and various reconstructive procedures can be applied.

METHODS

The retrospective study carried out has analyzed 173 patients submitted to surgery for skin cancers located in the eyelid region with particular reference to the period January 2005 to January 2012. We analyzed certain data (age, sex, histological types, affected portion of eyelid, incidence recurrence by histological type, incidence recurrent tumors previously treated by surgery [secondary], type of removal, type of reconstruction, and mean time elapsed between the demolitive act and disease recurrence) both individually and in correlation with each other. Multivariate analysis (Cox algorithm) was used to identify those variables that had a clear statistical significance.

RESULTS

Melanoma and lentigo maligna have the highest tendency to relapse (33%), but squamous cell carcinoma has more rapid replicative capacity.

CONCLUSIONS

Extensive demolition should always be followed by extensive reconstruction. Even through intervention with an extensive demolition in cases of large tumors in the eyelid and cantus, it has not been possible to avoid the recurrence of the disease. The average time of recurrence when compared with reconstruction varies between 28 (minimum) and 39 months (maximum).

Principles of Periocular Reconstruction following Excision of Cutaneous Malignancy

Reconstruction of periocular defects following excision of cutaneous malignancy can present difficulties for oculofacial and reconstructive surgeons. The intricate anatomy of the eyelids and face requires precise restoration in order to avoid postoperative functional anesthetic concerns. Various reconstructive procedures based on common principles, location and size of the defect, can be applied to achieve restoration with the best possible functional and aesthetic outcomes.

Partial and total lower lid reconstruction: our experience with 41 cases

PURPOSE

To report our experience on lid reconstruction in patients with epitheliomas.

METHODS

A total of 41 consecutive patients affected by basal cell (n=32) or squamous cell carcinoma (n=9) underwent partial (n=35) or total (n=6) surgical demolition of the lower lid. Surgical defects<25% (n=10) received direct closure. If the defect involved 30-60% of the eyelid (n=21), a Tenzel semicircular flap or lateral advancement flap with a free mucosal graft was used. If the entire lid or a major part of the outer lamella had to be reconstructed (n=10), a cheek advancement flap was used, with a free mucosal graft if the posterior lamella was involved. The success rates and the cosmetic and functional results were evaluated.

RESULTS

All 21 flaps used for partial reconstruction remained viable, whereas 1 of the 10 cheek flaps developed partial distal necrosis. Of the 27 mucosal grafts, 2 had to be removed for total necrosis, and 2 developed partial necrosis. In all cases, normal lid function and acceptable cosmetic results were obtained. Complications occurring in 4 cases (1 ectropion and 3 epiphora) were successfully managed with appropriate surgical procedures.

CONCLUSIONS

Local flaps are the gold standard for lower lid reconstruction as they are highly reliable and guarantee optimal results. The technical details described in this study can help in achieving such results.