Outcomes after surgical resection of lower eyelid tumors and reconstruction using a nasal chondromucosal graft and an upper eyelid myocutaneous flap

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.

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.

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

Reconstruction of eyelid defects, especially the posterior lamella, remains challenging because of its anatomical complexity, functional considerations, and aesthetic concerns. The goals of eyelid reconstruction include restoring eyelid structure and function and achieving an aesthetically acceptable appearance. An in-depth understanding of the complex eyelid anatomy and several reconstructive principles are mandatory to achieve these goals. Currently, there are multiple surgical treatment options for eyelid reconstruction, including different flaps, grafts, and combinations of them. This comprehensive review outlines the principles of reconstruction and discusses the indications, advantages, and disadvantages of currently available surgical techniques. We also propose our clinical thinking for solving specific clinical questions in eyelid reconstruction and offer perspectives on new potential methodologies in the future.

How and when of eyelid reconstruction using autologous transplantation

Reconstructive surgery of the eyelid after tumor excision, trauma or other causes can be challenging, especially due to the complexities of the anatomic structures and to the necessity of both functional and aesthetic successful outcomes. The aim of this minireview was to investigate the use of tissue transplantation in eyelid reconstruction. Surgical procedures are various, based on the use of both flaps, pedicled or free, and grafts, in order to guarantee adequate tissue reconstruction and blood supply, which are necessary for correct healing. Common techniques normally include the use of local tissues, combining non-vascularized grafts with a vascularized flap for the two lamellae repair, to attempt a reconstruction similar to the original anatomy. When defects are too wide, vast, deep, and complex or when no adjacent healthy tissues are available, distant area tissues need to be recruited as free flaps or grafts and paired with mucosal layer reconstruction. With regards to the anterior lamella, full thickness skin grafts are commonly preferred. With regards to the reconstruction of posterior lamella, there are different graft options, which include conjunctival or tarsoconjunctival, mucosal or palatal or cartilaginous grafts usually combined with local flaps. Free flap transplantation, normally reserved for rare select cases, include the use of the radial forearm and anterolateral flaps combined with mucosal grafts, which are surgical options currently reported in the literature.

Auricular skin-cartilage sandwich graft technique for full-thickness eyelid reconstruction

Full-thickness deficiency of eyelid tissues can result in coloboma or retraction or both. Here we report our initial experience on the use of auricular skin-cartilage sandwich graft technique for full-thickness eyelid deformities. Five patients (4-32 years) underwent the procedure. Patients with full-thickness eyelid deformity were included. Three patients were operated for large-sized coloboma and two for eyelid retraction. One patient had congenital, and four patients had acquired etiology. The following parameters were specifically assessed: correction of deformity, ocular surface problems, graft status, and epithelization of skin-cartilage graft. All the patients had a good correction of eyelid position, except one patient who had severe eyelid retraction (8 mm) at presentation. None of our patients had corneal erosion/defect, persistent ocular surface redness, or graft loss. The auricular skin-cartilage sandwich graft technique produces optimal results with no graft loss. Advancement of orbicularis muscle in between the auricular skin and cartilage grafts (sandwich technique) is an imperative step that leads to the survival of both grafts.

Three-Dimensional Tarsal Plate Reconstruction Using Lower Lateral Cartilage of the Nose

BACKGROUND

Many types of graft tissue have been used to reconstruct the posterior lamella of the eyelids in cases of full-thickness defect, lid retraction, and loss of lower lid stability. In this study, lower lateral cartilage of the nose was used for the reconstruction of posterior lamella of the eyelids, which mimics the tarsal plate in shape, thickness, and size.

MATERIAL AND METHODS

This study included 10 patients who underwent lid reconstruction to support tarsal plate strength and repair full-thickness defects of the eyelids due to tumor excision and trauma. While anterior lamella was reconstructed with local or regional flaps, posterior lamella was repaired by using either chondromucosal or chondral graft of the lower lateral cartilage of the nose. Graft harvesting was performed on the inner surface of the alar rim by turning it inside out.

RESULTS

Cartilage grafts were sufficient to reconstruct the tarsal plate in all of the patients having eyelid defects of various sizes. In 3 patients, horizontal half of the eyelid was defective, in 3 patients 3/4, and in 2 patients 4/5 of the lids were missing. The inferior eyelid was totally reconstructed in 1 patient. Surgical outcomes provided good lid symmetry and esthetics, patient satisfaction, and proper lid function without any nasal deformity, incision scar, or discomfort.

CONCLUSIONS

Ala graft provides a thin, pliable, and curved cartilage for the eyelid reconstruction. It has a high similarity with the anatomy of the tarsal plate, making it adaptable to the convex surface of the eyeball, and making 3 dimensional repair possible.

Eyelid Reconstruction: An Algorithm Based on Defect Location

ABSTRACT

Eyelid reconstruction is a complex topic. This review looks at articles from 1990 to 2018 on eyelid reconstruction that had at least 10 patients and a mean 6 month follow-up. The authors present the results of our findings and propose an algorithm to guide the surgeon in choosing the best technique based on location, size, and lamella. Defects less than 1/3rd of the upper or lower eyelid may be closed primarily. Anterior and posterior lamella defects of the lower eyelid greater than 1/3rd in size should be reconstructed with a double mucosal and myocutaneous island flap. Those greater than 50% in size should be recreated with a Tripier flap for the anterior lamella and conchal chondroperichondral graft for the posterior lamella. For total lid reconstruction, a Fricke flap is best for the anterior lamella and the tarsoconjunctival free graft/lateral orbital rim periosteal flap is best for the posterior lamella. Full-thickness defects between 1/3rd and 2/3rd in size of the upper eyelid should be reconstructed with a myotarsocutaneous flap and those greater than 2/3rd should be reconstructed with a Cutler-Beard flap for the anterior lamella and auricular cartilage for the posterior lamella. For the medial canthal region, the island pedicle and horizontal cheek advancement flap is recommended for the anterior lamella and a composite upper lid graft for the posterior lamella. For the lateral canthal region, a bilobed flap is recommended for the anterior lamella and a periosteal flap for the posterior lamella.

Upper eyelid reconstruction using a combination of a nasal septal chondromucosal graft and a Fricke flap: a case report

Sebaceous carcinoma is a malignant neoplasm that usually arises in the sebaceous glands of the eyelids. Its pathogenesis is unknown; however, irradiation history, immunosuppression, and use of diuretics are known risk factors. The mainstay of treatment for sebaceous carcinoma of the eyelid is wide surgical resection with a safety margin of 5 to 6 mm, which often results in full-thickness defects. The reconstruction of a full-thickness defect of the eyelid should be approached using a three-lamella method: a mucosal component replacing the conjunctiva, a cartilage component for the tarsal plate, and a flap or skin graft for the skin of the eyelid. In this case, a fullthickness defect of the upper eyelid was reconstructed after tumor removal using a combination of a nasal septum chondromucosal composite graft and a forehead transposition flap, also known as a “Fricke flap.” The flap was designed to include a line of the eyebrow on the lower margin of the flap to replace the eyelash removed during tumor excision. The wound healed completely, without any early or late complications, and the outcome was satisfactory.

Therapeutics of xeroderma pigmentosum: A PRISMA-compliant systematic review

Xeroderma pigmentosum is a rare hereditary autosomal recessive genodermatosis. At present, there are many treatment options for xeroderma pigmentosum, covering medical/procedural, surgical and combined modalities. However, the quality of these interventions has not been assessed. Our study aimed to perform a systematic review of the literature regarding the treatment of xeroderma pigmentosum. Multiple medical databases were accessed with the Medical Subject Headings terms; "xeroderma pigmentosum," "therapeutics" and "surgical procedures, operative" from January 2000 to April 2019, including articles published in Portuguese, Spanish and English (PROSPERO-CRD42018114858). Two hundred and ninety-eight studies were found in the databases researched, of which, after applying the inclusion criteria, only 33 studies remained. The 33 complete articles were read by three of the authors, having been found: 16 reported medical/procedural and 17 reported surgical treatments. Only one clinical study presented a good level of evidence (EL: 2): a randomized clinical trial using a T4 endonuclease V (T4N5) liposome lotion which reduced the development of skin lesions in patients with xeroderma pigmentosum. Amongst surgical modalities, all studies presented low evidence level (EL: 4). Three illustrative cases are also presented, to emphasize the multiple number of times that surgical modalities may be required in these patients. The therapeutic modalities, both clinical and surgical, for xeroderma pigmentosum presented a low level of scientific evidence which did not allow meta-analysis. More therapeutic studies, both clinical and surgical, with better scientific evidence are needed.

Reconstruction of giant full-thickness lower eyelid defects using a combination of palmaris longus tendon with superiorly based nasolabial skin flap and palatal mucosal graft

Reconstruction of a full-thickness lower eyelid defect is challenging. We aim to use palmaris longus tendon to improve clinical outcomes in eyelid reconstruction. We generated a novel "three-layer structure" tissue by combination of palmaris longus tendon with superiorly-based nasolabial skin flap and palatal mucosal graft and applied in eyelid reconstruction surgery in 34 patients with significant full-thickness lower eyelid defects. The satisfaction scores were assessed in each patient to evaluate their cosmetic and functional outcomes in follow-up visits. The mean follow-up period was 15 months (range, 6-24 months). Satisfactory results were obtained in 100% patients. No patients reported deformities, obvious scars at the donor sites, or abnormalities of hand function on the surgical side. Our results demonstrated that the three-layer structure incorporating palmaris longus tendon for the reconstruction of giant full-thickness defects in lower eyelid is an effective procedure with satisfactory long-term results.

Angular artery island flap for eyelid defect reconstruction

Eyelid reconstruction is a challenging surgical procedure because of the special function and structure of the eyelids. There are various useful techniques which can be used to reconstruct eyelid defects. In this report, the authors aimed to present the clinical results of angular artery-based island flap for the repair of the full thickness eyelid defects. This presented series consists of eight patients with full-thickness eyelid defects. Oncologic resection was the reason for all of them. Five of the patients had lower eyelid defects and the other three had upper eyelid defects. Nasojugal angular artery-based axial flap was used in reconstruction in all patients. The inferior limit of the flap was the alar rim level in order to make the flap totally axial. A tunnel was created under the orbicularis oculi muscle in cases where the medial portion of the eyelids was left intact and healthy. Septal chondromucosal graft was used to repair posterior lamella of the eyelid. The follow-up period of the cases was from 12 months to 22 months, with a mean follow-up period of 16 months. There was only one patient with reconstructed upper eyelid needed flap defatting. There was no ectropion or wound healing problem observed during the follow-up period. This presented series shows that angular artery-based axial flap and septal chondromucosal graft combination is a simple and safe technique for both upper and lower eyelid full-thickness defect reconstruction. The donor site of this flap heals with an inconspicuous scar concealed in the nasojugal area.