Ear helix flap for reconstruction of total loss of the upper eyelid

Full-thickness total upper eyelid reconstruction with a lid switch flap and a reverse superficial temporal artery flap

BACKGROUND

Reconstruction of the upper eyelid with the same eyelid tissue is desirable because of the ability to achieve eye opening/closing and corneal protection, and a lid switch flap is a useful method. For total defects, almost all of the tissues of the lower eyelid should be used; however, the reconstruction of the lower eyelid donor site has often been undervalued. Reconstruction with an insufficient amount of soft tissue often results in complications such as lagophthalmos and ectropion. Here, we report our method of management of total upper eyelid defects and secondary reconstruction of the lower eyelid donor site.

METHOD

A lid switch flap is designed on the lower eyelid as the first operation. As important points, the height of the flap of the anterior lamina should be the same but the conjunctiva as the posterior lamina should be harvested up to the conjunctival fornix to obtain sufficient tissue. After switching the flap, the lower eyelid donor site is reconstructed with sufficient tissue: cheek mucosa, conchal cartilage, and a reverse superficial temporal artery flap as a three-layered structure.

RESULTS

Three patients were treated using our method, and we achieved favorable results with a sufficient amount of soft tissue for the reconstruction of the lower eyelid.

CONCLUSION

Reconstruction of the upper eyelid with sufficient tissue from the lower eyelid is important for eyelid function.

Functional reconstruction of total upper eyelid defects with a composite radial forearm-palmaris longus tenocutaneous free flap: A report of two cases

This report presents reconstruction of wide- and full-thickness upper eyelid defects with a composite radial forearm-splitting palmaris longus tendon flap, which maintains eyelid opening and closing functions and supporting tissue in a Meibomian gland carcinoma in the right upper eyelid (case 1) and Merkel cell carcinoma in the right upper eyelid (case 2). After tumor resection with excisional margins, the defects involved the muscle, tarsal, and mucosa, with defect sizes of 60 × 40 mm and 85 × 40 mm, respectively. A radial forearm flap with the palmaris longus tendon was transferred. The tendon was split into two strips: the upper strip was fixed to the frontal muscles for the opening function and the lower strip to the medial palpebral ligament and orbicularis oculi muscle to maintain the closing function. Flap vessels were anastomosed to the superficial temporal artery and vein through the subdermal tunnel. Postoperative courses were uneventful. At the 5-year (case 1) and 4-year (case 2) follow-up periods, there were no tumor recurrence and keratalgia, and the eyelid opening and closing functions were maintained. This approach may contribute to achievement of not only the opening function but also the closing function of the reconstructed eyelid.

Supermicrosurgery: History, Applications, Training and the Future

Supermicrosurgery, a technique of dissection and anastomosis of small vessels ranging from 0.3 to 0.8 mm, has revolutionized the fields of lymphedema treatment and soft tissue reconstruction. The technique offers several distinct benefits to microsurgeons, including the ability to manipulate small vessels that were previously inaccessible, and to minimize donor-site morbidity by dissecting short pedicles in a suprafascial plane. Thus, supermicrosurgery has become increasingly popular in recent years, and its applications have greatly expanded since it was first introduced 20 years ago. While supermicrosurgery was originally developed for procedures involving salvage of the digit tip, the technique is now routinely used in a wide variety of microsurgical cases, including lymphovenous anastomoses, vascularized lymph node transfers and perforator-to-perforator anastomoses. With continued experimentation, standardization of supermicrosurgical training, and high quality studies focusing on the outcomes of these novel procedures, supermicrosurgery can become a routine and valuable component of every microsurgeon's practice.

Total upper eyelid reconstruction by single staged malar-cheek flap

We report a case of total upper eyelid reconstruction by a new technique after excision of an eyelid tumour. The eyelid was reconstructed by a horizontal, laterally based flap from just under the lower eyelid combined with a chondro-mucosal graft from the nasal septum. Surgical outcome was an excellent aesthetically reconstructed eyelid, which was mobile and properly gliding on the globe to achieve complete eye closure.

Lower lid reconstruction utilizing auricular conchal chondral-perichondral tissue in patients with neoplastic lesions

Purpose. To assess surgical outcomes of lower lid reconstruction surgery using auricular conchal tissue. Methods. This prospective study included 20 patients that underwent reconstructive lower lid surgery using autologous auricle chondral-perichondral graft tissue. Auricle tissue was used to provide adequate support and protection with similar conjunctiva tarsal structures on overlying soft tissues in patients with pathologic inferior lid tissue loss requiring reconstructive surgery. Biopsies with histopathology and cytology analysis were taken after 1 year. Cytology analysis using CK19 was used to confirm newly formed conjunctiva overlying the graft. Results. All patients showed no graft rejection. Surgical outcomes were generally good, with minimal or no ocular complications. 16 of 20 patients had excellent results, showing good lid symmetry and esthetics, minimal auricular discomfort, patient satisfaction and proper lid function. Surgical outcomes were highly dependent on proper post-op conjunctiva formation. All patients were positive for CK19, thus indicating proper conjunctiva tissue formation. Conclusions. Lower lid reconstruction surgery using auricular chondral-perichondral conchal tissue is a good alternative in patients with neoplastic lesions. Autologous chondral-perichondral tissue provides good functional and mechanical support in the reconstructed lid, thus reducing the risks of ectropion and corneal exposure and ensuring a protected ocular surface.

Columella lengthening by a vascularized preauricular flap

BACKGROUND

A short columella can result in significant cosmetic and functional deformities. Various techniques such as local flap transfer and composite grafts have been reported for columellar lengthening, but the overall results remain unsatisfactory. Transferring a local flap cannot provide new tissue for the columella, which limits its application. Composite grafting can provide new tissue volume, and the composite tissue from the preauricular region has an excellent color and texture match. However, the lack of a stable blood supply for the composite graft restricts its clinical application due to problems such as viability, dimensions, and atrophy. To overcome these limitations, the authors harvested a vascularized preauricular flap for columella lengthening.

METHODS

Based on the superficial temporal vessels, the vascularized preauricular flap was harvested as a free flap and transferred to the columella region. The recipient vessels were angular vessels or facial vessels, and microsurgical anastomosis was performed between recipient vessels and the pedicle. The lateral femoral circumflex vessels were used as vascular grafts when the pedicle was not long enough.

RESULTS

Eight patients who had short columellas were reconstructed with vascularized preauricular flaps. Six flaps were harvested in a reverse fashion, and the remaining two flaps were harvested in an anterograde direction. All the flaps survived well and showed a good color and texture match without hypertrophic scars. An average of 13.3 mm improvement in length was obtained for the eight patients. Two patients underwent a secondary debulking procedure to thin the flap.

CONCLUSION

The free vascularized preauricular flap procedure is a reliable method for columellar lengthening and has wide clinical application.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Single-stage frontalis muscle flap for full-thickness reconstruction of the upper eyelid

BACKGROUND

Full-thickness upper eyelid defects present a reconstructive challenge. Defects greater than 50% of the upper eyelid have traditionally been reconstructed with bulky full-thickness forehead flaps, Cutler-Beard flaps, Mustarde eyelid switches, and cheek rotation advancements, all mandating a second-stage surgical procedure. We propose a novel technique for full-thickness upper eyelid reconstruction based on a frontalis muscle flap elevated from the resection defect, thus resulting in no additional forehead scar.

METHODS

Our patient is a 48-year-old woman with an enlarging right upper eyelid sebaceous cell carcinoma. A subsequent single-stage resection resulted in a medial full-thickness defect of 75% of the upper eyelid. The lateral and medial canthi were preserved. A palatal mucoperiosteal graft was harvested for the reconstruction of the posterior lamella. Dissection was carried through the excision defect in a preseptal plane over the supraorbital rim and subcutaneously over the frontalis muscle. A caudally pedicled frontalis muscle flap was elevated and inset to the defect edges with mild tension. Reconstruction of the skin defect of the upper eyelid was completed with a full-thickness preauricular skin graft.

RESULTS

The patient had no complications and demonstrated good function and aesthetic result at 15 weeks and at 9 months postoperatively.

CONCLUSIONS

Frontalis muscle flap-based reconstruction offers a viable option for upper eyelid defects that are full thickness and encompass more than 50% of the eyelid. We obtained a functionally and aesthetically pleasing outcome with this single-stage procedure using a preexisting incision with minimal donor-site morbidity.

Rescue of vision in burn patients with total eyelid loss

OBJECTIVE

For severe burn victims suffering from total loss of upper and lower eyelids, skin graft or skin flap is normally used to cover the lesion and to protect the cornea, preventing corneal ulcer and simultaneously preparing for corneal transplantation. However, a new problem arises after the formation of the new palpebral fissure, that is, the reconstructed eyelids cannot open and close like the normal eyelids and the eyeball movement is limited, which exposes the cornea to dry air resulting in ulceration. In this article, we present a simple technique to partially solve this problem.

METHODS

Five burn victims who lost their eyelids received treatment: stumps of upper and lower eyelids bulbar conjunctiva were dissected and pulled together as the lining of the conjunctival sac. Intermediate split-thickness skin was then immediately grafted as the new eyelids' skin. After 3 months, a 2-cm transverse incision was made 5mm below the normal palpebral fissure to open the conjunctival sac and new 'eyelids' were formed.

RESULTS

The patients were followed for 2-9 years. No lagophthalmos and xerophthalmia were found. When the patients raised their heads in the supine position, they could see outside. When they bowed their heads, the cornea was protected. Their remaining vision was rescued and an average 0.4 vision recovered. Most of the patients went back to work.

CONCLUSION

The opening and closing function of the eyelids can partially be replaced by movements of the head and neck using this technique. It seems to be a reliable option to rescue the vision in these types of challenging situations.

Using bipedicled myocutaneous Tripier flap to correct ectropion after excision of lower eyelid basal cell carcinoma

Many techniques have been described for correcting ectropion, but when the ectropion follows skin cancer excision, only a technique that replaces missing skin should be used. The bipedicled Tripier flap tends to give some excess bulk at each end but gives an excellent correction of ectropion. The aim of this study was to apply musculocutaneous bipedicled Tripier flap from upper lid for correction of ectropion due to previous excision of lower-lid malignancies and evaluate its outcome. This was a prospective case-series study. In this study, 15 patients (6 women, 9 men), ranging from 35 to 72 years old (mean, 51 years) underwent operation with Tripier flap for reconstruction of ectropion because of basal cell carcinoma (BCC) resection. In patients with ectropion, Tripier flap with or without ear or nasal septal cartilage was used for reconstruction of deformities 3 months after lower-lid reconstruction with local flaps. All patients were satisfied, and ectropion was corrected in all cases. There were no complications such as dry eye or corneal abrasion after operation. Also, we had not any case of ischemic flap. We suggest that Tripier flap is one of the best methods for reconstruction of lower-lid retraction or ectropion. This is a desirable method, functionally and aesthetically.

Perforator flaps and supermicrosurgery

The introduction of supermicrosurgery, which allows the anastomosis of smaller caliber vessels and microvascular dissection of vessels ranging from 0.3 to 0.8mm in diameter, has led to the development of new reconstructive techniques. New applications of this technique are for crushed fingertip replantations with venule grafts, toe tip transfers for fingertip loss, partial auricular transfers for total tracheal and eyelid defects, and lymphaticovenular anastomoses under local anesthesia for lymphedema. Regarding free flaps, free perforator-to-perforator flaps, including deep inferior epigastric perforator or paraumbilical perforator flaps, gluteal artery perforator flaps, thoracodorsal artery perforator flaps, anterolateral thigh perforator flaps, superficial circumflex iliac artery perforator flaps, tensor fasciae lata perforator flaps, and medial plantar perforator flaps, with a short pedicle, have been used for extremity and facial defects. The success rate is almost the same as that of usual free flap transfers with large and long pedicles. The advantages of these flaps are the simple operation and the short time needed for flap elevation, plus the fact that the flaps can be obtained from anywhere in concealed areas. The disadvantages are the need for supermicrosurgical technique and the anatomic variation of these perforators.

Use of vascularised cartilage as an additional interposition in temporomandibular ankylosis surgery: Rationale, advantages and potential benefits

Context:

Surgery for the release of temporomandibular joint (TMJ) ankylosis is a commonly performed procedure. Various interposition materials have been tried with varying success rates. However, none of these procedures attempt to recreate the architecture of the joint as the glenoid surface is usually left raw.

Aims:

We aimed to use a vascularised cartilage flap and to line the raw surface of the bone to recreate the articular surface of the joint.

Settings and Design:

There is a rich blood supply in the region of the helical root, based on branches from the Superficial Temporal Artery (STA), which enables the harvest of vascularised cartilage from the helical root for use in the temporomandibular joint.

Materials and Methods:

Two cases, one adult and the other a child, of unilateral ankylosis were operated upon using this additional technique. The adult patient had a bony segment excised along with a vascularised cartilage flap for lining the glenoid. The child was managed with an interposition graft of costochondral cartilage following the release of the ankylosis, in addition to the vascularised cartilage flap for lining the glenoid.

Results:

The postoperative mouth opening was good in both the cases with significant reduction in pain. However, the long-term results of this procedure are yet to be ascertained.

Conclusions:

The vascularised cartilage flap as an additional interposition material in temporomandibular joint surgery enables early and painless mouth-opening with good short-term results. The potential applicability of this flap in various pathologies of the temporomandibular joint is enormous.

A reverse-flow composite flap in the rat

Reverse-flow flaps are currently particularly used for the reconstruction of defects of the distal part of the extremities. Despite their common usage there have been many reports of postoperative complications, especially resulting in partial or total flap necrosis. There is insufficient knowledge of flap haemodynamics, physiology and wound healing properties in reverse-flow flaps. Development of the proper experimental models is needed to investigate these issues. The purpose of this study was to describe a new reverse-flow flap model in the rat. A total of 20 adult Wistar rats weighing 200-250 g were used in this experiment. In five rats, the vascular anatomy of the auricle of the rat was determined by anatomic dissection and microangiography. In the experimental group (N=5), 1x1 cm reverse-flow composite flaps were harvested as a semi-island shape, based on the distal course of the medial branch of the anterior auricular artery. In the control group, consisting of five rats, the flap was designed and raised based on the proximal course of the medial auricular artery, again in a semi-island shape. In the remaining five animals, a square-shaped composite tissue of the whole layer of the auricle, 1x1 cm in size, was harvested dividing all the bases circumferentially. The composite tissue was replaced in situ. While the former was considered a conventional antegrade-flow flap subgroup, the latter was designated as a graft subgroup. All flaps were replaced in situ. The survival of the flap was evaluated on postoperative day 7 by direct observation and microangiography. The skin island of all the reverse-flow flaps and conventional antegrade-flow flaps survived completely giving a success rate of 100%, whereas all grafts in the control group underwent complete necrosis. Microangiographic studies revealed the vascularity of the reverse-flow and antegrade-flow flaps, identifying the course of the auricular arteries. In conclusion, with its evident advantages of easy to design and harvesting, reliable survival pattern and consistent vascular structure, our new flap model will provide a means for future studies on flap haemodynamics, physiology in reverse-flow flaps.

The arterial anatomy of the eyelid: importance for reconstructive and aesthetic surgery

PURPOSE

The aim of the study was to investigate the arterial distribution of the eyelids.

METHODS

The location, course, length and diameter of eyelid arteries were determined in 19 preserved and latex injected adult male cadaver heads.

RESULTS

The diameter of the medial palpebral artery was found to be 1.50+/-0.28mm on the right, and 0.70+/-0.12mm on the left. The diameter of the lateral palpebral artery was measured as 0.62+/-0.10mm on the right, and 0.59+/-0.12mm on the left. The medial palpebral arteries travelling in the medial part of the eyelids usually arose as separate branches for the upper and lower lids, as superior and inferior medial palpebrals. In all cases, four arterial arcades, the marginal, peripheral, superficial orbital, and the deep orbital arcades, were revealed in the upper palpebra. These arterial arcades gave off small perforating branches. The perforating branches were identified on both sides of the tarsal plate and the orbicularis muscle. In four cases (11%) visible arterial variation was found near the inferolateral end of the levator palpebrae. Although many differences in the arterial features of the eyelid have been noted, there may not be a significant difference in the basic vasculature of the palpebra among races. A better understanding of the palpebral vascularity should allow modification of reconstructive techniques and reduce postoperative complications after eyelid surgery.

[Abbé-Mustardé's flap with lower lid transposition: three clinical cases]

The ideal solution first recommended is the use of Abbé-Mustardé's flap with lower lid transposition to rebuild the total loss of the upper eyelid. Every step of the surgical technique has been detailed to improve the result and keep the drawbacks under control. After having read articles on this subject, we describe three clinical cases, which enable us to compare with others surgical techniques that cannot rebuild all the levels of the eyelids and the edge of the eyelashes.

The reverse auricular flap for the reconstruction of extended defects of the lower eyelid

The authors present eight cases of lower eyelid reconstruction after extended excision of cutaneous carcinomata. To recreate the supporting function of the lower eyelid it is necessary to reconstruct a rigid structure, which must replace the tarsus and has to be covered by sufficiently thin skin. A condrocutaneous helix island flap, based on the frontal branch of the temporal artery, allows us to reconstruct both lamellae of the eyelid at the same time. The reverse flow to the flap through this vascular pedicle is assured by the anastomotic branches from the supratrochlear and supraorbital arteries. Using this flap we have been able to recreate morphology and function of the lower eyelid with a good cosmetic result in the donor site as well.

Total and Subtotal Upper Eyelid Reconstruction with the Nasal Chondromucosal Flap: A 10-Year Experience

BACKGROUND

The authors review their 10-year experience with the nasal chondromucosal flap for total and subtotal upper eyelid reconstruction.

METHODS

After several modifications, the flap is now designed along the lateral nasal wall and is based on the terminal branch of the dorsal nasal artery, to include the subcutaneous tissues down to the periosteum and the cranial portion of the upper lateral cartilage. A skin graft is applied for cutaneous coverage. The flap can be harvested unilaterally or contralaterally.

RESULTS

Fifteen patients, aged 50 to 75 years, have been operated on with this technique for total or subtotal defects of the upper eyelid since 1993. Follow-up included assessment of position, closure, presence of epiphora, length of palpebral rim, eyelid opening, levator function, aesthetic balance, and donor-site morbidity. The flap result was viable in every patient, without total or partial necrosis. Static parameters were within normal ranges, and 8 to 18 mm of levator function (mean, 13 mm) was achieved.

CONCLUSIONS

Compared with other frequently used techniques, namely, the Cutler-Beard advancement flap and the Mustarde lid switch flap, this procedure is a one-stage operation, does not damage the lower lid, and provides a thin, mobile eyelid with an anatomically complete reconstruction. The nasal chondromucosal flap has thus become the authors' standard for large full-thickness defects of the upper lid.

Use of the subcutaneously based nasolabial flap in lower eyelid reconstruction

A 54-year-old male had a history of approximately 18 months, with a diagnostically proven squamous cell carcinoma of the lower left eyelid. The full-thickness subtotal defect was reconstructed with the Hughes procedure (tarsoconjunctival flap) combined with a subcutaneously based nasolabial flap for skin coverage. To our knowledge, the use of the subcutaneous based nasolabial flap in this context has not been described previously. Use of the nasolabial flap may be considered for eyelid reconstruction.