The maximal Hughes procedure

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.

Myotarsal flap - a versatile entity for lower eyelid reconstructions

The purpose is to present a new surgical technique using myotarsal (MT) flap for reconstruction of small to subtotal full thickness defects - up to 8 mm in height - of lower eyelids, without needing concomitant supplementary procedures. MT flap consists of a 3 mm tarsal strip with attached levator complex. It does not have conjunctival lining or pedicle. Versatility of the flap extends to correction of mild to severe ptosis, and retraction of upper eyelids. This is a retrospective personal series of 163 patients, who underwent surgical reconstruction with MT flap overlaid with quilted skin graft (modified myotarsal flap) after excision of malignant tumours of lower eyelid. Surgery was on day case basis under LA. Patients were assessed for aesthetic and functional outcome, and complications. No patient had any complication. Assessment of outcome included corneal and ocular surface health and protection, eye closure, tear secretion, and lid contours. These were aesthetically and functionally satisfactory. Histology confirmed complete tumour clearance, and clinical diagnosis. There was no recurrence of tumour. An astounding, new, unique and original observation of the study is that cornea and ocular surface remained undamaged throughout, despite absence of conjunctival lining of MT flap. This goes against all current tenets of oculoplasty. Use of the modified MT flap is a safe, versatile, and effective procedure yielding satisfactory aesthetic and functional results for reconstruction of the lower eyelid.

Review of Eyelid Reconstruction Techniques after Mohs Surgery

Mohs micrographic surgery achieves high cure rates while preserving healthy tissue making it the optimal treatment for skin cancer. The goals of eyelid reconstruction after Mohs surgery include restoring eyelid structure and function while attaining acceptable aesthetic results. Given the variety of eyelid defects encountered after Mohs surgery, a thorough understanding of the complex eyelid anatomy as well as an in-depth knowledge of the numerous reconstructive techniques available are required to accomplish these reconstructive goals. In this article, the authors review eyelid anatomy and discuss a variety of techniques used for the reconstruction of defects involving the periocular region.

Eyelid reconstruction using the "Hughes" tarsoconjunctival advancement flap: Long-term outcomes in 122 consecutive cases over a 13-year period

This article evaluates the complications and long term functional and cosmetic outcomes of tarsoconjunctival advancement flaps for repairing a range of lower eyelid defects in a large cohort of consecutive cases. A retrospective series of 122 consecutive cases of eyelid reconstruction using tarsoconjunctival-advancement flaps was conducted at Waikato Hospital, or Hamilton Eye Clinic, New Zealand. All cases of lid reconstruction using tarsoconjunctival-advancement flaps between January 1, 2001 until April 3, 2014 were included for analysis. All patients provided written consent for surgery and the study complied with New Zealand Health and Disability Ethics Committee guidelines and the Declaration of Helsinki. Data were collected on patient demographics, lesion histology, defect size, adjuvant surgical procedures required for reconstruction, surgical and postoperative complications, cosmesis and patient satisfaction. Patients requiring lower eyelid reconstruction were predominantly male (56%) and basal cell carcinoma was the most common pathology (>80%). Male gender was associated with larger tarsoconjunctival-advancement-flap width (P-value = 0.0432), larger maximum flap width (20 vs 15 mm), and required on average more adjuvant procedures for reconstruction (1.80 vs 1.48, P-value = 0.02). Mean duration to flap division was 37 days and decreased over the duration of the study. Complicated cases were associated with shorter duration to flap division. Mean follow-up was 7 months, complications were observed in 14% with revision required in 4%. Tarsoconjunctival flap reconstruction of the lower lid is suitable for a range of defect sizes and produces excellent functional and cosmetic outcomes. Complications are relatively infrequent and may be associated in some cases with decreased duration to flap division.

A Modified Bifurcated Periosteal Flap for Simultaneous Reconstruction of Upper and Lower Lateral Canthal Tendons

A bifurcated periosteal flap is useful for simultaneous reconstruction of the upper and lower lateral canthal tendons. The original technique harvested the flap horizontally from the frontal process of the zygoma, which mostly resulted in an insufficient flap length because of the narrowness of the zygoma. Here, the authors report the use of a modified bifurcated periosteal flap, raised from the superolateral orbital rim. The lower flap was positioned to slant inferiorly to create a downward slope of the lower eyelid for smooth lacrimal drainage by gravity. The authors applied this technique to 2 patients and obtained good cosmetic results without complications such as entropion, ectropion, lower-eyelid sagging, epiphora, or lateral canthal deformity.

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.

Lower Eyelid Reconstruction for Iatrogenic Eyelid-to-Globe Malposition

An 86-year-old man with iatrogenic eyelid-to-globe malposition had a combination of medial tarsal strip, lateral periosteal sling, and inferior tarsal support with the ear cartilage. An appropriate apposition between the globe and lower eyelid was established postoperatively with good tear meniscus and acceptable cosmetic results.

[Hughes' operation and combined procedures]

BACKGROUND

The Hughes procedure is a standard and widely used technique for lower eyelid reconstruction. This paper presents the results of 55 patients who underwent reconstruction of the anterior and posterior lamella with the Hughes procedure at the University eye clinic in Salzburg between 2002 and 2012.

PATIENTS AND METHODS

This study included 55 patients who underwent lower eyelid reconstruction performed with the Hughes procedure including a full skin graft. In 95 % of patients (52/55) this method was performed after tumor resection. The defect size of the lower lid was at least 10 mm horizontally and ranged between 10 and 15 mm. Of the patients three were treated with a combined Hughes and Tenzel procedure whereas in five cases the Hughes procedure was combined with an autologous tarsoconjunctival flap of the contralateral upper lid and a local full skin rotational flap.

RESULTS

In 42 out of 55 patients both the eyelid function as well as the restoration of good cosmesis could be achieved. In 6 out of the remaining 13 patients suffering from minor complications, the function and cosmesis were restored after secondary minor surgery or additional conservative treatment. For six patients, further reconstructive surgery was necessary and one experienced a major complication in the form of a recurrence of basal cell carcinoma necessitating exenteration.

CONCLUSIONS

The Hughes procedure is a well-suited technique for eyelid reconstruction of shallow defects extending beyond 10 mm horizontally and involving up to 100 % of the eyelid. The latter require a combined procedure such as the Hughes procedure and an autologous tarsoconjunctival flap and skin graft.

Levator aponeurosis sandwich flap for reconstruction of upper eyelid defect

A 72-year-old woman suffered from a sebaceous gland carcinoma on her left upper eyelid. The tumour was 13 × 5 mm without metastasis. The tumour was excised with a 5-mm safety margin, resulting in a large, full-thickness defect in which almost all of the tarsal plate, approximately half of the orbicularis oculi muscle, and part of the levator aponeurosis were lost. Reconstruction of the upper eyelid was successfully performed with a levator aponeurosis sandwich flap, upon which the posterior lamella was covered by a free tarsal graft with medial and lateral periosteal flaps, and a skin graft from the contralateral upper eyelid for the anterior lamella. No lagophthalmos was demonstrated after the operation. Six months postoperatively, there was no tumour recurrence, no ocular complications, and good cosmetic results.

Partial spontaneous cross union post-division of hughes flap

We report three cases of partial spontaneous canthal cross union, a rare complication in cases where Hughes flaps are used to reconstruct lower eyelid defects that also involve the canthi. All cases of spontaneous cross union were identified within 2 months of uneventful division of Hughes' flap. Two cases were successfully divided with good aesthetic results although one patient was not keen on surgery, as it was aesthetically acceptable to him. The postulated mechanism was either the proximity of the divided nonepithelial margins or the failure to trim the residual upper eyelid tarsoconjunctival remnant. We recommended adequate trimming of the residual upper eyelid tarsoconjunctival remnant and an early postoperative review to prevent adhesions from developing.

Reconstruction of the eyelids after mohs surgery

A variety of defects of the upper and lower eyelids can be encountered after Mohs surgery. The goals of eyelid reconstruction are to provide structural and functional restoration with an acceptable aesthetic result. A thorough knowledge of the intricate anatomy of the eyelids combined with familiarity of the wide variety of reconstructive options is required to achieve these goals. In this article, we review the anatomy of the eyelids, and we present commonly used techniques for reconstruction of the upper and lower eyelids and the medial and lateral canthal regions after Mohs surgery.

[Comparison of the aesthetic outcome and complication rate of reconstructive surgical procedures of the eyelid after basalioma excision]

BACKGROUND

The therapy of choice of the basalcellcarcinoma is the surgical removal often combined with soft-tissue reconstruction. Aim of this study was to evaluate the subjective aesthetic outcome and the complication rate in consequence of the chosen surgical procedure.

METHOD

57 patients formerly treated by surgery enclosing free grafts, Hughes flaps, interpolated flaps or primary wound closures were included. The patients were examined to evaluate possible surgery derived complications. Furthermore the aesthetic outcome was assessed by a questionnaire.

RESULTS

After an interpolated flap nearly 30% of the patients were without any complications and after a Hughes flap 21.4%. In contrast 43.8% of the patients after primary wound closure showed any complications and even 57% of the patients treated with a free graft. Concerning the aesthetic outcome 92.3% of the patients undergoing an interpolated flap were subjective satisfied or even very satisfied with their aesthetic outcome.

CONCLUSION

Regarding the complication rate the free graft and the primary wound closure seem to be superior. On the contrary the interpolated flap demonstrated a considerable better estimated aesthetic outcome.

Hypertrophic changes of the lower eyelid margin after hughes procedure for eyelid reconstruction: the management and outcomes

PURPOSE

To describe the management of lower eyelid margin hypertrophy as a complication of the Hughes procedure for eyelid reconstruction.

METHODS

A retrospective review of all patients with lower eyelid hypertrophy after Hughes procedure. Patient demographics, management, histologic findings, and outcomes were recorded. The patients underwent wedge excision of the hypertrophic segment of the eyelid with direct closure achieved in the majority of cases.

RESULTS

Five patients were identified. The mean age at presentation was 66 years. The mean onset for the hypertrophic margin was 8.4 weeks after the Hughes flap. Four patients complained of ocular irritation and 1 patient had a constant ocular discharge. All patients were concerned by the appearance of the eyelid margin. Four patients received topical steroid treatment and 4 patients underwent triamcinolone subcutaneous injections with no improvement. The wedge excision was successful in 4 patients at the mean follow-up of 10 months, with no recurrence of the hypertrophic margin. One patient was reviewed in another center.

CONCLUSION

The authors found no beneficial effect with topical or subcutaneous courses of steroids on eyelid margin hypertrophy. In situations of horizontal eyelid laxity, a full-thickness wedge excision offers a good means of removing the offending eyelid segment.

Lateral canthal fixation using an oblique vertically orientated asymmetric periosteal transposition flap

Herein a modification of the highly useful lateral tarsal strip procedure is presented. The refinement of the technique uses an oblique, vertically orientated, asymmetric, periosteal transposition (OVAPT) flap from the lateral orbital rim to fix the tarsal strip. From a consecutive series of 53 patients, A cohort of 49 procedures on 41 patients with a minimum of 3-month follow up is described. The procedure had a high rate of success in terms of canthal fixation over the median 14-month follow up. There was only one case of late stretching of the canthal repair in an anophthalmic orbit, one case of recurrent cicatricial ectropion due to an inadequate skin graft, and finally a case of early recurrent tarsal ectropion. The OVAPT flap further enhances the stability of the tarsal strip procedure, and allows greater control of lid position and tension. The pull is in a superior and lateral direction, mimicking that of the lateral canthal tendon.

Total lower eyelid reconstruction using paranasal flap

The main aim of this study is to evaluate the advantages, disadvantages, and aesthetic results of the total lower eyelid reconstruction with paranasal flap. The other reconstruction methods are also revisited.Ten patients, who were operated for the reconstruction of total lower eyelid defects between November, 1999 and April, 2005 in our department were included in this study. The total lower eyelid defects of all patients were reconstructed using paranasal flap for anterior lamella and chondromucosal, chondrocutaneous or mucosal graft for posterior lamella. Follow-up time was ranged between 3-35 months. The advantages, disadvantages and complications were defined and aesthetic results of the patients were also evaluated by using a questionnaire which was filled by patients at third month after reconstruction. All flaps and grafts survived, partial or total necrosis was not encountered but one patient with ectropion had a secondary reconstructive procedure. The aesthetic results of the patients were also satisfactory. The paranasal flap is very reliable and safe method for total lower eyelid reconstruction.

Eyelid reconstruction with acellular human dermal allograft after chemical and thermal burns

OBJECTIVE

To evaluate the efficacy of eyelid reconstruction with acellular dermal allograft in patients with eyelid defect after chemical and thermal burns.

METHOD

Eyelid reconstruction was performed in 15 eyelids of 13 patients during the period of June 2001-October 2004 by a single senior surgeon (Chen). Among them five patients had thermal burns, and eight patients had chemical burns. The acellular dermal allograft was used as a tarsus substitute that was sutured into the place between the levator aponeurosis in upper lid or retractor in lower eyelid and the remaining tarsus.

RESULTS

After a mean follow-up of 9 months, satisfactory function and cosmesis were obtained. No implant rejection or severe complications were observed.

CONCLUSION

Acellular dermal allograft may be used safely as a posterior lamellar spacer graft after chemical and thermal burns; the allograft appears to be biocompatible and does not aggravate the inflammation in the injured eyelid.

The 'RITE' use of the Fricke flap in periorbital reconstruction

PURPOSE

To revisit an important but outmoded periorbital reconstructive technique. We present cases to illustrate the usefulness of the Fricke flap and describe a method of rapid intraoperative tissue expansion (RITE), which can enhance the applicability and effectiveness of the Fricke flap. A comparison between those cases performed with and without adjunctive RITE was not made due to the low numbers available.

METHODS

A retrospective review of clinical cases.

RESULTS

A total of 20 cases in which the Fricke flap was used for periorbital reconstruction were reviewed. The mean patient age was 64.7 years; the male-to-female ratio was 1:1. The patient follow-up ranged from 1 to 8 years with a mean of 4.2 years. The most common cause (65%) of periorbital defect was excision of eyelid malignancy. Necrosis of the terminal segment of the flap requiring further surgical intervention occurred in 10% (2/20). In both of these cases, the surgeons were trainees, with the complications being due to poor surgical technique. In the first case, the flap base was too narrow and in the second case, the distal end of the flap was thinned excessively. The functional result was excellent in 10/20 (50%), good in 5/20 (25%), fair in 3/20 (15%), and poor in 2/20 (10%). The cosmetic result was excellent in 3/20 (15%), good in 12/20 (60%), fair in 3/20 (15%), and poor in 2/20 (10%).

CONCLUSION

The Fricke flap is an important and, in selected cases, an indispensable technique in periorbital reconstruction.

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.