Eyelid Reconstruction

Novel Reconstructive Technique for Lower Eyelid Defects: Marginal Approach for Releasing the Lid with Closure Handling Technique (MARCH Technique)

Background: This study introduces a novel surgical approach, the Marginal Approach for Releasing the lid with Closure Handling technique (MARCH technique), a single-step sparing tissue technique, for the reconstruction of medium to large full-thickness lower eyelid defects and its outcomes. Methods: The research considers a single-centre case series with a description of the MARCH technique. Patients with a full-thickness medium to large lower eyelid defect underwent this technique, which combines inferior cantholysis, splitting of lamellae and island or advancement flaps. Demographic data, lid defect size, histology and postoperative outcomes were collected. Results: The surgical procedure was performed in fifteen patients (nine males and six females). The mean age was 73.9 years (range 48-95 years old). Local anaesthesia was used in 86.7% of cases. The mean defect size was 68.7% (range 50% to 79%) of the lid length. All patients presented good results with no significant complications. Conclusions: The MARCH technique seems to be an excellent first-line approach in reconstructing medium to large full-thickness lower eyelid defects. Its single-step approach, tissue-sparing and minimally aggressive nature and ability to potentially guide eyelash positioning and restore the lacrimal system with a more anatomical position make it a promising option. Enrolling more patients and a longer follow-up would provide a better assessment.

Eyelid Reconstruction

Reconstruction of the eyelid is a complex process that requires an understanding of eyelid anatomy and various reconstructive techniques to restore function and appearance. The eyelids, essential for globe protection, moisture retention, and expression, contain the lacrimal system and intricate musculature that make reconstruction challenging. Tumor excision commonly results in defects in the eyelid that require careful reconstructive planning, with consideration for defect dimensions, location, and involvement of surrounding tissue. This review presents reconstructive techniques commonly used in the management of eyelid defects.

Customized Reconstruction of Lower Eyelid Defects

BACKGROUND

A lower eyelid defect is a loss of skin, muscle, and underlying structures that can occur due to trauma, malignant or benign tumors, burns, or other causes. The conventional surgical treatment of lower lid defects has several limitations, including visible scarring, narrowing of the eye, and ectropion. Here, we combined the use of a customized mid-face lift with a free mucochondral graft to overcome the disadvantages of existing methods.

METHODS

Forty patients underwent reconstructive surgery using a customized mid-face lift with or without a free mucochondral graft for a lower lid defect between April 2013 and October 2020. Patients were discharged shortly after surgery and were expected to visit the outpatient clinic periodically for 12 months.

RESULTS

The causes of lower eyelid defects were malignancy, trauma, foreign body granuloma, and other causes. Four patients reported complications, including 2 cases of chemosis, 1 case of a hematoma, and 1 case of corneal abrasion, who reportedly performed well after 2 weeks of conservative therapy. No patient required revision during the average follow-up period.

CONCLUSIONS

Customized reconstruction demonstrated a better aesthetic reconstruction of the lower eyelid. This method represents a good option for reconstructing lower lid defects.

The Utility of the Paramedian Forehead Flap in Lower Eyelid Reconstruction

BACKGROUND

Malignant cutaneous eyelid tumors account for approximately 10% of all cutaneous cancers. Like other cancerous skin lesions, treatment commonly involves excision with wide margins, requiring tissue reconstruction. The use of the paramedian forehead flap (PMFF) has been described for reconstruction of the medial and upper eyelid, but literature is lacking for its use in lower eyelid anterior lamella reconstruction. We present a case series of patients who underwent reconstruction of lower eyelid defects using the PMFF.

CASE PRESENTATIONS

We present 2 patients who underwent reconstruction of lower eyelid defects using the PMFF surgical technique. The patients had previous history of lower lid repair with other reconstructive methods because of cancerous eyelid lesions. In addition, both received adjuvant radiation therapy, which led to development of ectropion. Postoperative signs, symptoms, and photographs were collected to monitor outcomes.

MANAGEMENT AND OUTCOMES

Reconstructions were performed by the collaborative efforts of a facial plastic reconstructive surgeon and oculoplastic surgeon using a staged PMFF approach. Postoperatively, both patients had significant improvement in ophthalmologic symptoms, particularly ectropion and lagophthalmos. At their most recent follow-up visit, they were satisfied with their functional and aesthetic outcomes.

CONCLUSION

The PMFF may be safely used to reconstruct defects of the lower eyelid anterior lamella. In this study, the PMFF has proven to be an excellent option for patients with complications after previous lower eyelid reconstructions or history of radiation therapy. Overall, the PMFF should be considered as part of the surgeon's reconstructive ladder when addressing lower eyelid defects.

Medial Canthus Reconstruction with the Paramedian Forehead Flap

Background:

The medial canthus represents the medial confluence of the upper and lower eyelid margins and plays an integral role in the lacrimal duct system. Various flaps have been utilized for the reconstruction of the lower eyelid in the medial canthal region. Our institution primarily utilizes the paramedian forehead flap for the reconstruction of medial canthus defects. Our study looked to evaluate the work of a single plastic surgeon and identify their postoperative outcomes.

Methods:

A retrospective chart review was conducted at Beaumont Health System, Royal Oak, for patients who underwent medial canthal repair by the lead surgeon between the years 2014 and 2018. Demographic data, operative details, complications, medical comorbidities, and patient outcomes were retrospectively gathered and analyzed.

Results:

A total of five patients were isolated. Patients underwent paramedian forehead flap medial canthal repair by the lead surgeon and were found to tolerate the procedure well. All patients had clinically viable flaps with aesthetically pleasing results.

Conclusions:

Utilization of the paramedian forehead flap leads to successful medial canthal repair with adequate coverage. Although the paramedian forehead flap requires three stages to complete, the procedure leaves patients with aesthetically pleasing results. In addition, the paramedian forehead flap has limited cases of ectropion. With the right expertise and patient population, the paramedian forehead flap can be highly successful in the repair of medial canthal defects.

The Role of Rigid Suspension and Fixation in Treating Lagophthalmos After Lower Eyelid Reconstruction

ABSTRACT

A patient with severe eyelid defects caused by a car accident was admitted to the Plastic Surgery Department of the First Hospital of Jilin University. The lower eyelid was first reconstructed with autogenous palatal mucosa and a temporal musculocutaneous flap, which provided adequate tissue volume. Postoperatively, eyelid closure was good. After long-term follow-up, the reconstructed lower eyelid showed laxity and downward movement. The eyelid could not close completely and lagophthalmos occurred. Then, the lower eyelid was suspended by the fascia lata. The suture at the point of fixation became loose again after the operation. Incomplete eyelid closure recurred. Finally, palmaris longus tendon graft suspension combined with screw fixation was used to obtain a satisfactory therapeutic effect. In summary, rigid suspension and fixation can provide adequate lateral tension to resist lower reconstructed eyelid shifting and lagophthalmos, which is important for the maintenance of lasting effects.

Porcine Urinary Bladder Extracellular Matrix for Treatment of Periocular Skin Defects

PURPOSE

To describe the experience of 4 oculoplastic surgeons with porcine bladder matrix for periocular anterior lamella and donor site skin defects either as stand-alone treatment or in conjunction with other reconstructive procedures. The authors hypothesized that defect size and location influence the requirement for additional matrix treatments or ancillary procedures.

METHODS

Following the Institutional Review Board approval, the authors conducted a retrospective review of 17 patients treated with porcine bladder matrix at 2 oculoplastic practices between 2016 and 2018. Powdered matrix was applied to the skin defect and overlaid with a matrix sheet. Subsequent rounds of matrix treatment or other reconstructive procedures were performed as necessary. Defect size and location were correlated to the number of ancillary matrix treatments or surgical procedures via univariate analysis.

RESULTS

Twenty-five sites (21 primary and 4 donor) in 17 individuals (8-95 years, M = 58.8 years, 10 males) were treated with porcine bladder matrix. All wounds healed successfully. Additional matrix treatments were administered at 5 sites. Ancillary procedures were performed for 7 sites. Upper lid involvement and larger defect size tended to require additional ancillary procedures (p = 0.006), while lower eyelid and other periocular defects required fewer procedures (p < 0.001).

CONCLUSION

Porcine bladder matrices are useful adjuncts to healing periocular anterior lamella defects in various settings. Such repairs are useful in nonsurgical candidates, but must take into account varying levels of complexity based on lesion location. Smaller defects are more conducive to application of matrices as stand-alone treatment, while larger or upper eyelid defects often require additional procedures.