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

What Is the Best Candidate to Replace the Tarsus? A Biomechanical, Histological, and Optical Study Comparing Five Grafts

Purpose

Reconstruction of the posterior lamella after eyelid tumor removal is challenging and not consensual. Tarsus is the most suitable graft, but is only available in small amounts. Herein, we aim to determine the most appropriate way to replace the tarsus by comparing the biomechanical, histological, and optical properties of five commonly used grafts.

Methods

This study was conducted at the University hospital of Nice between June 2019 and June 2020. Five posterior lamella grafts (tarsus, conchal cartilage, sclera, hard palate, and dermis) were harvested in five fresh frozen cadavers. Biomechanical properties were assessed by tractometry. Collagen and elastin fibers were analyzed by using histological analysis and optical characterization with the second harmonic generation imaging.

Results

The mean Young's modulus was 8.92 MPa (range, 2.90-22.90 MPa), 1.05 MPa (range, 0.39-1.76 MPa), 8.72 MPa (range, 2.0-23.50 MPa), 2.57 MPa (range, 0.41-4.35 MPa), and 1.44 MPa (range, 0.71-2.30 MPa) for the tarsus, the conchal cartilage, the sclera, the hard palate mucosa, and the dermis, respectively. The mean tensile strength was 3 MPa (range, 1.70-6.88 MPa), 0.54 MPa (range, 0.13-0.79 MPa), 2.87 MPa (range, 1.23-5.40 MPa), 1.4 MPa (range, 0.21-2.40 MPa) and 1.0 MPa (range, 0.46-1.43 MPa) for the tarsus, the conchal cartilage, the sclera, the hard palate mucosa, and the dermis, respectively. Hard palate mucosa was the closest to the tarsus regarding the ratio of elastin and collagen fibers. The average second harmonic generation intensity was 221 arbitrary units (a.u.) (range, 165-362 a.u.), 182 a.u. (range, 35-259 a.u.), 369 a.u. (range, 206-533 a.u.), 108 a.u. (range, 34-208 a.u.), and 244 a.u. (range, 195-388 a.u.) for the tarsus, the conchal cartilage, the sclera, the hard palate mucosa, and the dermis, respectively. The hard palate mucosa and the dermis were the closest to the tarsus regarding the collagen fiber size and orientation, respectively.

Conclusions

By attributing 2 points for each characteristic (biomechanical, histological, and optical), the hard palate mucosa and the sclera seem to be the most suitable grafts to replace the tarsus.

Translational Relevance

The aim of this article was to assess the biomechanical, histological and optical characteristics of five of the most commonly used tarsal grafts; this may be helpful in decisions for clinical practice.

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.

Surgical Techniques Following Free Cartilage Grafting

BACKGROUND

Reconstruction of surgical defects with free cartilage grafts poses unique challenges.

OBJECTIVES

To characterize surgical techniques following free cartilage grafting.

MATERIALS AND METHODS

A literature review was performed using the Embase, PubMed Medline, Cochrane Library, ClinicalTrials.gov, and Web of Science databases from inception to May 21, 2021. Studies describing free cartilage grafts harvested from the ear or nose under local anesthesia, specifically for reconstruction of facial surgical defects, were selected for inclusion. Only surgical defects resulting from tumor resection were included.

RESULTS

In total, 34 studies involving 713 patients with 723 surgical defects met inclusion criteria. The mean age of patients was 63.3 ± 10.4 years. Free cartilage grafts were most commonly harvested from the ear (93.1%). The most common recipient site was the nose (90.3%), followed by the lower eyelid (6.7%) and ear (3.0%).

CONCLUSION

Free cartilage grafts are an effective reconstructive option for patients with deep or cartilaginous defects that have compromised structural support on the nose, ear, or eyelid.

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.

The addition of a conjunctival flap to a posterior lamella auricular cartilage graft: A technique to avoid corneal complications

PURPOSE

To present the benefits of the addition of a conjunctival flap when correcting lower eyelid retraction using an auricular cartilage graft.

METHODS

An auricular cartilage graft was obtained either from the concha o the scaphoid fossa. When preparing the receiving bed, the conjunctival incision was made 2 mm below the inferior margin of the lower eyelid tarsus, therefore, a conjunctival flap arising from the inferior border of the tarsus was obtained. The cartilage graft was placed in the lower eyelid. The inferior border of the graft was sutured to the retractors and conjunctiva using absorbable sutures. The superior border was sutured to the inferior tarsus, so that de conjunctival flap covered the superior portion of the graft.

RESULTS

Fourteen patients underwent the surgical technique. No corneal complications were observed in the early or late postoperative period. Donor site complications were not encountered.

CONCLUSIONS

The confection of a conjunctival flap that lines the superior portion of an auricular cartilage graft in the lower eyelid provides protection against corneal postoperative complications until the graft is epithelized.

Management of orbital complications in palatomaxillary reconstruction: A review of preemptive and corrective measures

BACKGROUND

Reconstruction of orbit-sparing palatomaxillary defects requires consideration of globe dystopia, orbital volume, eyelid position and function, and the nasolacrimal system to preserve and optimize vision, globe protection, and appearance. We describe the fundamentals of orbital and eyelid anatomy, common orbital complications related to palatomaxillary reconstruction, and preemptive and corrective surgical techniques to be utilized during and after globe-sparing palatomaxillary reconstruction.

METHODS

We present a review of the literature supplemented by clinical case examples.

RESULTS

We advocate for the use of preemptive and corrective techniques to ensure optimal aesthetic and functional outcomes for patients with orbital defects.

CONCLUSIONS

Recognition and anticipation of problems in patients undergoing midface ablative and reconstructive procedures are vital to the implementation of corrective measures. Incision choice, orbital volume restoration, appropriate orbital floor reconstruction, and permanent or temporary lower eyelid suspension during the primary surgery can all significantly impact the development of long-term orbital complications.

Posterior lamellar reconstruction: a comprehensive review of the literature

The aim of the review is to describe the different techniques and materials available to reconstruct the tarsoconjunctival layer of the eyelid; to analyze their indications, advantages, and disadvantages. We searched the Cochrane, PubMed, and Ovid MEDLINE databases for English articles published between January 1990 and January 2017 using variations of the following key words: "posterior lamella," "eyelid reconstruction," "tarsoconjunctival," "flap," and "graft." Two reviewers checked the abstracts of the articles found to eliminate redundant or not relevant articles. The references of the identified articles were screened manually to include relevant works not found through the initial search. The search identified 174 articles. Only a few articles with a therapeutic level of evidence were found. Techniques for the posterior lamellar reconstruction can be categorized as local, regional, and distant flaps; tarsoconjunctival, heterotopic, homologous, and heterologous grafts. Several techniques and variations on the techniques exist to reconstruct the posterior lamella, and, for similar indications, there's no evidence of the primacy of one over the other. Defect size and location as well as patient features must guide the oculoplastic surgeon's choice. The use of biomaterials can avoid possible complications of the donor site.

Successful Treatment of Infectious Scleritis by Pseudomonas aeruginosa with Autologous Perichondrium Graft of Conchal Cartilage

Infectious scleritis by Pseudomonas aeruginosa is a well-known vision-threatening disease. In particular, scleral trauma following pterygium surgery may increase the risk of sclera inflammation. Surgical debridement and repair is necessary in patients who do not respond to medical treatments, such as topical and intravenous antibiotics. We reports herein the effectiveness of an autologous perichondrium conchal cartilage graft for infectious scleritis caused by Pseudomonas aeruginosa. This procedure was performed on four eyes of four patients with infectious scleritis who had previously undergone pterygium surgery at Gyeongsang National University Hospital (GNUH), Jinju, Korea from December 2011 to May 2012. Pseudomonas aeruginosa was identified in cultures of necrotic scleral lesion before surgery. The conchal cartilage perichondrium graft was transplanted, and a conjunctival flap was created on the scleral lesion. The autologous perichondrium conchal cartilage graft was successful and visual outcome was stable in all patients, with no reports of graft failure or infection recurrence. In conclusion, autologous perichondrium conchal cartilage graft may be effective in surgical management of Pseudomonal infectious scleritis when non-surgical medical treatment is ineffective. Further studies in larger, diverse populations are warranted to establish the effectiveness of the procedure.

Oncologic surgery of the eyelid and orbital region

Oncologic surgery of the eyelid and orbital region is a challenge in dermatologic surgery. This region presents difficulties and possible complications that do not exist at other sites, including ectropion, epiphora, corneal exposure, keratitis, conjunctivitis, and lagophthalmos. Adequate oncologic surgery associated with the best possible functional and cosmetic result requires extensive knowledge of the anatomy, innervation, and blood supply of the eyelid and anatomy of the lacrimal apparatus. We present examples of reconstructive surgical techniques that can be used after the excision of tumors of the upper or lower eyelid, with descriptions of the different flaps and grafts employed in our department in recent years. We also review the surgical techniques according to the site and size of the lesions.