Two Development Flaps for Eyelid Margin Reconstruction

Introduction

The eyelid is a vital facial aesthetic and purposeful unit. As probably the most subtle construction of the eyelid, the eyelid margin issues vastly. It offers tensional help to make the eyelid cling to the globe. It additionally lubricates the oculus by secreting meibum that’s concerned in forming the tear movie, distributes tears when blinking, prevents tear overflow, and retains sebum out of the attention.^1,2 In reconstructive surgical procedure, the eyelid is taken into account a bilamellar construction. The anterior lamella consists of pores and skin, connective tissue, and the orbicularis muscle, and the posterior lamella consists of the tarsus and the palpebral conjunctiva. In addition to having the identical construction because the eyelid, the eyelid margin has some distinctive anatomy. Eyelashes emerge from the pores and skin. The grey line is probably the most superficial portion of the orbicularis muscle, and surgeons often decide the resection thickness of the lesion primarily based on whether or not the grey line is invaded. Meibomian gland orifices throughout the tarsus secrete meibum. The dermis step by step transitions into the mucosa behind the meibomian gland orifices till the mucocutaneous junction.² An ideal reconstruction requires suturing every lamella and exactly aligning the eyelash line, grey line, and meibomian gland orifices.

The eyelid is a standard website of pores and skin lesions, accounting for five–10% of all pores and skin tumors due to the multiplicity of tissue and publicity to daylight. Round 79–84% of eyelid lesions are benign, steadily together with nevi, squamous cell papillomas, basal cell papillomas, seborrheic keratoses, and epidermal cysts. Amongst malignant tumors, basal cell carcinoma is the most typical kind (round 80%).^3–5 Most benign tumor resections depart defects of lower than 50% of the eyelid width, whereas malignant tumors at all times lead to bigger defects. The classification of eyelid defects is conventionally primarily based on their horizontal width relative to the eyelid width: small defects are lower than 25% of the eyelid width, medium defects are 25–50%, and enormous defects are greater than 50%.

On this research, we launched another eyelid margin reconstruction technique for small and medium defects and a novel design for lowering ocular harm. We used an oblong development musculocutaneous flap for anterior lamellar reconstruction and a specifically designed rectangular development tarsoconjunctival flap for posterior lamellar reconstruction. The novel design was a slice of tarsus pared off from the free fringe of the tarsoconjunctival flap, which created an area such that the corresponding remnant conjunctiva might simply bend ahead and canopy the tarsal edge. The chance of ocular issues was thus decreased. We analyzed 24 sufferers who had acquired eyelid margin reconstruction by this technique. Information on postoperative medical outcomes, issues, and affected person satisfaction have been obtained. All sufferers have been adopted up nose to nose or on-line for at the very least one yr.

Supplies and Strategies

This research was a single-center case sequence of sufferers from the follow of a single skilled plastic reconstructive surgeon at a tertiary middle. We consecutively recruited outpatients within the Division of Plastic Surgical procedure within the Second Affiliated Hospital of Harbin Medical College from 2014 to 2021. The inclusion standards have been (1) eyelid margin mass and (2) willingness to obtain eyelid margin reconstruction by the reported technique. The exclusion standards have been (1) eyelid margin mass involving most or all the tarsus and (2) lower than one yr of follow-up. Sufferers’ age; gender; lesion location, depth, and dimension; outcomes; and follow-up time have been collected in medical data. Outcomes together with asymmetry, eyelid distortion or deformity, eyelash discontinuity, Vancouver Scar Scale (VSS) rating, incapacity of opening and shutting the eyelid, ocular discomfort, entropion or ectropion, eyelid retraction, trichiasis, and recurrence have been assessed by two plastic surgeons and scored none (0), slight (1), reasonable (2), or extreme (3). For VSS, 0–3 was none; 4–6 was slight; 7–9 was reasonable; and 10–13 was extreme.⁶ Every affected person’s whole rating was classed as glorious (0–10), good (11–20), or poor (21–30). A affected person satisfaction survey was carried out, with potential scores of not happy, barely happy, reasonably happy, or very happy. All information have been collected in a a number of style.

Our research was permitted by the Medical Ethics Committee of the Second Affiliated Hospital of Harbin Medical College. Knowledgeable consent was obtained from all sufferers.

Surgical Process

Incision

Beneath 1% lidocaine and 1:100,000 adrenaline, an oblong resection of mass on the eyelid margin was carried out (#11 tremendous level blade) 1 mm from its edge. For lesions invading the grey line, full-thickness resection was carried out. If the grey line was intact, the posterior lamella was reserved. Hemostasis was then achieved, and lesion tissue was despatched for histopathology examination.

Posterior Reconstruction by Tarsoconjunctival Flap with Particular Design

For full-thickness eyelid margin defects, we began with posterior lamellar reconstruction utilizing a specifically designed development tarsoconjunctival flap (Figures 1A–D and 2A–D). We flipped the eyelid inside out with the assistance of an assistant or sutures with the cheek. We incised the palpebral conjunctiva and tarsus alongside the prolonged vertical strains of the oblong defect. The peak of the flap was the identical as that of the defect. We bluntly separated the tarsus and muscle and eliminated a pair of canine triangles. After producing an oblong tarsoconjunctival flap, we pared off an roughly 0.5-mm-thick piece of tarsus from its free edge (Figure 3A). We first separated the tarsus and conjunctiva utilizing the #11 fine-point blade. By clipping the orbicularis oculi muscle and tarsus collectively, we immobilized the tarsoconjunctival flap. The opposite handcrafted the blade cling to the tarsus and used the reverse approach to separate about 0.5-mm-deep conjunctiva from the tarsus. The blade was at a 45-degree angle from the flap edge. The conjunctiva retracted after separation. We then shaved the tarsus. We swiveled the blade positioned between the tarsus and conjunctiva into the route vertical to the tarsus and shaved a 0.5-mm-thick piece of tarsus (Figure 3B). The corresponding remnant conjunctiva flap lastly folded ahead to cowl the tarsus edge after suturing between the anterior and posterior lamellas (Figure 3C and D). This not solely prevented tarsus edge abrasion of the cornea and bulbous conjunctiva but in addition stored the suture away from the eyeball. We then superior the oblong tarsoconjunctival flap and sutured beneath the conjunctiva (7–0 Vicryl undyed braided).

Determine 1 (A) The total-thickness mass and the incisions (blue line) designed on the conjunctiva; (B) The total-thickness eyelid margin defect after excising the mass; (C) Excising a pair of canine triangles on the posterior lamellar eyelid; (D) Advancing the tarsoconjunctival flap alongside the arrow route and suturing; (E) The total-thickness mass and the incisions (blue line) designed on the pores and skin; (F) The total-thickness eyelid margin defect after excising the mass; (G) Excising a pair of canine triangles on the anterior lamellar eyelid; (H) Advancing the musculocutaneous flap alongside the arrow route and suturing.

Determine 2 (A) The total-thickness eyelid margin mass; (B) The incisions designed on the palpebral conjunctiva; (C) The total-thickness eyelid margin defect after excising the mass; (D) Advancing the tarsoconjunctival flap and suturing beneath the conjunctiva; (E) The total-thickness eyelid margin mass and the incisions designed on the pores and skin; (F) The total-thickness eyelid margin defect after excising the mass; (G) Excising a pair of canine triangles on the anterior lamellar eyelid; (H) Advancing the orbicularis oculi musculocutaneous flap and suturing.

Determine 3 (A) A 0.5-mm-thick piece of tarsus pared off from the tarsoconjunctival flap’s free edge; (B) The {photograph} of the free fringe of the tarsoconjunctival and conjunctival flap; (C) The conjunctiva folded ahead after suturing (dotted strains), protecting the tarsus edge; (D) The {photograph} exhibits the sting of the sutured anterior and posterior lamellas.

Anterior Reconstruction by Musculocutaneous Flap

For anterior lamella defects or full-thickness defects after posterior lamella reconstruction, we used an oblong development orbicularis oculi musculocutaneous flap to reconstruct the anterior lamella (Figures 1E–H, 2E–H, 4 and 5). Vertical incisions have been prolonged to the identical top because the defect, after which half or all the orbicularis oculi muscle was separated bluntly. We frequently designed the canine triangles on the root of eyelashes for an not easily seen scar. Nonetheless, if the lesion was extensive and positioned on the higher eyelid with a double eyelid crease, we additionally thought-about incising the canine triangles alongside the double eyelid crease (Figure 6). We then superior the orbicularis oculi musculocutaneous flap and sutured it. When suturing the free edges of the musculocutaneous flap and the tarsoconjunctival flap, we guided the needle ahead by means of the foundation of the conjunctival flap, then downward by means of the entrance higher a part of the tarsus of the tarsoconjunctival flap and eventually by means of the musculocutaneous flap (7–0 Vicryl undyed braided) (Figure 3C, d). The knot was tied on the floor of the musculocutaneous flap, away from the eyeball and threads have been minimize brief sufficient to keep away from ocular harm or lengthy sufficient to be immobilized on the cheek.

Determine 4 (A) The anterior lamella eyelid margin mass and incisions (blue line) on the pores and skin; (B) The anterior lamella eyelid margin mass didn’t invade the grey line; (C) The anterior lamella eyelid margin defect after excising the mass; (D) Excising a pair of canine triangles; (E) Advancing the musculocutaneous flap alongside the arrow route and suturing.

Determine 5 (A) The anterior lamella eyelid margin mass on the pores and skin; (B) The anterior lamella eyelid margin mass didn’t invade the grey line; (C) The anterior lamella eyelid margin defect and incisions designed on the pores and skin; (D) Excising a pair of canine triangles; (E) After advancing the musculocutaneous flap and suturing when closing the eyes; (F) After advancing the musculocutaneous flap and suturing when opening the eyes.

Determine 6 (A) Designed incisions of the lesion and canine triangles alongside the double eyelid crease; (B) Excising the lesion and canine triangles and making the development flap; (C) Suturing the development flap; (D) The preoperative look; (E) The postoperative look.

Postoperative Care

We modified dressings after three days and eliminated sutures after seven days.

Outcomes

We included 24 consecutive sufferers (25 lesions). The demographics, medical traits, and outcomes of all sufferers are proven in Table 1. There have been no modifications in participant choice or remedy. All sufferers have been elective instances paid for by themselves. We included 4 medium lesions and 21 small lesions. Twenty sufferers acquired anterior lamellar reconstruction (Figures 7 and 8), and 4 sufferers with full-thickness defects acquired bilamellar reconstruction (Figures 9 and 10). All lesions have been benign nevi. Nearly all sufferers skilled eyelash discontinuity. Eyelash discontinuity was noticeable in instances during which lesions lay on the center of the higher eyelid margin, particularly when closing the eyes (Figure 7), and it was unclear for lesions close to the canthus. One affected person introduced slight distortion—notching of the decrease eyelid margin—and thus slight asymmetry two months after surgical procedure (Figure 9). The notching improved naturally after one yr. Sufferers reported no distortion or deformity, scar, incapacity of opening and shutting the eyelid, ocular discomfort, eyelid entropion or ectropion, eyelid retraction, trichiasis, or recurrence. For one affected person with an higher eyelid marginal lesion (case one), the canine triangles have been designed within the double eyelid crease, whereas others have been on the root of the eyelash. It had little impact on the morphology of the double eyelid crease when the canine triangles sat close to the double eyelid crease. The result scores ranged from 0 to three, and the common rating was 1.23±0.69, indicating that the impact of the reconstruction was glorious. All sufferers have been very happy with the surgical procedure. The common follow-up time was 5.75 years.

Desk 1 Demographics, Medical Traits and Outcomes

Determine 7 (A) The preoperative look; (B) The postoperative look one week after surgical procedure; (C) The postoperative look six months after surgical procedure when trying straight forward; (D) The postoperative look six months after surgical procedure when trying down; (E) The postoperative look six months after surgical procedure when closing the eyes.

Determine 8 (A) The preoperative look of case 24; (B) The postoperative look one week after surgical procedure; (C) The postoperative look six months after surgical procedure.

Determine 9 (A) The preoperative look of case 11; (B) The postoperative look one week after surgical procedure; (C) The postoperative look two months after surgical procedure.

Determine 10 (A) The preoperative look of case seven; (B) The postoperative look one week after surgical procedure; (C) The postoperative look six years after surgical procedure.

Dialogue

Some standards exist for aesthetic eyelid reconstruction: (1) the eyelid margin retains a correct distance from the scleral limbus, (2) the pores and skin resembles the close by regular pores and skin, and (3) the lateral scleral triangle and canthal angle are crisp.7 Our technique appeared profitable in eyelid margin reconstruction for small to medium defects. Most members obtained passable eyelid margin reconstruction with good aesthetic and purposeful outcomes. Eyelash discontinuity was acceptable on account of its minor impact on aesthetic look and might be hidden simply.

One affected person had slight decrease eyelid notching. We inferred that the rationale was that the tarsus top of the tarsoconjunctival flap couldn’t produce adequate help for a medium decrease eyelid margin defect. This defect was the biggest amongst all members, with a 15-mm width and 1-mm top within the posterior lamella within the decrease eyelid. The peak of the inferior tarsus was a lot lower than the superior tarsus, solely 3.5–5 mm at most. No less than 4 mm of tarsus top is required to help the eyelid margin. One other potential motive was a lot retraction pressure from the development flaps since we reserved the retractors.

The distinctive issues of eyelid reconstruction embody wound dehiscence, cornea and bulbar conjunctiva harm, eyelid ectropion, entropion, retraction, ptosis, trichiasis, and even lagophthalmos and publicity keratitis.⁸ Sustaining correct horizontal eyelid margin pressure is essential. Our technique used the remnant tarsus to take care of the unique tarsus width, remodeling the additional transverse pressure into vertical pressure. The novelty of our technique was a specifically designed tarsoconjunctival flap, a tarsoconjunctival, conjunctiva solely flap really, designed to scale back ocular harm. Paring off a 0.5-mm-thick tarsus from its free edge launched area to allow the corresponding conjunctiva remnant to be folded ahead. Therefore, the conjunctiva totally lined the free tarsus edge, and the suture seam was avoided the eyeball, stopping cornea and bulbar conjunctiva abrasion. Equally, a Japanese surgeon emphasised the necessity to suture the conjunctiva as a lot as potential to reconstruct the whole margin and stop free tarsus ablation.⁹ Our idea—the pared tarsus within the tarsoconjunctival flap—might be prolonged to different posterior lamellar reconstruction procedures. The purpose is to maintain the tarsus or different different grafts barely shorter than the conjunctiva or mucosa.

For small and medium eyelid margin defects, direct closure was the most typical and easy technique, particularly in instances of excessive eyelid pores and skin laxity. Defects have been trimmed into triangles or pentagons and closed with varied suture strategies.^10–12 A vertical scar was inevitable, so some strategies, comparable to curvilinear pentagonal wedge resection or resection under the musculocutaneous flap, have been proposed to decrease its size.^13,14 Typically combining direct closure with canthotomy and cantholysis was essential to keep away from wound dehiscence or palpebral fissure deformation attributable to excessive horizontal pressure. For these instances, surgical complexity and harm to regular tissue elevated, and direct closure was not most well-liked. Second-intention therapeutic of marginal defects might additionally obtain acceptable outcomes, primarily for small to medium anterior lamella defects, in addition to full-thickness defects within the decrease eyelid.^15,16 Second-intention therapeutic induced minimal trauma and shortened the operation interval with compromised aesthetic look and therapeutic time. Provided that Asians are extra susceptible to scar formation than Europeans, we advise that second-intention therapeutic ought to be carried out cautiously as a sort of remedy of exclusion. Not too long ago, laser and radiofrequency ablation have obtained glorious beauty outcomes for small eyelid margin lesions, and the charges of recurrence and issues have declined following the event of this system.¹⁷ In contrast with different strategies, flaps might higher preserve the unique eyelid margin contour and horizontal pressure. For medium and enormous defects, varied flaps and grafts are used independently or cooperatively to attain eyelid margin reconstruction. The consensus is that the 2 lamellas of the eyelid ought to be reconstructed independently. Mainstream follow is that both lamella ought to possess a vascularized pedicle within the eyelid reconstruction. Nonetheless, a current research reported that each free grafts for 2 lamellas additionally achieved good blood perfusion and survival.¹⁸ The anterior lamella will be repaired by development, rotation, and transposition flaps, such because the Tenzel flap, Tripier flap, or Cutler-Beard flap, or by free pores and skin and musculocutaneous grafts. The Tenzel flap is the most typical approach used for repairing medium defects or supplementing different strategies to restore massive defects. A pedicled close by transposition flap might present good mobility and little pressure when repairing medium to massive marginal defects.^19,20 Part of the decrease eyelid typically needs to be compromised to reconstruct the higher eyelid due to the higher eyelid’s larger purposeful significance.²¹ The V-Y development flap is also used to restore eyelid marginal defects, regardless of the numerous scar.²² The oblong development flap is a greater match for small and medium or transversal lesions and leaves much less vital scars. The posterior lamella will be reconstructed by a pedicled tarsoconjunctival flap, such because the Hughes flap; free tarsoconjunctival graft (Hubner’s tarsomarginal graft); composite grafts combining mucosa with nasal septal cartilage, onerous palate, or acellular dermal matrix; or a periosteal flap.^23,24 The Hughes flap and Hubner’s tarsomarginal grafts are the most typical. The tarsoconjunctival flap of our technique is definitely a Hughes-type eyelid pedicle flap containing the residual tarsus which might keep away from the issues attributable to the grafts. A number of printed research show that the tarsoconjunctival flap might restore the eyelid margin defects with any width, even whole or near-total eyelid margin, of each the higher and decrease eyelid.^25–29 Nonetheless, adequate remnant tarsus is critical (at the very least 3–4 mm) to help the eyelid margin. Provided that, we imagine this technique is extra appropriate for higher eyelid margin reconstruction as a result of increased tarsus than the decrease eyelid and is an efficient choice for the transverse defect of which the horizontal width is far larger than the vertical top.

Our technique has some limitations. It can’t be used to restore lesions that invade most or all the tarsus due to the dearth of accessible tarsus for development. Though this technique might restore the defects with any width, wider defects are often accompanied by larger vertical top. It was a pity that our report didn’t embody any affected person with massive eyelid margin defect however adequate tarsus. Though related European instances have been reported, we nonetheless require the Asian instances to confirm the impact of this technique for big eyelid margin reconstruction because the Asians have much less out there eyelid tissue than the Europeans. For big anterior defects, a rotation or transposition flap ought to be chosen first relatively than the development flap. The development flap would undermine a considerable amount of regular tissue and depart facial scars no matter pores and skin laxity.

Conclusion

We reviewed 24 sufferers who acquired eyelid margin reconstruction by our reported technique: anterior lamellar reconstruction by an development musculocutaneous flap and posterior lamellar reconstruction by an development tarsoconjunctival flap. The tarsoconjunctival flap was specifically designed to scale back the danger of ocular issues. Our technique appeared profitable in aesthetic and purposeful eyelid margin reconstruction for small and medium defects, with few issues. We imagine it’s an particularly good choice for transverse defects. Sooner or later, its strengths and limitations might be obtained from a comparative research with different reconstruction strategies. The research on the massive eyelid margin defects with adequate tarsus for the Asians is required as nicely.