Reconstruction of an Extensive Full-Layer Defect of the Upper Eyelid

A 92-year-old woman with a history of hypertension and dyslipidemia presented with a 2-month rapidly growing nodule on the right upper eyelid. The nodule was soft, measuring 5 × 6 mm, and was accompanied by eyelash epilation (Figure 1).

The patient underwent partial biopsy, and the nodule was diagnosed as sebaceous gland carcinoma.

Radical full-thickness tumor resection with 1-cm free margins was performed.

The overlying soft tissue, tarsus, palpebral conjunctiva, and upper lacrimal punctum were resected. This created a full-thickness defect involving subcutaneous fat, orbicularis oculi muscle, orbital fat, tarsus, levator palpebrae muscle, and palpebral conjunctiva (Figure 2).

The eyelid is divided into overlapping zones that encompass the esthetic unit.¹ Zone 1 includes the upper eyelid, zone 2 encompasses the lower eyelid, zone 3 contains the medial canthal region, zone 4 embraces the lateral canthal region, and zone 5 covers any area outside zones 1 to 4 but contiguous with these zones.

The defect in this case was in zone 1, and therefore the following discussion focuses on the reconstruction of defects in zone 1. Previous studies have described strategies for zone 1 defect reconstruction. Partial-thickness defects exceeding 50% of the eyelid width are reconstructed with full-thickness skin grafts—harvested from the opposite upper eyelid, retroauricular area, or supraclavicular area—or lateral orbital flap.² Defects of less than 50% of the eyelid width can be closed using myocutaneous advancement flaps including the orbicularis oculi muscle.³ For full-thickness defects, both anterior and posterior lamellae must be reconstructed. Defects of up to 25% of the eyelid width can be closed by simple reefing; moreover, in some cases, lateral canthotomy and cantholysis of the superior crus are performed. For defects exceeding 25% to 50% of the eyelid width, which cannot be closed primarily, myocutaneous advancement flaps (including the orbicularis oculi muscle), skin grafts, or lower eyelid switch flaps may be used in addition to sliding upper eyelid tarsoconjunctival flaps.

Larger upper eyelid defects exceeding 50%, as in this case, require lower eyelid switch or bridge flaps, both of which need a second operation to cut the flap pedicles. Switch flaps are more suitable for both large vertical and horizontal defects. The Mustardé switch flap has been widely described as an axial pattern flap that includes the entire lower eyelid layer vascularized by the marginal arcade and is used with the malar flap; however, it can cover large defects but needs a wide-range subcutaneous separation and leaves a large scar.⁴ In contrast, bridge flaps are suitable for large horizontal defects, and the typical reconstruction method is the Cutler-Beard bridge flap technique.⁵ The edge of the lower eyelid is not incised; the flap requires whole-layered transfer from 5 mm below the eyelid edge and does not include the tarsus. Its advantage is that the separating range is small and the scar is minimal.

Furthermore, the Hughes procedure is a reconstructive procedure wherein a layered incision is made in the posterior lobe of the eyelid and the composite tissue of the eyelid tarsus and conjunctiva is used as a flap to replace the missing posterior eyelid lobe.⁶ This method is mainly used to replace the flap of the upper eyelid for malignant tumors arising in the lower eyelid and requires a second operation to cut the flap pedicles. A modified Hughes procedure for upper eyelid reconstruction using a horizontal orbicularis oculi myocutaneous flap for the anterior lobe has also been reported.⁷

The reconstruction of larger upper eyelid full-thickness defects exceeding 50% of the eyelid width can lead to ectropion formation once the flap is healed due to the natural contracture that occurs during wound healing. Ectropion formation is caused by a backward movement of the malar flap and the influence of gravity (in a case of Mustardé switch flap reconstruction) and a resection of the lower eyelid skin (in a case of Cutler-Beard bridge flap reconstruction). Technical considerations for both lower eyelid switch flaps and bridge flaps are necessary to avoid this late complication.

The modified Hughes procedure is superior to the conventional Cutler-Beard bridge flap and Mustardé switch flap techniques because it is much less invasive and less likely to cause ectropion; the incision made during the modified Hughes procedure is minimal and the skin of the lower eyelid is not removed.

The hybrid flap of the posterior lamellar reconstruction according to the modified Hughes procedure and the anterior lamellar reconstruction, which requires orbicularis oculi myocutaneous flap advancement by utilizing the cranial skin laxity, are chosen to avoid postoperative complications (Figures 3 and 4).

The larger the horizontal defect and the longer the distance of flap advancement the greater the tendency for upper eyelid deformity occurrence; however, the deformity can be minimized with the longitudinal myocutaneous advancement flap utilizing the cranial skin laxity.

It is important to divide the tarsus on the mucosal side to include only the bare minimum tarsus in the flap and leave a thicker part of the tarsus in the lower eyelid as much as possible to avoid inversion or ectropion and trichiasis due to loss of lower eyelid tissue including the tarsus (Figure 5). Entropion or ectropion of the lower eyelid and deformity of the upper eyelid can be prevented using this method. Eyelid opening and closing is satisfactory 5 months after surgery (Figure 6).

In patients with upper eyelid full-thickness defects exceeding 50% of the eyelid width and with sufficient skin laxity in the upper eyelid, the posterior lamella should preferably be reconstructed using a tarsoconjunctival flap and the anterior lamella using an myocutaneous advancement flap with the excess cranial skin.