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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.
Reconstruction of full-thickness eyelid defects has to provide a mobile lid with corneal protection, good aesthetic quality, and acceptable donor site morbidity.
For this purpose, skin, support and conjunctiva must be reconstructed. We describe the use of the Hughes procedure
(tarsoconjunctival flap) in conjunction with a subcutaneous based nasolabial transposition flap. To our knowledge, the use of the subcutaneous based nasolabial flap in this context has not been described previously.
1. Case report
A 54-year-old male was booked for surgery after treatment by an ophthalmologist and a dermatologist. There was 18 months history of a diagnostically proven squamous cell carcinoma of the lower left eyelid. The recurrent carcinoma was infiltrating the tarsal plate but there were no signs of deep infiltration into the orbital cavity. The reconstructive procedure included a mucosal lining with the tarsoconjunctival flap (Hughes procedure), while the 38×30 mm2 skin defect was reconstructed using a subcutaneously based nasolabial flap. Frozen specimens sampling was obtained, to verify a microscopically complete resection. Three weeks later, the tarsoconjuntival flap was subsequently separated; care was taken to cover the lid margin with excess conjunctiva, in order to avoid hair growth towards the cornea (Fig. 1, Fig. 2, Fig. 3) . Three months postoperative clinical assessment revealed neither ectropion nor entropion (see Fig. 4(a) and (b)) .
Fig. 1The defect seen after frozen specimens sampling and excision including a subtotal resection of the lower eyelid, preserving the lacrimal duct medially. The skin defects measured 38 mm in wide and 30 mm in high.
Fig. 3(A) The nasolabial flap has been dissected, on a subcutaneously pedicled. (B) The nasolabial flap has been transposed 90 degrees anticlockwise, and prepared for inset.
Fig. 4(A) One-month postoperative result: note the symmetry, and the redness of the conjunctival flap. (B) Lateral view: no excessive bulkiness of the nasolabial flap.
Reconstruction of the eyelid with mucosal lining, support and cutaneous cover to achieve normal appearance and function, are still a challenge to the surgeon. Siegel
described the use of a nasolabial flap to cover a shallow lower eyelid defect combined with a palatal mucosal graft. The flap pedicle includes the angular artery. In our reconstruction, the blood supply is derived from the infraorbital artery (IOA) and the anastomoses between the lateral nasal artery and branches of IOA.
Although the flap has a random pattern of blood, it acts as an axial flap (perforator from the IOA), due to the extensive vascularisation of the face. In our case, the defect was extensive, including the orbicularis muscle together with a 38 mm wide and 30 mm high skin defect.
Conventional techniques for the reconstruction of extensive lower eyelid defects include the use of nasal septal cartilage,
By contrast, when compared with other mucosal grafts, e.g. the nasal septum, the hard palate mucosa is claimed to sustain the characteristics of conjunctiva and tarsus with lining and support.
described the tarsoconjunctival flap in 1937, which included a dissection and split of the tarsus and advancement from the upper eyelid. Maloof A et al.
reported the procedure used for extensive defects, anchoring the tarsoconjunctival flap to oblique medial and lateral periosteal flaps in the demand for stability, calling this the ‘The Maximal Hughes procedure’.
The tarsoconjunctival flap is equally useful for subtotal or total defects involving the medial or lateral canthal tendons.
The cheek rotation flap offers an alternative surgical approach for cutaneous cover, but a high complication rate has been reported with ectropion, entropion, and epiphora due to the cicatricial healing
or accidental damage to the forehead branch of the facial nerve. The Hughes procedure tends to mechanically counteract the downward pull, seen with the cheek, or local transposition flap, as is seen with the surgical procedure used here, with a subcutaneous based nasolabial transposition flap.
The advantages with the use of nasolabial flaps are the inconspicuous donor scar concealed in the nasolabial fold, and the reliable vascularity of the flap. In contrast to the cheek rotation flap, particularly in the male patient, the medial displacement of the hair-baring area is avoided by the use of nasolabial flaps.
When the surgical defect is extensive after lower eyelid trauma, carcinoma, cicatricial secondary healing, congenital defects or sequelae, the nasolabial flap may be considered for eyelid reconstruction.
References
Hughes W.L
A new method for rebuilding a lower eyelid. Report of a case.
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