Triple-Flaps for lateral canthus reconstruction: A novel technique.

A 45 year old female presented with a pigmented lesion in the right periocular region. The mass was present on the lateral 1/3 of the lower eyelid and involving the lateral 1/8 of the upper eyelid. Full thickness excision with wide tumor-free margins was done and the residual defect was repaired. Histopathological examination confirmed the diagnosis of nodulo-ulcerative basal cell carcinoma. In this report, we describe a novel technique for reconstruction of large lateral canthus defect by using three local flaps. With triple-flaps technique extensive defects involving the lateral canthus can be repaired without difficulty with a good functional and aesthetic outcome.

Introduction

Most of the periocular basal cell carcinomas (BCC) arise on the lower eyelid (35.2%), medial canthus (48.5%), upper eyelid (10.7%) and least often near the lateral canthus (5.6%).[1] These tumors mandate complete excision with wide margins to prevent recurrence. Such procedures often result in large periocular defects which require extensive reconstruction to restore the anatomy and function of the eyelids. While the principles of eyelid reconstruction are well-established, achieving good functional and aesthetic reconstruction remains challenging. Till now, various techniques of lateral canthus reconstruction have been described in the literature.[2-4] In this case report we shall describe a novel technique of lateral canthus and eyelids reconstruction by using triple –flaps.

Case Report

A 45-year-old female patient presented with pigmented lesion of the right periocular region which was gradually progressive in size and painless since 2 years. On external examination there was a brownish-black colored nodular mass involving the lateral 1/8 of upper eyelid, lateral 1/ 3 of the lower eyelid and the lateral canthus [Figure 1]. The rest of the anterior and posterior segment examination was normal. The ocular movements were full and free. A clinical diagnosis of basal cell carcinoma of the right eyelid was made. Complete excision of the tumor with 4mm of clear margin involving full thickness of the eyelids and lateral canthus tendon was done leaving behind deeper fibers of the pre-septal orbicularis oculi muscle. Following excision biopsy, the residual defect involved the lateral ¼ of upper eyelid, lateral ½ of the lower eyelid and the lateral canthus [Figure 2]. The defect was repaired by a novel triple-flap technique in which the lateral ¼ of the posterior lamellar defect of the lower eyelid was covered by periosteal flap (first flap) raised from the lateral orbital rim [Figure 3a]. The residual central ¼ was covered by a tarsoconjunctival flap (second flap) from the upper eyelid [Figure 3b]. The lateral end of the tarsus of the upper eyelid was sutured to the base of the periosteal flap at the level of lateral canthal angle. The residual anterior lamellar defect of the upper eyelid and the lower eyelid was covered by a temporal advancement flap (third flap) after dividing into two parts [Figure 3c]. The central ¼ defect of the anterior lamella of the lower eyelid was covered by skin graft taken from the pre-auricular region [Figure 3d]. Histopathological examination confirmed the diagnosis of nodulo-ulcerative type of basal cell carcinoma and all the resected margins were free from the tumor. The post-operative period was uneventful. The patient was doing well at three month follow up visit, with no recurrence of the tumor [Figure 4].

Figure 1

The brownish-black colored nodular mass involving the lateral ⅛ of upper eyelid, lateral ⅓ of the lower eyelid and the lateral canthus.

Figure 2

The residual defect was involving the lateral ¼ of upper eyelid, lateral ½ of the lower eyelid and the lateral canthus.

Figure 3

(a-d) Showing the periosteal flap (first flap) raised from the lateral orbital rim to cover the lateral ¼ of lower eyelid (a). The tarsoconjunctival flap (second flap) is taken from the upper eyelid (b). The temporal advancement flap (third flap) was divided into two parts to cover the upper and lower eyelid (c). The central ¼ defect of the anterior lamella of the lower eyelid was covered by skin graft (d)

Figure 4

Good cosmetic outcome following triple-flap technique with no recurrence at 3 months follow up period.

Discussion

Basal cell carcinoma (BCC) of the eyelid is the commonest cutaneous malignancy of periocular region, accounting for 80-90% of cases. Most periocular BCCs arise on the lower eyelid and medial canthus, and least often near the lateral canthus.[5] Complete resection of these tumor generally results in large defects, the repair of which is challenging. Several techniques of eyelid reconstruction have been described in literature.[346] Spinelli et al. were the first to recommend a systematic approach based on aesthetic subunits; they have divided the periocular region into 5 zones (I, II, III, IV and V). The upper lid (zone I) and lower lid (zone II), combined with the medial canthus (zone III) and lateral canthus (zone IV), encompass the periorbital area proper. Zone V represents contiguous cheek, nasal and brow tissues.[7] Under this categorization, our defect consisted of zones I, II and IV. The reconstruction of lateral canthus has been described by using distal periosteal tissue flap elevated from the orbital rim which was then mobilized into the orbital cavity to act as an anchoring point at the lateral canthus. Such periosteal flaps can be several millimeters in length, allowing them to form part of the reconstructed posterior lamella, thus reducing the size of the posterior lamella graft required.[2] In our case similar lateral periosteal flap was used to reconstruct the posterior lamella of the lower eyelid which was further combined with the tarso-conjunctival and temporal advancement flaps. Therefore, we called it a triple-flap technique. Previously, the use of triple-flaps has been described for the reconstruction of the medial canthus defects.[89] To the best of our knowledge, there is no existing literature on reconstruction of lateral canthus by triple flap technique.

In our technique, the combination of multiple mono-pedicle flaps is advantageous in providing good and faster healing, easy mobilization during surgery, easy availability of tissues and excellent cosmesis in terms of skin color and texture. The only disadvantages of this technique are staged procedure, temporary deformity before flap division and absence of eyelashes in the lateral ½ of the lower eyelid. However, the latter can be camouflaged very easily by cosmetics.

We suggest that the triple-flap technique of multiple local mono-pedicle flaps is a very good method for reconstructing lateral canthus defects, as it maintains the natural contour of the lateral canthus angle and has a good cosmetic outcome.