Subtotal lower lid reconstruction from upper eyelid full thickness bridge flap with earlier 2(nd) stage surgery at 3 weeks.

Sir,

Eyelid reconstructions are required in variety of situations after trauma and tumour excisions. Small lid defects can be directly closed. Larger defects including reconstruction of complete eyelid requires complex procedures, involving transfer flaps from the unaffected eyelid or adjacent areas.

A 49-years-old female patient presented with the chief complaints of swelling in the left lower lid for two years. It started as small nodule in left lower eyelid and progressively increased in size. Left lower eyelid margin was thickened, [Figure 1] and eye lashes were sparse over the swelling. The swelling was 16 mm horizontally sparing the punctum medially but closer to the lateral canthus, and the vertical extent was 14 mm sparing the lower fornix. It appeared multi-lobulated from the conjunctival side and was yellowish in colour. Investigations revealed no local or distant metastasisand biopsy cofirmed sebaceous cell carcinoma of the lid.

Figure 1

The lower lid sebaceous gland carcinoma at presentation

After wide excision of the lesion a two stage lower lid reconstruction just opposite to the Cutler-Beard Flap procedure for upper lid reconstruction as devised by Betharia SM, Kumar S.[1] was planned. In the first stage, after excision of the lesion in a V shapewith a 3mm tumour free margin a 22 mm in the lower lid defect was formed [Figure 2]. The lower part of the V was sutured by approximating the two edges. The upper part, which was now the defect, was reconstructed with the rectangular flap from the upper lid [Figure 3]. This flap was sutured in two layers-posterior tarso-conjunctival and anterior musculo-cutaneous with the remaining free edges of the lower lid [Figure 4].

Figure 2

Triangular flap of lower lid excised along with tumour and apex closed as V-Y

Figure 3

The upper lid full thickness bridge flap raised and sutured with the gap

Figure 4

Lower lid defect closed and upper lid rim left as such at the end of stage I surgery

In the second stage after 3 weeks, the division of the flap covering the globe was done with concavity downwardsand lid margin was created by suturing the skin and conjunctiva over the divided tarsal plate edge [Figure 5]. The insertion of the levator was identified and sutured over the remaining upper lid tarsal plate while conjunctiva and skin was also sutured back.

Figure 5

Upper lid gap stitched in different layers ensuring LPS anchoring to tarsus

Sebaceous gland carcinoma is one of the most dangerous tumours of eyelids because it mimics chalazion and if curetted, it metastasizes fast. It can spread by direct, lymphatic and haematogenous routes. It is sometimes a part of the Muir Tore syndrome, a rare hereditary, autosomal dominant cancer syndrome with cancers of the colon, breast, and genitourinary tract, and skin lesions, such as keratoacanthomas and sebaceous tumors.

During surgical excision, the delineation of tumour margins are difficult because of unrecognized satellite lesions and multicentricity so, the local recurrence is encountered and follow up is essential. It can be misdiagnosed on histo-pathological examination if lipid stains are not used.

Compared to the upper lid, the lower lid is not as critical in maintaining the integrity of the cornea. Therefore, most of the techniques seldom utilize the upper lid component to reconstruct the lower lid as this may affect the upper lid function. The principle of total eyelid reconstruction is to have a movable lid that protects cornea, looks aesthetically good and have minimum donor site morbidity. In the Cutlet-Beard procedure,[2] a full-thickness cutaneo-conjunctival inferior eyelid advancement flap is made and is a reliable method for reconstruction of total or subtotal upper eyelid defects with ideal colour and tecture match. If one can avoid destabilization of the donor site or retraction of the recipient site, the inverse construction is equally successful and less complicated.

The classical reconstruction of the total lower eyelid is done by two-stage tarso-conjunctival flap with full thickness skin graft (Hughes's flap).[3] The first stage is the creation of a tarsoconjunctival flap and after suturing the flap to the defect, the area is covered with a temporal skin flap; the 2nd stage is carried out after 6-9 weeks, where the palpebral fissure is opened by dividing the flap creating a conjunctiva lined lid margin. The other option is Mustarde[4] cheek advancement flap with chondro-mucosal graft (obtained from the nasal septum). The cheek rotation flap[5] for the reconstruction of the lower lid leavesa scar on the face.

The partial use of the upper eyelid flap (tarso-conjunctival) is the standard approach for the reconstruction of the lower lid with most acceptable results. If the whole thickness of upper eyelid is used as flap,[1] it makes the technique easier, safer and faster. The function of the levator palpebrae superioris is not affected [Figure 6]. While in classical technique, the 2nd stage is carried out at 6-9 weeks;[2] we have done it at 3 weeks as the eyelid flap is very well vascularised and heals well. Thus morbidity of prolong eye closure was avoided.

Figure 6

Normal post-operatively look and lid function after 3 months

The incision is placed at the lid fold sparing 5 mm of tarsal plate for upper lid stability and the scar lie in the natural lid groove for better cosmetic look. The width of the upper lid bridge flap should be sufficient to prevent the damage to the marginal vessel arcade. The line of incision should be with a slight concavity downwards. The levator muscle should be carefully identified and sutured back in the second stage so as to keep the upper lid functioning. Lid notching, entropion and ectropion should be avoided while attaching the levator on the tarsal plate. The merits of the procedure are; early rehabilitation, no lagophthalmos, lid position matches with the opposite eye in all gazes [Video 1].