Surgical reconstruction of medial eyelid defects using margin transposition, tarsal graft, and periosteal strip

ABSTRACT

Purpose

Surgical reconstruction of medially located lower eyelid defects can be challenging. The Hughes procedure, considered the standard for reconstruction in such cases, often falls short in terms of cosmetic outcomes. An alternative approach that combines medial transposition with a tarsal graft and periosteal strip has shown promise. Here, we aim to demonstrate the cosmetic advantages of medial transposition of a preserved temporal lower eyelid over other techniques.

Method

We conducted a retrospective study involving seven well-documented patients who underwent the procedure described below. The study was approved by the University’s Ethics Committee.

Results

All patients were followed up for one year. Lower eyelid defects spanned 50–80% of their total length, situated in the central third of the eyelid or the central to medial portion. Postoperative complications were minimal, with all patients exhibiting good cosmetic, functional, and anatomical outcomes at follow-up.

Conclusion

The absence of eyelashes is well tolerated if it is lateral, but when the defect is medial, medial transposition could be a good alternative to the familiar Hughes surgical intervention.

KEYWORDS:

• Oculoplastic surgery
• eyelid tumors
• basal cell carcinoma
• medial transposition

Introduction

The reconstruction of centrally located lower eyelid defects can be challenging, particularly if the cosmetic outcome is as important as the functional one. The Hughes procedure is the standard reconstruction approach for such cases.^1,2 However, one disadvantage of this method is its necessity for a two-stage process, along with the variability in the appearance of the modified eyelid margin, which affects the central part of the eyelid. This two-stage approach can lead to cosmetic and functional defects, resulting in a red, irregular, and uncomfortable eyelid margin.

Medial transposition, combined with a tarsal graft and a periosteal strip, has not been widely reported in the literature and represents a relatively novel method in oculoplastic surgery, particularly in eyelid tumor surgeries. A similar technique has been suggested by other authors, which we evaluated for comparison.

Aim

To highlight the advantages of medial transposition of a preserved temporal portion of the lower eyelid in terms of cosmetic outcomes compared to other techniques.

Materials and methods

This retrospective study includes seven well-documented patients who underwent the procedure described below. All demographic data were removed, as the purpose of this paper is to evaluate cosmetic outcomes. Lower eyelid defects spanned between 50 and 80% of the entire eyelid and were located in the middle third or the middle to medial part of the eyelid. The surgeries were performed from 2021 to 2022 at the Eye Clinic – Pleven.

Surgical technique

Surgeries were performed under local anesthesia using Lidocaine with or without Bupivacaine.

We adhered to the generally accepted guidelines for resection, ensuring a planned tumor-free margin of 3–5 mm.

After tumor excision, a full-thickness medial defect was created, with a healthy eyelid located temporally adjacent to it (Figure 1).

Figure 1. Medial surgical defect 70%.

Initially, the healthy temporal portion of the lower eyelid, along with its adjacent structures (eyelid margin, skin, and muscles), were detached from the lateral canthal tendon. This detachment was achieved by making a full-thickness vertical temporal incision up to the level of the excisional defect but not beyond the orbital rim. It is also possible for the vertical incision to involve only the posterior lamella (if the anterior lamella has sufficient laxity to be transposed medially).

The anterior lamella of the healthy half of the lower eyelid was partially released. The skin and orbicularis oculi muscle were cut parallel to the lash line up to the level of the excisional defect, ensuring not to cut less than 5 mm from it to preserve the eyelash follicles and tarsus. The posterior lamella remained intact.

The anterior lamella was then dissected between the orbicularis oculi muscle and the orbital septum up to the level of the inferior orbital rim. Thus, we obtained a freely movable portion of the eyelid with an intact lid margin, on which the anterior lamella was interrupted at the level of the excision defect, and the posterior lamella remained attached to deeper tissues (Figure 2). We differentiated the parts as follows: a fixed portion of the anterior lamella horizontally aligned with the excisional defect; a free portion comprising the entire posterior lamella, dissected up to the level of the orbital rim; and a segment of the anterior lamella that included the eyelid margin along with the eyelashes and healthy tarsus.

Figure 2. Medial transposition of an intact temporal part of the eyelid.

Transposition and suturing of this movable portion to the medial canthal tendon (if the latter was intact) or to the periosteum in the medial canthal area were then performed. This process created a new medial eyelid zone and temporal eyelid defect.

A strip of periosteum was peeled off temporally from the orbital rim, with its tip elevated above the level, while its base remained at the level of the lateral canthus. This arrangement allowed for the temporal eyelid angle to be lifted and pulled outward when sutured. A periosteal strip was used to replace the inferior temporal canthal ligament, adding a few millimeters to the entire length of the eyelid. The newly created temporal eyelid defects were repaired in a layer-by-layer fashion. The posterior lamella was reconstructed using a tarsal graft from the upper eyelid tarsus, and the anterior lamella was repaired with a local skin flap or free skin graft. The tarsal graft was fixed medially to the tarsus of the transposed eyelid and temporally to the strip of detached periosteum (Figure 3).

Figure 3. Taking a donor tarsus from an upper eyelid and suturing it to the healthy tarsus medially and to the periosteal band temporally.

The wound was sutured at two levels: the posterior lamella was reconstructed using Vicryl 4/0 or 6/0, and for the anterior lamella, a silk 6/0 was used.

The final stage of the operation involved the placement of mattress sutures through the entire thickness of the eyelid. In our cases, 2–3 mattress sutures were found to be adequate.

In the early postoperative period, the cosmetic results of combined plastic surgery can appear poor, which may concern less experienced surgeons. However, in the late postoperative period, as the swelling subsides – the wound heals, with significant improvement observed (Figure 4).

Figure 4. А- First day post-surgery, B- Three months post-surgery.

Results

We report the results of seven patients who underwent surgery over the course of one year, using the abovementioned technique. The surgeries were conducted under a microscope, which, in our opinion, contributed to good histological control of the wound edges. The lower eyelid defects ranged from 50% to 80% of the total length and were located in the middle third or the middle-to-medial part of the eyelid. Histology confirmed basal cell carcinoma (BCC) in all patients. Surgery was performed in two stages: excision and reconstruction, with reconstruction being performed after histological verification of clear wound margins.

All patients were followed up for one year. Postoperative complications were minimal. In one patient, a release of the mattress sutures was observed, but did not lead to any complications. Another patient exhibited mild ectropion, which resolved within the first postoperative month. In two patients, a pigmented scar was noted but faded by the sixth month. All patients experienced tearing and irritation during the first 2–3 weeks after surgery. Follow-up examinations revealed good cosmetic, functional, and anatomical outcomes in all patients.

Discussion

Eyelid tumors, whether benign or malignant, require surgical removal. The selection of the surgical technique considers the size and location of the tumor and the involvement of adjacent tissues. Clinical indicators of malignancy and the presence of an inflammatory reaction around the tumor are reasons for a wider excision. Recurrence or a surgical scar from previous surgery also influence the choice of operative technique.^3–5

In our study, we applied the abovementioned technique in patients with tumors involving 2/3 of the central or nasal part of the lower eyelid, including the eyelid margin. For such defects, there are several options for reconstruction, including a free skin flap in combination with a tarsal or cartilage graft⁶ or the Hughes procedure, among others.^1,2,7,8 The disadvantage of these methods is the resulting lack of a proper lash line, especially of eyelashes, leading to a cosmetically unsatisfactory outcome, even if the functional and anatomical results are favorable. In medial transposition, the absence of eyelashes is shifted temporally. From a cosmetic point of view, the absence of eyelashes and an irregular lash line are more tolerated if they are temporal.

Perry and Allen used a similar technique with very good results.⁹ In our approach, we transposed an entire eyelid margin, where the anterior lamella was incised along the bottom of the surgical defect resulting from the previous excision. The posterior lamella was bent but still attached to its original location, and the lateral canthal ligament was detached. With this approach, we obtained a smooth horizontal incision in the anterior lamella at the level of the excision defect, which healed with minimal scarring. Moreover, detaching the lateral inferior ligament makes the lower eyelid mobile, providing an additional length of several millimeters for medial transposition of its free part, which was necessary in all our cases. The posterior lamella remained intact. The authors cited above reported leaving the lateral lid margin intact and transposing only the posterior lamella, with the anterior lamella being dissected, which does not change its location. This technique also yields good results and should be highly valued. However, in cases where additional length is needed, we prefer our technique.

A crucial factor for the survival of the graft and the transposed eyelid is the placement of mattress sutures, with/without a bolster. These sutures press the transposed structures against each other, aiding the establishment of blood supply.

We did not suture the donor tarsal bed of the upper eyelid. However, in the presence of an irregular scar that changes the function of the upper eyelid, we filled the defect with an amniotic membrane or oral mucosa. Taking the donor tarsus too high and allowing conjunctival growth can lead to mild to moderate ptosis. In most cases, dissection of the conjunctiva up to the superior fornix eliminates the ptosis.

In some cases, dissecting a periosteum strip is not feasible due to previous surgeries or damage to the temporal area, among other reasons. In such cases, harvesting a donor tarsus can be done using the method described by Eva Hewes.¹⁰ Conversely, for smaller defects, dissection of only a periosteal band without a tarsal graft may suffice. However, the fact that a periosteal band alone is sufficient for reconstruction raises doubts about the need for medial transposition. In these cases, direct closure is likely possible and the best option.

During healing, every surgical wound goes through the phases of reparative inflammation. The final stage is associated with the formation of mature connective tissue, which can contract. Contraction of the wound defect leads to the formation of irregular scars by pulling the surrounding tissues and altering the normal position of the eyelid. Regardless of how successful a surgery is, the healing process varies among individuals, and in some cases, it may lead to the formation of a keloid scar.

Positional anomalies are major complications following eyelid tumor surgery. Ectropion, entropion, and trichiasis are commonly observed. Mild positional abnormalities may occur alongside good functional outcomes. In these cases, additional surgical interventions can be avoided. When there is a good anatomical and functional outcome but an unsatisfactory cosmetic result (pigmentation, cicatrix), an additional cosmetic procedure can be considered after the sixth month mark, when the recovery period of the wound is over. This timeframe also varies from patient to patient due to individual wound healing patterns.

Conclusion

Medial transposition can be an excellent alternative to the well-known Hughes surgical procedure. The method yields very good cosmetic and functional outcomes. However, it significantly extends the operative time and requires a well-trained surgical team. Generally, the absence of eyelashes is well tolerated when it occurs laterally but compromises cosmetic appearance when it is medial. Therefore, the technique involving medial transposition of the lateral healthy part of the eyelid also offers advantages, achieving good surgical and cosmetic results.

Author contributions

All authors contributed equally to the study, including patient follow-up, conception and study design, data analysis, writing, revision, and final article preparation. There are no other parties to acknowledge.

Statement of ethics

The study was conducted in accordance with the principles of human experimentation as defined in the Declaration of Helsinki, local Good Clinical Practice guidelines, and the institutional guidelines of the Medical University of Pleven (Ethics Committee approval No. 716-KENID/January 12 2023).

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Data availability statement

Data are available upon request due to privacy or other restrictions.

Additional information

Funding

This study is financed by the European Union-NextGenerationEU, through the National Recovery and Resilience Plan of the Republic of Bulgaria, project № BG-RRP-2.004-0003-C01.