Background
Upper eyelid full-thickness defects are caused by tumour excision, trauma or congenital colobomas. Small defects (less than 33% of eyelid margin involvement) can be repaired by direct closure with superior cantholysis if necessary [
1]. The most commonly used procedure for moderate defects (33–50% involvement) is the inverted semi-circular flap [
1], and the Cutler-Beard flap [
1‐
4] is used for large defects (over 50% involvement). The reconstruction of large upper eyelid full-thickness defects represents a challenge in ocular plastic surgery because of the complicated anatomy and function. Certain surgical procedures, including the Cutler-Beard flap and Mustarde lid switch [
1,
5], are available, but all these procedures have limitations. We have developed a new method that could provide a useful solution to this challenging problem for both large and moderate defects. Three cases are described to showcase this technique.
Discussion
The most commonly used technique to treat moderate upper eyelid defect is a lateral canthal tendon incision and semi-circular “Tenzel” flap [
1,
8]. Large full-thickness upper eyelid defects are a challenge in ocular plastic surgery. Certain surgical procedures are available for reconstructing large full-thickness upper eyelid defects, but all these procedures have limitations. The Cutler-Beard procedure is likely the most popular in use, although the reconstructed upper eyelid is not sufficiently stable due to a lack of tarsus [
1‐
4]. Moreover, the lanugo hairs present on the reconstructed upper eyelid may cause corneal irritation. The Mustarde lid switch procedure is not widely practised because of corneal irritation caused by the pedicle, among other reasons [
1,
5]. Other techniques are mainly tarsoconjunctival substitutes, including hard palate [
9], nasal septal chondromucosal [
10], and free tarsomarginal grafts [
11]. Hard palate and nasal septal chondromucosal grafts may be preferable as an option for lower eyelid rather than upper eyelid reconstruction because of corneal damage [
1]. The survival risk and eyelash absence associated with free tarsomarginal grafts are mentioned in some studies [
11].
The aim and novelty of our technique was the use of the lower eyelid tarsus, periosteal flap, and temporal skin-orbicularis flap to reconstruct an upper eyelid defect. We considered the lower eyelid and periorbital skin as an integral whole. We rotated them integrally to reconstruct the defect but treated each lamella differently and delicately. Consequently, we named this new procedure lamellar rotation surgery. We vertically incised the lower eyelid tarsus and disconnected the inferior retractor and conjunctiva, sparing the anterior orbicularis muscle and skin. As a result, the temporal part of the tarsus attained a high degree of flexibility and adequate nutrition from the intact orbicularis muscle and eyelid skin. The lateral periosteal flap was used not only to form a new lateral canthal tendon but also to reconstruct the posterior lamella to support the eyelid tissue.
The reconstructed upper eyelid should be more stable after lamellar rotation surgery than after the Cutler-Beard procedure because of the rotated tarsus. The pedicle of the Mustarde lid switch procedure may irritate the cornea because the intact tarsus of the lower eyelid maintains a degree of rigidity [
1,
5], whereas our procedure could avoid this limitation due to the disconnected, flexible tarsus. In addition, the junction of the rotated flap and lower eyelid will be elongated because it comprises orbicularis skin. The flexibility of the upper eyelid will also improve after the first-stage surgery.
For a total upper eyelid defect, our procedure can provide a new eyelid margin to prevent upper eyelid skin contact with the cornea. The smooth surface and glands of the tarsus can also benefit the cornea.
A decrease in the length of the horizontal palpebral fissure and two-stage surgery are the limitations of our procedure. This procedure may also result in amblyopia if applied to children.
Our study also has the following limitations: a small sample size, non-comparative design because of the rare incidence, and short follow-up because of long-distance travel and economy.
Although we have treated only three cases, we believe that our procedure can help to address the challenge of upper eyelid defects and should complement existing surgical methods. However, all three cases were elderly individuals with tumours, and we have no experience with trauma or congenital colobomas. Further studies with larger sample sizes are required to further validate the findings of this study and to modify the procedure, for example, if there is a need for the superior lateral periosteal flap.
Acknowledgments
The author is grateful to Yu Nie, M.S., Feng Zhou, M.S., Weiyan Liang, Ph.D., Yingying Lu, Ph.D., Haihua Tang, Ph.D., at Tianjin Aier Eye Hospital, Yi Li, Ph.D. at Beijing Aier Eye Hospital for their assistance in this study. The author also thanks the Library of Tianjin Eye Hospital.