Scandinavian Journal of Plastic and Reconstructive

Surgery and Hand Surgery

ISSN: 0284-4311 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/iphs19

Combination of periocular myocutaneous flaps for

one-stage reconstruction of extensive defects of
the eyelid

Kostas G. Boboridis, Stavros A. Dimitrakos, Nick S. Georgiadis & Nick T.

Stangos

To cite this article: Kostas G. Boboridis, Stavros A. Dimitrakos, Nick S. Georgiadis & Nick T.
Stangos (2005) Combination of periocular myocutaneous flaps for one-stage reconstruction of
extensive defects of the eyelid, Scandinavian Journal of Plastic and Reconstructive Surgery and
Hand Surgery, 39:2, 100-103

To link to this article: http://dx.doi.org/10.1080/02844310410017960

Published online: 08 Jul 2009.

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 Scand J Plast Reconstr Surg Hand Surg, 2005; 39: 100
/103

CASE REPORT

Combination of periocular myocutaneous flaps for one-stage

reconstruction of extensive defects of the eyelid

KOSTAS G. BOBORIDIS, STAVROS A. DIMITRAKOS, NICK S. GEORGIADIS &

NICK T. STANGOS

Ophthalmology Department, Aristotle University of Thessaloniki, Greece

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Abstract
We present the reconstructive challenge after excision of a large periocular tumour in a patient who needed early visual
rehabilitation. The periocular full thickness deficit of his only sighted eye was reconstructed with a combination of
periocular myocutaneous flaps and a free buccal mucosal graft. Adequate functional and cosmetic results with early visual
rehabilitation were achieved in a single procedure.

Key Words: Eyelid defect, periocular flap, reconstruction, tumour excision, basal cell carcinoma, SOOF lift

Introduction previous attempts for excision were unsuccessful and

Numerous two-stage lid-sharing procedures have
been described for the repair of the anterior and
posterior lamella, during reconstruction of full
thickness eyelid defects, after excision of tumours
[1,2]. Hughes and Hewes tarsoconjunctival flap for
the lower lid, the Cutler-Beard lower lid bridge
flap for the upper lid, and the Mustarde lower
or upper lid rotation flap are the cross lid
flaps most often used with visual obscuration for
two to three weeks before postoperative division
[3,4]. Reconstruction of the deficit may be challen-
ging in patients in whom the need for early visual
rehabilitation dictates the avoidance of lid-sharing
techniques and implementation of other one-stage
procedures.
We present our experience of a case of an extensive
full thickness deficit involving both eyelids and
the lateral canthus of the only sighted left eye
after excision of an extensive basal cell carcinoma
(BCC) [5].
Case report
A 76-year-old man presented with a five-year history
of a gradually enlarging left periocular tumour. Two
resulted in extensive scarring and irregular aggressive
spread of the tumour in the periocular tissues. His
visual acuity was negligible in the right eye because
of uncontrolled refractory glaucoma, and 8/10 in the
involved left eye. His medical history included severe
renal failure and uncontrolled hypertension after a
left nephrectomy two years earlier. He was living
alone with no family or social support, so he required
early visual rehabilitation.
Description of the tumour
A nodular BCC confirmed histologically was erod-
ing the whole lower lid, and extended 23 mm
vertically from the edge of the lid. It had spread 18
mm to the skin of the lateral canthal angle and
deeper over the inferotemporal bulbar conjunctiva
where it formed a wide symblepharon band to the
adjacent limbus and possibly also the insertion of
the lateral rectus muscle. The lateral half of the
anterior lamella and margin of the upper lid were
also involved, where it extended 14 mm vertically
(Figure 1a ). Clinical examination and magnetic
resonance (MR) scans showed no deep orbital
extension, globe or bony erosion and there were no

Correspondence: Kostas Boboridis, MD, PhD, Pavlou Mela 16, GR 546 22 Thessaloniki, Greece. Tel: /30 2310 260066. Fax: /30 2310 252966. E-mail:
kosbob@otenet.gr

(Accepted 12 March 2004)

ISSN 0284-4311 print/ISSN 1651-2073 online # 2005 Taylor & Francis
DOI: 10.1080/02844310410017960

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palpable regional lymph nodes. Functionally he had
cicatricial lower lid ectropion with inadequate clo-
sure of the lid, lagophthalmos with exposure kerato-
pathy, and epiphora. Movements of the eye were also
impaired with cicatricial restriction in adduction and
elevation.
Excision
The lesion was excised under general anaesthesia
with a 3 mm safety margin of healthy skin beyond
the clinically detectable edge of the tumour. The full
thickness deficit of the lower eyelid including 2 mm
of the horizontal canaliculus and lacrimal punctum
extended 26 mm vertically from the margin of the
lid. The involved skin and conjunctiva of the lateral
canthal angle were excised down to bare sclera and
periosteum. Full-thickness resection of the lateral
half of the upper lid 17 mm from the lid margin was
also required. The inferotemporal quadrant of the
bulbar conjunctiva and limbal area were excised and
care was taken to free the insertion of the lateral
Reconstruction of defects of the eyelid 101
Figure 1. (a ) Nodular BCC infiltrating the lower lid,
lateral canthal area, lateral half of the upper lid, and
inferotemporal bulbar conjunctiva. Black stars indicate
the medial margins; white arrows indicate the superior,
inferior, and lateral margins of the planned excision.
(b ) Extend of the defective tissue in the eyelid after
excision of the tumour. White arrows indicate the
remnants of the upper and lower eyelid. Black arrow
shows the exposed insertion of the lateral rectus muscle
and black stars mark the exposed inferior orbital rim.
(c ) Satisfactory reconstruction of the lid with local flaps
sutured in place, before the placement of sutures to
deepen the fornix. Straight arrows show the sliding
direction of the advancement skin flaps. Curved arrow
indicates the rotation of the suprabrow skin flap for
reconstruction of the lower lid.
rectus muscle from suspected adhesions to the
tumour (Figure 1b ). The excised lesion together
with specimens from deeper tissues and orbital fat
were sent for frozen section examination to exclude
deeper extension or skip lesions and confirm com-
plete removal of the tumour.
Reconstruction of the lid
The requirement for fast recovery and early visual
rehabilitation made any two stage lid-sharing proce-
dure inappropriate. A free graft of buccal mucosa
was harvested for reconstruction of the bulbar
conjunctiva and posterior lamella of the lower lid
and lateral canthal area. A laterally sliding tarsocon-
junctival Hewes flap from the remaining half of the
upper lid was mobilised to reconstruct the posterior
lamella of the defect in the upper lid. The defect in
the lower lid was vertically reduced by raising the
cheek and midface soft tissues with a supraperiosteal
sub-orbicularis oculi fat (SOOF) lift secured to the
periosteum of the inferior orbital rim with inter-
 102 K. G. Boboridis et al.

rupted 5/0 polypropylene sutures. A lateral supra-

brow pedicled myocutaneous flap 20 mm wide was
rotated downwards and its base advanced medially
with a simplified McGregor sliding flap of the
temporal skin for the reconstruction of the lower
lid and lateral canthal anterior lamella. This was
secured to the medial canthus and periosteum of the
anterior lacrimal crest with a 5/0 polypropylene
suture and to the medial stump of the lid with 6/0
polyglactin 910 sutures. A vertical sliding myocuta-
neous flap was mobilised for covering the deficit in
the upper lid anterior lamella and was secured to the
underlying tarsoconjunctiva and surrounding skin
with 6/0 polyglactin 910 sutures. The remaining of
the levator aponeurosis was sutured to the skin flap
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at the desired height of the newly-formed skin crease

(Figure 1c ). Fornix-deepening sutures (4/0 polypro-
pylene) placed from the posterior lamella, engaged
the arcus marginalis and were tied over bolsters on
the skin at the end of the procedure. These were
removed after the second week whereas all skin
sutures were removed after one week. The cut
canaliculus was opened and marsipulised with 8/0
polyglactin 910 sutures on the mucosal graft, to form
the posterior lamella [6]. The lateral canthal angle
was left relatively exposed for postoperative mon-
itoring of possible deeper recurrence of the tumour.
A lateral tarsorrhaphy was reserved for later repair of
this area after recurrence had been excluded. A
pressure eye dressing and ice packs to minimise
tissue swelling were applied for 24 hours. Next day
visual rehabilitation of the only sighted eye was
possible and the patient was followed up as an
outpatient. The recovery period was unremarkable
and there was no evidence of recurrence 18 months
postoperatively. The position and function of the
lid were restored with no symptomatic ectropion
and no lagophthalmos (Figure 2). The marsipulised
lower canaliculus remained patent with adequate
drainage of tears, no symptoms of epiphora,
patent on syringing and disappearance of fluorescein
in less than a minute. The patient rejected the option
of tarsorrhaphy for further repair of the lateral
canthus.
Discussion
Reconstruction of an extensive defect in the eyelid of
the only sighted eye was possible with the mobilisa-
tion of adjacent tissues in the form of sliding or
rotational flaps so that the visual axis remained
unobstructed. Complete excision of the tumour
and reconstruction were achieved with minimal
manipulation of tissue in a relatively short time (90
minutes) with the combination of several small
localised flaps in a single-stage procedure. Estab-
Figure 2. (a ) Position of the lid 18 months postoperatively. Two
mm of inferior sclera show with a well-formed margin to the lid
and no epiphora. (b ) ‘‘Fleshy’’ appearance of buccal mucosa over
the inferotemporal conjunctiva, relatively exposed lateral angle,
and scars hardly visible on the temporal and suprabrow skin area.
lished procedures with greater local morbidity and a
prolonged recovery period such as the Mustarde
cheek rotational flap or midforehead rotational flap
were avoided [7]. Any lid sharing procedures that
obstructed the visual axis and required a secondary
operation were also deemed unsuitable. This opera-
tion with its short recovery period and early rehabi-
litation was well tolerated by the patient with
satisfactory functional and cosmetic outcomes.
Mobilisation of local flaps may be considered
effective options to the established lidsharing recon-
structive procedures for extensive periocular defects,
particularly when early visual rehabilitation is the
objective [8].
References
[1] Mustarde JC. Two-stage reconstruction of the upper lid.
Trans Ophthalmol Soc U K 1966;86:197.
[2] Spinelli HM, Jelks GW. Periocular reconstruction: a systema-
tic approach. Plast Reconstr Surg 1993;91:1017
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[3] Hewes EH, Sullivan JH, Beard C. Lower eyelid reconstruction
by tarsal transposition. Am J Ophthalmol 1976;81:512
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[4] Hughes WL. Total lower lid reconstruction: technical details.
Trans Am Ophthalmol Soc 1977;74:321
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[5] Tenzel RR. Lower lid and lateral canthal reconstruction.
Trans New Orleans Acad Ophthalmol 1982;30:308
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[6] McCord CD. Canalicular resection and reconstruction by
canaliculostomy. Ophthalmic Surg 1980;11:440
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Reconstruction of defects of the eyelid 103
[7] Heywood AJ, Quaba AA. A cheek island flap for the lower
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/6.
[8] Anderson RL, Edwards JJ. Reconstruction by myocutaneous
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