INTRODUCTION
Reconstruction of eyelid defects focuses on two major targets: restoring the
anatomy and eyelid function. This can be a challenging task, especially in
larger defects, such as those occurring after oncologic procedures in young
people with minimal tissue laxity and elderly patients with scleroatrophic skin,
and in cases of trauma or burns with significant tissue loss.
Several reconstructive techniques have been developed and the surgical choice
usually depends on the affected portion of the eyelid and the extent of the
defect. Reconstructive procedures must maintain the function and integrity of
the periorbital structures while seeking adequate aesthetic repair. The
objectives of eyelid reconstruction should consider the following aspects:
Smooth and soft internal conjunctival mucosa - eye lubrication;
A stable eyelid margin with rigid support such as the tarsus in order
to ensure shape and stability;
Eyelid stiffness in the canthal ligaments;
Functionally active muscles that allow tonus;
Adequate eyelid occlusion to maintain eye protection;
Acceptable aesthetic result in terms of facial symmetry.
In this study, the authors presented the use of zygomatic-palpebral flap, a
technique initially described by Hermann Eduard Fritze in 1845, which despite
its antiquity has proven to be a safe and versatile option with good results for
lower eyelid reconstruction.
OBJECTIVE
This study aimed to present an optional technique for the reconstruction of
defects of the anterior lamella of the lower eyelid using the
zygomatic-palpebral skin flap. This technique is an excellent alternative in
cases of scleroatrophic skin in elderly patients, as well as in young people not
presenting upper eyelid skin redundancy, which prevents, for example, the use of
upper eyelid grafts or flaps such as that of Fricke or Tripier. Moreover, this
technique is also indicated for retraction due to burns, trauma or in
association with other techniques.
METHODS
The flap was indicated in cases of ectropion, reconstruction after resection of
neoplasms, and in association with other flaps, such as those of Hughes, in
order to cover cartilage grafts and retractions caused by burns. It consisted in
a transposition flap composed of skin and underlying subcutaneous tissues,
randomized. This technique is based on the use of local flaps with highly
similar characteristics to the defect area, allowing it to mimic functions while
being safe and feasible.
The procedure for creating the flap was the same in all cases. The limits of the
receiving area were evaluated (Figure 1A),
and based on the extent of the defect, the donor area was delimited in the
ipsilateral malar region. Then, the flap was marked in the zygomatic region
(Figure 1B) from the lateral corner of
the eyelid, descending perpendicularly to 90º in relation to the lower ciliary
margin. The skin flap was raised along with a sufficient thick layer of
subcutaneous tissue in order to fill the defect entirely (Figures 1C, 1D).
Subsequently, the transposition process took place, followed by closure of the
donor and receiving areas using deep subdermal stitches (4-0 polydioxanone) and
simple separated stiches (6-0 monofilament nylon) superficially (Figure 1E).
Figure 1 - Technique sequence of the zygomatic-palpebral flap procedure used
for correction of senile ectropion. A: Ectropion;
B: Flap design; C: Incision and
dissection; D: Flap transposition; E:
Immediate postoperative period; F: Second postoperative
day.
Figure 1 - Technique sequence of the zygomatic-palpebral flap procedure used
for correction of senile ectropion. A: Ectropion;
B: Flap design; C: Incision and
dissection; D: Flap transposition; E:
Immediate postoperative period; F: Second postoperative
day.
RESULTS
The zygomatic-palpebral flap for lower eyelid reconstruction allowed the
restoration of height and palpebral vertical length, preventing and correcting
ectropion. The immediate results (Figure 1F) and late results in terms of
aesthetics, scar quality and function were satisfactory and well accepted by
both patients and surgical team, with adequate eyelid occlusion and preserved
eye lubrication.
Lymphatic edema of the flap was the greatest complaint in operated cases, but it
resolved spontaneously within approximately 6 months. Infection, surgical
dehiscence, hematomas, and other complications were not recorded. Figures 2 and 3 present cases of reconstruction of the lower eyelid due to a skin
cancer in a young and in an elderly patient, respectively. Moreover, correction
of a scar ectropion in a burn victim is presented in Figure 4.
Figure 2 - Basal cell carcinoma of the lower eyelid. A: Marking
of the lesion; B: Defect greater than 50% of the
anterior lamella in a young patient without excess skin;
C: Immediate postoperative; D:
Sixmonth postoperative result.
Figure 2 - Basal cell carcinoma of the lower eyelid. A: Marking
of the lesion; B: Defect greater than 50% of the
anterior lamella in a young patient without excess skin;
C: Immediate postoperative; D:
Sixmonth postoperative result.
Figure 3 - Squamous cell carcinoma of the lower eyelid. A:
Marking of lesion and surgical margin of resection in total plane;
B: Reconstruction of posterior and middle lamella
with Hughes flap; C: Positioning of the
zygomatic-palpebral flap for reconstruction of the defect and
closure of the donor area; D: Sixmonth postoperative
result.
Figure 3 - Squamous cell carcinoma of the lower eyelid. A:
Marking of lesion and surgical margin of resection in total plane;
B: Reconstruction of posterior and middle lamella
with Hughes flap; C: Positioning of the
zygomatic-palpebral flap for reconstruction of the defect and
closure of the donor area; D: Sixmonth postoperative
result.
Figure 4 - Thermal burn seizure. A: Cicatricial ectropion;
B: Marking the flap and the extension of the
receiving area; C: Immediate postoperative;
D: Sixmonth postoperative result.
Figure 4 - Thermal burn seizure. A: Cicatricial ectropion;
B: Marking the flap and the extension of the
receiving area; C: Immediate postoperative;
D: Sixmonth postoperative result.
DISCUSSION
The eyelids cover and protect the eyes. Their function is to protect the eyes
against excessive light, trauma, or dryness. Moreover, they contain glands that
produce mucus, lubricants, and lipids that make up the tear film. Eyelids are
divided into three lamellae. The anterior lamella contains skin and muscle, the
middle lamella contains the orbital septum, and the posterior lamella contains
tarsus, tarsal plates, and the retractor muscles of the eyelid and conjunctiva.
The skin of the eyelids is extremely thin, and the skin of the upper eyelid is
thinner than that of the lower eyelid, since there is little subcutaneous fat at
the base of the eyelid skin.
Eyelid reconstruction techniques involve the restoration of all lamellae, with at
least one of these layers having to be well vascularized. Flaps are preferable
when compared to grafts due to the like-to-like phenomenon - similarity with the
adjacent skin in texture, color, thickness, and elasticity, besides having
intrinsic blood supply, maintenance of tactile sensation, the same surgical
field, and durability. However, for partial thickness defects, skin grafts may
be highly recommended. A satisfactory reconstruction of the lower eyelid should
allow juxtaposition of the eyelid to the eyeball in order to prevent the onset
of ectropion.
The eyelid reconstruction technique is chosen based on the thickness and extent
of the defect. Direct closure techniques can be used in defects of up to 30% in
young patients, and up to 45% in elderly patients. In borderline cases, a
lateral cantholysis may provide additional relaxation for wound closure.
Local and regional flaps are useful for reconstruction of the lamella. Flaps, as
described previously by Tenzel, Hughes, Mustardé, and Cutler, are well known
among plastic surgeons and are useful for reconstruction of large defects, as
well as cartilage grafts1-6. Tarsus with free margin associated with
myocutaneous flap can be used for reconstruction of the posterior lamella.
A literature review showed that the choice of the technique for lower eyelid
reconstruction varied according to the skin texture, scars adjacent to the
recipient area, patient’s age, probable aesthetic result, size of the defect,
and already used alternatives. The zygomatic-palpebral flap technique has some
advantages, including the ease of execution, minimal bleeding, low morbidity of
the donor area, and the ability to perform it under local anesthesia. Although
some authors questioned that the flap design did not consider any of the
aesthetic subunits of the face (this being the greatest reservation found in the
literature), the scars along the malar region are usually considered as
aesthetically acceptable by the patients and surgical teams.
CONCLUSION
Zygomatic-palpebral flap is an alternative technique that can be used in cases of
scleroatrophic skin in elderly patients and young patients without sufficient
tissue to reconstruct major defects.
COLLABORATIONS
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AGM
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Analysis and/or data interpretation, conception and design study,
data curation, project administration, writing - original draft
preparation, writing - review & editing.
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MPSN
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Analysis and/or data interpretation, data curation, project
administration.
|
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LRCCT
|
Data curation, writing - original draft preparation.
|
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MTRC
|
Data curation.
|
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CRRC
|
Data curation.
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VAP
|
Data curation.
|
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JPRP
|
Data curation.
|
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Rev Bras Cir Plast. 2012;27(2):243-8. DOI: http://dx.doi.org/10.1590/S1983-51752012000200013
1. Universidade Federal do Triângulo Mineiro,
Uberaba, MG, Brazil.
Corresponding author: Aluísio Gonçalves
Medeiros Rua José de Alencar, nº 904, apto 203 - Abadia, Uberaba, MG,
Brazil Zip Code 38025-120 E-mail: aluisiogm@hotmail.com
Article received: June 20, 2018.
Article accepted: November 11, 2018.
Conflicts of interest: none.
