INTRODUCTION
Detailed knowledge of the eyelids and ocular region anatomy (Figure 1) helps the surgeon select the best surgical
technique capable of restoring eye function and perfecting the aesthetic result.
The eyelid is divided into an anterior and posterior lamella. The anterior
lamella is composed of skin and orbicularis muscle. The posterior lamella is
composed of the conjunctiva, tarsus, and eyelid retractor muscles. The orbital
septum can be considered a median lamella and is not usually reconstructed. The
ocular conjunctiva on the surface of the globe is continuous with the
conjunctiva that lines the eyelids’ inner surface; this relationship needs to
be
maintained or restored during reconstruction to preserve eyelid function1,2.
Figure 1 - Palpebral anatomy. Division of the eyelid structures into
anterior, middle and posterior lamellae (Source: Atlas of Aesthetic
Eyelid and Periocular Surgery, 20043).
Figure 1 - Palpebral anatomy. Division of the eyelid structures into
anterior, middle and posterior lamellae (Source: Atlas of Aesthetic
Eyelid and Periocular Surgery, 20043).
The periorbital zones can be didactically divided, as shown in Figure 2, and are numbered from I to V.
Figure 2 - Eyelid zones. Representative illustration of the division of the
periorbital region into zones numbered from I to V.
Figure 2 - Eyelid zones. Representative illustration of the division of the
periorbital region into zones numbered from I to V.
Surgical excision of skin tumors is one of the most frequent causes of eyelid
defects. Basal cell carcinoma (BCC) is the most frequent tumor in this location,
corresponding to about 90% of cases, with a predominance of lesions in the lower
eyelid1. Squamous cell carcinoma,
sebaceous carcinoma, and melanoma are less prevalent histological types2. The defects resulting from the excision
of cutaneous eyelid tumors require detailed knowledge of the periorbital
region’s anatomy and the most appropriate surgical approaches for the success
of
reconstruction.
OBJECTIVE
The objective of the work is to apply different forms of reconstruction of eyelid
defects located specifically in zone II and III or that corresponding to the
lower eyelid and the medial angle, respectively.
METHODS
Serie of seven patients between 69 and 90 years old with a surgical wound on the
lower eyelid, after removal of malignant tumors, with defects ranging from
approximately 30% to 80% of horizontal extension (Table 1). Patients underwent local anesthesia with or
without sedation or general anesthesia. After complete excision of the tumor
located in the lower eyelid, surgical reconstruction was performed, according
to
the extent and depth, using neighborhood flaps or skin grafting. In none of the
cases, tarsal reconstruction with cartilage graft was not performed, which is
usual in lower eyelid surgeries with extensive involvement of this anatomical
structure (Figure 2).
Table 1 - Materials and methods.
Patient |
Sex |
Age |
Tumor |
Location |
Surgical Technique |
Patient 1 |
M |
90 |
Sebaceous carcinoma |
Zone III |
Imre flap |
Patient 2 |
F |
69 |
Basal cell carcinoma |
Zone III |
Paramedian frontal flap |
Patient 3 |
F |
76 |
Basal cell carcinoma |
Zone III |
Glabellar flap |
Patient 4 |
F |
73 |
Basal cell carcinoma |
Zone III |
Esser flap |
Patient 5 |
M |
81 |
Basal cell carcinoma |
Zone II and III |
Esser flap |
Patient 6 |
M |
76 |
Basal cell carcinoma |
Zone III |
Imre flap |
Patient 7 |
F |
86 |
Basal cell carcinoma |
Zone II and III |
Skin graft |
Table 1 - Materials and methods.
Different flaps were drawn and made, and a more superficial defect was repaired
with a skin graft from the preauricular area.
Case 1
Skin graft: 86-year-old patient, whose lesion affected the skin,
reaching zone III, resection was performed with preservation of the middle
and posterior lamella structures. Skin grafting was performed, obtaining
ipsilateral anterior preauricular skin and repairing the defect (Figure 3).
Figure 3 - Patient underwent full-thickness pre-auricular skin grafting
after excision of BCC in zone II.
Figure 3 - Patient underwent full-thickness pre-auricular skin grafting
after excision of BCC in zone II.
More superficial defects can be repaired with skin grafts, constitute donor
areas: retroauricular and preauricular skin in some cases of the upper
eyelid, as they have similarities with the eyelid skin1,4.
Case 2
Paramedian frontal flap: patient presented a recurrent lesion in
the right eye (RE) medial canthus with ten months of evolution. Resection
and intraoperative freezing were performed. The generated defect had depth
up to the orbit periosteal region. The patient had several scar areas in the
nasal and glabellar dorsal region; the paramedian and contralateral frontal
flap was selected for reconstruction (Figure 4).
Figure 4 - Paramedian frontal flap: patient presented with a recurrent
lesion in the medial corner of the RE, with 10 months of
evolution.
Figure 4 - Paramedian frontal flap: patient presented with a recurrent
lesion in the medial corner of the RE, with 10 months of
evolution.
Cases 3 and 4
Imre flap: two male patients were selected, the first of them
with a large lesion, with partial blockage of the visual axis. He underwent
resection with intraoperative freezing. The pathology revealed to be
sebaceous carcinoma. The second case was a 76 years old male, with
histopathological diagnosis of BCC (Figures 5 and 6).
Figure 5 - Imre flap, reconstruction of a major defect in the left
medial canthus, with excellent functional and cosmetic
results.
Figure 5 - Imre flap, reconstruction of a major defect in the left
medial canthus, with excellent functional and cosmetic
results.
Figure 6 - Imre flap: surgical sequence.
Figure 6 - Imre flap: surgical sequence.
Case 5
Glabellar flap: 76-year-old patient with an ulcerated lesion in
the transition region from the medial palpebral canthus to the nasal dorsum.
It was performed a glabellar flap (Figure 7).
Figure 7 - Transposed glabellar flap to restore anatomy of the left
medial canthus.
Figure 7 - Transposed glabellar flap to restore anatomy of the left
medial canthus.
Cases 6 and 7
Esser flap: A 73-year-old woman and an 81-year-old man were
operated on, both diagnosed with BCC (Figures 8 and 9).
Figure 8 - Esser flap after wide detachment is rotated to correct
defects in zone II and III.
Figure 8 - Esser flap after wide detachment is rotated to correct
defects in zone II and III.
Figure 9 - Case 7. Esser flap with good final scar positioning.
Figure 9 - Case 7. Esser flap with good final scar positioning.
RESULTS
Seven patients aged between 69 and 90 years were operated on, four females and
three males, six with a BCC diagnosis, and one with a sebaceous tumor. All
operated cases were located in periorbital zones II and/or III, in the medial
canthus of the unilateral lower eyelid. All of them evolved with useful function
without retraction or distortion of the anatomy and preservation of the lacrimal
pathways’ drainage.
DISCUSSION
In superficial lesions, a free skin graft is used, which is preferably obtained
from the retroauricular region. The skin to be grafted, after cleaning the
subcutaneous cell tissue, is sutured in the recipient bed, and a Brow dressing
is made. Five days after the dressing is done, the tie-over is removed4. In deep lesions where the bone part is
exposed after resection, the glabella VY flap is used, which is practical and
simple; two incisions forming an inverted V in the glabella region are made,
then the flap is detached and slid to the place where the lesion was resected
and sutured1,5.
In cases where the ends of the eyelids are included in the resection, the
frontomedial flap is used. In these cases, the surgery will be performed in two
stages - the frontomedial flap is initially transposed; after 3 to 4 weeks, the
second time is done: the pedicle is resected, the rest being taken to its
original bed. Then the area is degreased, and the ends of the eyelids are
remade5,6.
The frontal flap is safe, with little morbidity in the donor area, and is an
essential option for eyelid reconstructions. The need for a posterior surgical
procedure for resectioning the pedicle and the excess volume of flap fat tissue
is one of the main disadvantages of this procedure. The patient presented an
adequate postoperative evolution without complications7,8.
When the defect is greater than 50% of the lower eyelid, and this same defect has
a circular shape, the Imre sliding flap should be considered. The incision is
parallel to the lower palpebral margin, extending to the inner canthus and
descending to the nasolabial fold. This flap must be well taken off throughout
the genian region to avoid ectropion9.
The use of the Imre flap provided good aesthetic and functional result, similar
to other flaps commonly used for that kind of reconstructions, such as Mustardé,
Esser, and the glabellar flap for the medial canthus. As an advantage, we
believe that this method ensures a better positioning of the final scar in the
natural grooves of the face9.
The simple or bilobed glabellar flap is characterized by its transposition of
skin from the glabellar region to the medial eye canthus. It is essential to
incorporate the vascular pedicle of this flap into the supratrochlear artery.
The result may not reproduce the concavity typical of the medial eye canthus.
It
is important to note that hair in the glabellar region represents a disadvantage
in using this flap since it can provide hair growth in an area of glabrous
skin, such as the inner eye canthus1,6.
The Esser flap is used to repair significant defects in the lower eyelid. Its
incision begins in the lateral canthus, extends upwards, and descends to the
preauricular region (Figures 8 and 9). The entire flap is dissected in the
genian and preauricular region through a plane immediately above the
musculoaponeurotic system, and, finally, it is rotated and advanced to cover
the
defect1,5,7.
CONCLUSION
Eyelid reconstruction requires not only precise anatomical knowledge, but also
the most varied surgical techniques to obtain a functional and aesthetically
satisfactory result and, thus, minimize postoperative complications.
REFERENCES
1. Mélega JM. Cirurgia Plástica - os princípios e a atualidade I.
Rio de Janeiro: Guanabara Koogan; 2004.
2. Baker SR. Retalhos locais em reconstrução facial. 2º ed. Rio de
Janeiro: DiLivros; 2009.
3. Spinelli HM, Lewis AB, Elahi E. Atlas of aesthetic eyelid &
periocular surgery. New York: W. B. Saunders; 2004.
4. Galimberti G, Ferrario D, Casabona GR, Molinari L. Utilidade dos
retalhos de avanço e rotação para fechamento de defeitos cutâneos na região
malar. Surg Cosmet Dermatol. 2013;5(1):769.
5. Sasson EM, Codner MA. Eyelid reconstruction. Operat Tech Plast
Reconstr Surg. 1999;6(4):250-64.
6. Lima EA. Enxertia de tecido palpebral na reconstrução de tumores
cutâneos. Surg Cosmet Dermatol. 2010;2(4):333-5.
7. Spinelli HM, Jelks GW. Periocular reconstruction: a systematic
approach. Plast Reconstr Surg, 1993;91(6):1017-24;discussion:
1025-6.
8. Kakizaki H, Madge SN, Mannor G, Selva D, Malhotra R. Oculoplastic
surgery for lower eyelid reconstruction after periocular cutaneous carcinoma.
Int Ophthalmol Clin. 2009;49(4):143-55.
9. Metzger JT. Joseph Imre, Jr., and the Imre flap. Plast Reconstr
Surg Transplant Bull. 1959 Mai;23(5):501-9.
1. Hospital Federal de Ipanema, Department of
Plastic Surgery, Rio de Janeiro, RJ, Brazil.
Corresponding author:
Délcio Aparecido Durso Rua Antônio Parreiras 126, Apart. 803,
Ipanema, Rio de Janeiro, RJ, Brazil. Zip Code: 22411-020, E-mail:
delciodurso@gmail.com
Article received: July 08, 2019.
Article accepted: July 15, 2020.
Conflicts of interest: none.