Ophthalmology Volume 121, Number 2, February 2014 5. Viard C, Nakashima K, Lamory B, et al. Imaging microscopic structures in pathological retinas using a flood-illumination adaptive optics retinal camera. Proc SPIE 2011;7885: 488–509.
Outcomes of Upper Eyelid Reconstruction Although numerous operative options are available, upper eyelid reconstruction is often challenging. The reconstructive process needs to ensure that the structure and function of the upper eyelid are maintained to prevent complications, such as a sightthreatening keratopathy or severe discomfort.1 We reviewed a large number of upper eyelid reconstructions after tumor resection to ascertain the techniques used, outcomes, and postoperative complications. We undertook a retrospective, multicenter, consecutive case series, involving patients recruited from 6 tertiary oculoplastic centers. We included patients who underwent reconstructive surgery for fullthickness upper eyelid defects after tumor excision involving the eyelid margin, and that required bilamellar reconstruction. Patients whose eyelid defects only involved the anterior lamella or did not involve the eyelid margin were excluded. Institutional review board approval was obtained. We included 126 eyelids from 125 patients who underwent bilamellar upper eyelid reconstruction. One patient underwent bilateral surgery. The mean age of the patients was 70.4 years (standard deviation 13.2). The study included 65 males (52%) and 60 females (48%). The mean follow-up time was 144.76 weeks (range, 4e721). The tumor types, reconstruction techniques, and size of eyelid defects are summarized in Tables 1, 2, and 3 (available at http://aaojournal.org), respectively. Early postoperative complications were defined as those occurring within 2 weeks after surgery. The most common complications were lagophthalmos in 23 cases (18.3%), exposure keratopathy in 21 (16.7%), corneal abrasion in 4 (3.2%), and wound dehiscence in 4 (3.2%). Late postoperative complications (Table 4; available at http://aaojournal.org) were defined as those occurring >2 weeks after surgery. These included 26 cases (20.6%) of exposure keratopathy. In addition, 5 patients underwent a further wedge excision for tumor-involved margins (after a formal reconstruction), and 2 ultimately required orbital exenteration. Upper eyelid retraction occurred in 19 cases (15%), of which 8 were reconstructed using tarsoconjunctival flaps and 11 were reconstructed using other techniques (including 2 hard palate grafts, 1 Cutler-Beard flap, 2 modified Cutler-Beard flaps, 1 forehead flap, 2 free tarsoconjunctival grafts, and 3 composite grafts). There was no difference between tarsoconjunctival flaps and other techniques in the outcomes of upper eyelid retraction, upper eyelid entropion, and lagophthalmos. In all, 29 cases (23.0%) required additional reconstructive surgery. Nevertheless, complications persisted in 14 of these cases (11.1%). The final outcomes, after all further reconstructive surgery, showed that 18 cases (14.3%) had lagophthalmos, 21 cases (16.7%) had persistent exposure keratopathy, 14 cases (11.1%) had upper eyelid retraction, 11 cases (8.7%) had upper eyelid entropion, 12 cases (9.5%) had a blepharoptosis, 5 cases (4.0%) had wound contracture, and 1 case each with trichiasis, wound
612
granuloma, lateral canthal rounding, and corneal scar. The level of ocular comfort was “good” in 104 (82.5%) cases, “satisfactory” in 4 cases, “managing” in 6 cases, and “poor” in 8 cases. Thirty-five cases (27.8%) required the use of long-term ocular lubricants. Donor site complications included 1 granuloma in the contralateral upper eyelid from which a tarsoconjunctival graft had been harvested, and 1 lower eyelid ectropion (a tarsoconjunctival flap combined with a periosteal flap and lateral myocutaneous flap). There was no association between postoperative complications and age, gender, and the tumor histologic classification. Bilamellar repair of large upper eyelid defects may result in some degree of eyelid rigidity manifested by mechanical ptosis and lagophthalmos, with resulting corneal exposure. In addition, graft contraction, which is secondary to centripetal movement of the elastic fibers in the skin, results in shrinkage and subsequent retraction of the eyelid.2 Lagophthalmos may result from loss of eyelid protractor function as well.3 The tarsoconjunctival flap was the most common technique used in this series, because it avoids potential damage to the other eyelid and is a single-stage procedure. The Müller’s muscle and levator aponeurosis were recessed as described by Irvine and McNab.4 Although 16% of the cases (8/50) had lid retraction, the common complications of retraction, lagophthalmos, and entropion did not seem to be more frequent with tarsoconjunctival flaps. Marginal entropion may occur if the anterior lamella (either a skin-muscle flap or a full-thickness skin graft) advances around the eyelid margin due to a lack of stability. This occurred in 18 cases (8 tarsoconjunctival flaps, 5 cases of free tarsal graft with a local skin-muscle flap, 2 modified Cutler-Beard flaps, 2 sandwich flaps, 1 Cutler-Beard flap, and a lower eyelid-switch flap), with 72.2% occurring >1 month postoperatively, despite anterior lamellar recession by 1 to 2 mm. Management of the entropion may involve an anterior lamellar excision with or without the use of a tarsomarginal graft in an attempt to create a more stable margin or a marginal rotation procedure. Nine of these cases underwent further reconstructive procedures: 5 had an anterior lamellar recession, 1 of which needed a concurrent mucous membrane graft, and 2 underwent a wedge resection. The majority of surgeons preferred to use free tarsal or tarsomarginal grafts in line with the principle of replacing the posterior lamellar with similar tissue. Recent histologic studies suggest that hard palate grafts do not uniformly undergo metaplasia with persistent areas of parakeratosis found in some grafts.5 The authors acknowledge that this is a retrospective study involving multiple surgeons using a wide variety of techniques, and the constraint of small numbers for some of the techniques used. Furthermore, it also illustrates the difficulty in ensuring optimal functional results in reconstructing upper eyelid defects, as evidenced by the significant rate of adjunctive surgery required (23.0%), and the high incidence of postoperative complications (56.3%). This experience may enable clinicians to better inform patients of the likelihood of additional reconstructive procedures being required postoperatively.
EUGENIE W.T. POH, FRCSED(OPHTH)1,2 BRETT A. O’DONNELL, FRANZCO3 ALAN A. MCNAB, FRANZCO4 TIMOTHY J. SULLIVAN, FRANZCO5 BRENT GASKIN, FRANZCO5
Reports RAMAN MALHOTRA, FRCOPHTH6 SAJ ATAULLAH, FRCOPHTH7 PAUL S. CANNON, FRCOPHTH7 BRIAN LEATHERBARROW, FRCOPHTH7 WENG O. CHAN, MBCHB1 GARRY DAVIS, FRANZCO1 DINESH SELVA, FRANZCO1 1 South Australian Institute of Ophthalmology, Royal Adelaide Hospital, Adelaide, Australia; 2Tan Tock Seng Hospital, National Healthcare Group Eye Institute, Singapore; 3Royal North Shore Hospital, Sydney, New South Wales, Australia; 4Royal Victorian Eye and Ear Hospital, Melbourne, Australia; 5Royal Brisbane Hospital, Queensland, Australia; 6Queen Victoria Hospital, East Grinstead, United Kingdom; 7 Manchester Royal Eye Hospital, United Kingdom
References 1. Morley A, de Sousa JL, Selva D, et al. Techniques of upper eyelid reconstruction. Surv Ophthalmol 2010;55:256–71. 2. Leibovitch I, Huilgol SC, Hsuan JD, et al. Incidence of host site complications in periocular full thickness skin grafts. Br J Ophthalmol 2005;89:219–22. 3. deSousa J, Leibovitch I, Malhotra R, et al. Techniques and outcomes of total upper and lower eyelid reconstruction. Arch Ophthalmol 2007;125:1601–9. 4. Irvine F, McNab AA. A technique for reconstruction of upper lid marginal defects. Br J Ophthalmol 2003;87:279–81. 5. Weinberg DA, Tham V, Hardin N, et al; Eyelid mucous membrane grafts: a histologic study of hard palate, nasal turbinate and buccal mucosal grafts. Ophthal Plast Reconstr Surg 2007;23:211–6.
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Ophthalmology Volume 121, Number 2, February 2014 Table 1. Tumor Types (n ¼ 126) Tumor Types Basal cell carcinoma Sebaceous gland carcinoma Squamous cell carcinoma Bowen’s disease (squamous cell carcinoma in situ) Merkel cell carcinoma Melanoma Malignant fibrohistiocytosis
Table 3. Mean Area of Upper Eyelid Defects Mean Area of Upper Eyelid Defect (mm2)
No. of Cases (%) 69 25 14 11 5 1 1
(54.8) (19.8) (11.1) (8.7) (4.0) (0.8) (0.8)
Reconstructive Technique Tarsoconjunctival flap Free tarsal graft Sandwich flap Direct closure
364.01133.4 318.7231.0 266.3216.9 293.8763.5
Values are presented as means standard deviations.
Table 2. Reconstruction Techniques (n ¼ 126) Method of Reconstruction
No. of Cases (%)
Tarsoconjunctival advancement flap Anterior lamella flap Skin graft (full thickness) Combined with periosteal flap Free Tarsoconjunctival grafts (þ upper lid anterior lamella flap) Direct closure Tarsoconjunctival substitutes Auricular cartilage (þ modified Cutler-Beard anterior lamella flap) Hard palate (þ upper lid anterior lamella flap) Composite grafts Sandwich flap Forehead flap Lateral myocutaneous flap Cutler-Beard flap Lid switch flap Periosteal flap Periosteal flap þ temporalis fascia
50 (39.7) 28 18 4 21 (16.7)
613.e1
19 (15.1) 10 (7.9) 6 4 9 (7.1) 5 (4.0) 4 (3.2) 2 2 2 1 1
Table 4. Additional Surgery to Correct for Late Complications Late Complication (>2 Weeks Postop Reconstruction) Upper lid retraction Upper lid entropion Lagophthalmos Ptosis Trichiasis Lower lid ectropion Rounded lateral canthus Medial canthal scar Poor lid function
Additional Corrective Persistent No. of Surgery Complication After Cases (%) (n [ 29 lids) Corrective Surgery 19 18 22 14 2 1 1 1 1
(15.1) (14.3) (17.5) (11.1) (1.6) (0.8) (0.8) (0.8) (0.8)
10 9 11 4 2 1 1 1 1
5 2 7 2 1 1
Outcomes of Upper Eyelid Reconstruction Although numerous operative options are available, upper eyelid reconstruction is often challenging. The reconstructive process needs to ensure that the structure and function of the upper eyelid are maintained to prevent complications, such as a sightthreatening keratopathy or severe discomfort.1 We reviewed a large number of upper eyelid reconstructions after tumor resection to ascertain the techniques used, outcomes, and postoperative complications. We undertook a retrospective, multicenter, consecutive case series, involving patients recruited from 6 tertiary oculoplastic centers. We included patients who underwent reconstructive surgery for fullthickness upper eyelid defects after tumor excision involving the eyelid margin, and that required bilamellar reconstruction. Patients whose eyelid defects only involved the anterior lamella or did not involve the eyelid margin were excluded. Institutional review board approval was obtained. We included 126 eyelids from 125 patients who underwent bilamellar upper eyelid reconstruction. One patient underwent bilateral surgery. The mean age of the patients was 70.4 years (standard deviation 13.2). The study included 65 males (52%) and 60 females (48%). The mean follow-up time was 144.76 weeks (range, 4e721). The tumor types, reconstruction techniques, and size of eyelid defects are summarized in Tables 1, 2, and 3 (available at http://aaojournal.org), respectively. Early postoperative complications were defined as those occurring within 2 weeks after surgery. The most common complications were lagophthalmos in 23 cases (18.3%), exposure keratopathy in 21 (16.7%), corneal abrasion in 4 (3.2%), and wound dehiscence in 4 (3.2%). Late postoperative complications (Table 4; available at http://aaojournal.org) were defined as those occurring >2 weeks after surgery. These included 26 cases (20.6%) of exposure keratopathy. In addition, 5 patients underwent a further wedge excision for tumor-involved margins (after a formal reconstruction), and 2 ultimately required orbital exenteration. Upper eyelid retraction occurred in 19 cases (15%), of which 8 were reconstructed using tarsoconjunctival flaps and 11 were reconstructed using other techniques (including 2 hard palate grafts, 1 Cutler-Beard flap, 2 modified Cutler-Beard flaps, 1 forehead flap, 2 free tarsoconjunctival grafts, and 3 composite grafts). There was no difference between tarsoconjunctival flaps and other techniques in the outcomes of upper eyelid retraction, upper eyelid entropion, and lagophthalmos. In all, 29 cases (23.0%) required additional reconstructive surgery. Nevertheless, complications persisted in 14 of these cases (11.1%). The final outcomes, after all further reconstructive surgery, showed that 18 cases (14.3%) had lagophthalmos, 21 cases (16.7%) had persistent exposure keratopathy, 14 cases (11.1%) had upper eyelid retraction, 11 cases (8.7%) had upper eyelid entropion, 12 cases (9.5%) had a blepharoptosis, 5 cases (4.0%) had wound contracture, and 1 case each with trichiasis, wound
612
granuloma, lateral canthal rounding, and corneal scar. The level of ocular comfort was “good” in 104 (82.5%) cases, “satisfactory” in 4 cases, “managing” in 6 cases, and “poor” in 8 cases. Thirty-five cases (27.8%) required the use of long-term ocular lubricants. Donor site complications included 1 granuloma in the contralateral upper eyelid from which a tarsoconjunctival graft had been harvested, and 1 lower eyelid ectropion (a tarsoconjunctival flap combined with a periosteal flap and lateral myocutaneous flap). There was no association between postoperative complications and age, gender, and the tumor histologic classification. Bilamellar repair of large upper eyelid defects may result in some degree of eyelid rigidity manifested by mechanical ptosis and lagophthalmos, with resulting corneal exposure. In addition, graft contraction, which is secondary to centripetal movement of the elastic fibers in the skin, results in shrinkage and subsequent retraction of the eyelid.2 Lagophthalmos may result from loss of eyelid protractor function as well.3 The tarsoconjunctival flap was the most common technique used in this series, because it avoids potential damage to the other eyelid and is a single-stage procedure. The Müller’s muscle and levator aponeurosis were recessed as described by Irvine and McNab.4 Although 16% of the cases (8/50) had lid retraction, the common complications of retraction, lagophthalmos, and entropion did not seem to be more frequent with tarsoconjunctival flaps. Marginal entropion may occur if the anterior lamella (either a skin-muscle flap or a full-thickness skin graft) advances around the eyelid margin due to a lack of stability. This occurred in 18 cases (8 tarsoconjunctival flaps, 5 cases of free tarsal graft with a local skin-muscle flap, 2 modified Cutler-Beard flaps, 2 sandwich flaps, 1 Cutler-Beard flap, and a lower eyelid-switch flap), with 72.2% occurring >1 month postoperatively, despite anterior lamellar recession by 1 to 2 mm. Management of the entropion may involve an anterior lamellar excision with or without the use of a tarsomarginal graft in an attempt to create a more stable margin or a marginal rotation procedure. Nine of these cases underwent further reconstructive procedures: 5 had an anterior lamellar recession, 1 of which needed a concurrent mucous membrane graft, and 2 underwent a wedge resection. The majority of surgeons preferred to use free tarsal or tarsomarginal grafts in line with the principle of replacing the posterior lamellar with similar tissue. Recent histologic studies suggest that hard palate grafts do not uniformly undergo metaplasia with persistent areas of parakeratosis found in some grafts.5 The authors acknowledge that this is a retrospective study involving multiple surgeons using a wide variety of techniques, and the constraint of small numbers for some of the techniques used. Furthermore, it also illustrates the difficulty in ensuring optimal functional results in reconstructing upper eyelid defects, as evidenced by the significant rate of adjunctive surgery required (23.0%), and the high incidence of postoperative complications (56.3%). This experience may enable clinicians to better inform patients of the likelihood of additional reconstructive procedures being required postoperatively.
EUGENIE W.T. POH, FRCSED(OPHTH)1,2 BRETT A. O’DONNELL, FRANZCO3 ALAN A. MCNAB, FRANZCO4 TIMOTHY J. SULLIVAN, FRANZCO5 BRENT GASKIN, FRANZCO5
Reports RAMAN MALHOTRA, FRCOPHTH6 SAJ ATAULLAH, FRCOPHTH7 PAUL S. CANNON, FRCOPHTH7 BRIAN LEATHERBARROW, FRCOPHTH7 WENG O. CHAN, MBCHB1 GARRY DAVIS, FRANZCO1 DINESH SELVA, FRANZCO1 1 South Australian Institute of Ophthalmology, Royal Adelaide Hospital, Adelaide, Australia; 2Tan Tock Seng Hospital, National Healthcare Group Eye Institute, Singapore; 3Royal North Shore Hospital, Sydney, New South Wales, Australia; 4Royal Victorian Eye and Ear Hospital, Melbourne, Australia; 5Royal Brisbane Hospital, Queensland, Australia; 6Queen Victoria Hospital, East Grinstead, United Kingdom; 7 Manchester Royal Eye Hospital, United Kingdom
References 1. Morley A, de Sousa JL, Selva D, et al. Techniques of upper eyelid reconstruction. Surv Ophthalmol 2010;55:256–71. 2. Leibovitch I, Huilgol SC, Hsuan JD, et al. Incidence of host site complications in periocular full thickness skin grafts. Br J Ophthalmol 2005;89:219–22. 3. deSousa J, Leibovitch I, Malhotra R, et al. Techniques and outcomes of total upper and lower eyelid reconstruction. Arch Ophthalmol 2007;125:1601–9. 4. Irvine F, McNab AA. A technique for reconstruction of upper lid marginal defects. Br J Ophthalmol 2003;87:279–81. 5. Weinberg DA, Tham V, Hardin N, et al; Eyelid mucous membrane grafts: a histologic study of hard palate, nasal turbinate and buccal mucosal grafts. Ophthal Plast Reconstr Surg 2007;23:211–6.
613
Ophthalmology Volume 121, Number 2, February 2014 Table 1. Tumor Types (n ¼ 126) Tumor Types Basal cell carcinoma Sebaceous gland carcinoma Squamous cell carcinoma Bowen’s disease (squamous cell carcinoma in situ) Merkel cell carcinoma Melanoma Malignant fibrohistiocytosis
Table 3. Mean Area of Upper Eyelid Defects Mean Area of Upper Eyelid Defect (mm2)
No. of Cases (%) 69 25 14 11 5 1 1
(54.8) (19.8) (11.1) (8.7) (4.0) (0.8) (0.8)
Reconstructive Technique Tarsoconjunctival flap Free tarsal graft Sandwich flap Direct closure
364.01133.4 318.7231.0 266.3216.9 293.8763.5
Values are presented as means standard deviations.
Table 2. Reconstruction Techniques (n ¼ 126) Method of Reconstruction
No. of Cases (%)
Tarsoconjunctival advancement flap Anterior lamella flap Skin graft (full thickness) Combined with periosteal flap Free Tarsoconjunctival grafts (þ upper lid anterior lamella flap) Direct closure Tarsoconjunctival substitutes Auricular cartilage (þ modified Cutler-Beard anterior lamella flap) Hard palate (þ upper lid anterior lamella flap) Composite grafts Sandwich flap Forehead flap Lateral myocutaneous flap Cutler-Beard flap Lid switch flap Periosteal flap Periosteal flap þ temporalis fascia
50 (39.7) 28 18 4 21 (16.7)
613.e1
19 (15.1) 10 (7.9) 6 4 9 (7.1) 5 (4.0) 4 (3.2) 2 2 2 1 1
Table 4. Additional Surgery to Correct for Late Complications Late Complication (>2 Weeks Postop Reconstruction) Upper lid retraction Upper lid entropion Lagophthalmos Ptosis Trichiasis Lower lid ectropion Rounded lateral canthus Medial canthal scar Poor lid function
Additional Corrective Persistent No. of Surgery Complication After Cases (%) (n [ 29 lids) Corrective Surgery 19 18 22 14 2 1 1 1 1
(15.1) (14.3) (17.5) (11.1) (1.6) (0.8) (0.8) (0.8) (0.8)
10 9 11 4 2 1 1 1 1
5 2 7 2 1 1
