Reconstruction of a Lower Eyelid Defect With a V to Y Island Flap
August 2012 | Volume 11 | Issue 8 | Original Article | 988 | Copyright © 2012
Repair of full thickness defects in the lower eyelid following extirpation of malignant tumors presents a challenge to the reconstructive
surgeon. There are several techniques to choose from, depending on the defect's size and location.
J Drugs Dermatol. 2012;11(8):988-990.
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Defects up to 25% of the eyelid can be closed primarily with or without concomitant canthotomy and cantholysis. 1 A semicircular advancement flap combined with canthal release (Tenzel flap) can be used for closure of larger defects, measuring 25% to 50% of the eyelid, and with certain modifications, up to 75% to 80%.1-3 Large defects may be reconstructed with a tarsoconjunctival flap from the ipsilateral upper eyelid (Hugh's procedure) in two steps1,4 or by the Mustarde rotational cheek flap,5 Fricke's transposition cheek flap,6 forehead flap with fascial lining,7 temporoparietal fascia flap lined with a nasal septal chondromucosal graft, and covered with a retroauricular full-thickness skin graft.8 The use of V-Y island flaps in facial reconstruction is well described, including modifications such as the bipedicle subcutaneous island flap.9 Recently, lower eyelid reconstruction with a V-Y island flap combined with a conjunctival advancement flap for lining was described by Garces et al.10
Herein we describe our experience with a simple, one stage technique for lower eyelid reconstruction by an inferiorly based V-Y island flap for the reconstruction of full thickness lower eyelid defects.
PATIENTS AND METHODS
Between 2005 and 2011, nine patients (7 males, 2 females) underwent reconstruction of full thickness lower eyelid defects after Mohs micrographic surgery for skin malignancy. The average patient age and relative defect size compared to the entire eyelid was 64.7% and 47%, respectively. Individual parameters including age, relative defect size, aesthetic outcome, complications and follow-up are summarized in Table 1.
A triangular island flap is planned inferior to the defect, with its base located superiorly (aligned with the inferior margin of the defect). The vertical length of the flap is 1.5 times that of the defect's width. Local anesthesia, consisting of an admixture of lidocaine, bupivacaine, and adrenalin 1:100,000 is administered while utilizing pain reduction techniques.11 Following skin incisions, the flap is pulled upwards with a skin hook (Figure 1) while concomitantly undermining inferiorly and laterally subcutaneously; this aids superior displacement and insetting of the flap into the defect. The flap is sutured with silk 6-0 sutures while its superiorly oriented apex is kept 3 mm above the eyelid rim. This allows inward folding of the flap edge, providing a natural looking rim. Postoperatively, topical antibiotic ointment is applied twice daily and sutures are removed after one week.
As shown in Table 1, aesthetic results ranged from moderate to excellent with the majority of patients having very good or excellent aesthetic results (Figure 2). Three cases demonstrated a small ectropion that did not warrant surgical correction, of which one was attributed to recurrence of the tumor in the surgical scar and underwent re-excision. Figure 3 demonstrates postoperative results with good scarring, no trap door deformity, absence of eyelashes on the flap, and minor, negligible ectropion. Two patients had bilateral senile ectropion, a condition that was not affected by the reconstructive procedure. Several patients exhibited minimal signs of trap door deformity,