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Principles of Periocular Reconstruction following Excision of Cutaneous Malignancy

Principles of Periocular Reconstruction following Excision of Cutaneous Malignancy Hindawi Publishing Corporation Journal of Skin Cancer Volume 2012, Article ID 438502, 6 pages doi:10.1155/2012/438502 Review Article Principles of Periocular Reconstruction following Excision of Cutaneous Malignancy Scott M. Hayano, Katherine M. Whipple, Bobby S. Korn, and Don O. Kikkawa Division of Ophthalmic Plastic and Reconstructive Surgery, UCSD Department of Ophthalmology, Shiley Eye Center, 9415 Campus Point Drive, La Jolla, CA 92093-0946, USA Correspondence should be addressed to Don O. Kikkawa, dkikkawa@ucsd.edu Received 4 August 2012; Revised 18 November 2012; Accepted 21 November 2012 Academic Editor: Giuseppe Argenziano Copyright © 2012 Scott M. Hayano et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Reconstruction of periocular defects following excision of cutaneous malignancy can present difficulties for oculofacial and reconstructive surgeons. The intricate anatomy of the eyelids and face requires precise restoration in order to avoid postoperative functional anesthetic concerns. Various reconstructive procedures based on common principles, location and size of the defect, can be applied to achieve restoration with the best possible functional and aesthetic outcomes. 1. Introduction frozen tissue examination, or permanent sections [14]. Frozen sections for certain types of tumors, such as With advancing age, cutaneous malignancy around the eye melanoma and sebaceous cell carcinoma, can be difficult to becomes more prevalent. The most common skin cancers interpret and may require formalin fixation to ensure com- that present in the periocular region are basal cell carci- plete tumor excision. Adherence of the tumor to the bony noma, squamous cell carcinoma, sebaceous cell carcinoma, orbit necessitates additional techniques described below. and malignant melanoma [1]. These tumors are usually diagnosed by incisional biopsy. Following tumor removal in 3. Orbital Bony Involvement the periocular region, reconstruction of the defect requires understanding of the differences and uses of soft tissue If the tumor is adherent to the periosteum, removal of the flaps and skin grafts [2–9]. Flaps are usually preferred over involved periosteal segment and burring of the underlying grafts because homogeneity of skin color and texture more bone is typically all that is required. The patient should likely leads to better unification with surrounding tissue have ongoing tumor surveillance with imaging. If there [10]. Many techniques have been described and the reader is significant bony destruction by the tumor, osteotomy should familiarize themselves with the more commonly used should be performed with removal of the involved segment procedures covered in this paper [2, 3, 6–9, 11]. Because the [15]. Any sharp edges that result from removal should be eyelid is a layered structure, appropriate layered reconstruc- rounded to prevent penetration of overlying soft tissue. tion is essential, with the goal towards restoring periocular Dural exposures should be covered, however, primary bone function and minimizing any postsurgical complications [4, grafting should be avoided. 12]. Proper eyelid volume and shape should be strived for [4, 13]. 4. Principles of Eyelid Reconstruction 2. Tumor Excision Reconstruction of the eyelid following tumor excision is Removal of periocular neoplasms requires clear surgical mar- designed based upon the size and depth of the defect, the gins, which can be attained by Moh’s micrographic surgery, inclusion of the lateral canthus or medial canthus, and 2 Journal of Skin Cancer (a) (b) (c) (d) (e) (f) Figure 1: (a) Initial presentation of basal cell carcinoma in an 89-year-old patient involving the right lower eyelid (thick arrow) and right upper eyelid (thin arrow). (b) After Moh’s resection, a large surgical wound measuring 5 cm by 2 cm involving 95% of the right lower eyelid and 60% of the right upper eyelid is present. (c) A periosteal flap was elevated from the lateral orbital rim and rotated medially to reconstruct the posterior lamella of the upper lid and provide an anchor for the lower lid. (d) A tarsoconjunctival flap was then harvested from the remaining superolateral tarsus of the right upper lid and rotated inferiorly to reconstruct the posterior lamella of the right lower eyelid (arrow). (e) Completed reconstruction with anterior lamellar full thickness skin graft from the left upper eyelid. (f) One year postoperative. whether the lacrimal system is involved. Each physician will be used if there is insufficient adjacent tissue. Procedures that devise a plan for reconstruction based on one’s familiarity, include lid sharing, such as a Cutler-Beard flap or Hughes experience, and preference with different eyelid restoration tarsoconjunctival flap, should be avoided in children in the techniques. The ultimate goal of every eyelid reconstruction amblyogenic stage of development [19]. If the defect has been is to create a stable eyelid margin, to ensure the eyelid has replaced with skin grafts, the new tissue must be properly proper dimensions and tension when open and closed, to anchored into place in order to avoid any postoperative eyelid obtain eyelid symmetry with no rough or uneven internal malposition. surfaces, and to optimize aesthetics [16]. It is important to follow a systematic approach to eyelid reconstruction [20]. Eyelid margin defects can be closed There are fundamental guidelines that should be fol- using specific methods depending on how much of the lowed with every reconstruction effort. First, the surgeon horizontal lid length is removed. If the wound involves less should assess the defect. Partial-thickness defects involve than 20 percent of the upper or lower lid margin in younger skin and orbicularis, whereas full-thickness defects extend individuals and up to 30 percent in older patients, it can be from skin through conjunctiva. When using free grafts, a closed primarily. Extra length can be obtained by performing vascular source must be provided by either the anterior or a lateral canthotomy and cantholysis. A Tenzel semicircular posterior lamella. Free grafts replacing the anterior lamella advancement flap can be used for reconstructing defects must not be placed upon a free graft reconstructing the that include 25 to 50 percent of the upper or lower lid. posterior lamella and vice versa because of the lack of For defects that involve over 50 percent of the lid margin a vascular supply. An orbicularis advancement flap can of the lower eyelid, a Hughes tarsoconjunctival flap with be interposed between two free grafts with success [17]. a full-thickness skin graft or a Mustarde cheek rotational Defects involving the posterior lamella can be restored flap with a posterior lamellar graft can be used (Figure 1). using grafts from the hard palate, nasal chondromucosa, The tarsoconjunctival flap is favored and can be opened upper tarsus (pedicle based or free), or ear cartilage [18]. in 2-3 weeks. Defects greater than 50 percent of the The anterior lamella is best reconstructed by transferring upper lid may use a Cutler-Beard pedicle or Leone flap neighboring tissue. Full-thickness skin grafts from the upper [21]. lid, inner upper arm, retroauricular, or supraclavicular may Journal of Skin Cancer 3 (a) (b) (c) (d) (e) Figure 2: (a) Preoperative photo of a 62-year-old female with basal cell carcinoma of right medial canthus (arrow). (b) Local resection creating a 1.5 × 2.0 cm defect. (c) Adjacent tissue transfer flap created via an infraciliary incision and relaxing incision at the lateral aspect of the nose. The flap is then advanced superiorly and medially (arrow) to fill in approximately 85% of the wound. (d) A small rhomboid flap is elevated from the upper lid and rotated inferiorly to fill in the remaining wound (arrow). (e) One year postoperative. 5. Canthal Reconstruction opposite eyelid’s tarsus or a pedicle-based graft from the tarsus adjacent to the defect are preferred. The upper and The medial and lateral canthi are sites where multiple lowertarsusisdifferent in dimension, measuring 10–12 mm aesthetic units overlap and present difficulties in attempting in the upper lid and 4-5 mm in the lower lid. Other to preserve unique characteristics in that region [22]. alternatives are hard palate mucosa and ear or nasal cartilage. Appropriate horizontal tension of the eyelid is important When a considerable amount of soft tissue is excised during because it lowers the chances of eyelid malposition and tumor removal, dermis fat grafts may be used for restoring exposure of the cornea [12]. Proper anchoring of the eyelid the deficient volume in order to ensure proper positioning of along the medial and lateral canthus is essential for proper the eyelid [4, 24]. function and aesthetics. Flaps using the periosteum can be used to rebuild canthal ligaments that structurally support the posterior lamella. Free skin grafts can be placed over 7. Reconstruction of the Anterior Lamella periosteal flaps if used. One must take into account negative vectors, which necessitates that the periosteal flap must be Neighboring tissue flaps are preferred because the tissue located superiorly enough to the eye to avoid unwanted color and texture is most similar to the original tissue that exposure [3, 7, 11, 12]. If part of the periosteum is removed was removed due to exposure to similar environmental during tumor excision, the canthi can be remodeled using conditions [2, 3, 7, 9, 14](Figure 2). Alternative options a small titanium plate fixed with sutures instead. Small include free skin grafts from the upper eyelid, retroauricular, defects (less than 1 cm) can be allowed to heal via secondary supraclavicular, and inner arm (Figure 3). When there intention. are insufficient full-thickness skin grafts obtainable, split- thickness skin grafts are acceptable. However, split-thickness grafts contract more postoperatively. Compared to the 6. Reconstruction of the Posterior Lamella posterior lamella, the type of anterior lamella reconstruction Reconstruction of the posterior lamella is best carried out influences more the final aesthetic outcome [3, 25]. Relaxing using grafts from the tarsus [23]. Free grafts from the incisions for flaps are useful when made along adjoining 4 Journal of Skin Cancer (a) (b) (c) (d) Figure 3: (a) a 65-year-old male status after Moh’s resection for lentigo maligna melanoma in the right lower lid, cheek, and lateral nasal wall. The defect measured 5 cm by 4 cm. (b) It was decided to decrease the size of the defect using adjacent tissue flaps prior to considering use of a skin graft. Alternatively, a skin graft could be placed for the entire defect; however, it is our preference to use adjacent tissue whenever possible. An infraciliary incision with nasolabial extensions allows for the lateral midface and cheek to be rotated medially and superiorly to fill approximately 60% of the wound (straight arrow). In addition, this keeps the tension horizontal rather than vertical. A rhomboid flap is raised superiorly and rotated inferiorly to fill in the superior aspect of the wound (curved arrow). (c) A full thickness skin graft from the inner upper arm is used to fill in the remaining wound (arrow). (d) Eleven months postoperatively showing mild residual ectropion of right lower lid. (a) (b) (c) Figure 4: (a) A 67-year-old male status after Moh’s excision of basal cell carcinoma of the superomedial right upper eyelid creating a 3 × 2.5 cm wound, which also included the preseptal and infrabrow region. (b) A glabellar flap is harvested centrally and rotated inferiorly and laterally to reconstruct the defect. Since the defect involved only the anterior lamella, no posterior lamella or muscle layer reconstruction was necessary. (c) 10 months postoperatively with an excellent result. aesthetic units. To avoid eyelid retraction and ectropion, vascular plexus can provide adequate blood flow to support vertical skin tension in the lower eyelid must be monitored random flaps. Complications are more common in patients [3, 7, 9, 11, 14]. with a history of facial surgery, smoking, vascular disease, and radiation. It is important to minimize horizontal tension, which is 8. Flap Design why incisions should be made in conjunction with relaxed The face and eyelids have extensive vascular supply. Because skin tension lines [2, 5, 7, 9, 22]. This promotes proper of this, the design of rotational flaps based on a particular wound healing and decreases the chances of tissue necrosis arterial supply is not necessary (Figure 4). The subdermal and eyelid malposition. Most of the time, the problem of Journal of Skin Cancer 5 Table 1: Complications of eyelid reconstruction. References Eyelid retraction [1] U. Abdi, N. Tyagi, V. Maheshwari, R. Gogi, and S. P. Tyagi, “Tumours of eyelid: a clinicopathologic study,” Journal of the Cicatricial ectropion or entropion Indian Medical Association, vol. 94, no. 11, pp. 405–418, 1996. Ptosis [2] G. J. Harris and S. C. Logani, “Multiple aesthetic unit flaps Lagophthalmos for medial canthal reconstruction,” Ophthalmic Plastic and Reconstructive Surgery, vol. 14, no. 5, pp. 352–359, 1998. Dry eye [3] G. J. Harris and N. Perez, “Anchored flaps in post-Mohs Tumor recurrence reconstruction of the lower eyelid, cheek, and lateral canthus: Trichiasis avoiding eyelid distortion,” Ophthalmic Plastic and Reconstruc- tive Surgery, vol. 19, no. 1, pp. 5–13, 2003. Infection [4] C. Hintschich, “Periocular plastic surgery,” Deutsches Arzteb- Graft failure latt international, vol. 107, no. 9, pp. 141–146, 2010. Scarring [5] N. Jowett and A. M. Mlynarek, “Reconstruction of cheek defects: a review of current techniques,” Current Opinion in Hyper or hypopigmentation Otolaryngology and Head and Neck Surgery,vol. 18, no.4,pp. 244–254, 2010. [6] A. J. Kaufman, “Periorbital reconstruction with adjacent- tissue skin grafts,” Dermatologic Surgery, vol. 31, no. 12, pp. tension is lessened due to the fact that many skin cancer 1704–1706, 2005. patients are elderly with increased skin elasticity. Wound [7] J. A. Khan and V. S. Garden, “Combined flap repair of moder- eversion is best achieved using mattress sutures and results in ate lower eyelid defects,” Ophthalmic Plastic and Reconstructive aesthetically pleasing closures compared to simple running Surgery, vol. 18, no. 3, pp. 202–204, 2002. sutures [26]. Deeper sutures in the superficial musculo- [8] I. M. J. Mathijssen and J. C. Van Der Meulen, “Guidelines for reconstruction of the eyelids and canthal regions,” Journal of aponeurotic system (SMAS) layer can be used to minimize Plastic, Reconstructive and Aesthetic Surgery,vol. 63, no.9,pp. wound tension [2, 3, 11]. These sutures in the SMAS can also 1420–1433, 2010. be placed in a “hang-back” fashion with deeper anchoring to [9] J. R. Patrinely, H. M. Marines, and R. L. Anderson, “Skin flaps the periosteum [3, 5–7, 24]. Midfacial defects require sutures in periorbital reconstruction,” Survey of Ophthalmology, vol. that mimic the support of the orbitomalar ligament. 31, no. 4, pp. 249–261, 1987. [10] P. Fogagnolo, G. Colletti, D. Valassina, F. Allevi, and L. Rossetti, “Partial and total lower lid reconstruction: our ex- 9. Complications perience with 41 cases,” Ophthalmologica, vol. 228, no. 4, pp. 239–243, 2012. Despite the surgeon’s best effort, occasional complications [11] D. O. Kikkawa, B. N. Lemke, and R. K. Dortzbach, “Relations may occur (see Table 1). Approximately 10 percent of cases of the superficial musculoaponeurotic system to the orbit may require additional surgery to correct lid malposition. and characterization of the orbitomalar ligament,” Ophthalmic This rate may be higher in patients with a history of Plastic and Reconstructive Surgery, vol. 12, no. 2, pp. 77–88, radiation, smoking, and previous surgery. Secondary skin grafting may be required. Patients with large tumors or [12] A. Saito, N. Saito, H. Furukawa et al., “Reconstruction of perineural invasion are at a particular risk for recurrence and periorbital defects following malignant tumour excision: a report of 50 cases,” Journal of Plastic, Reconstructive & Aesthetic the index of suspicion should remain high in these patients. Surgery, vol. 65, no. 5, pp. 665–670, 2012. [13] W. L. F. Wessels,F.R.Graewe, andP.V.Van Deventer,“Recon- struction of the lower eye lid with a rotation-advancement 10. Conclusion tarsoconjunctival cheek flap,” Journal of Craniofacial Surgery, vol. 21, no. 6, pp. 1786–1789, 2010. Reconstruction of periorbital defects following Moh’s [14] P. Wojcicki and M. Zachara, “Surgical treatment of eyelid surgery requires special attention to both aspects of aesthetic tumors,” Journal of Craniofacial Surgery,vol. 21, no.2,pp. appearance and eyelid function [2, 3, 7, 8, 12, 25]. Many 520–525, 2010. different techniques and principles have been described, and [15] H. M. Rosen, “Periorbital basal cell carcinoma requiring the surgeon has some latitude to achieve the best result ablative craniofacial surgery,” Archives of Dermatology, vol. [2, 3, 6–8, 11, 25]. Whileitisimportant to follow asystematic 123, no. 3, pp. 376–378, 1987. reconstructive algorithm, it is our opinion that each patient [16] Orbit, Eyelids, and Lacrimal System,section 7, American is unique and a plan must be formulated for each individual Academy of Ophthalmology, 2011. following fundamental principles. [17] D. Paridaens and W. A. van den Bosch, “Orbicularis muscle advancement flap combined with free posterior and anterior lamellar grafts: a 1-stage sandwich technique for eyelid reconstruction,” Ophthalmology, vol. 115, no. 1, pp. 189–194, Acknowledgment This paper was supported by an unrestricted grant from [18] F. Inchingolo, M. Tatullo, F. M. Abenavoli et al., “Upper eyelid Research to Prevent Blindness, New York, USA. reconstruction: a short report of an eyelid defect following a 6 Journal of Skin Cancer thermal burn,” Head and Face Medicine, vol. 5, no. 1, article 26, 2009. [19] J. Ahmad, D. W. Mathes, and K. M. Itani, “Reconstruction of the eyelids after Mohs surgery,” Seminars in Plastic Surgery, vol. 22, no. 4, pp. 306–318, 2008. [20] J. R. O. Collin, AmanualofSystematicEyelidSurgery,Elsevier, 3rd edition, 2006. [21] N. Subramanian, “Reconstructions of eyelid defects,” Indian Journal of Plastic Surgery, vol. 44, no. 1, pp. 5–13, 2011. [22] P. H. Bowman, S. W. Fosko, and M. E. Hartstein, “Periocular reconstruction,” Seminars in Cutaneous Medicine and Surgery, vol. 22, no. 4, pp. 263–272, 2003. [23] A. M. Hafez, “Reconstruction of large upper eyelid defect with two composite lid margin grafts,” Middle East African Journal of Ophthalmology, vol. 17, no. 2, pp. 161–164, 2010. [24] B. S. Korn,D.O.Kikkawa,S.R.Cohen,M.Hartstein, andC. C. Annunziata, “Treatment of lower eyelid malposition with dermis fat grafting,” Ophthalmology, vol. 115, no. 4, pp. 744– 751, 2008. [25] A. C. Suryadevara and K. S. Moe, “Reconstruction of eyelid defects,” Facial Plastic Surgery Clinics of North America, vol. 17, no. 3, pp. 419–428, 2009. [26] B. R. Moody, J. E. McCarthy, J. Linder, and G. J. Hruza, “Enhanced cosmetic outcome with running horizontal mat- tress sutures,” Dermatologic Surgery, vol. 31, no. 10, pp. 1313– 1316, 2005. 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Principles of Periocular Reconstruction following Excision of Cutaneous Malignancy

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Copyright © 2012 Scott M. Hayano et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract

Hindawi Publishing Corporation Journal of Skin Cancer Volume 2012, Article ID 438502, 6 pages doi:10.1155/2012/438502 Review Article Principles of Periocular Reconstruction following Excision of Cutaneous Malignancy Scott M. Hayano, Katherine M. Whipple, Bobby S. Korn, and Don O. Kikkawa Division of Ophthalmic Plastic and Reconstructive Surgery, UCSD Department of Ophthalmology, Shiley Eye Center, 9415 Campus Point Drive, La Jolla, CA 92093-0946, USA Correspondence should be addressed to Don O. Kikkawa, dkikkawa@ucsd.edu Received 4 August 2012; Revised 18 November 2012; Accepted 21 November 2012 Academic Editor: Giuseppe Argenziano Copyright © 2012 Scott M. Hayano et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Reconstruction of periocular defects following excision of cutaneous malignancy can present difficulties for oculofacial and reconstructive surgeons. The intricate anatomy of the eyelids and face requires precise restoration in order to avoid postoperative functional anesthetic concerns. Various reconstructive procedures based on common principles, location and size of the defect, can be applied to achieve restoration with the best possible functional and aesthetic outcomes. 1. Introduction frozen tissue examination, or permanent sections [14]. Frozen sections for certain types of tumors, such as With advancing age, cutaneous malignancy around the eye melanoma and sebaceous cell carcinoma, can be difficult to becomes more prevalent. The most common skin cancers interpret and may require formalin fixation to ensure com- that present in the periocular region are basal cell carci- plete tumor excision. Adherence of the tumor to the bony noma, squamous cell carcinoma, sebaceous cell carcinoma, orbit necessitates additional techniques described below. and malignant melanoma [1]. These tumors are usually diagnosed by incisional biopsy. Following tumor removal in 3. Orbital Bony Involvement the periocular region, reconstruction of the defect requires understanding of the differences and uses of soft tissue If the tumor is adherent to the periosteum, removal of the flaps and skin grafts [2–9]. Flaps are usually preferred over involved periosteal segment and burring of the underlying grafts because homogeneity of skin color and texture more bone is typically all that is required. The patient should likely leads to better unification with surrounding tissue have ongoing tumor surveillance with imaging. If there [10]. Many techniques have been described and the reader is significant bony destruction by the tumor, osteotomy should familiarize themselves with the more commonly used should be performed with removal of the involved segment procedures covered in this paper [2, 3, 6–9, 11]. Because the [15]. Any sharp edges that result from removal should be eyelid is a layered structure, appropriate layered reconstruc- rounded to prevent penetration of overlying soft tissue. tion is essential, with the goal towards restoring periocular Dural exposures should be covered, however, primary bone function and minimizing any postsurgical complications [4, grafting should be avoided. 12]. Proper eyelid volume and shape should be strived for [4, 13]. 4. Principles of Eyelid Reconstruction 2. Tumor Excision Reconstruction of the eyelid following tumor excision is Removal of periocular neoplasms requires clear surgical mar- designed based upon the size and depth of the defect, the gins, which can be attained by Moh’s micrographic surgery, inclusion of the lateral canthus or medial canthus, and 2 Journal of Skin Cancer (a) (b) (c) (d) (e) (f) Figure 1: (a) Initial presentation of basal cell carcinoma in an 89-year-old patient involving the right lower eyelid (thick arrow) and right upper eyelid (thin arrow). (b) After Moh’s resection, a large surgical wound measuring 5 cm by 2 cm involving 95% of the right lower eyelid and 60% of the right upper eyelid is present. (c) A periosteal flap was elevated from the lateral orbital rim and rotated medially to reconstruct the posterior lamella of the upper lid and provide an anchor for the lower lid. (d) A tarsoconjunctival flap was then harvested from the remaining superolateral tarsus of the right upper lid and rotated inferiorly to reconstruct the posterior lamella of the right lower eyelid (arrow). (e) Completed reconstruction with anterior lamellar full thickness skin graft from the left upper eyelid. (f) One year postoperative. whether the lacrimal system is involved. Each physician will be used if there is insufficient adjacent tissue. Procedures that devise a plan for reconstruction based on one’s familiarity, include lid sharing, such as a Cutler-Beard flap or Hughes experience, and preference with different eyelid restoration tarsoconjunctival flap, should be avoided in children in the techniques. The ultimate goal of every eyelid reconstruction amblyogenic stage of development [19]. If the defect has been is to create a stable eyelid margin, to ensure the eyelid has replaced with skin grafts, the new tissue must be properly proper dimensions and tension when open and closed, to anchored into place in order to avoid any postoperative eyelid obtain eyelid symmetry with no rough or uneven internal malposition. surfaces, and to optimize aesthetics [16]. It is important to follow a systematic approach to eyelid reconstruction [20]. Eyelid margin defects can be closed There are fundamental guidelines that should be fol- using specific methods depending on how much of the lowed with every reconstruction effort. First, the surgeon horizontal lid length is removed. If the wound involves less should assess the defect. Partial-thickness defects involve than 20 percent of the upper or lower lid margin in younger skin and orbicularis, whereas full-thickness defects extend individuals and up to 30 percent in older patients, it can be from skin through conjunctiva. When using free grafts, a closed primarily. Extra length can be obtained by performing vascular source must be provided by either the anterior or a lateral canthotomy and cantholysis. A Tenzel semicircular posterior lamella. Free grafts replacing the anterior lamella advancement flap can be used for reconstructing defects must not be placed upon a free graft reconstructing the that include 25 to 50 percent of the upper or lower lid. posterior lamella and vice versa because of the lack of For defects that involve over 50 percent of the lid margin a vascular supply. An orbicularis advancement flap can of the lower eyelid, a Hughes tarsoconjunctival flap with be interposed between two free grafts with success [17]. a full-thickness skin graft or a Mustarde cheek rotational Defects involving the posterior lamella can be restored flap with a posterior lamellar graft can be used (Figure 1). using grafts from the hard palate, nasal chondromucosa, The tarsoconjunctival flap is favored and can be opened upper tarsus (pedicle based or free), or ear cartilage [18]. in 2-3 weeks. Defects greater than 50 percent of the The anterior lamella is best reconstructed by transferring upper lid may use a Cutler-Beard pedicle or Leone flap neighboring tissue. Full-thickness skin grafts from the upper [21]. lid, inner upper arm, retroauricular, or supraclavicular may Journal of Skin Cancer 3 (a) (b) (c) (d) (e) Figure 2: (a) Preoperative photo of a 62-year-old female with basal cell carcinoma of right medial canthus (arrow). (b) Local resection creating a 1.5 × 2.0 cm defect. (c) Adjacent tissue transfer flap created via an infraciliary incision and relaxing incision at the lateral aspect of the nose. The flap is then advanced superiorly and medially (arrow) to fill in approximately 85% of the wound. (d) A small rhomboid flap is elevated from the upper lid and rotated inferiorly to fill in the remaining wound (arrow). (e) One year postoperative. 5. Canthal Reconstruction opposite eyelid’s tarsus or a pedicle-based graft from the tarsus adjacent to the defect are preferred. The upper and The medial and lateral canthi are sites where multiple lowertarsusisdifferent in dimension, measuring 10–12 mm aesthetic units overlap and present difficulties in attempting in the upper lid and 4-5 mm in the lower lid. Other to preserve unique characteristics in that region [22]. alternatives are hard palate mucosa and ear or nasal cartilage. Appropriate horizontal tension of the eyelid is important When a considerable amount of soft tissue is excised during because it lowers the chances of eyelid malposition and tumor removal, dermis fat grafts may be used for restoring exposure of the cornea [12]. Proper anchoring of the eyelid the deficient volume in order to ensure proper positioning of along the medial and lateral canthus is essential for proper the eyelid [4, 24]. function and aesthetics. Flaps using the periosteum can be used to rebuild canthal ligaments that structurally support the posterior lamella. Free skin grafts can be placed over 7. Reconstruction of the Anterior Lamella periosteal flaps if used. One must take into account negative vectors, which necessitates that the periosteal flap must be Neighboring tissue flaps are preferred because the tissue located superiorly enough to the eye to avoid unwanted color and texture is most similar to the original tissue that exposure [3, 7, 11, 12]. If part of the periosteum is removed was removed due to exposure to similar environmental during tumor excision, the canthi can be remodeled using conditions [2, 3, 7, 9, 14](Figure 2). Alternative options a small titanium plate fixed with sutures instead. Small include free skin grafts from the upper eyelid, retroauricular, defects (less than 1 cm) can be allowed to heal via secondary supraclavicular, and inner arm (Figure 3). When there intention. are insufficient full-thickness skin grafts obtainable, split- thickness skin grafts are acceptable. However, split-thickness grafts contract more postoperatively. Compared to the 6. Reconstruction of the Posterior Lamella posterior lamella, the type of anterior lamella reconstruction Reconstruction of the posterior lamella is best carried out influences more the final aesthetic outcome [3, 25]. Relaxing using grafts from the tarsus [23]. Free grafts from the incisions for flaps are useful when made along adjoining 4 Journal of Skin Cancer (a) (b) (c) (d) Figure 3: (a) a 65-year-old male status after Moh’s resection for lentigo maligna melanoma in the right lower lid, cheek, and lateral nasal wall. The defect measured 5 cm by 4 cm. (b) It was decided to decrease the size of the defect using adjacent tissue flaps prior to considering use of a skin graft. Alternatively, a skin graft could be placed for the entire defect; however, it is our preference to use adjacent tissue whenever possible. An infraciliary incision with nasolabial extensions allows for the lateral midface and cheek to be rotated medially and superiorly to fill approximately 60% of the wound (straight arrow). In addition, this keeps the tension horizontal rather than vertical. A rhomboid flap is raised superiorly and rotated inferiorly to fill in the superior aspect of the wound (curved arrow). (c) A full thickness skin graft from the inner upper arm is used to fill in the remaining wound (arrow). (d) Eleven months postoperatively showing mild residual ectropion of right lower lid. (a) (b) (c) Figure 4: (a) A 67-year-old male status after Moh’s excision of basal cell carcinoma of the superomedial right upper eyelid creating a 3 × 2.5 cm wound, which also included the preseptal and infrabrow region. (b) A glabellar flap is harvested centrally and rotated inferiorly and laterally to reconstruct the defect. Since the defect involved only the anterior lamella, no posterior lamella or muscle layer reconstruction was necessary. (c) 10 months postoperatively with an excellent result. aesthetic units. To avoid eyelid retraction and ectropion, vascular plexus can provide adequate blood flow to support vertical skin tension in the lower eyelid must be monitored random flaps. Complications are more common in patients [3, 7, 9, 11, 14]. with a history of facial surgery, smoking, vascular disease, and radiation. It is important to minimize horizontal tension, which is 8. Flap Design why incisions should be made in conjunction with relaxed The face and eyelids have extensive vascular supply. Because skin tension lines [2, 5, 7, 9, 22]. This promotes proper of this, the design of rotational flaps based on a particular wound healing and decreases the chances of tissue necrosis arterial supply is not necessary (Figure 4). The subdermal and eyelid malposition. Most of the time, the problem of Journal of Skin Cancer 5 Table 1: Complications of eyelid reconstruction. References Eyelid retraction [1] U. Abdi, N. Tyagi, V. Maheshwari, R. Gogi, and S. P. Tyagi, “Tumours of eyelid: a clinicopathologic study,” Journal of the Cicatricial ectropion or entropion Indian Medical Association, vol. 94, no. 11, pp. 405–418, 1996. Ptosis [2] G. J. Harris and S. C. Logani, “Multiple aesthetic unit flaps Lagophthalmos for medial canthal reconstruction,” Ophthalmic Plastic and Reconstructive Surgery, vol. 14, no. 5, pp. 352–359, 1998. Dry eye [3] G. J. Harris and N. Perez, “Anchored flaps in post-Mohs Tumor recurrence reconstruction of the lower eyelid, cheek, and lateral canthus: Trichiasis avoiding eyelid distortion,” Ophthalmic Plastic and Reconstruc- tive Surgery, vol. 19, no. 1, pp. 5–13, 2003. Infection [4] C. Hintschich, “Periocular plastic surgery,” Deutsches Arzteb- Graft failure latt international, vol. 107, no. 9, pp. 141–146, 2010. Scarring [5] N. Jowett and A. M. Mlynarek, “Reconstruction of cheek defects: a review of current techniques,” Current Opinion in Hyper or hypopigmentation Otolaryngology and Head and Neck Surgery,vol. 18, no.4,pp. 244–254, 2010. [6] A. J. Kaufman, “Periorbital reconstruction with adjacent- tissue skin grafts,” Dermatologic Surgery, vol. 31, no. 12, pp. tension is lessened due to the fact that many skin cancer 1704–1706, 2005. patients are elderly with increased skin elasticity. Wound [7] J. A. Khan and V. S. Garden, “Combined flap repair of moder- eversion is best achieved using mattress sutures and results in ate lower eyelid defects,” Ophthalmic Plastic and Reconstructive aesthetically pleasing closures compared to simple running Surgery, vol. 18, no. 3, pp. 202–204, 2002. sutures [26]. Deeper sutures in the superficial musculo- [8] I. M. J. Mathijssen and J. C. Van Der Meulen, “Guidelines for reconstruction of the eyelids and canthal regions,” Journal of aponeurotic system (SMAS) layer can be used to minimize Plastic, Reconstructive and Aesthetic Surgery,vol. 63, no.9,pp. wound tension [2, 3, 11]. These sutures in the SMAS can also 1420–1433, 2010. be placed in a “hang-back” fashion with deeper anchoring to [9] J. R. Patrinely, H. M. Marines, and R. L. Anderson, “Skin flaps the periosteum [3, 5–7, 24]. Midfacial defects require sutures in periorbital reconstruction,” Survey of Ophthalmology, vol. that mimic the support of the orbitomalar ligament. 31, no. 4, pp. 249–261, 1987. [10] P. Fogagnolo, G. Colletti, D. Valassina, F. Allevi, and L. Rossetti, “Partial and total lower lid reconstruction: our ex- 9. Complications perience with 41 cases,” Ophthalmologica, vol. 228, no. 4, pp. 239–243, 2012. Despite the surgeon’s best effort, occasional complications [11] D. O. Kikkawa, B. N. Lemke, and R. K. Dortzbach, “Relations may occur (see Table 1). Approximately 10 percent of cases of the superficial musculoaponeurotic system to the orbit may require additional surgery to correct lid malposition. and characterization of the orbitomalar ligament,” Ophthalmic This rate may be higher in patients with a history of Plastic and Reconstructive Surgery, vol. 12, no. 2, pp. 77–88, radiation, smoking, and previous surgery. Secondary skin grafting may be required. Patients with large tumors or [12] A. Saito, N. Saito, H. Furukawa et al., “Reconstruction of perineural invasion are at a particular risk for recurrence and periorbital defects following malignant tumour excision: a report of 50 cases,” Journal of Plastic, Reconstructive & Aesthetic the index of suspicion should remain high in these patients. Surgery, vol. 65, no. 5, pp. 665–670, 2012. [13] W. L. F. Wessels,F.R.Graewe, andP.V.Van Deventer,“Recon- struction of the lower eye lid with a rotation-advancement 10. Conclusion tarsoconjunctival cheek flap,” Journal of Craniofacial Surgery, vol. 21, no. 6, pp. 1786–1789, 2010. Reconstruction of periorbital defects following Moh’s [14] P. Wojcicki and M. Zachara, “Surgical treatment of eyelid surgery requires special attention to both aspects of aesthetic tumors,” Journal of Craniofacial Surgery,vol. 21, no.2,pp. appearance and eyelid function [2, 3, 7, 8, 12, 25]. Many 520–525, 2010. different techniques and principles have been described, and [15] H. M. Rosen, “Periorbital basal cell carcinoma requiring the surgeon has some latitude to achieve the best result ablative craniofacial surgery,” Archives of Dermatology, vol. [2, 3, 6–8, 11, 25]. Whileitisimportant to follow asystematic 123, no. 3, pp. 376–378, 1987. reconstructive algorithm, it is our opinion that each patient [16] Orbit, Eyelids, and Lacrimal System,section 7, American is unique and a plan must be formulated for each individual Academy of Ophthalmology, 2011. following fundamental principles. [17] D. Paridaens and W. A. van den Bosch, “Orbicularis muscle advancement flap combined with free posterior and anterior lamellar grafts: a 1-stage sandwich technique for eyelid reconstruction,” Ophthalmology, vol. 115, no. 1, pp. 189–194, Acknowledgment This paper was supported by an unrestricted grant from [18] F. Inchingolo, M. Tatullo, F. M. Abenavoli et al., “Upper eyelid Research to Prevent Blindness, New York, USA. reconstruction: a short report of an eyelid defect following a 6 Journal of Skin Cancer thermal burn,” Head and Face Medicine, vol. 5, no. 1, article 26, 2009. [19] J. Ahmad, D. W. Mathes, and K. M. Itani, “Reconstruction of the eyelids after Mohs surgery,” Seminars in Plastic Surgery, vol. 22, no. 4, pp. 306–318, 2008. [20] J. R. O. Collin, AmanualofSystematicEyelidSurgery,Elsevier, 3rd edition, 2006. [21] N. Subramanian, “Reconstructions of eyelid defects,” Indian Journal of Plastic Surgery, vol. 44, no. 1, pp. 5–13, 2011. [22] P. H. Bowman, S. W. Fosko, and M. E. Hartstein, “Periocular reconstruction,” Seminars in Cutaneous Medicine and Surgery, vol. 22, no. 4, pp. 263–272, 2003. [23] A. M. Hafez, “Reconstruction of large upper eyelid defect with two composite lid margin grafts,” Middle East African Journal of Ophthalmology, vol. 17, no. 2, pp. 161–164, 2010. [24] B. S. Korn,D.O.Kikkawa,S.R.Cohen,M.Hartstein, andC. C. Annunziata, “Treatment of lower eyelid malposition with dermis fat grafting,” Ophthalmology, vol. 115, no. 4, pp. 744– 751, 2008. [25] A. C. Suryadevara and K. S. Moe, “Reconstruction of eyelid defects,” Facial Plastic Surgery Clinics of North America, vol. 17, no. 3, pp. 419–428, 2009. [26] B. R. Moody, J. E. McCarthy, J. Linder, and G. J. Hruza, “Enhanced cosmetic outcome with running horizontal mat- tress sutures,” Dermatologic Surgery, vol. 31, no. 10, pp. 1313– 1316, 2005. 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