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Lamellar rotation surgery: a new procedure for repairing upper eyelid defects
© The Author(s). 2018
- Received: 11 June 2018
- Accepted: 24 October 2018
- Published: 7 November 2018
To report “Lamellar Rotation Surgery”,a new technique for repairing large and moderate full-thickness upper eyelid defects.
A two-stage technique is described in which a vertical incision is made in the tarsus of the lower eyelid with elevation of the lateral posterior lamella while sparing the lower eyelid orbicularis and skin to be rotated superiorly to form the reconstructed posterior lamella of the upper eyelid. Additionally, a lateral periosteal flap is used to reconstruct the lateral canthal tendon, and a McGregor procedure is used to reconstruct the anterior lamella of the upper eyelid. The flap is divided during a second-stage surgery at 3 months. Three cases are described to showcase this technique.
Good functional and aesthetic results were achieved for the eyelids.
This new procedure may help to address the challenge of repairing full-thickness defects of the upper eyelid.
Registration number: ChiCTR1800018990, 20 Oct 2018, retrospectively registered.
- Upper eyelid defect
- Eyelid reconstruction
- Lamellar rotation surgery
Upper eyelid full-thickness defects are caused by tumour excision, trauma or congenital colobomas. Small defects (less than 33% of eyelid margin involvement) can be repaired by direct closure with superior cantholysis if necessary . The most commonly used procedure for moderate defects (33–50% involvement) is the inverted semi-circular flap , and the Cutler-Beard flap [1–4] is used for large defects (over 50% involvement). The reconstruction of large upper eyelid full-thickness defects represents a challenge in ocular plastic surgery because of the complicated anatomy and function. Certain surgical procedures, including the Cutler-Beard flap and Mustarde lid switch [1, 5], are available, but all these procedures have limitations. We have developed a new method that could provide a useful solution to this challenging problem for both large and moderate defects. Three cases are described to showcase this technique.
Second-stage surgery (Fig. 4)
The most commonly used technique to treat moderate upper eyelid defect is a lateral canthal tendon incision and semi-circular “Tenzel” flap [1, 8]. Large full-thickness upper eyelid defects are a challenge in ocular plastic surgery. Certain surgical procedures are available for reconstructing large full-thickness upper eyelid defects, but all these procedures have limitations. The Cutler-Beard procedure is likely the most popular in use, although the reconstructed upper eyelid is not sufficiently stable due to a lack of tarsus [1–4]. Moreover, the lanugo hairs present on the reconstructed upper eyelid may cause corneal irritation. The Mustarde lid switch procedure is not widely practised because of corneal irritation caused by the pedicle, among other reasons [1, 5]. Other techniques are mainly tarsoconjunctival substitutes, including hard palate , nasal septal chondromucosal , and free tarsomarginal grafts . Hard palate and nasal septal chondromucosal grafts may be preferable as an option for lower eyelid rather than upper eyelid reconstruction because of corneal damage . The survival risk and eyelash absence associated with free tarsomarginal grafts are mentioned in some studies .
The aim and novelty of our technique was the use of the lower eyelid tarsus, periosteal flap, and temporal skin-orbicularis flap to reconstruct an upper eyelid defect. We considered the lower eyelid and periorbital skin as an integral whole. We rotated them integrally to reconstruct the defect but treated each lamella differently and delicately. Consequently, we named this new procedure lamellar rotation surgery. We vertically incised the lower eyelid tarsus and disconnected the inferior retractor and conjunctiva, sparing the anterior orbicularis muscle and skin. As a result, the temporal part of the tarsus attained a high degree of flexibility and adequate nutrition from the intact orbicularis muscle and eyelid skin. The lateral periosteal flap was used not only to form a new lateral canthal tendon but also to reconstruct the posterior lamella to support the eyelid tissue.
The reconstructed upper eyelid should be more stable after lamellar rotation surgery than after the Cutler-Beard procedure because of the rotated tarsus. The pedicle of the Mustarde lid switch procedure may irritate the cornea because the intact tarsus of the lower eyelid maintains a degree of rigidity [1, 5], whereas our procedure could avoid this limitation due to the disconnected, flexible tarsus. In addition, the junction of the rotated flap and lower eyelid will be elongated because it comprises orbicularis skin. The flexibility of the upper eyelid will also improve after the first-stage surgery.
For a total upper eyelid defect, our procedure can provide a new eyelid margin to prevent upper eyelid skin contact with the cornea. The smooth surface and glands of the tarsus can also benefit the cornea.
A decrease in the length of the horizontal palpebral fissure and two-stage surgery are the limitations of our procedure. This procedure may also result in amblyopia if applied to children.
Our study also has the following limitations: a small sample size, non-comparative design because of the rare incidence, and short follow-up because of long-distance travel and economy.
Although we have treated only three cases, we believe that our procedure can help to address the challenge of upper eyelid defects and should complement existing surgical methods. However, all three cases were elderly individuals with tumours, and we have no experience with trauma or congenital colobomas. Further studies with larger sample sizes are required to further validate the findings of this study and to modify the procedure, for example, if there is a need for the superior lateral periosteal flap.
The new procedure may help to address the challenge of repairing full-thickness defects of the upper eyelid.
The author is grateful to Yu Nie, M.S., Feng Zhou, M.S., Weiyan Liang, Ph.D., Yingying Lu, Ph.D., Haihua Tang, Ph.D., at Tianjin Aier Eye Hospital, Yi Li, Ph.D. at Beijing Aier Eye Hospital for their assistance in this study. The author also thanks the Library of Tianjin Eye Hospital.
Availability of data and materials
The datasets produced during and/or analyzed during the current study available from the corresponding author on reasonable request.
QJL drafted, revised the manuscript and conducted operation. All authors have read and approved of the final manuscript.
Ethics approval and consent to participate
The study was approved by the Ethics Committee at Tianjin Aier Eye Hospital. Written informed consents were obtained from all participants.
Consent for publication
Written informed consent was obtained from the patients for publication and any accompanying images.
The authors declare that they have no competing interests and no financial competing interests.
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