Journal of Surgery Current Trends & Innovations Category: Clinical Type: Research Article
Choosing the Appropriate Reconstructive Technique for Eyelid Defects after Tumor Excision
- Sokol Isaraj1*, Ina Kola2, Erisa Kola3
- 1 Department Of Surgery, “Mother Theresa” University Hospital Center Of Tirana, Tirana, Albania
- 2 Plastic Surgery Resident, “Mother Theresa” University Hospital Center Of Tirana, Tirana, Albania
- 3 Department Of Pathology And Forensic Medicine, “Mother Theresa” University Hospital Center Of Tirana, Tirana, Albania
*Corresponding Author:Sokol Isaraj
Department Of Surgery, “Mother Theresa” University Hospital Center Of Tirana, Tirana, Albania
Received Date: Oct 16, 2019 Accepted Date: Oct 30, 2019 Published Date: Nov 06, 2019
Due to the anatomic location reconstruction of the eyelids after tumor removal remains one of the most challenging tasks in reconstructive surgery. Our strategy favors a progression from direct closure, when possible, to use of local flaps in combination with chondro-mucosal grafts for bi-lamellar reconstruction.
Material and methods
After institutional review board approval, we collected and analyzed the medical records of 97 patients who underwent eyelid surgery for skin cancer between May 2016-May 2019 in a tertiary care center.
97 patients were operated for a skin cancer of the eyelid over the 3 years period. There were 52 males and 45 females aged between 36 to 84 years. The lower eyelid was the most common site involved, followed by the medial canthus, upper eyelid and the lateral canthus. The histopathological report classified basal cell carcinoma as the most common type. Surgical techniques progressed from simple excision and direct closure, to complex reconstructions such as skin grafting, cantholysis, flaps plus septal chondro-mucosal grafts for subtotal or total eyelid reconstruction.
This is a retrospective, descriptive study with emphasis on the different surgical techniques along with the outcomes of three patients after eyelid reconstruction with chondro-mucosal graft and skin flaps. The present study emphasizes the advantages of using chondro-mucosal grafts in comparison to other grafts. We were able to achieve excellent aesthetic outcomes without facing any structural complications such as flap failure, dehiscence, infection, ectropion, recurrence, irregular eyelid margins.
A single-stage reconstruction has been our target, without compromising the functional and aesthetic results .
MATERIALS AND METHODS
Tumors were located on the lower eyelid in 46 patients (48%), on the upper eyelid in 9patients (9%), involvement of the medial canthus was found in 37 patients (38%) and the lateral can thus was affected in only in 5 patients (5%) (Figure 2).
Based on the histopathological report, basal cell carcinoma was the most frequent type of cancer, present in 73 patients (75%), followed by squamous cell carcinoma in 19 patients (2%), sebaceous gland carcinoma in two patients (2%), keratoachanthoma in two patients (2%) and fibrous histiocytoma in only one patient (1%) (Figure 3).
Small-sized tumors located on the lower eyelid skin with less than 3 mm in diameter, which involved less than 20% of the lid margin were excised with healthy tissue margin and closed primarily. This approach was used in 20 patients (Figure 4).
Medium-sized tumors located on the lower eyelid, larger than 4 mm in diameter, were excised with 3-4 mm healthy tissue margin. For the reconstruction, neighboring tissue flaps are preferred such as cheek advancement flap, glabellar flap, paramedian forehead flap, nasolabial flap, Trippier flap, dorsal nasal flap and transposition flap. Alternative options involve full-thickness skin graft harvested from the postauricular region, supraclavicular region and split-thickness skin grafts.
In patients with large-sized tumors that affected more than 50 percent of the lower eyelid or full defect of the eyelid, the internal layer was reconstructed with a chondro-mucosal graft and the external layer was reconstructed with cheek advancement flap or paramedian forehead flap. Although grafts can be harvested from the ear (as a composite chondro-cutaneous graft) or the hard palate mucosa, in our patients, grafts were, in all cases, taken from the nasal septum. A large nasal septal chondro-mucosal graft was harvested and divided to separately reconstruct the lower eyelid posterior lamella and in one case the upper eyelid. In brief, an incision through one layer of mucosa and cartilage was followed by sub-perichondrial freeing of cartilage from the mucosa of the other side. Grafts were secured to medial and lateral tissues with absorbable sutures. The nasal mucosa was used as coverage of conjunctival defect, whereas the septal cartilage used as supporting material. The outer layer of the lower eyelid was covered with a cheek advancement flap in two patients (for lower lid reconstruction), and in one patient the paramedian forehead flap was used (for upper lid reconstruction). The ultimate goal in eyelid reconstruction for full-thickness defect, should address the inner layer (conjunctiva and tarsus), and the outer layer (skin and muscle).
In 37 patients, the tumor was located in the region of the medial canthus. In two patients with small defects, they were closed by direct suturing. In 35 patients with medium to larger defects, glabellar flap, paramedian forehead flap, nasolabial flap, Limberg flap and a rotation flap from the dorsal nasal skin and full-thickness skin graft harvested from the retro auricular region, supraclavicular region, were used.
In 5 patients the tumor was located in the region of lateral canthus. In one of those the defect was closed primarily after a cantholysis, and in three others cheek advancement flap, bilobed flap and temporal transposition flap were used.
In 9 patients the tumor was located in the upper eyelid. In four of them the defect was small and closed primarily and in five others the resultant defect was of medium size and was closed by means of a flap: paramedian forehead flap, bilobed flap. In one patient with full-thickness defect with total eyelid removal, the chondro-mucosal graft was used for the posterior lamellar reconstruction and a paramedian forehead flap (on a subcutaneous pedicle) for skin resurfacing.
Case presentation 1
Postoperative functional and cosmetic results were satisfactory (Figures 5E and 5F). In long-term follow up, no signs of ectropion were seen; the septal donor site showed good healing, scar formation was minimal.
Case presentation 2
Case presentation 3
Postoperative functional and cosmetic results were acceptable, four months follow-up showing very good cosmetic results.
In our series of patients, we noticed a slight predominance of males, and the major part of them, were at the sixth decade of life when diagnosed. After critical review of the literature we noticed that in various different studies the lower eyelid was the most common site affected by malignant tumors . The left eyelid was most commonly associated with malignant tumors. These results are explained by the chronic UV exposure, that makes the lower eyelid more predisposed to various types of skin cancers. On the other hand, driving is linked to more skin cancers on the left part of the face, consequently the eyelid tumors are not symmetrically distributed .
Histologically, basal cell carcinoma was the most common type . Basal cell carcinoma based on its biological behavior, most commonly presents as ulceration on the surface that doesn’t go away, hence it raises concerns and make patients seek medical advice earlier . However, we encountered a lot of cases who presented with bigger lesions. This is due to their negligence to seek medical advice or to health infrastructure making it sometimes difficult to present sooner, because of their slow growth and resemblance, to benign lesions especially in the initial stage. Late surgical treatment is a significant negative prognostic factor.
Tumors located in the immediate vicinity of the eyelid margin require prompt and radical management . As a basic principle in plastic surgery, grafts should be used when there is an adequate vascular bed to enhance their survival. Therefore, combining a nonvascularized graft for one lamella with a vascularized flap for the other should be the rule . Mustardé incorporates the cheek advancement into defects >25% of the lower lid up to total lower lid losses, he prefers a free composite graft of nasal septum covered by the flap (30). We believe that the cheek advancement flap procedure is the most effective procedure for the reconstruction of the outer layer of the lower eyelid, as other reports have also indicated . It offers considerable amount of skin with very little deformity of the donor area, while the flap is thin and no bulkiness is generally seen when healing is completed. For larger eyelid defects, the surgeon should evaluate the degree of horizontal eyelid laxity before choosing the reconstructive procedure . An ideal eyelid reconstruction should be by replacing the missing tarso-conjunctival structures and skin, protecting the globe, giving the area a natural appearance, with only minor donor defect morbidity, being completed as a one-stage procedure . These preliminary results show that the technique can be used in both lower and upper eyelid full thickness reconstructions . Reconstruction of upper eyelid defect is very intricate, because, unlike the lower eyelid, there is not enough available tissue around it and preservation of function and contour is more demanding to achieve .
As a graft for an inner layer, chondro-mucosal grafts from the nasal septum have been used, for many years. Grafts from other sites including upper lateral nasal cartilages, full-thickness grafts from the contralateral lid, ear cartilage, buccal mucosa, and hard palate mucosa have also been reported to provide good results . According to some authors, mucous membrane harvested from the palate together with the stroma resembles histologically the tarso-conjunctival component . The disadvantages of this type of graft are as follows: (1) the surgeon may be unfamiliar with the donor region; (2) the graft may contain a minor salivary gland, leading tomucoid secretion that is difficult to treat; and (3) metaplasia of the epithelium occurs 3 to 6 months after surgery, making the technique unadvisable for upper eyelid repair because of the risk of corneal abrasion. Postoperative pain and discomfort were also reported with this type of graft . The harvest of ear cartilage is simple, and its morbidity is minimal. Moreover, ear cartilage has a spherical surface and fits well to a bulbar surface . The disadvantage of using ear cartilage graft is that there is no mucosa combined with the ear cartilage grafts. According to us, referring to Marks and coworkers, auricular composite grafts are too thick to be considered perfect for eyelid replacement . Where as Matsuo and associates feel that conchal cartilage is ideally suited for lower eyelid reconstruction, as it is thin and supple and resembles the curvature of the globe. They report using conchal cartilage grafts alone when eyelid support and lining are needed, placing the graft in such a way that the graft perichondrium forms the posteriorlamella. Epithelialization from the surrounding mucosa is noted in 3-4 weeks .
Both a chondro-mucosal graft from the nasal septum and an ear cartilage graft are free grafts without a blood supply. Nasal chondro-mucosal grafts have been recommended because of the strong hyaline cartilage of the nose, which is closely associated with the mucus secreting lining of the nasal mucosa . To prevent corneal irritation, a small fringe of nasal mucosa must be turned anteriorly over the cartilage to meet the remaining skin of the eyelid so that squamousepithelium does not come into contact with the globe . Mustardé favors septal mucosal grafts because of the long-term stability of this cartilage . The disadvantage is the length of the procedure, as the dissection of the chondro-mucosal flap should be careful and gentle, to reduce chances of perforation of the nasal septum and nasal bleeding .
Most of cases are cancers of basal cell type and, if treated early, can result in better functional and cosmetic result. Customizingre construction is necessary to provide the proper surgery for each patient. Excision of the lesion with a 3- to 4-mmmargin is believed to be a safe management in basal cell carcinoma.
Reconstruction of the defect is done according to the size of the defect and the involvement of the different layers of the lids, from simple closure for defects of less than 1/3 of the palpebral fissure, to skin grafts for defects only of the skin, and complex reconstruction with chondro-mucosal grafts and flaps for skin replacement. Appropriate reconstruction surgery management requires a specialized plan for each patient.
This study has demonstrated the two most significant factors in achieving good reconstruction results: The composition of the graft for internal lining and the design of the flap for external cover.
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Citation: Isaraj S, Kola I, Kola E (2019) Choosing the Appropriate Reconstructive Technique for Eyelid Defects after Tumor Excision. J Surg Curr Trend Innov 3: 023.
Copyright: © 2019 Sokol Isaraj, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.