Single-stage reconstruction of a large lower eyelid defect using a full-thickness bilamellar autograft

Dear Editor,

Large full-thickness lower eyelid defects are reconstituted by the Hughes [1] procedure, which advances a nourishing flap with a blood-supplying pedicle combined with another free graft or a flap. However, it is a “two-stage” surgery with visual axis obscuration for several weeks and requires a secondary surgery to divide the pedicle, which is both time-consuming and tiring with pedicle-related complications. Therefore, “one-step” surgical alternatives have been developed such as advancement/rotation flaps combined with a flap or a graft to avoid these drawbacks [2]. Recent investigations have reported that a flap with a blood-supplying pedicle is not obligatory to ensure sufficient perfusion to the newly repaired defective eyelid, which is supplied by the rich vascularity of the eyelid margin remnants and the tear film, suggesting a “one-step” grafting instead of “two-step eyelid-sharing” surgeries [3]. Furthermore, a porcine model has recently demonstrated the viability of a bilamellar autograft as a “one-step” alternative and suggested trying this approach in humans [4].

All these findings advocate that “single-step” reconstruction by using bilamellar autograft (myocutaneous + tarsoconjunctival = TC) is possible for simultaneous repair of the anterior and posterior lamellas in such defects. Therefore, the present case reports the procedure’s clinical utility and delineates the surgical technique with the long-term functional and cosmetic outcomes.

Herein, I introduce a “single-step” surgical repair technique by a free full-thickness bilamellar autograft in a non-smoking 52-year-old woman with a large lower eyelid defect (> 50% in-width) following malignant tumour excision. The patient had no cardiovascular disease or poor wound healing. The defect had medial and lateral tarsal remnants and an insufficient amount of redundant surrounding skin.

The boundary of visible tumour of the left lower eyelid (Fig. 1A) was first identified (Fig. 1B, yellow-arc) and the tumour was excised with a 3-mm safety margin (Fig. 1B, red-arc) on each site (Fig. 2A), and sent for histopathological analysis (basal cell carcinoma). Bilamellar autograft, smaller than the horizontal opening, was harvested by excising a pentagon from the middle of the opposite lid (10 × 7 mm) (Fig. 2B) to allow direct suturing of the iatrogenic defect. The graft was transplanted to the defective area with its conjunctival side lying on the globe (Fig. 2B) and the graft edges were sutured (6/0 absorbable) to the medial, proximal and lateral marginal remnants in three layers: one – the deeper TC-eyelid retractors, two – the middle orbicularis muscle, three – the skin so that the autograft maintains sufficient local oxygenation from the near periphery (Fig. 2C). The knots were buried anteriorly to prevent contact with the globe.

A dressing was placed with topical ointment 3-times a day for a week. The first-week control revealed a viable autograft without any signs of sloughing or rejection (Fig. 2D). No complications were encountered but madarosis with trichiasis developed at the repaired area. Margin erythema of the repaired lid was not seen, which is a frequent complication of “double-stage” surgeries. The follow-up-time was 18 months. The aesthetic outcome was excellent as the final eyelid position was within 1 mm of the contralateral side (Fig. 2F) without graft ischemia, necrosis or failure, but madarosis. The functional result was also satisfying as ocular protection was sufficient. The patient did not require any further surgery.

The repair of large eyelid defects needs a skilful approach regarding the eyelid contour and stability. The basic restoration principle for larger defects (> 50% in length) is to combine one nourishing pediculated-flap for one lamella with another graft/flap for the other lamella so that adequate perfusion of the blood is supplied to the newly reconstructed areas [1]. However, these “two-step lid-sharing” procedures have the disadvantage of long-lasting visual axis blockage for several weeks with a secondary intervention and pedicle-associated complications [1]. As a result, several “single-stage” approaches have been reported like bipedicle TC flaps and flap-graft combinations [2]. I presented a “single-stage” alternative to previously described “one-step” options and used only one bilamellar autograft for large eyelid defect repair. In fact, auto-transplantation of a bilamellar graft to the defective lid contradicts accepted doctrine and maybe an invitation to complete failure from ischemia. However, here is shown that it is not the case and excellent outcomes were obtained with immediate visual rehabilitation. This finding is encouraging and supports the recent animal, experimental and clinical reports with viable and healed grafts, suggesting diffusion from the rich oxygenated nearby vascularity and the tear film followed by a vascular ingrowth from the remaining healthy eyelid margin. Healing by secondary intention may also be another possible contributing factor for graft survival. This indicates that a vascularized pedicle may be unnecessary and the surgeon can get away with the problem if the defect size is not larger than two-thirds of the horizontal lid margin and if the harvested graft is not larger than 10–12 mm horizontally and 6–8 mm vertically. Our finding was consistent with the result that a vascularized pedicle is unnecessary for tarsal flaps (< 13 mm in width) and with the bilamellar autografts in animal models [4]. The closest technique to the present approach is upper lid repair using two composite eyelid-margin autografts [5]. However, this approach needs again a local myocutaneous advancement flap along with full-thickness incisions of the donor’s both upper and lower eyelids in the sound eye.

Various advantages of the present technique can be summarized as:

1) large (but not the whole) eyelid defects can be repaired in a “one-step” manner;

2) vertical tension of eyelid-sharing operations does not occur;

3) the meibomian gland orientation is normal as it allows the free bilamellar graft turning upside-down when compared with “double-stage” procedures that cause non-physiological inverted oil flow; 4) covering the seeing eye does not require; 5) donor-site complications of “two-step” procedures (retraction, entropion) are not encountered; 6) recipient-site drawbacks (marginal eyelid erythema) do not occur; 7) operation time is short; and 8) it does not require a second surgical intervention.

In conclusion, the “single-step” repair by using bilamellar graft is an easy, fast, safe and effective procedure with a short learning-curve and may be a reconstruction alternative to conventional “two-step” procedures and modern “one-step” options. However, flap-flap or flap-graft combinations are obligatory if the defect size involves more than two-thirds of the lid margin or if poor wound healing is anticipated.

Funding: The author received no financial support for the research, authorship, and publication of this article.

Conflict of Interest: Author Cem Evereklioglu declares that he has no conflict of interest.

Ethics approval: The procedure performed in the study involving a human participant was in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Institutional Review Board of Erciyes University approved this study (approval number: 2022/79)

Informed consent: Informed consent was obtained from the individual participant.

Patient consent: The patient signed informed consent regarding publishing her data and photographs.

Dr. Cem Evereklioglu

Department of Ophthalmology

Division of Oculoplastic, Orbital and Lacrimal Surgery

Erciyes University Medical Faculty

Kayseri

Turkey

e-mail: cemevereklioglu@gmail.com