UPPER EYELID INJURY WITH PARTIAL LOSS. CASE REPORT

INTRODUCTION

Upper eyelid injuries with loss of tissues can be treated in various ways depending on the scope and location of the defect. Some form of flaps and grafts can be used for reconstruction ^1–9. Use of a transposition skin flap with tarsal and conjunctival reconstruction is one of the options of reconstructing partial loss of the upper eyelid¹. A similar procedure was used also in our patient with partial loss of her upper eyelid.

CASE REPORT

A 31-year-old patient sustained an injury with 40% loss of the lateral part of her upper eyelid on the left side after a fall. A full-thickness defect of the eyelid affected the lateral canthal tendon in the direction medially towards the residual part of the eyelid. Supraorbitally, there was a margin of the levator aponeurosis (Fig. 1). Medical history without any complaints. In preoperative history there was no ocular or eyelid pathology.

The missing part of the tarsus was reconstructed using a cartilage graft harvested from the dorsal access, from the concha of the left auricle. The cartilage was thinned and sutured into the defect. We fixed the cartilage graft in place to the medial part of the upper eyelid tarsus, in the lateral part to the lateral canthal tendon and supraorbitally to the levator aponeurosis.

The conjunctival defect was reconstructed in the extent of 80% by mobilization of conjunctiva from the fornix. The remaining part of the defect was left to heal spontaneously by epithelization. The cutaneous part of the eyelid was reconstructed using a transposition flap with the base in the lateral part. The flap was mobilized above the defect, under the eyebrows. The secondary defect was covered with a full-thickness skin graft from the postauricular area (Fig. 2). Ocular irritation during the healing period was controlled using steroid drops and ointment. The course of healing was free of complications (Fig. 3 a, b). The skin graft was excised three months after the reconstruction. At the same time we reduced the skin excess of the flap. Both the appearance and function of the eyelid are satisfactory two years after the surgery (Fig. 4).

DISCUSSION

In case of an upper eyelid injury with loss of tissue, it is very important to perform reconstruction to restore protection of the cornea and bulbus. When treating an eyelid defect, functional and aesthetic requirements must be taken into account. The method of closure of the upper eyelid defect depends on its extent and location.

Direct suture with possible lateral cantholysis can be performed in some cases ^1–4. In larger defects, various types of flaps and grafts can be used including their combinations. For example, the sliding tarsoconjunctival flap^2–4, semi-circular flap (Tenzel)⁵, bridge flap (Cutler-Beard)⁶, Mustardé lid switch flap⁷, or temporal forehead flap (Fricke)^2,3 can be used for the reconstruction.

As regards the free grafts, mucosa of the mouth can be used for conjunctival replacement^2–4, the tarsus and conjunctiva can be replaced using a tarsoconjunctival graft from the contralateral upper eyelid ^2–4,8 or nasal chondromucosa ^1,4. For example, a skin graft from the postauricular area ^1,4,8,9 or from the contralateral upper eyelid ^1,2,4,9 can be used to replace the skin cover.

Carraway described the use of a composite septal mucosal graft and a local pedicle flap. A pedicle flap is mobilized from the remaining upper eyelid skin and brought in place over the graft¹.

Scuderi et al. used a nasal chondromucosal flap for the reconstruction of total and subtotal upper eyelid defects. A skin graft is applied for skin coverage ⁹.

Patrinely et al. used a tarsoconjunctival graft from the contralateral upper eyelid to reconstruct the upper eyelid. A bipedicle myocutaneous advancement flap is then fashioned from the remaining superior eyelid tissue, and sutured to the anterior surface of the graft. Bipedicle donor site is then closed with a full-thickness skin graft ⁸.

Ear cartilage should not be in direct contact with the cornea because of the risk of corneal damage ^2,4. Some authors suggest that this can by overcome, for example, by moving the conjunctiva from the upper fornix to cover the inner surface ⁴.

Ear cartilage can be used, for example, together with the Cutler-Beard flap to complete the upper eyelid tarsus ^2,3.

In our case, we decided to reconstruct the upper eyelid tarsus using an ear cartilage which could be largely covered with mobilized conjunctiva. The skin cover was reconstructed with a transposition flap. This procedure preserves the lower eyelid intact. The method offers an alternative solution for a defect in the lateral part of the upper eyelid.

Declaration of interest: The author report no conflict of interest. The author alone is responsible for the content and writing of this article.

Corresponding author:

Ivo Němec, M.D.

Trauma Center, Military University Hospital Prague

U Vojenské nemocnice 1200,

Prague 6, 169 02,

Czech Republic

E-mail: Ivo.Nemec@uvn.cz