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Reconstruction of the Eyelid Using A Myocutaneous Island Flap CHARLESSTEPHENSON,MD
Abstract: Traditionally, skin flaps have been based upon a contiguous skin pedicle. Recently the concept has re-emerged that the important blood supply frequently lies subjacent to the flap. A temporally based island flap composed of skin and orbicularis muscle, nourished only by its subjacent pedicle, has been successfully used in the reconstruction of 91 eyelid defects. [Key words: eyelid reconstruction, frozen section control, Hughes eyelid reconstruction, island flap, myocutaneous flap, tarsal graft, V-V construction.] Ophthalmology 90: 1 060-1 065, 1983
Traditionally when a skin flap has been prepared in reconstructive surgery, it has been customary to form the flap in a manner that will maintain an attachment to its contiguous skin for the purpose of assuring an adequate blood supply. There have been, however, isolated advocates of the use of island flaps based only upon a subcutaneous pedicle. In 1889 Manchot emphasized the concept that the most important blood supply of skin usually lies in subjacent, rather than contiguous tissue, 1
and in 1898, G. H. Monks described the reconstruction of an eyelid by means of an island flap based upon the superficial temporal artery.2 In Monks' procedure, the island of skin was brought into the lid defect through a subcutaneous tunnel. Esser (Holland, 1917) was well known as an advocate of the use of island flaps for neck and face reconstruction. The Esser flap, like Monks' procedure, was based upon a specific identified artery.3 Kazanjian and Converse, in their text on The Surgical Treatment of Facial Injuries, mention briefly the use of a temporally based island flap for eyelid reconstruction that was based upon random subjacent blood supply.4
Notwithstanding occasional reports such as these, the concept of the use of an island flap for eyelid reconstruction has gained very little acceptance, though it has recently become popular for reconstruction of the breast,S
From the Departments of Ophthalmology, University of California, San Diego. California, and Lorna Linda University School of Medicine, Lorna Linda, California.
Reprint requests to Charles Stephenson, MD, 9834 Genesee Avenue. Suite 316, La Jolla, CA 92037.
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neck,6 and other areas.7 The latter are large flaps composed of an island of skin that is transported and based upon a specific muscle pedicle whose vacular supply has been identified.s They are termed "myocutaneous flaps," although "musculocutaneous" would be semantically more accurate.9 In 1960, Kubacek,1O followed by Barronll and Emmett,12 published several articles advocating the use of small island flaps for reconstruction of nasal, paranasal, and forehead defects. Because of the excellent blood supply to the face, the small flaps that they described can be placed randomly without regard to a specific identified vascular element in the pedicle.
The reports of Kubacek et al stimulated me to adapt the island flap for eyelid reconstruction. This paper presents my experience in a series of 91 consecutive cases in which a small temporally based island flap composed of skin and orbicularis muscle was used to reconstruct the eyelid. This is the first report of a series of such cases and the first detailed description of the procedure. In 78 cases, the defect was between 30 and 70% of the eyelid width. In 13 cases, the myocutaneous island flap was combined with a modified Hughes procedure to reconstruct successfully defects of 70 to 100% of the lower eyelid. I did not find that combining the two procedures had any major benefit and is probably less time efficient than repairing the larger defects entirely by a modified Hughes procedure. The follow-up time in this series is 5 months to 5 years. Sixteen cases were upper eyelids and 75 cases were lower eyelids. Nasal, central, and temporal defects were reconstructed successfully by this method. A defect that extends into the lateral canthus, however, is somewhat more difficult to repair. The island flaps in
0161-6420/83/0900/1060/$1.10 © American Academy of Ophthalmology
STEPHENSON • MYOCUTANEOUS ISLAND FLAP
Fig 1. Myocutaneous island flap being developed for repair of central lower eyelid defect. (Can also be used for repair of upper eyelid defect). Incision line "a" is placed 2 mm above lateral canthal angle. Incision line "b" is placed at the level of the inferior margin oflid defect. Incisions are made through skin and orbicularis muscle.
Fig 3. V-V closure completed. The lid/cheek tissue is pulled upward and attached to deep fascia or periosteum oflateral orbital rim, (arrow), to prevent retraction of reconstructed lid.
this series are "random" in that no specific vascular elements are identified and incorporated into the pedicle. Due to the plethoric blood supply of periocular tissue, these flaps remain viable when the pedicle comprises only the supportive tissue deep to the orbicularis muscle in the area between the lateral orbital rim and the globe (Fig 11). In addition to the clinical confirmation in this series, this fact was also affirmed experimentally by the reconstruction of a large eyelid defect in a rhesus monkey in which fluorescein perfusion was used to monitor the flap development (Fig 18). My experience in this series agrees with the observation of Ian McGregor that ". . . the extremely rich blood supply of the eyelids permits survival of flaps with the most tenuous of attachments." 13 In two additional cases, a larger temporally based myocutaneous island flap was used successfully to line an exenterated orbit.
Fig 2. F1ap in position. To obtain the necessary flap mobility, the lateral canthal tendon and orbital septum are completely divided. The subjacent pedicle beneath that portion of the flap that is medial to the lateral orbital rim provides the principal blood supply to the flap (Fig II, arrow). Where a temporal segment of the lid is a component of the flap (Fig 2, arrow), its lower lid retractors and conjunctiva remain attached, and thus also nourish the flap, (Fig 5c).
TECHNIQUE
The flap is based in the lateral canthal area and advanced nasally with a V-Y closure (Figs 1-3). When the lower eyelid is to be reconstructed, the procedure is commenced by marking a horizontal incision line that extends temporally from a point 2 mm above the lateral canthal angle (Fig 1a). The length of of this line is one and onefourth times the horizontal dimension of the defect to be reconstructed. A second parallel line is then drawn below the first (Fig 1 b). The distance between "a" and "b" should approximate the vertical dimension of the eyelid defect. In an upper eyelid reconstruction, line "a" is placed 2 mm below the lateral canthal angle and line "b" is placed the appropriate distance above it. It should be emphasized that if the vertical proportions of the flap are greater than necessary, the cosmetic result will be impaired because the skin of the flap tends to become elevated and irregular in surface contour. If the flap, as initially prepared, has an excess of vertical dimension, the excess skin should be resected. In repairing lower eyelids with large vertical defects, a good cosmetic result is more likely when the flap is designed to be no more than 1 0 ml in vertical dimension and the inferior part of the defect is covered by a ftee skin graft (Figs 14-17). A useful feature of this operation is that when the resection is for a malignant tumor, much ofthe flap can be developed while awaiting the frozen section report. Only the lateral extent of the flap remains to be determined after the pathologist reports that the margins are free of tumor. After the required length of the flap has been defined, the temporal ends of the parallel incision lines are connected by a "V."
The initial incisions are made through the skin and most of the fibers of the orbicularis muscle. The appro-
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OPHTHALMOLOGY • SEPTEMBER 1983 • VOLUME 90 • NUMBER 9
Fig 4. Case I. Central 70% of lower tarsal lid resected for basal cell carcinoma.
Fig 6. Case I. The flap has been lined with a tarsal graft and is ready to be sutured to lateral canthal tendon. Observe deficiency of skin inferior to flap (arrow).
priate limb of the lateral canthal tendon is then severed completely. Ifmore mobility is required, the flap is pulled nasally and the pedicle palpated to determine the locus of restriction, and that area is divided. Common points of restriction are: undivided fibers of the orbicularis muscle, the lateral canthal tendon, and the lateral orbital septum. In repairing smaller eyelid defects, the reconstructed segment may be lined with conjunctiva that is advanced from the adjacent fornix. Except in the smallest defects, I now routinely use a free tarsal transfer graft from an upper eyelid to form the inner lamella of the reconstructed segment (Fig 5). Nasal or auricular cartilage is alternative tissue for this purpose. After the flap and any remaining temporal eyelid segment has been advanced and sutured into position, the lateral canthal angle is reformed with a 6-0 absorbable synthetic suture. To prevent retraction of the reconstructed lower eyelid, the flap should also be pulled upward and anchored to the
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Fig 5. Case I. Remaining temporal segment of lid (a) moved nasally, and free tarsal graft from upper lid (b) sutured to lateral margins. Conjunctiva and lower lid retractors remain attached to mobilized temporal segment (c). The island of skin and orbicularis muscle is "d."
Fig 7. Case I. Note that skin deficiency in Figure 6, has been eliminated by undermining and pulling the remaining lid/cheek tissue upward and attaching it to periosteum of lateral orbital rim.
Fig 8. Case I. Six months after surgery.
STEPHENSON • MYOCUTANEOUS ISlAND FLAP
Fig 9. Case 2. Basal cell carcinoma that is encroaching on medial canthus.
Fig 11. Case 2. The mobilized island flap and its subjacent pedicle (arrow).
Fig 13. Case 2. Six months after surgery.
Fig 10. Case 2. Tumor excision was frozen section monitored using free strip margins and mapping.
Fig 12. Case 2. Immediately after surgery.
periosteum of the lateral orbital rim (Fig 3, arrow). In an upper eyelid reconstruction, it is important to employ a temporary tarsorrhaphy for 10 days to prevent retraction of the reconstructed segment.
CASE REPORTS
Case No.1. A 73-year-old white man presented with a small cicatricial ectropion of the left lower lid and a rather subtle lesion on the lid margin that was reported to be of 8 months duration. A biopsy determined the presence of a basal cell carcinoma. At the definitive surgery, a full-thickness segment of the tarsal lid was resected en bloc. This resection was judged to include all of the tumor plus 2 mm clear margins. Free strip margins approximately 2 X 7 mm in size were then excised from the borders of the remaining lid. They were placed on a diagram of the surgical site and labelled. Frozen sections of
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OPHTHALMOLOGY • SEPTEMBER 1983 • VOLUME 90 • NUMBER 9
Fig 14. Case 3. After free strip margin mapping with frozen section controlled resection of fourth recurrence of sclerosing basal cell carcinoma. (No mapping or frozen section control of previous resections)
Fig 16. Case 3. A free skin graft (arrow) supplements the flap.
Fig 18. Pedicle (arrow) that successfully sustained an experimental island flap eyelid reconstruction in a rhesus monkey. '
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Fig 15. Case 3. The flap lacks the vertical dimension to fill the defect completely.
Fig 17. Case 3. Six months after surgery. (No recurrence of tumor in a 5-year follow-up.)
these specimens revealed residual tumor in both temporal and nasal margins. To obtain clear margins, it was ultimately necessary to resect 70% ofthe tarsal lid (Fig 4). Reconstruction was by means of a myocutaneous island flap with free tarsal graft (Fig 5b) transferred from an upper lid. In the three years since surgery, there has been no recurrence of tumor; the lid has maintained a normal position, and the eye is comfortable (Fig 8).
Case No.2 (Figs 9-13). A 77-year-old white woman presented with a large elevated lesion on the nasal one-third of the left lower eyelid of 3 years duration (Fig 9). Biopsy determined that it was a basal cell carcinoma. Definitive tumor resection was monitored by the same type of frozen section control as in case No. 1. Approximately 50% of the lid and part of the medial canthus was resected (Fig 10). Reconstruction was by means of a myocutaneous island flap and a free tarsal transfer graft from an upper lid (Figs 11, 12). The reconstructed lid has remained in good position; the eye remains comfortable, and there has been no tumor recurrence in a 3-year follow-up.
Case No.3 (Figs 14-17). A 58-year-old white woman pre-
STEPHENSON • MYOCUTANEOUS ISLAND FLAP
Table 1. Indications for Eyelid Reconstruction
Malignancy Trauma Congenital anomaly
Total Cases
81 6 4
91
Table 2. 10 Complications in Series of 91 Cases
Upper eyelid retraction Lower eyelid retraction Wound separation Ectropion (lower eyelid) Symblepharon
3 2 2 2 1
10
sented in 1978 with a biopsy proven recurrent sclerosing basal cell carcinoma in the right lower eyelid and medial canthus. There had been four previous resections of a similar tumor in this location in the antecedent 14 years (none with frozen section or mapping control). The eyelid now had a medial ectropion and fixation to underlying tissue. Frozen section control, as in the previous cases, was used to monitor resection of the nasal one-half of the eyelid and of medial canthal soft tissue (Fig 14). Resection was carried through muscle and to the periosteum of the anterior lacrimal crest. Reconstruction was by means of a myocutaneous island flap, supplemented inferiorly with a free skin graft (Figs 15, 16). There has been no tumor recurrence in the five years since this surgery.
Case No.4 (Fig 18). This case is included primarily to demonstrate the pedicle upon which the myocutaneous flap is based. Ninety percent of the lower tarsal lid was resected experimentally in a rhesus monkey. Sixty-five percent of the lid was reconstructed by a large myocutaneous island flap, and the remainder was reconstructed with a small Wendell Hughes-type tarsoconjunctival flap. With the flap attached only by a small subjacent pedicle (Fig 18), intravenous fluorescein was injected. The flap did not perfuse quickly or uniformly, however, the skin tone of the flap remained normal after surgery and there was no suggestion of any necrosis.
SUMMARY AND DISCUSSION
An operation is described for reconstruction of the eyelid using an island pedicle flap composed of skin and
orbicularis muscle. The procedure has been found to be effective in the repair of defects of 30 to 70% of the eyelid width. This report is based upon a series of 91 cases. The indications for eyelid reconstruction in this series are listed in Table 1. There were ten complications (Table 2); but in no instance was there a problem with viability of the island flap. The three complications of upper eyelid retraction occurred early in the series. There have been no instances of such a post-operative retraction since an intermarginal suture has been routinely placed and maintained between the temporal one-third of the eyelids for ten days after surgery. The one case of symblepharon also occurred early in the series and was caused by preparation of a flap that was too short horizontally.
REFERENCES
1. Manchot C. Die Hautarterien des mensch lichen K6rpers. Leipzig: Vogel, 1889; 1-56.
2. Converse JM. Kazanjian & Converse's Surgical Treatment of Facial Injuries, 3d ed. Baltimore: Williams & Wilkins, 1974; Vol. 1,526.
3. Esser JF. Studies in plastic surgery of the face. I. Use of skin from the neck to replace face defects. II. Plastic operations about the mouth. III. The epidermic inlay. Ann Surg 1917; 65:297-315.
4. Kazanjian VH, Converse JM. The Surgical Treatment Of Facial Injuries. Baltimore: Williams & Wilkins, 1949; 223.
5. MUhlbauer W, Olbrisch R. The Latissimus dorsi myocutaneous flap for breast reconstruction. Chir Plast 1977; 4:27.
6. Bertotti JA. Trapezius-musculocutaneous isla.nd flap in the repair of major head and neck cancer. Plast Reconstr Surg 1980; 65: 16-21.
7. McCraw JB, Penix JO, Baker JW. Repair of major defects of the chest wall and spine with the latissimus dorsi myocutaneous flap. Plast Reconst Surg 1978; 62:197-206.
8. Mathes JS, Nahai F. Clinical Atlas Of Muscle And Musculocutaneous Flaps. SI. Louis: CV Mosby, 1979; vii-xii.
9. McCraw JB, Dibbell 00, Carraway JH. Clinical definition of independent myocutaneous vascular territories. Plast Reconstr Surg 1977; 60:341-52.
10. Kubacek V. Transposition flaps on the face on a subcutaneous pedicle. Acta Chir Plast 1960; 2:108.
11. Barron IN, Emmett AJJ. Subcutaneous pedicle flaps. Br J Plast Surg 1965; 18:51-78.
12. Emmett AJJ. The closure of defects by using adjacent triangular flaps with subcutaneous pedicles. Plast Reconstr Surg 1977; 59:45-
52. 13. McGregor IA. Fundamental Techniques Of Plastic Surgery and Their
Surgical Applications, 6th ed. Edinburgh: Churchill Livingstone, 1975; 244.
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