We read a very interesting article that was recently published in Plastic and Reconstructive Surgery regarding a subcutaneous pedicle flap technique for eyelid reconstruction.1 The authors suggested the orbicularis oculi myocutaneous vertical V-Y advancement flap technique for treating upper eyelid defects. They reported the method to be simpler and less invasive than other techniques, in addition to allowing a good functional and aesthetic reconstruction for all the patients treated.
We have previously attempted a similar technique for a patient with meibomian gland cancer of the upper eyelid, and have already published a case report on this technique2 (Fig. 1). In our opinion, the vertical V-Y advancement flap technique is particularly suitable for elderly patients with slack skin. When an advancement flap is set downward from the upper region, the flap may easily retract due to the contraction of the wound around the flap, which may consequently cause ectropion. Thus, it is better to shift the flap in the horizontal direction. For this purpose, the horizontal advancement flap3 and the Mustardé switch flap4 are adequate, and are currently the most frequently used flaps. However, in some cases in which there is excess skin, where the defect is horizontally long and vertically short, the vertical advancement flap is useful (Fig. 2). In such cases, Z-plasty on the vertical scar may be necessary at a later stage. When making the vertical V-Y flap, relaxed upper eyelid skin and definitely making the pedicle are needed.
Another essential key to success is the longer mucosal graft for the conjunctival defect. To reconstruct a full-thickness defect and a posterior lobe defect of the upper lid, hard-palate mucosa is preferred in our institution. This probably causes mucosal atrophy to some degree; therefore, a mucosal graft that is 1.5 mm longer should be applied when treating conjunctival defects. We believe that appropriate surgical indication, careful consideration of the flap, and sufficient abruption of the pedicle, as mentioned above, lead to excellent lid reconstruction and avoid ectropion.
Kenji Kusumoto, M.D., Ph.D.
Natsuko Kakudo, M.D., Ph.D.
Department of Plastic and Reconstructive Surgery
Kansai Medical University
Yutaka Ogawa, M.D., Ph.D.
Otowa Memorial Hospital
1. Demir Z, Yüce S, Karamürsel S, Celebioglu S. Orbicularis oculi myocutaneous advancement flap for upper eyelid reconstruction. Plast Reconstr Surg.
2. Kakudo N, Shimotsuma A, Ogawa Y. Use of local flap for reconstruction of the upper eyelid after surgery for malignancy. Jpn J Clin Ophthalmol. (Rinsho Ganka)
3. Okada E, Iwahira Y, Maruyama Y. The V-Y advancement myotarsocutaneous flap for upper eyelid reconstruction. Plast Reconstr Surg.
4. Mustardé JC. Reconstruction of the upper lid, and the use of nasal mucosal grafts. Br J Plast Surg.
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