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Lower Eyelid Reconstruction: A New Classification Incorporating the Vertical Dimension

Alghoul, Mohammed S. M.D.; Bricker, Jonathan T. B.A.; Vaca, Elbert E. M.D.; Purnell, Chad A. M.D.

Plastic and Reconstructive Surgery: August 2019 - Volume 144 - Issue 2 - p 443-455
doi: 10.1097/PRS.0000000000005882
Reconstructive: Head and Neck: Original Articles
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Background: Lower eyelid defects are traditionally classified based on depth and 25 percent increments in defect width. The authors propose a new classification system that includes the vertical defect component to predict functional and aesthetic outcomes.

Methods: A retrospective review of patients who underwent lower lid reconstruction performed by a single surgeon was performed. Defects were classified into four categories based on the vertical component: (1) pretarsal; (2) preseptal; (3) eyelid-cheek junction; and (4) complex pretarsal/preseptal. Preoperative and postoperative central and lateral marginal reflex distance-2 values were obtained. Aesthetic outcomes were evaluated by three blinded reviewers. Outcomes were compared using one-way analysis of variance and analysis of covariance with Bonferroni corrected post hoc comparisons to control for defect area and width.

Results: Thirty-four patients underwent reconstruction of lower eyelid defects. There were 12 pretarsal defects (type I), nine preseptal defects (type II), nine eyelid-cheek defects (type III), and four complex pretarsal/preseptal defects (type IV). Postoperative retraction was highest in the complex pretarsal/preseptal group at 75 percent, with a significantly greater change from preoperative to postoperative central and lateral marginal reflex distance-2 compared with the other groups (p < 0.01) and worse postoperative mean aesthetic scores (p < 0.001). Type IV patients had significantly more revision operations (mean, 5.5) compared with the other groups (p < 0.001).

Conclusions: The vertical dimension of lower eyelid defects is an important variable. A new classification system is proposed that supplements width-based methods for improved surgical planning and prediction of postoperative outcomes in lower eyelid reconstruction.

CLINICAL QUESTION/LEEVL OF EVIDENCE: Therapeutic, IV.

Chicago, Ill.

From the Division of Plastic and Reconstructive Surgery, Northwestern Memorial Hospital.

Received for publication May 23, 2018; accepted December 27, 2018.

Presented at the Midwestern Association of Plastic Surgeons Annual Meeting, in Chicago, Illinois, April 14, 2018.

Disclosure:None of the authors have conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s website (www.PRSJournal.com).

Mohammed S. Alghoul, M.D., Division of Plastic and Reconstructive Surgery, Northwestern Memorial Hospital, 675 North St. Clair Street, Galter Building, Suite 19-250, Chicago, Ill. 60611, mo.alghoul@gmail.com, Instagram: @mohammedalghoulmd, Twitter: @DrMoAlghoul, Facebook: @dralghoul

Functional outcomes are paramount when reconstructing lower eyelid defects by maintaining the normal lower eyelid height, position, and closing mechanics to protect tear film integrity. In addition, criteria for an aesthetic reconstruction include the following: (1) recreating a natural lid margin that contours to the globe resting at the lower scleral limbus that is distinct from the preseptal segment, (2) anterior lamella resurfacing with skin that has qualities similar to those of the contralateral side, and (3) restoring a crisp lateral scleral triangle and canthal angle.

Traditional teaching in lower eyelid reconstruction endorses replacement of the bilamellar structure with a combination of grafts and flaps based on defect depth and width. As such, defects are classified based on 25 percent increments of lower eyelid width.1–4 An often overlooked yet critical component in eyelid defect reconstruction is the missing vertical subunit(s) (Fig. 1). As a defect involves more vertical components, structural support of the eyelid is progressively lost. Furthermore, as the vertical defect height increases, the ability to use local flaps while maintaining low tension on the lid margin becomes more challenging. It has been our experience that defects involving both the lid margin and underlying support structures are particularly challenging and at high risk for postoperative lower lid malposition.

Fig. 1.

Fig. 1.

In this article, we propose and evaluate a new classification of lower eyelid defects, based on the missing vertical subunits. We hypothesized that the vertical component of an eyelid defect can predict the risk of lower lid malposition and aesthetic outcomes after reconstruction. Our aim is that this classification system will complement existing width-based algorithms and aid in operative planning and patient counseling on the risk of postoperative lower lid malposition.

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PATIENTS AND METHODS

We performed a retrospective chart review of patients who underwent reconstruction of lower eyelid defects from 2013 to 2017 performed by the senior author (M.S.A.). Clinical lower lid retraction was evaluated and documented by the senior author. Objective postoperative functional outcomes were evaluated by measuring the preoperative and postoperative central and lateral margin reflex distance-2 to assess the lower lid position. The marginal reflex distance-2 values (both central and lateral) were defined as the distance between the center of the pupil to the lower lid margin at the central portion and lateral limbus, respectively. This measurement is to be differentiated from the marginal reflex distance-1, which is the distance between the corneal light reflex to the center of the upper lid margin.5 The defect size (in square centimeters) and the percentage width of each defect to the total lower lid width were measured. All measurements were performed using Adobe Illustrator (Adobe, Inc., San Jose, Calif.) after standardizing the images to a scleral limbus diameter of 11.5 mm.6 A positive delta margin reflex distance-2 value indicates a postoperative increase in margin reflex distance-2. For patients without a preoperative photograph, comparisons were made to the contralateral eye. Three independent, blinded plastic surgeons evaluated the aesthetic outcome of each repair based on well-defined criteria with a maximum possible score of 4 (Table 1). The interrater reliability for aesthetic evaluation was calculated using intraclass correlation. Outcome measures were compared among the four defect types using one-way analysis of variance with the Tukey honestly significant difference post hoc comparisons, and subsequently using one-way analysis of covariance with Bonferroni corrected post hoc comparisons to control for defect area and width. Values of p < 0.05 indicated statistical significance. IBM SPSS (IBM Corp., Armonk, N.Y.) was used for statistical analysis.

Table 1.

Table 1.

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Defect Classification System

Patients were divided into four groups based on the location and vertical component of the defect (Fig. 2):

Fig. 2.

Fig. 2.

  • I. Pretarsal defects: Defects confined to the pretarsal segment of the lower eyelid regardless of the width or depth. This group was further subdivided into two subgroups:
  1. IA. The tarsal plate is not involved.
  2. IB. Tarsal plate is involved.
  3. II. Preseptal defects: Defects that involve the preseptal segment of the lower lid with variable thickness and preserve the tarsal plate.
  4. III. Eyelid-cheek junction defects: Defects that involve the eyelid-cheek junction, ranging from skin-only to composite soft-tissue and bone defects as seen in maxillectomy.
  5. IV. Complex pretarsal and preseptal defects: Defects that involve the tarsal plate and extend inferiorly into the preseptal segment and/or beyond, with variable thickness.
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RESULTS

The senior author (M.S.A.) performed all reconstructions except for one patient, on whom he performed an ectropion repair after a reconstruction performed by another surgeon. Thirty-four patients were included (16 women and 18 men), with a mean age of 65 years (range, 23 to 87 years). Mean follow-up time was 36 weeks (range, 4 to 218 weeks). Cause included basal cell carcinoma (65 percent), squamous cell carcinoma (21 percent), melanoma (5 percent), sebaceous carcinoma (3 percent), osteosarcoma (3 percent), and sebaceous hyperplasia (3 percent). The mean defect size was 3.7 cm2, ranging from 0.2 to 23 cm2. Mean defect size varied between groups; however, this was only significantly different between eyelid-cheek defects (mean, 7.6 cm2) and pretarsal defects (mean, 0.7 cm2) (Table 2) (p = 0.009). Mean defect width differed significantly between type I (35 percent) and type III (72 percent) (p = 0.01) patients and between type I and type IV (78 percent) (p = 0.02) patients. One type IV patient had had a prior resection and reconstruction performed by another surgeon of a squamous cell carcinoma that involved the lid margin extending to the preseptal segment. This patient presented with lower lid retraction and a new eyelid lesion that proved to be sebaceous cell carcinoma. One patient underwent preoperative chemotherapy, and one patient required postoperative radiation therapy. One patient developed a recurrence of squamous cell carcinoma involving the infraorbital canal and required enucleation and free flap reconstruction.

Table 2.

Table 2.

Various reconstructive techniques were used for each group of defects (Fig. 3). Type IA defects were repaired with full-thickness skin graft (Fig. 4) or blepharoplasty skin-only flap. For type IB defects, reconstructive methods included primary closure, Tenzel semicircular flap with periosteal flap, medial canthoplasty with lower canaliculostomy, and Hughes tarsoconjunctival flap with blepharoplasty skin-muscle flap (Fig. 5). (See Video, Supplemental Digital Content 1, which demonstrates pretarsal defect reconstruction, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/D576.)

Fig. 3.

Fig. 3.

Fig. 4.

Fig. 4.

Fig. 5.

Fig. 5.

Video 1.

Video 1.

In type II defects, reconstructive methods included full-thickness skin graft, rotation advancement flap, V-Y advancement flap (Fig. 6), vertical cheek flap, and deep plane cervicofacial flap. (See Video, Supplemental Digital Content 2, which demonstrates preseptal defect reconstruction, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/D577.) For type III defects, reconstructive methods ranged from rotation flap, to large deep-plane cervicofacial flap (Fig. 7) and split calvarial bone grafts for anterior maxilla and inferior orbital rim, to free anterolateral thigh and vastus lateralis flap with iliac crest bone graft for inferior orbital rim and orbital floor reconstruction. (See Video, Supplemental Digital Content 3, which demonstrates eyelid-cheek defect reconstruction, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/D578.)

Fig. 6.

Fig. 6.

Video 2.

Video 2.

Fig. 7.

Fig. 7.

Video 3.

Video 3.

For type IV defects, a combination of multiple reconstructive techniques was used to rebuild the tarsal plate and restore the anterior lamella and lower lid soft tissues. Tarsal plate reconstruction included Hughes tarsoconjunctival flap supported with a dermal or biological spacer graft. Anterior lamellar reconstruction included deep-plane cervicofacial flap and an extended blepharoplasty skin-muscle flap, with or without a Tripier orbicularis myocutaneous flap from the upper lid (Fig. 8). (See Video, Supplemental Digital Content 4, which demonstrates complex pretarsal and preseptal defect reconstruction, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/D579.) One patient had a less involved defect with a skin-only preseptal component that was replaced with a full-thickness skin graft.

Fig. 8.

Fig. 8.

Video 4.

Video 4.

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Aesthetic Outcomes

The mean aesthetic score of reconstructed type IV defects (1.5) was significantly worse than for type I (3.8), II (3.46), and III (3.17) defects (p < 0.001). Interrater reliability was 0.96 (p < 0.001). A moderate but significant negative correlation was observed between aesthetic outcome and defect area and width (r = −0.51, p = 0.004; r = 0.58, p < 0.001, respectively). When aesthetic score was corrected for by defect area and width, type IV still had a significantly lower mean rating compared with all other types (Tables 3 and 4) (p < 0.001).

Table 3.

Table 3.

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Lid Malposition and Complications

There was a 0 percent (zero of 12) and 11 percent (one of nine) incidence of postoperative retraction for type I and type II defects, respectively, whereas type III had an incidence of 33 percent (three of nine). Type IV defects had the highest incidence of retraction at 75 percent (three of four). Retraction was objectively quantified using central and lateral change in marginal reflex distance-2. Type IV defects had a significantly greater change from preoperative to postoperative central and lateral change in marginal reflex distance-2 (mean, 3.06 and 3.17 mm, respectively) compared to each of the other groups (type I, −0.058 and −0.20; type II, 0.55 and 0.55; and type III, 0.85 and 0.75; p < 0.05). A change in both central and lateral change in marginal reflex distance-2 was positively correlated with defect area (r = 0.65, p < 0.001; r = 0.72, p < 0.001, respectively) and defect width (r = 0.61, p < 0.001; r = 0.56, p < 0.001, respectively).

When change in marginal reflex distance-2 was corrected for by defect area by means of one-way analysis of covariance, type IV had a statistically significant greater change in central change in marginal reflex distance-2 compared with type III (p = 0.02), and approached significance compared to type I (Table 3) (p = 0.088). Type IV also had a statistically significant greater change in lateral change in marginal reflex distance-2 compared to types I and III (p = 0.03, p = 0.002, respectively). When controlling for defect width, type IV had a significantly greater change in lateral change in marginal reflex distance-2 compared to types I and II (Table 4) (p = 0.05 and p = 0.03, respectively). Consequently, type IV had significantly more revision operations (mean, 5.5) and postoperative office visits (mean, 15.3) compared with the other groups (p < 0.001). Examples of patients with lid malposition are shown in Videos 2 and 4 (see Video, Supplemental Digital Content 2, type II defect, http://links.lww.com/PRS/D577, and Video, Supplemental Digital Content 4, type IV defect, http://links.lww.com/PRS/D579). Postoperative complications are summarized in Table 5.

Table 4.

Table 4.

Table 5.

Table 5.

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DISCUSSION

Lower eyelid defects are historically classified according to the percentage of missing width, as this guides the type of reconstructive procedure to be performed.1–4,7 As a result, a progression from primary closure to local flaps to lid-sharing procedures has been recommended with increasing defect width. The shortcoming of this classification system is that it focuses mainly on pretarsal eyelid margin defects, and it does not necessarily predict postoperative outcomes in isolation. For example, type IB defects of less than 25 percent width had similar functional and aesthetic outcomes compared to type IB defects of greater than 50 percent width, although they underwent significantly different reconstructive procedures (primary closure versus lid sharing, respectively) (Fig. 9). Both defect area and width differed significantly between groups; therefore, we accounted for these differences in our analysis. Although controlling for defect area and width reduced the number of statistically significant differences in retraction measurements, significant differences remained. In addition, aesthetic outcomes remained significantly worse for type IV defects. Therefore, the vertical component is a predictor of both aesthetic and functional outcomes, independent of defect size and width. This anatomical classification system can help supplement the width-based system and assist in selecting the right reconstructive procedure.

Fig. 9.

Fig. 9.

Several support structures help maintain lower eyelid shape and position. The tarsoligamentous sling provides both medial and lateral support, whereas the orbicularis oculi muscle provides anterior support through its baseline tone and active contraction.1,4,8 Inferior support is provided through several structures, including bone, facial retaining ligaments, and orbital and facial fat compartments. This inferior support is critical for maintaining lower lid position and preventing retraction. The senior author uses the analogy of the Willis Tower in Chicago, where the top narrow segment of the building is resting on a progressively wider base that provides it with the necessary structural support to remain erect. (See Figure, Supplemental Digital Content 5, which shows the Willis Tower analogy. Structural support of the lower eyelid margin is dependent on a progressively wider base of lower eyelid subunit. The risk of lower eyelid malposition increases progressively as more structural support levels are lost, http://links.lww.com/PRS/D580.) Our classification system groups patients based on the amount of structural support lost in a given lower lid defect. This support must be restored with careful planning to maintain lower lid position.

There is no question that the larger the defect and the more vertical subunits involved, the worse the outcome. However, controlling for defect size highlighted a few points that are worth discussing. Type III adjusted change in marginal reflex distance-2 became smaller because this group had larger defect size and width and relatively less retraction, and therefore continued to show a significant difference from type IV across the board. Type 2, in contrast, had higher change in marginal reflex distance-2, although it was not statistically significant, compared with types I and III, perhaps because of the one case of retraction that occurred because of the wrong choice of reconstructive procedure. Finally, the aesthetic scores were not significantly altered and continued to be significantly worse for type IV compared with the other groups.

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Type I: Pretarsal Defects

Pretarsal defects involve the lid margin with preservation of inferior eyelid support structures (Figs. 4 and 5) (see Video, Supplemental Digital Content 1, http://links.lww.com/PRS/D576). Our data indicate that pretarsal defects should have excellent cosmetic and functional outcomes. In type IA defects, a full-thickness skin graft or a blepharoplasty skin and/or muscle flap can be safely used, depending on skin laxity.9 Reconstruction of type IB defects follows the classic percentage-of-missing-width paradigm.1,3,4 Primary closure is appropriate for defects less than 25 percent of the lid margin, with lateral canthotomy/cantholysis and/or Tenzel flap to close progressively larger defects.4,10 Once a defect is wider than 50 percent of the lid, notching and thinning of the tarsal plate can develop at the suture line, and a tarsoconjunctival lid-sharing procedure should be used (Fig. 9). If the lacrimal drainage system is involved and the lower canaliculus can be intubated, a lower canaliculotomy over stent can be performed. If a significant portion of the canaliculus is missing, lacrimal system reconstruction can be performed secondarily.

Complications can be minimized by several technical considerations. The key to successful reconstruction is to establish anatomical horizontal tension. This is accomplished through lid-tightening procedures, including a lateral canthoplasty and periosteal flap. The gray line must be meticulously aligned under proper tension to prevent notching. Finally, if a Hughes flap is to be used, a vertical height of at least 4 mm should be transposed into the defect to provide adequate height for the reconstructed lid margin.

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Type II: Preseptal Defects

Because the pretarsal segment of the lid is intact, these defects are often the easiest to repair (see Video, Supplemental Digital Content 2, http://links.lww.com/PRS/D577.). Repair complexity depends on defect depth. If the orbicularis oculi muscle is preserved, acceptable cosmesis can be attained with a similar quality full-thickness skin graft from the upper eyelid or postauricular area. A horizontally oriented rotation advancement flap (hatchet flap) that is designed within the boundaries of the preseptal orbicularis can close most defects with excellent cosmetic outcomes.11 The back-cut created in this type of flap eliminates downward pulling forces on the lid that can occur with a pure rotational flap with a short arc. A V-Y advancement flap is also a viable option when the dimensions of the defect permit (Fig. 6).12 For larger defects, a cervicofacial flap may be needed. Finally, larger defects that involve the orbicularis can be closed with a lid-sharing approach using the unipedicled or bipedicled Tripier orbicularis myocutaneous flap if redundant upper lid skin is present.13,14

To prevent complications in this group, vertically oriented flaps should be avoided, as this results in a downward force on the lid margin and cicatricial ectropion, as was seen in one patient.15 If the orbital septum is not involved, this should be left untouched to minimize scarring during healing. Postoperative injection of 5-fluorouracil can help improve cosmetic results of full-thickness skin grafts.16 Canthal tightening is usually not needed when closing a type II defect, except when the defect is large and the flap arc of rotation is in close proximity to the lateral canthus.

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Type III: Eyelid-Cheek Defects

Type III defects are preseptal defects that extend into the cheek with preservation of the tarsal plate (see Video, Supplemental Digital Content 3, http://links.lww.com/PRS/D578). They vary in size and depth, and directly compromise lower eyelid soft-tissue and/or skeletal support, which can lead to lower lid retraction. The principles of reconstruction are similar to type II for soft-tissue defects. With large defects, a deep-plane cervicofacial flap provides ideal resurfacing.17–19 Bony reconstruction, with carefully gauged mild overcorrection, is necessary for composite soft-tissue/bone defects, as mobilized cervicofacial flaps are invariably thinner than the thick midface soft tissue. When the defect size is prohibitive of local reconstruction, free tissue transfer should be considered along with skeletal support and soft-tissue resuspension.20,21 Concomitant lower lid tightening should be considered in patients with preexisting lower lid laxity.

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Type IV: Complex Pretarsal and Preseptal Defects

Typically, this group of defects are a consequence of aggressive malignancies that require wider and occasionally staged resection, which results in worse soft-tissue edema and chemosis at the time of reconstruction (see Video, Supplemental Digital Content 4, http://links.lww.com/PRS/D579). This group had the worst aesthetic outcomes and the highest incidence of postoperative retraction, and required multiple corrective surgical procedures. With loss of the tarsal plate, preseptal support, and potentially the eyelid-cheek junction, all three levels of support are lost, resulting in a high risk for postoperative malposition (see Figure, Supplemental Digital Content 5, http://links.lww.com/PRS/D580). The only patient who did not develop postoperative retraction in this group had a partial-thickness, skin-only defect in the preseptal segment, and therefore did not lose significant structural support.

Despite our high complication rate, we have several recommendations to help improve outcomes in this challenging group. If a staged resection is planned, a complete tarsorrhaphy should be performed with gentle compression dressing to help minimize chemosis at the time of reconstruction. If the tarsal plate is replaced, consideration should be given to supporting the tarsal graft or flap with a spacer graft for increased support and to overcorrect when gauging the vertical height to minimize postoperative retraction. For the anterior lamella, we recommend judicious use of full-thickness skin grafts to cover the Hughes tarsoconjunctival flap, instead of bringing a blepharoplasty or cervicofacial flap up to cover the lid margin.22–24 These flaps can instead be used for lid-cheek or preseptal reconstruction. Using superiorly based local flaps, when available, such as the paramedian forehead flap, Tripier flap, or a suprabrow (Fricke) flap can potentially help minimize vertical and rotational tension on the lower eyelid margin.25 Free tissue transfer is a final option for large defects, but comes with its own set of problems, including cosmesis.20,21

The series represents a single surgeon’s experience; the choice of flaps, approaches, and techniques used may not be representative of all eyelid surgeons. Because of the small patient cohort, the effect of other potential confounding factors for lower lid malposition, including age, eye vector, radiation therapy, and type of procedure cannot be sufficiently analyzed. The cases do not represent every possible combination of defects; nevertheless, the findings are significant and clinically relevant. A small number of patients had a short follow-up period; however, those patients had smaller, less complex defects and were unlikely to develop long-term retraction. Future studies that include a larger number and variety of defects are needed to validate our findings. Despite these limitations, we believe that this anatomical classification can be a useful tool, as it identifies four distinct groups of defects with unique sets of challenges and predictable outcomes. Each type requires the application of specific reconstructive principles based on the restoration of structural support of the lower lid. This classification can help improve patient counseling by identifying patients at risk for complications.

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CONCLUSIONS

We propose a new vertical subunit supplement to width-based lower eyelid defect classification. This classification predicts both functional and aesthetic reconstructive outcomes. As the number of vertical components lost increases, one can anticipate a greater risk of lid malposition and a need for more aggressive reconstructive interventions.

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REFERENCES

1. Codner MA, McCord CD, Mejia JD, Lalonde D. Upper and lower eyelid reconstruction. Plast Reconstr Surg. 2010;126:231e–245e.
2. Spinelli HM, Jelks GW. Periocular reconstruction: A systematic approach. Plast Reconstr Surg. 1993;91:1017–1024; discussion 1025–1026.
3. Tomassini GM, Ricci AL, Covarelli P, et al. Surgical solutions for the reconstruction of the lower eyelid: Canthotomy and lateral cantholisis for full-thickness reconstruction of the lower eyelid. In Vivo 2013;27:141–145.
4. Alghoul M, Pacella SJ, McClellan WT, Codner MA. Eyelid reconstruction. Plast Reconstr Surg. 2013;132:288e–302e.
5. Putterman AM. Margin reflex distance (MRD) 1, 2, and 3. Ophthalmic Plast Reconstr Surg. 2012;28:308–311.
6. Rüfer F, Schröder A, Erb C. White-to-white corneal diameter: Normal values in healthy humans obtained with the Orbscan II topography system. Cornea 2005;24:259–261.
7. Yüce S, Demir Z, Selçuk CT, Celebioğlu S. Reconstruction of periorbital region defects: A retrospective study. Ann Maxillofac Surg. 2014;4:45–50.
8. Griffin G, Azizzadeh B, Massry GG. New insights into physical findings associated with postblepharoplasty lower eyelid retraction. Aesthet Surg J. 2014;34:995–1004.
9. Hayashi A, Mochizuki M, Kamimori T, Horiguchi M, Tanaka R, Mizuno H. Application of Kuhnt-Szymanowski procedure to lower eyelid margin defect after tumor resection. Plast Reconstr Surg Glob Open 2017;5:e1230.
10. Tenzel RR, Stewart WB. Eyelid reconstruction by the semicircle flap technique. Ophthalmology 1978;85:1164–1169.
11. Gurunluoglu R, Williams SA, Olsen A. Reconstructive outcomes analysis of lower eyelid and infraorbital skin defects using 2 hatchet flaps: A 6-year experience. Ann Plast Surg. 2014;72:657–662.
12. Marchac D, de Lange A, Bine-bine H. A horizontal V-Y advancement lower eyelid flap. Plast Reconstr Surg. 2009;124:1133–1141.
13. Elliot D, Britto JA. Tripier’s innervated myocutaneous flap 1889. Br J Plast Surg. 2004;57:543–549.
14. Maghsodnia G, Ebrahimi A, Arshadi A. Using bipedicled myocutaneous Tripier flap to correct ectropion after excision of lower eyelid basal cell carcinoma. J Craniofac Surg. 2011;22:606–608.
15. Rathore DS, Chickadasarahilli S, Crossman R, Mehta P, Ahluwalia HS. Full thickness skin grafts in periocular reconstructions: Long-term outcomes. Ophthalmic Plast Reconstr Surg. 2014;30:517–520.
16. Yoo DB, Azizzadeh B, Massry GG. Injectable 5-FU with or without added steroid in periorbital skin grafting: Initial observations. Ophthalmic Plast Reconstr Surg. 2015;31:122–126.
17. Becker FF, Langford FP. Deep-plane cervicofacial flap for reconstruction of large cheek defects. Arch Otolaryngol Head Neck Surg. 1996;122:997–999.
18. Jacono AA, Rousso JJ, Lavin TJ. Comparing rates of distal edge necrosis in deep-plane vs subcutaneous cervicofacial rotation-advancement flaps for facial cutaneous Mohs defects. JAMA Facial Plast Surg. 2014;16:31–35.
19. Kroll SS, Reece GP, Robb G, Black J. Deep-plane cervicofacial rotation-advancement flap for reconstruction of large cheek defects. Plast Reconstr Surg. 1994;94:88–93.
20. Ghadiali LK, Patel P, Levine JP, Gold KG, Lisman RD. Microvascular free flap for total eyelid reconstruction with a visually useful eye. Ophthalmic Plast Reconstr Surg. 2016;32:e109–e111.
21. Molnar JA, Yan JG, Matloub HS. A prefabricated free flap for eyelid reconstruction. J Reconstr Microsurg. 1998;14:479–482; discussion 483–484.
22. Hishmi AM, Koch KR, Matthaei M, Bölke E, Cursiefen C, Heindl LM. Modified Hughes procedure for reconstruction of large full-thickness lower eyelid defects following tumor resection. Eur J Med Res. 2016;21:27.
23. Ooms LS, Beets MR, Grosfeld EC, et al. Reconstruction of the lower eyelid using Hughes’ tarsoconjunctival flap: Follow up of 28 cases. J Plast Reconstr Aesthet Surg. 2014;67:e177–e179.
24. Bartley GB, Putterman AM. A minor modification of the Hughes’ operation for lower eyelid reconstruction. Am J Ophthalmol. 1995;119:96–97.
25. Wilcsek G, Leatherbarrow B, Halliwell M, Francis I. The ‘RITE’ use of the Fricke flap in periorbital reconstruction. Eye (Lond.) 2005;19:854–860.

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