The lower lid was reconstructed by flap procedure with a propeller flap for anterior lamella and with a cartilage graft from aural scapha for the posterior lamella. One week later, the flap was divided under local anesthesia. Although the flap remained somewhat bulky then, probably because of a high B/A ratio of 0.88, neither corneal ulcer nor deformity that required revision in the lid was present 3 months postoperatively (Fig. 1B).
A 71-year-old man was diagnosed with sebaceous carcinoma of right upper lid (Fig. 2A). A full-thickness wedge of upper lid tissue was excised under general anesthesia. For a 20-mm wide defect, a switch flap was designed on the pedicle of lateral side in lower lid as a full-thickness flap of 15 mm in diameter to fill the defect from lower lid to upper lid.
The lower lid was reconstructed by primary suture (Fig. 2B). One week later, the flap was divided under local anesthesia. Thirty-six months postoperatively, neither corneal ulcer nor deformity to necessitate revision in the eyelid was present (Fig. 2C).
A 71-year-old woman was diagnosed with sebaceous carcinoma of right upper lid (Fig. 3A). A full-thickness wedge of upper eyelid tissue was excised under general anesthesia. For a 21-mm wide defect, a switch flap was designed on the pedicle of medial side in lower lid as a full-thickness flap of 13 mm in diameter to fill the defect from lower lid to upper lid.
The lower lid was reconstructed by the flap procedure with a McGregor Z-plasty (Fig. 3B). Eleven days later, the flap was divided under local anesthesia. Twenty-four months postoperatively, neither corneal ulcer nor deformity to necessitate revision in the eyelid was present (Fig. 3C).
The aim of reconstruction of a full-thickness eyelid defect is to provide the patient with a moveable lid with perfect corneal protection, good aesthetic quality, and acceptable sequelae at the donor site.7
Recommendations for periocular reconstruction are suggested based on the classification system that analyzed various reconstructive options and the type and frequency of complications encountered.8 The classical lid-sharing procedure is the Cutler-Beard bridge flap, which can cover large defects in the upper lid, without disturbing the donor lower lid margin.1
The core of the Cutler-Beard technique is to fill an upper lid defect, across the cornea, with full-thickness lower lid tissue by harvesting it there and basing it on an inferior pedicle. The flap is divided at 4 to 8 weeks after surgery at the level of the upper eyelid margin. The disadvantage of this procedure lies in the absence of tarsus, which often causes a lack of stability of the upper lid and also persistent lower lid instability, which is due to disruption of the lower eyelid retractors. Moreover, there is no lid margin or eyelashes in the reconstructed flap.2 To address these limitations, several modifications to the classical Cutler-Beard flap have been proposed.2,3
The switch flap, another lid-sharing flap, was originally described by Mustardé4 for the correction of upper eyelid defects in 1971. In this technique, a full-thickness flap on a pedicle is switched from lower lid to upper lid to reconstruct a large full-thickness eyelid defect there. The pedicle is usually divided in 2 to 3 weeks, which is much sooner than 4 to 8 weeks needed in a Cutler-Beard flap. The switch lid flap, however, has not so far been practiced widely. That is probably because it takes somewhat higher levels of technical expertise to assure consistently good outcome. In the Mustardé method, the upper lid is reconstructed with a switch flap, whereas the donor site of the lower lid is reconstructed with primary closure or by flap procedure. Skills taken for granted in plastic and reconstructive surgery are in fact needed to get good results in the upper eyelid reconstruction as described by Mustardé4 in detail in 1971.
Among the eyelid reconstruction of the defect resulting from malignant tumor, key points of the switch lid flap procedure to get good functional and aesthetic result have not been described in upper eyelids more than a quarter of the horizontal length of the eyelid before.9
Uemura and his team have used switch flaps for the repair of upper eyelid defects with satisfactory results. The main advantage of this technique is that it provides a stable movable lid with intact lid margin and eyelashes and leaves no notable deformity at the donor site. The donor site can be reconstructed by direct closure with or without cantholysis. If the defect is so large, as in cases 2, 4, and 6 here, as to excise the whole upper lid, simple switching of lower lid to upper would cover the defect. In such cases, the large lid defect left at the donor site is reconstructed by the flap procedure with a propeller flap or a McGregor Z-plasty. Considerable difficulty has in fact been reported in obtaining good results in patients with large upper lid defects for whom a switch flap was apparently applicable.6 The disadvantage of the switch flap technique may also lie in the fact that it is a 2-stage procedure and that it can cause visual handicap in most cases. The handicap would be especially acute in a 1-eyed patient as the flap covers the cornea for a long time. To lessen the visual handicap, we made it a rule, for the past 15 years, to divide the flap within 2 weeks, in 7 to 11 days in most cases, after the switch flap procedure. To get good results and less complication due to cross eyelid method, we are thinking that the pedicle should be divided earlier than usual in 2 to 3 weeks.
As a result of this protocol that we have maintained, we have seen no serious complications such as exposure keratitis and corneal ulcer. And switch flaps have taken alive with no event.
Lastly, let us discuss the width of a flap relative to the defect in upper eyelid. The width of a flap relative to the defect has never been discussed to get good aesthetic results in the past literature. Composite grafts in eyelid reconstruction was reported by Cannon et al10 in 2011. When the size of graft corresponding to defects was the same as that of the defect of resection, bulkiness was reported as one of the complications.
In switch flap procedure, the flap needs to be at least 4 mm wide to include the marginal arcade, as it is usually one-half to two-thirds of the upper eyelid defect.3 This is an important point for good aesthetic results. Our analysis of the width of the size of flaps reveals that the mean of defect widths after excision of tumor (A) is 18.8 mm (range, 15–25 mm), the mean of widths of switch flaps (B) is 13.3 mm (range, 8–22 mm), which gives the mean of B/A ratios as 0.69 (range, 0.5–0.88). This mean ratio of 0.69 falls within the suitable range of 0.5–0.7 for the switch flap method, attesting to the acceptable level at which the Uemura team has treated their patients. There was one case, though, that needed a revision surgery for bulky flap of the upper eyelid. The patient had flap division at day 11 after first surgery with a B/A ratio of 0.8. This somewhat high B/A ratio of 0.8 was probably why the case ended up needing revision.
Uemura and his team found the switch flap technique to be a satisfactory method for the reconstruction of large full-thickness eyelid defects. They have experienced a high success rate with this technique; they managed, over the last 15 years, to make flaps at B/A ratios of 0.5–0.7 and divided flaps in 7 to 14 days subsequent to initial surgery—considerably earlier than in other conventional techniques for the treatment of eyelid defects resulting from resection of large tumors.
The authors thank many ophthalmic surgeons in Saga University Hospital and their secretary Kyoko Ohkubo at the Saga University Hospital for getting the database ready for the study.
Patients provided written consent for the use of their images.
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