Free Tarsal Graft and Free Skin Graft for Lower Eyelid Reconstruction

Purpose: To determine whether reconstruction of lower eyelid defects involving the eyelid margin with a free tarsal graft and an overlying free skin graft, without retention or provision of any vascular support, would yield acceptable functional and cosmetic results. Methods: We present here a clinical series of 4 patients treated between April 2019 and September 2019 who underwent reconstruction of large postcarcinoma excision, eyelid-margin-inclusive eyelid defects. Surgery was performed by the same surgeon (J.G.B.) at the Westchester Medical Center, Department of Ophthalmology and Dobbs Ferry Hospital in New York. Without retaining a conjunctival pedicle (modified Hughes procedure), and without a myocutaneous or other vascularized flap, the lower eyelids were reconstructed with a free tarsal graft and a separate overlying free skin graft. The primary outcomes measured were eyelid apposition to the globe, margin reflex distance 2 at least 6 months postoperatively, ocular surface integrity, and patient comfort and patient satisfaction with the procedure. Results: The patients included in the clinical series ranged in age from 73 to 82, 3 were men and 1 women. Each had recent Moh’s excision of carcinoma (3 basal; 1 squamous) resulting in large tissue defects of the lower eyelids. All carcinomas were T1N0M0. The mean postoperative margin reflex distance 2 of the reconstructed eyelids was 5.5 mm, range 5–7.5 mm. Two of the 4 patients underwent a secondary revision within 2–3 weeks following initial reconstruction for lateral ectropion or dehiscence. All eyelids were well-opposed to the globes after revision (except for the nasal eyelid in patient number 2 who had a preexisting ectropion from prior carcinoma excision in the same eyelid). Functional and esthetic results were on par with those of the modified Hughes procedure. All 4 patients were pleased that they had chosen to undergo the procedure being discussed. Conclusion: In this clinical series of 4 patients, reconstruction of lower eyelid defects with a free tarsal graft and overlying free skin graft resulted in an acceptable functional and esthetic lower eyelid suggesting that retention of or provision of vascular support in either the anterior or posterior lamella may not be necessary.