Clinical examination revealed a large post-Mohs full-thickness defect of the right lower eyelid involving:
1) Loss of anterior and posterior lamella
2) Extension to the conjunctival fornix
3) Involvement of the lateral canthus
4) Partial involvement of the medial canthal ligament
Additional findings included:
1) Periocular scarring from previous excisions and reconstructive procedures
2) Evidence of prior eyelid reconstruction including Hughes flap
3) Multiple healed scars across the facial region consistent with repeated treatment of basal cell carcinomas
Ocular examination confirmed:
1) Adequate globe protection
2) No obvious corneal exposure or ulceration
3) Intact extra-ocular movements
4) Acceptable visual acuity
The defect involved greater than 75% of the lower eyelid, requiring reconstruction of both lamellae and restoration of eyelid suspension.

Key factors considered during operative planning included:
1. Defect size and lamellar loss – Large full-thickness eyelid defects require separate reconstruction of anterior and posterior lamellae.
2. Previous surgery and scarring – Prior procedures limited local reconstructive options and increased the need for vascularised tissue transfer.
3. Structural support – Loss of tarsus and canthal support required tendon-based suspension to prevent postoperative ectropion.
4. Oncological clearance – Complete tumour removal using Mohs micrographic surgery was essential before reconstruction.
5. Donor site suitability – The radial forearm free flap was selected due to its: Thin pliable tissue, reliable vascular pedicle, ability to include palmaris longus tendon.
6. Multidisciplinary planning – Close collaboration between dermatology, oncology, ophthalmology, and plastic surgery teams was required.

The defect includes loss of both the anterior and posterior lamellae, with involvement of the lateral canthus and medial canthal ligament, and extends to the conjunctival fornix. After confirmation of clear margins, the wound was debrided and margins freshened, removing devitalised tissue and creating a well-vascularised wound bed with exposed conjunctiva and periocular tissues, ready for definitive reconstruction.

A radial forearm free flap was designed over the radial artery territory on the volar forearm, with the skin paddle tailored to the size of the anterior lamellar defect. The radial artery and venae comitantes were dissected to obtain an adequate pedicle for microvascular anastomosis.
The palmaris longus tendon was identified and harvested with the flap to be used as a suspensory sling for eyelid support, providing structural stability similar to the tarsoligamentous system.

For this complex defect, a composite reconstruction was planned:
Posterior lamella: harvested hard palate graft to provide structural support and mucosal lining.
Anterior lamella: radial forearm free flap for skin coverage.
Eyelid support: palmaris longus tendon sling integrated into the flap for dynamic support.
Pre-harvest marking of the hard palate is critical to define graft dimensions while preserving the mucoperiosteum and avoiding injury to the greater palatine artery. The flap and tendon dimensions are calculated to match the defect and ensure proper eyelid contour and function post-reconstruction.

The radial forearm free flap was inset into the periocular defect to reconstruct the anterior lamella and provide soft-tissue coverage of the lower eyelid. The flap was carefully contoured to match the shape and size of the defect and secured to the surrounding eyelid margins using fine interrupted sutures (5-0 Monocryl and 5-0 Ethilon) to achieve precise alignment.
The palmaris longus tendon sling was positioned to support the reconstructed eyelid and was anchored to the periosteum of the medial and lateral orbital rim using 5-0 Vicryl, restoring eyelid suspension and maintaining appropriate lid position.
Following microvascular anastomosis of the radial artery to the facial artery and venous drainage to the facial vein using a 2.5-mm coupler, the flap demonstrated good perfusion, and the reconstruction was completed with layered closure.

This intra-operative photograph demonstrates the harvested hard palate mucoperiosteal graft, obtained from the patient’s palate for use in eyelid reconstruction. The graft provides rigid mucosal tissue with structural support, making it well suited for posterior lamella reconstruction of the lower eyelid. After careful elevation from the hard palate with preservation of surrounding mucosa, the graft is trimmed to the required size and prepared for inset into the eyelid defect. The donor site is typically managed with haemostasis and allowed to heal by secondary intention or protected with a dressing plate.

This intra-operative photograph demonstrates the final appearance following completion of the reconstruction of the right lower eyelid defect. The radial forearm free flap has been inset to recreate the anterior lamella, while the hard palate mucosal graft forms the posterior lamella. The palmaris longus tendon sling has been secured to the periosteum to provide structural eyelid support and restore lower eyelid suspension. The flap appears well perfused with satisfactory contour and alignment of the reconstructed eyelid. This image was taken at the end of the procedure prior to extubation.

Clinic photo

Clinic Photo – good eye closure

Clinic Photo

Clinic Photo

Key technical lessons from this case include:
Always reconstruct eyelids using lamellar principles – anterior and posterior lamella must be restored separately.
Hard palate grafts provide excellent tarsal substitute due to their rigidity and mucosal lining.
Radial forearm free flaps are ideal for periocular reconstruction because of their thin, pliable tissue.
Palmaris longus tendon slings restore eyelid suspension, reducing the risk of postoperative ectropion.
Ensure precise flap inset and tension control to preserve eyelid contour and function.
Meticulous microvascular technique is essential for flap survival in delicate periocular reconstruction.

Common challenges and complications include:
1) Ectropion due to inadequate eyelid suspension.
2) Flap bulkiness leading to poor eyelid contour.
3) Donor site morbidity following radial forearm flap harvest.
4) Corneal exposure and keratopathy if eyelid support is insufficient.
5) Compromised vascular anastomosis due to vessel scarring from prior surgery.
6) Recurrence of basal cell carcinoma, particularly in patients with Gorlin–Goltz syndrome.
Careful operative planning and multidisciplinary management are essential to minimise these risks.

Short-Term Management (First 1–2 Weeks):
1) Flap Monitoring – Regular free flap observations (colour, capillary refill, temperature, turgor, Doppler).
2) Haemodynamic Support – Maintain systolic BP >100 mmHg, monitor urine output and ensure adequate hydration.
3) Medications – LMWH 40 mg daily for VTE prophylaxis, broad-spectrum antibiotics for 5–7 days.
4) Ocular Care – Lubricating eye drops and ointment to prevent corneal exposure. Ophthalmology review if needed.
5) Wound Care – Topical antibiotic ointment to eyelid reconstruction site, monitor radial forearm donor site and skin graft.
6) Oral Donor Site Care – Soft diet and antiseptic mouth rinses following hard palate graft harvest.

Long-Term Management:
1) Functional Assessment
2) Regular review of eyelid position, lid closure, and ocular protection.
3) Scar and Flap Monitoring – Assess flap contour, scar maturation, and need for revision procedures.
4) Donor Site Follow-up – Monitor radial forearm donor site healing and function.
5) Oncological Surveillance – Lifelong dermatologic follow-up due to risk of recurrent BCCs in Gorlin–Goltz syndrome.
6) Multidisciplinary Care – Ongoing follow-up with plastic surgery, dermatology, oncology, and ophthalmology.