Case 08 2026: A Hella Lamella: A Three-Flap, Full-Thickness Lower Eyelid Reconstruction

Sondre F. Koren; Jette B. Løvenwald

Journal of Plastic, Breast & Reconstructive Surgery·Relatos de casos cirúrgicos revistos por pares, de acesso abertoRevisto por pares · Acesso aberto

Case 08 2026: A Hella Lamella: A Three-Flap, Full-Thickness Lower Eyelid Reconstruction · JPBRS

Relato de caso

Case 08 2026: A Hella Lamella: A Three-Flap, Full-Thickness Lower Eyelid Reconstruction

Sondre F. Koren¹, Jette B. Løvenwald¹

¹Roskilde, SUH

Publicado 28 de maio de 2026293 visualizações7 min de leitura

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Resumo

An 83-year-old male with atrial fibrillation, stage 4 chronic kidney disease, chronic heart failure, monoclonal gammopathy of undetermined significance (MGUS), and glaucoma presented with a 35 × 35 × 15 mm ulcerated squamous cell carcinoma (SCC) of the lateral right lower eyelid. Frozen section-guided full-thickness excision was performed under general anaesthesia. Reconstruction was accomplished in two stages. In the first stage, a combined pedicled tarsoconjunctival flap and a laterally-based periosteal flap (posterior lamella), and a cheek rotation flap (anterior lamella) were used. Frost sutures provided corneal protection during the 4-week inter-stage interval. In the second stage, flap division was performed under general anaesthesia, incorporating Müller's muscle release to prevent upper eyelid retraction. A small dehiscence at the medial flap junction had resulted in a minor notch, which was ultimately resolved with Z-plasty and release of the underlying inferior scar contracture on the cheek. Final histopathology confirmed highly differentiated SCC with clear margins. The multidisciplinary tumour board found no indication for adjuvant therapy. At 23 days following flap division, the patient was satisfied with the functional and aesthetic result. Patient medical history The patient underwent surgery after a 7-week history of a growing tumour of the cheek and lateral lower eyelid. The punch biopsy reported keratoacanthoma/highly differentiated SCC. The tumour had been observed to assess for spontaneous regression, but continued to grow. He had stage 4 chronic kidney disease, treated with Darbepoetin alfa (Aranesp), and glaucoma treated with Latanoprost eye drops, which he had not been taking for several months, with no documented decline

Pontos-chave de aprendizagem

Dicas

When planning the reconstruction, divide it into the posterior and anterior lamella. This breaks a complex reconstruction into more manageable parts.
Place stay sutures through the grey line of the upper eyelid. This, in combination with a Desmarres retractor, greatly facilitates the assistant's ability to maintain traction on the eyelid during surgery.
Angle the periosteal flap superiorly to reduce the risk of ectropion.

Armadilhas

Exercise caution when harvesting the temporal fascia to minimise the risk of injury to the frontal branch of the facial nerve.

Patient history

The patient underwent surgery after a 7-week history of a growing tumour of the cheek and lateral lower eyelid. The punch biopsy reported keratoacanthoma/highly differentiated SCC. The tumour had been observed to assess for spontaneous regression, but continued to grow. He had stage 4 chronic kidney disease, treated with Darbepoetin alfa (Aranesp), and glaucoma treated with Latanoprost eye drops, which he had not been taking for several months, with no documented decline in vision. His atrial fibrillation was managed with warfarin (Marevan) and beta-blockers. He was a non-smoker, ambulatory without assistive devices, living independently, and managing activities of daily living without assistance.

Examination

The patient presented with a 35 × 35 × 15 mm sharply demarcated, ulcerating tumour situated on the right lateral lower eyelid and zygomatic region, not involving the mucocutaneous junction, and causing a mild mechanical ectropion. The tumour was mobile over the underlying rigid structures. No regional lymph nodes were palpable.

Pre-operative considerations

Due to the localisation of the tumour and its sharp clinical demarcation, a decision was made - following consultation with a senior colleague - to excise the tumour with a 5 mm margin. This meant that approximately half of the eyelid would be removed by full-thickness excision, and given the tumour's thickness, invasion of the orbicularis muscle was suspected. This warranted reconstruction of the posterior lamella with a tarsoconjunctival flap and a periosteal flap, and of the anterior lamella with a cheek rotation flap.
The patient's warfarin (Marevan) was paused in accordance with regional guidelines, and prophylactic antibiotics were planned at a reduced dose due to the patient's chronic kidney disease. Given the anticipated duration of the procedure and the discomfort associated with operating in this region, the operation was performed under general anaesthesia.
Given the patient's glaucoma, his ophthalmologist was consulted regarding the safety of pausing Latanoprost eye drops during the inter-stage period, as the operated eyelid would remain closed until flap division.

Passo 1 — Excision of the tumor

The tumour was marked with a 5 mm margin, and a protective shell was placed on the cornea. The excision was taken down to the preseptal fat. Frozen sections were sent, and all margins returned negative. The upper lateral canthal ligament was left intact; the lower was excised.

Referências

Development and validation of a decision algorithm for eyelid reconstruction following oncological resection. Miotti G, Quaglia D, Novati FC, et al. World J Transplant. 2025 Jun 18;15(2):97571. doi: 10.5500/wjt.v15.i2.97571
Modified Hughes procedure for reconstruction of large full-thickness lower eyelid defects following tumor resection. Hishmi AM, Koch KR, Thomasen H, et al. European Journal of Medical Research. doi: 10.1186/s40001-016-0221-1
Hughes Procedure. EyeWiki — American Academy of Ophthalmology
Optimizing the periosteal flap for lateral eyelid reconstruction. McClellan WT, McCord C, Neusch R. Plastic and Reconstructive Surgery, 126(4):121–122, October 2010. doi:10.1097/01.prs.0000388845.97434.2e
The suspension (Frost) suture: experience and applications. Connolly KL, Albertini JG, Miller CJ, Ozog DM. Dermatologic Surgery, 41(3):406–410, March 2015. doi:10.1097/DSS.0000000000000313

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Case 08 2026: A Hella Lamella: A Three-Flap, Full-Thickness Lower Eyelid Reconstruction

Resumo

Pontos-chave de aprendizagem

Patient history

Examination

Pre-operative considerations

Passo 1 — Excision of the tumor

Referências

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Passo 2 — Raising the tarsoconjunctival flap as the first part of reconstructing the posterior lamella

Passo 3 — Periosteal flap for the second part of reconstructing the posterior lamella

Passo 4 — Reconstructing the anterior lamella

Passo 5 — Postoperative photo after completion of the first stage of the reconstruction

Passo 6 — Dividing the flap

Post-operative plan

Pearls

Pitfalls