Modified Hughes procedure for reconstruction of large full-thickness lower eyelid defects following tumor resection

Abstract

Background: Tarsoconjunctival flap advancement, or the Hughes procedure, is among the techniques of choice for reconstructing full-thickness lower eyelid defects so as to restore normal anatomy and function with the best possible cosmetic outcome. The purpose of this study is to report the outcome of a series of patients treated with a modified Hughes procedure following malignant tumor removal.

Methods: This retrospective study included 45 consecutive cases of modified Hughes procedures performed between January 2013 and October 2015. During Hughes flap creation an incisional plane was chosen in all cases, which left Müller's muscle attached to the superior tarsal margin, while disinserting the levator aponeurosis. All cases were grouped according to the horizontal length of the lower lid defect to be reconstructed, as well as to the type of anterior lamella reconstruction (free graft vs. inferiorly based advancement flap). Grouped data were compared for the rate of surgical success, defined as achievement of normal lid function and satisfactory cosmesis without needing further surgical interventions, and for the frequency of specific complications.

Results: Surgical success was achieved in 39 cases (87 %). The remaining cases required additional surgery for minor complications including lower-lid ectropion (4 %), pyogenic granuloma (4 %), or lower lid margin hypertrophy (2 %). Donor-site complications were not detected apart from one case of mild entropion with focal trichiasis. No case of premature flap rupture was seen. Neither the horizontal length of the lower lid defect (p = 0.489), nor the type of anterior lamella reconstruction (p = 0.349) significantly affected the surgical success. Particularly, there was no increased onset of lower-lid ectropion among patients receiving an advancement flap.

Conclusions: The modified Hughes procedure remains a well-suited technique for reconstructing lower eyelid defects involving up to 100 % of the horizontal lid length. Leaving Müller's muscle attached to the Hughes flap might prevent premature flap dehiscence without increasing the frequency of upper lid retractions in turn. Whether using a free skin graft or a skin-muscle advancement flap for anterior lamella reconstruction, seems to be insignificant for the functional-aesthetical outcome.

Keywords: Hughes flap; Lower eyelid tumor; Modified Hughes procedure; Oculoplastic surgery; Tarsoconjunctival flap.

Fig. 1

Diagram illustrating the basic steps of the modified Hughes procedure. a Left eye with a full-thickness lower eyelid defect involving >50 % of the horizontal lid length. b Approximation of the temporal and nasal wound margins using two pairs of forceps to measure the required width of the Hughes flap. c Everting the upper lid to expose the conjunctiva and measuring 4 mm of the marginal tarsus to be preserved. d Tarsoconjunctival flap is cut and extended down to cover the defected area. e Suture fixation of the Hughes flap (posterior lamella) and of a free skin graft (anterior lamella), which has been harvested from the contralateral upper eyelid. f Division of the pedicle about 0.5 mm above the lower lid margin, performed 6 weeks after Hughes flap fixation

Fig. 2

Photographs of a modified Hughes procedure. a A patient with a full-thickness lower eyelid defect with histopathologically confirmed tumor-free boundaries after BCC excision. b Measuring the defect size and the subsequently required Hughes flap width. c Incision in an inverted U shaped manner through conjunctiva and the full thickness of the tarsus. d Dissection of all fibromuscular levator aponeurosis attachments from the anterior tarsal surface e, f Edges of the Hughes flap are sutured to the remnants of the medial and lateral tarsus of the lower eyelid. g Preparation of an inferiorly based skin-muscle advancement flap. h Fixation of the advancement flap with absorbable sutures to the lateral wound margins and posteriorly to the Hughes flap. i The left eye post-surgically (before the pedicle division)

Fig. 3

Clinical images of two cases, both before malignant tumor excision and several months after Hughes flap division. a A 75-year-old patient with an ulcerative lower lid tumor in the left eye histopathologically proving to be a basal cell carcinoma (arrow: horizontal extent of the lid defect following pR0 resection). b Full recovery with normal lid function, normal lid position, and satisfactory cosmesis 30 months after Hughes flap division. c A 77-year-old male patient with a nodular lower lid tumor and focal eyelash loss in the right eye. Histopathological evaluation revealed a basal cell carcinoma. d Normal lower lid function and good esthetical outcome 10 months after separation of the Hughes flap

Fig. 4

Incisional planes for harvesting a Hughes tarsoconjunctival flap. a. Incision of the classical Hughes procedure (arrow) starting at the grey line of the lid margin, leaving the levator muscle aponeurosis and Müller’s muscle attached to the tarsal plate. b Currently, the most widely used incisional plane spares 4 mm of the marginal tarsus. Levator and Müller’s muscle attachments are completely separated from the tarsus leaving only a thin solely conjunctival pedicle. c Incisional plane used in the present study. While disinserting the levator aponeurosis from the tarsus, Müller’s muscle insertions are left attached to the superior tarsal border