Case Competition 2024 – All submitted cases Case 10 The Skaerlund-Stairway approach to reconstruction of upper eyelid defects
Keywords: Reconstruction of upper eyelid defects
Authors: Erik Gadsbøll (MD), Linda Wiboe (MD) and Marie-Louise Skaerlund Christensen (MD). Aalborg University Hospital, Denmark
An 81-year-old female, diagnosed with hypertension and aorta stenosis five years ago but otherwise healthy, was referred with a nodular basal cell carcinoma on the anterior lamella of the left upper eyelid. The tumor had been present three years before referral, measured 16x7mm, and involved ¾ of the upper eyelid. The patient, who lived part-time in Spain, was very tanned due to a lot of sun exposure. A thorough examination by doctors in the ophthalmology and plastic surgery departments was performed. A primary treatment plan for reconstruction was drawn, and an alternative plan was also prepared in case the defect became too large. Extensive knowledge of the anatomy was required to plan a satisfying result [1]. A pre-operative biopsy showed nodular basal cell carcinoma (BCC); however, per-operatively, it was proven to be a superficial nodular infiltrative BCC. The patient underwent freeze-guided excision of the tumor, and the defect was reconstructed with a contralateral free tarsoconjuctival flap functioning as a posterior lamella. A bipedicular orbicularis oculi muscle sandwich flap from the upper eyelid was dissected from its superior margin and moved inferiorly to its pre-tarsal position [2,3]. A full-thickness skin graft from the inside of the right upper arm was used as an anterior lamella. Finally, a Tenzel flap with lateral release was performed [4]. The skin graft used as anterior lamella had to be taken from the upper arm since the patient had prior upper blepharoplasty performed. Furthermore, the supraclavicular skin was significantly damaged from massive sun exposure. If the eyelid defect had been too large, a hard palate mucoperiosteal graft for posterior lamellar reconstruction would have been considered [5].
Before and after
Patient examination
Initially, the patient was referred by a private ophthalmologist to the ophthalmology department due to a suspicious tumor on the upper left eyelid. The tumor had been present for 2-3 years. There was no history of previous eyelid tumors. However, she had undergone bilateral upper blepharoplasty in 2017 with minimal excess skin as a result. The patient’s skin was very sun-damaged due to her partial residence in Spain. She had a big, ulcerated tumor with eyelash loss in the medial 2/3 of the left upper eyelid close to the left upper punctum, plus scattered loss of eyelashes in the lateral part. The tumor involved the inferior edge of the lid and measured 16 by 7 mm (width x height). The upper eyelid width was 25 mm in both eyes, and the eyebrow-to-eyelash distance was 20 mm on the right and 14 mm on the left lid. This distance was short on both sides, but the shorter distance on the left side was due to the shrinkage of the skin caused by the tumor. The best corrected preoperative visual acuity was 1,0 in the right and 0,5 in Snellen in the left eye. The left cornea showed superficial damage due to the uneven upper eyelid margin and signs of dry eye. Lacrimal syringing showed patency to the nose on the right side and partial patency on the left side. The left superior and inferior canaliculus was partially stenosed.
Pre-Operative Considerations
Reconstructive surgery in the periorbital region can be challenging if the full-thickness defect measures more than 50% of the eyelid and is combined with poor skin quality due to sun damage. Our considerations were:
- The tumor involved more than 50% of the upper eyelid and had to be resected in the presence of reduced eyebrow-to-eyelash distance. Periorbital flap reconstructions could not be used in this case due to the tumor size and the sun-damaged skin.
- As the tumor was large, a large amount of tissue had to be excised to be free of tumor tissue. A stairway resection was performed to preserve as much of the posterior lamella as possible, with subsequent full function of the eyelid elevation.
- Full-thickness eyelid defects with a width of more than 50% of the eyelid are usually reconstructed in two layers, of which at least one should be vascularized to obtain survival of the free graft. With two free grafts, an orbicularis muscle advancement flap in between was the optimal choice for survival.
- The tarsal plate is considered the backbone of the eyelid; thus, its repair was crucial.
- If the defect became too large, a hard palate mucoperiosteal graft combined with a periosteal flap for posterior lamellar reconstruction was considered.
Step 1: Anatomy
The eyelid anatomy is divided into the anterior lamella, which consists of the skin and the orbicularis oculi, and the posterior lamella, which consists of the tarsal plate and conjunctiva. Familiarity with the eyelid anatomy is essential during reconstruction.
Step 2: Excision of tumor
The tumor was marked, and a 4 mm margin was then marked around the tumor.
- A sharp vertical incision was made full thickness at the upper eyelid’s medial and lateral lower margins. The skin was excised, and the orbicularis muscle was retained upwards at the height of 4 mm down to the tumor’s deep margin.
Step 3: The Skaerlund-Stairway excision
The orbicularis muscle was removed to better distance the tumor, while the superior part of the tarsal plate was preserved to maintain the elevator function of the upper eyelid. On the back of the eyelid, the inferior posterior lamella (conjunctiva and tarsus) was removed at a 4 mm height, thus creating a stairway excision to preserve the superior part of the posterior lamella.
Step 4: The Skaerlund-Stairway excision with rest tarsal plate
The excision was performed in the subdermal layer, and the skin was then dissected in the subcutaneous layer up to the orbicularis muscle, which was then exposed more cranially at a horizontal plane. This was performed to maintain as much tissue as possible
Step 5: Waiting for pathology
The eyelid is sutured together so the eye does not become dry until the freeze-guided pathology answer arrives.
- The freeze-section pathology result confirmed the radical removal of the tumor—the total defect measured 25 by 12 mm in width and height. Five millimeters were left of the lid at the lateral canthus, and five millimeters were left below the eyebrow.
Step 6: Tenzel flap with an inferior arch
A Tenzel flap with an inferior arch was designed with a lateral release corresponding to the superior lateral canthal ligament. To minimize the defect, the lateral part of the upper eyelid was moved medially by 1 cm, which involved the dissected orbicularis muscle.
Step 7: Free tarsoconjuctival flap
A free tarsoconjuctival flap was harvested from the superior part of the tarsus of the contralateral upper eyelid, 15 mm in width and with 4 mm distance from the eyelid margin. The free tarsoconjunctival flap was then sutured with a single braided absorbable 6/0 suture to the lateral tarsal snip, the medial canthus, and superiorly to the remnant of the posterior lamella of the left upper eyelid.
Step 8: Bipedicular orbicularis muscle sandwich flap
A bipedicular orbicularis muscle sandwich flap was dissected free from below the orbital rim. It was then advanced down over the free tarsoconjunctival flap and sutured with a braided absorbable 6/0 continuous suture to the lower edge.
- A full-thickness skin graft was harvested from the inner right arm, trimmed, and sutured into the defect with single-fiber, non-absorbable 6/0 sutures. The graft was designed to be 4 mm wider and taller than the defect to counteract the expected shrinkage. Chloramphenicol ointment was applied onto the scars, three layers of a sterile paraffin compressive dressing were applied, and two eye pads were attached on top with broad Steri-Strips.
- A bi-canalicular short FCI Auto-Stable silicone stent was placed in the left canaliculi. Due to the tumor excision, 4 mm of canaliculus superior was missing.
Step 9: One week post-operatively
The compressive dressing was removed one week post-operatively with 100% graft survival. The patient could not open her left eye fully, which was expected.
Step 10: Two weeks post-operatively
At a follow-up two weeks post-operatively, no complications to the graft were recorded. There was an expected minor shrinkage in the graft, and a 2 mm lagophthalmos between the upper and lower eyelid was present. Lubricating eye drops (Viscotears) were recommended four times daily.
Step 11: Three month follow-up
At three months follow-up, again, no complications were recorded. The cosmetic result was very satisfactory to the patient and the surgeon. The graft seemed a bit hardened, therefore daily massages of the graft were recommended. The patient had a normal eyelid-closing mechanism. She reported reduced vision in the left eye and was assessed by an ophthalmologist; however, as no pathology was found, the cause was presumed to be dryness of the cornea. The patient was prescribed hard contact lenses in both eyes.
Step 12: Nine months post-operatively
Nine months post-operatively, the patient had an ophthalmological examination. She did not have complaints and gladly announced that she had no longer received any comments regarding the appearance of her left eyelid. Normal visual acuity of 1,0 with scleral contact lenses was measured in both eyes. A 2 mm lagophthalmos and a 3-4 mm blink lagophthalmos on the left side were still present. There were no clinical signs of tumor recurrence, and there was symmetry between the right and left eyelid.
Step 13: Twelve months post-operatively
Twelve months post-operatively, the patient was happy with the result. No complications were observed. The patient continuously used scleral contact lenses and achieved good vision and comfort. Clinically, there was no sign of tumor recurrence.
Step 14: Eyelashes tattooed
Eighteen months post-operatively, the patient had eyelashes tattooed onto the left upper lid in two sessions at three-month intervals. The pictures illustrate the eyelid before and after the first and second tattooing.
Post-Operative Plan
The authors recommend a similar post-operative plan as demonstrated in this case (see step 9-14).
- Achieving a favorable cosmetic and functional outcome with known techniques and a new Skaerlund-Stairway approach to reconstruct the upper eyelid. The Skaerlund-Stairway approach limits the eyelid closure defect and maintains the postoperative upper eyelid elevation. This is achieved by maintaining the attachment point for Mueller and levator muscles, which provide the elevation function of the upper eyelid.
- Minimal morbidity of the donor site of the graft.
- Thorough multidisciplinary pre-operative planning was important for success, including an alternative plan if needed.
- Improved vision for the patient, from 1,0/0,5 best-corrected to 1,0/1,0 with hard scleral contact lenses.
- The use of a free flap requires an experienced surgeon and is time-consuming.
- Shrinkage of the full-thickness skin graft is expected but can be counteracted by making the graft slightly larger than the defect.
- When a significant full-thickness resection is performed on the eyelid margin, many Meibomian glands are removed, which increases the risk of developing eye dryness. This can be treated with artificial tears, silicone plugs in the tear canals, and hard scleral contact lenses. These lenses decrease the mechanical stress from the uneven upper eyelid and act as a reservoir for tears.
- Lacking complete color match of the skin from the full-thickness skin graft.
References
- Kakizaki H, Malhotra R, Selva D. Upper eyelid anatomy: An update. Ann Plast Surg. 2009;63(3):336-343. doi: 10.1097/SAP.0b013e31818b42f7.
- Paridaens D, van den Bosch WA. Orbicularis muscle advancement flap combined with free posterior and anterior lamellar grafts: A 1-stage sandwich technique for eyelid reconstruction. Ophthalmology. 2008;115(1):189-194. doi: 10.1016/j.ophtha.2007.03.022.
- Mark A. Codner, MD, Clinton D. McCord, Jr., MD. Eyelid & periorbital surgery. Second edition ed. ; 2016
- Morley AMS, deSousa J, Selva D, Malhotra R. Techniques of upper eyelid reconstruction. Surv Ophthalmol. 2010;55(3):256-271. doi: 10.1016/j.survophthal.2009.10.004.
- Ito R, Fujiwara M, Nagasako R. Hard palate mucoperiosteal graft for posterior lamellar reconstruction of the upper eyelid: Histologic rationale. J Craniofac Surg. 2007;18(3):684-690. doi: 10.1097/scs.0b013e318053446d.
