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CASE REPORT
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Postavulsion complete loss of both lids with corneal injury and orbital floor fracture: A surgical challenge


1 Department of Plastic and Reconstructive Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
2 Department of Ophthalmology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
3 Department of Plastic Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

Date of Submission15-Jan-2021
Date of Decision10-May-2021
Date of Acceptance16-Jun-2021

Correspondence Address:
Sheerin Shah,
Department of Plastic and Reconstructive surgery, Dayanand Medical College and Hospital, Civil Lines, Ludhiana - 141 001, Punjab
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_22_21

  Abstract 


Total upper and lower eyelid reconstruction remains a challenging task for plastic and reconstructive surgeons. Repair of full-thickness defects >50% of the horizontal length of the lids can be particularly complex. Here, we discuss a case of a 52-year-old male who presented to the emergency with avulsion of the right upper and lower eyelids associated with corneal injury and orbital floor fracture. Among all the possible choices of locoregional flap available, we chose the paramedian forehead flap for anterior lamella reconstruction of both upper and lower lids, and the posterior lamella was reconstructed with buccal mucosal graft while orbital floor reconstruction was carried out with prosthesis. This reconstructive modality resulted in satisfactory function and esthetic outcome.

Keywords: Corneal injury, lid avulsion, orbital floor reconstruction, paramedian forehead flap



How to cite this URL:
Shah S, Rakesh D, Goel S, Mittal RK, Garg R, Singh K. Postavulsion complete loss of both lids with corneal injury and orbital floor fracture: A surgical challenge. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Dec 6]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=326105




  Introduction Top


Total upper and lower eyelid reconstruction remains a challenging task for plastic and reconstructive surgeons. Defects that result in full-thickness loss of tissue from the medial to lateral canthus commonly result from excision of malignant or benign tumors, trauma, and burns.[1],[2],[3] Repairing defects is imperative not only for the esthetic result but also for coverage of the exposed globe. With exposure resulting from eyelid defects, the patient is at risk for serious infection, further injury ultimately resulting in visual impairment. Repair of full-thickness defects >50% of the horizontal length of the lids can be particularly complex.

This is a case report where an adult male, who underwent full-thickness upper and lower eyelid reconstruction with concomitant orbital floor reconstruction with satisfactory results, has been described.


  Case Report Top


A 52 year old male presented to the emergency with a history of road traffic accident. He was referred to our hospital, from a local hospital, after giving first aid and applying sutures. On examination, the patient had a sutured wound over the right forehead in continuation with the lid. There was avulsion of a skin flap involving the right upper and lower eyelids [Figure 1]a. His eyeball appeared sunken and his visual acuity was decreased to perception of light. Both direct and indirect pupillary reflexes were normal. Corneal injury was managed with eye patch and antibiotic and lubricant drops as per ophthalmologist review.
Figure 1: (a) Lid defect at presentation, (b) intraoperative image after orbital floor reconstruction and debridement, (c) congestion of both lids on postoperative day 3, (d) debridement done in the dressing room on day 3, (e) postlamella reconstruction using buccal mucosal graft, (f) inset of left paramedian forehead flap

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The patient underwent a computed tomography face which revealed right orbital floor fracture with herniation of orbital fat into the maxillary sinus and no muscle entrapment, and the rest of the bony skeleton was intact. Routine hematological investigations were all within normal range.

The patient was taken up for wound debridement under general anesthesia. It was found that avulsion of skin flap started from the right medial canthus, avulsing both the lamella of upper and lower lids, along with part of the forehead, temporal area, and lateral cheek (supraperiosteal plane) [Figure 1]. Most of the levator palpebral superioris (LPS) muscle was damaged. The wound was repaired in layers, and orbital floor reconstruction using a titanium orbital floor reconstruction plate was done. After 3 days, there was congestion seen in the upper and lower lids which extended along the entire lid length, which was then debrided in the dressing room [Figure 1]c and [Figure 1]d. Cornea and conjuctiva were swollen and congested. Swab test from the conjunctiva was negative for any growth. To rule out endophthalmitis, an urgent B-scan was done, where the posterior chamber was found to be normal [Figure 2]. For the further prevention of exposure keratitis and healing of corneal injury, a left paramedian flap was planned under anesthesia. Posterior lamella reconstruction of both lids was done using a buccal mucosa full-thickness graft [Figure 1]e. This graft was sutured with monocryl 5-0, in continuity from upper to lower lid, covering the entire corneal surface of the defect. The paramedian flap was then elevated superficial to frontalis muscle in the distal part and together with muscle close to the periosteum in the proximal part in order to protect the vessels and then rotated passing over the nasal dorsum followed by trimming of flap distally to reconstruct the anterior lamella of both upper and lower eyelid defects together. The flap inset was done using nylon 3-0 simple interrupted sutures, and the donor site was closed primarily after undermining of the forehead skin with simple, interrupted sutures [Figure 1]f. The LPS was unfurled and sutured with the flap. A 0.5-cm area on the lateral side of the eye was not sutured for instillation of eye drops below the flap with the help of a soft silicone cannula for initial 5 days. Four weeks postoperatively, flap detachment was done [Figure 3]. Final lid separation into the upper and lower lids was done a week later [Figure 4]. His cornea had healed very well. At 3 months of follow-up, the patient has some movement of the upper lid with no corneal exposure. He is planned for flap thinning and conchal graft placement in the upper lid along with corneal transplant. After 6–8 weeks, a sling surgery for leftover ptosis can be done, if the vision improves or the patient desires.
Figure 2: (a) B-scan ocular ultrasound, (b) fluorescein dye testing showing corneal injury, (c) corneal conjunctival chemosis

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Figure 3: Paramedian forehead flap separation after 3 weeks

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Figure 4: Lid separation in the 4th week

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  Discussion Top


Total eyelid defects are infrequently encountered, and among these cases, the most commonly reported cause is trauma.[1],[2],[3] Various methods are currently applicable for full thickness reconstruction of eyelid defects.[4] Reconstructive surgical planning is determined by several factors including the nature of the defect, the health and age of the patient, the availability and integrity of surrounding tissues, and the surgeon's experience and preferences. The aim of these surgeries is to create a naturally appearing eyelid that cannot only protect the globe but also provide a stable lid margin, without thickness, and inelasticity of the eyelids. Attention to reconstruction of the bilamellar eyelid structure is essential.[5] We chose the buccal mucosal full-thickness graft for posterior lamella reconstruction of both upper and lower eyelids because the requirement of the defect was more and it helped in corneal ulceration healing. Posterior lamella reconstruction using hard-palate mucoperiosteal grafts or septal chondromucosal grafts, has also been suggested by few surgeons, due to their ability to provide structural support, but they are associated with significant donor site morbidity and their limited availability when defect size is more.[6] In the case report by Chait et al.,[7] buccal mucosal full-thickness graft was used for the posterior lamella and conchal graft placement under the lid margin was done after 2 months. Rubino et al.,[8] in their case report, demonstrated the secondary reconstruction of the posterior lamella with conjunctiva and sling of fascia graft for tarsus. We believe these reconstructed tarsus grafts will not only give support to the lid but also help in hinging the sling for subseguent ptosis surgery if needed.

Facial reconstruction using subunit principle should be practiced as far as possible to achieve the best cosmetic results. We failed to do that in our case because of the nature of the defect and surrounding injured area. Rubino et al.,[8] Yap and Earley,[9] and Thai et al.[10] have also used single free flap for combined upper and lower lid reconstruction and later on separated the lids and made posterior lamella.

Rotation cheek flap (mustarde flap) is a good option for large lower lid defects as cited in the literature.[11],[12] In our case, mustarde cheek flap was unavailable for lower lid reconstruction as the lateral cheek along with the temporal area was scarred. For anterior lamella reconstruction in upper eyelid Tenzel semicircular advancement, the flap is recommended when the defect is <2/3rd of the horizontal length of the eyelid and when there is availability of at least a little strip of full-thickness eyelid at the medial and lateral sides of the defect.[13] In our case, since there was a complete lid loss and lack of availability of temporal skin, Tenzel flap could not be used.

General teaching for full-thickness defects suggests direct closure can be appropriate for wounds <1/3rd of the horizontal length of the eyelid. Larger defects often require rotational flaps, shared flaps, free grafts, or a combination of these techniques.[14]

Various local flaps can be used in periorbital defect reconstruction depending on the size and location, sometimes being limited due to tissue availability. Among them, the paramedian forehead flap is preferred among surgeons for several reasons.[15],[16],[17],[18] Because this tissue is from the face, there is little difference in skin color, texture, and structural characteristics compared with free flaps from other parts of the body. Although the paramedian forehead flap was successful in our particular case, the choice must be made on a case-by-case basis to tailor the needs of the patients. Whatever flap is used, proper size and tissue volume must be attained to achieve a normal contour.[18],[19] When local regional flaps are unavailable, many authors have used free flaps for double-eyelid reconstruction.[8],[9],[10]

The paramedian forehead flap is mainly used in nasal reconstruction. It has a reliable robust vascularity being an axial patterned flap and allows a wide arc of rotation allowing coverage of large defects without tension. Plus, trimming and recontouring of the flap may be done to offer the best results. Several modifications of the flap have been purposed in the literature. It offers a large portion of donor tissue in addition to characteristics aforementioned, thus making it a viable option for the large, complex defects of the eyelid reconstructing a stable margin of the eyelid.[20] There are also disadvantages of the forehead flap like it being a two-staged procedure, donor site scar, and the thickness of the flap which could be avoided by careful perioperative debulking.[21]

Most articles reported in the literature have used split paramedian forehead flaps for repair of medial canthal defects of medial halves of the upper and lower eyelids.[22] For total upper and lower eyelid repair, the use of expanded forehead flap has been reported in the past.[23] However, we used a nonexpanded forehead flap immediately postdebridement to prevent worsening of keratitis and corneal ulceration of the eye which might result in potential visual loss.

Therefore, the use of a vertical paramedian forehead flap with a buccal mucosal graft remains a surgical option when approaching a patient with full-thickness upper and lower eyelid defect covering more than 2/3rd of horizontal length. Since no implant-associated complications, no persistent diplopia, restriction of eye movement, or enophthalmos was observed postoperatively, we did not see any contraindication for orbital floor reconstruction with prosthesis in an avulsion injury of both lids once adequate debridement has been done. In our patient on follow at 3 months, eyelid closure was adequate and no ectropion occurred, the patients being satisfied with their functional and cosmetic results.


  Conclusion Top


We conclude that the paramedian forehead flap represents a safe and simple flap for reconstruction of complete loss of upper and lower eyelids together, especially when surrounding skin is unavailable for flap harvest. Providing buccal mucosal graft on the inner surface of the flap, not only constructs posterior lamella but also helps in healing of corneal injury. This flap gave a satisfactory esthetic outcome and will be helpful for future functional recovery. Inability to use subunit principle for eyelid reconstruction and future need of staged ptosis correction were limitations in our case.

Consent

Informed consent from patient – the patient gave informed consent to be a part of this case report.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hay D. Reconstruction of both eyelids following traumatic loss. Br J Plast Surg 1971;24:361-4.  Back to cited text no. 1
    
2.
Achauer BM, Menick FJ. Salvage of seeing eyes after avulsion of upper and lower lids. Plast Reconstr Surg 1985;75:11-6.  Back to cited text no. 2
    
3.
Bedrossian RH, Sperry DW. Repair of avulsion of eyelids and cheek. Ann Ophthalmol 1988;20:31-4.  Back to cited text no. 3
    
4.
Nesi FA, Levine MR, Lisman RD, editors. Smith's Ophthalmic Plastic and Reconstructive Surgery. New York, NY: CV Mosby; 1997.  Back to cited text no. 4
    
5.
Holds JB. Lower eyelids reconstruction. Facial Plast Surg Clin N Am 2016;24:183-91.  Back to cited text no. 5
    
6.
Lalonde DH, Osei-Tutu KB. Functional reconstruction of unilateral, subtotal, full-thickness upper and lower eyelid defects with a single hard palate graft covered with advancement orbicularis myocutaneous flaps. Plast Reconstr Surg 2005;115:1696-700.  Back to cited text no. 6
    
7.
Chait LA, Cort A, Braun A. Upper and lower eyelid reconstruction with a neurovascular free flap from the first web space of the foot. Br J Plastic Surg 1980;33:132-35.  Back to cited text no. 7
    
8.
Rubino C, Farace F, Puddu A, Canu V, Posadinu MA. Total upper and lower eyelid replacement following thermal burn using an ALT flap – A case report. J Plastic Reconstr Aesth Surg 2008;61:578-81.  Back to cited text no. 8
    
9.
Yap LH, Earley MJ. The free 'V': A bipennate free flap for double eyelid resurfacing based on the second dorsal metacarpal artery. Br J Plast Surg 1997;50:280-3.  Back to cited text no. 9
    
10.
Thai KN, Billmire DA, Yakuboff KP. Total eyelid reconstruction with free dorsalis pedis flap after deep facial burn. Plast Reconstr Surg 1999;104:1048-51.  Back to cited text no. 10
    
11.
Tripier L. Musculo-cutaneous flap in the form of a bridge, applied to the reconstruction of the eyelids. C R Acad Hebd Seances Acad Sci 1889;109:620.  Back to cited text no. 11
    
12.
Mustarde JC. Reconstruction of eyelids. Ann Plastic Surg 1983;11:149-69.  Back to cited text no. 12
    
13.
Lo Torto F, Losco L, Bernardini N, Greco M, Scuderi G, Ribuffo D. Surgical treatment with locoregional flaps for the eyelid: A review. Biomed Res Int 2017;2017:6742537.  Back to cited text no. 13
    
14.
McCord CD Jr., Codner MA. Eyelid and Periorbital Surgery. St. Louis: Quality Medical Publishing, Inc.; 2008.  Back to cited text no. 14
    
15.
Dortzbach RK, Hawes MJ. Midline forehead flap in reconstructive procedures of the eyelids and exenterated socket. Ophthalmic Surg 1981;12:257-68.  Back to cited text no. 15
    
16.
Tahara S, Susuki T. Eye socket reconstruction with free radial forearm flap. Ann Plast Surg 1989;23:112-6.  Back to cited text no. 16
    
17.
Asato H, Harii K, Yamada A, Ueda K. Eye socket reconstruction with free-flap transfer. Plast Reconstr Surg 1993;92:1061-7.  Back to cited text no. 17
    
18.
Denny AD. Expanded midline forehead flap for coverage of nonnasal facial defects. Ann Plast Surg 1992;29:576-8.  Back to cited text no. 18
    
19.
Iwahira Y, Maruyama Y. Expanded unilateral forehead flap (sail flap) for coverage of opposite forehead defect. Plast Reconstr Surg 1993;92:1052-6.  Back to cited text no. 19
    
20.
Lu GN, Pelton RW, Humphrey CD, Kriet JD. Defect of the eyelids. Facial Plast Surg Clin North Am 2017;25:377-92.  Back to cited text no. 20
    
21.
Elshamma NA, Al Qabbani A, Alkatan HM, Al-Qattan MM. The use of forehead flaps in the management of large basal cell carcinomas of the medial canthus/medial lower eyelid in Saudi patients. Saudi J Ophthalmol 2013;27:223-5.  Back to cited text no. 21
    
22.
Martínez MM, de Vera JL. Medial canthal and eyelid reconstruction using the split paramedian forehead flap: A case report. Rev Esp Cir Oral Maxilofac 2020;42:29-31.  Back to cited text no. 22
    
23.
Lesavoy MA, Kohan E. Total upper and lower eyelid reconstruction using an expanded forehead flap. Ann Plast Surg 2011;67:502-4.  Back to cited text no. 23
    


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