Modified Second Stage Hughes Tarsoconjunctival Reconstruction for Lower Eyelid Defects

Abstract

Purpose : To describe a novel technique utilizing an amniotic membrane graft (AMT) to create the mucocutaneous portion of the lower eyelid margin in a modified Hughes eyelid reconstruction as a preventative measure or as secondary revision of a hyperemic, hypertrophic conjunctival margin.

Methods : Retrospective, non-comparative interventional study of 27 consecutive patients who underwent lower eyelid reconstruction after a Mohs procedure. The first step of the Hughes procedure was performed in a standard fashion using a tarsoconjunctival flap from the ipsilateral upper eyelid and a skin graft from the opposite upper eyelid. The second stage of the operation was accomplished by the division of the flap at a desired lower lid height with addition of an amniotic membrane graft (AMT) (Ambio 5^®, IOP Ophthalmics, Costa Mesa, CA) to the new mucocutaneous junction.

Results : 27 consecutive patients were included. 1 patient received AMT for a revision of a hyperemic lid margin following standard reconstruction, while 26 subsequent patients received AMT as a primary procedure at the time of the second stage separation. Indications for Mohs surgery included basal cell carcinoma (n=26) and squamous cell carcinoma in situ (n=1) of the lower eyelid. The mean size of the post Mohs defect was 3.58 ± 0.98 cm², involving 73.92 ± 18.8% of the lower eyelid. The canaliculus was involved in 12 patients (46.2%). The average time to flap division was 30.85 ± 7.82 days. The mean follow up time was 4.27 ± 3.95 months. There was no evidence of hyperemic or hypertrophic margin following a primary addition of the AMT (n=26) or recurrence of hyperemic margin after revision with addition of AMT (n=1) at follow-up.

Conclusions :
The addition of an AMT for the prevention of or for revision of a hyperemic, hypertrophic eyelid margin in the Hughes flap lower eyelid reconstruction is an excellent technique. The role of AMT addition to the second stage separation has favorable outcomes in this preliminary study; however warrants further investigation with larger number of patients and longer follow up.

This is an abstract that was submitted for the 2017 ARVO Annual Meeting, held in Baltimore, MD, May 7-11, 2017.

 

External photographs demonstrating results of amniotic membrane graft during stage 2 separation of modified Hughes procedure. Figure A., C., E. Pre re-construction lower eyelid defects and B., D., F. Post reconstruction at 12, 10 and 15 months follow up, respectively. Note well healed surgery sites without eyelid margin hyperemia and hypertrophy