Case 5: Reconstruction of lower right eyelid using a combined tarsoconjunctival flap, temporal fascial turn-over flap, transposition flap and full-thickness skin graft
Keywords: Lentigo maligna melanoma, Lower eyelid, Hughes tarsoconjunctival flap, temporal fascial turn-over flap, transposition flap, full-thickness skin graft.
Authors: Annika Gotholt Hansen (StudMed), Magnus Balslev Avnstorp (MD) and Jørgen Hesselfelt (MD). Roskilde, SUH, Denmark
A 73-year-old woman was referred to the Department of Plastic Surgery by her local dermatologist with lentigo maligna melanoma localized under her right eye, measuring 30×20 mm. The patient was initially diagnosed in 2011 with lentigo maligna and experienced recurrences in 2016, 2019, and again in 2022 with lentigo maligna melanoma. The diagnosis was confirmed by histological analysis of a punch biopsy (lentigo maligna melanoma recurrences 0.9 mm thick without ulceration and without dermal mitoses). Pre-existing conditions include Acute Myeloid Leukemia (AML), asthma, AFib, acute kidney injury, chronic ischemic heart disease, rheumatic aortic valve stenosis, hypercholesterolemia, heart failure, mitral valve insufficiency, type A aortic dissection, and bone marrow transplantation. Currently, she was medicated with Potassium chloride, Apixaban, Digoxin, Furosemide, Enalapril, Atorvastatin, Sulfamethoxazole + Trimethoprim, Ruxolitinib, Alendronate, and Fluticasone.
Before and after
Patient examination
The patient noticed reddish changes in the known area of lentigo and thus sought consultation with a dermatologist, who subsequently referred her to the plastic surgery department. Lentigo maligna melanoma (LMM) was localized on the lower right eyelid, measuring 30×20 mm. Episcopically, it appeared asymmetric and poorly defined, with some network structure at the edge and heterogeneously pigmented with 3-4 colors. Overall, the clinical examination agreed with the finding of LMM. There was no lymphadenopathy in the head, neck, periclavicular, axillary, inguinal, or popliteal regions. The diagnosis was confirmed by histological analysis with a 4mm punch biopsy. Recurrence of Lentigo maligna melanoma, 0.9 mm thick without ulceration and without dermal mitoses. Therefore, indication for re-excision with a 1 cm margin.
Pre-Operative Considerations
The patient underwent an incisional biopsy, confirming the presence of lentigo maligna melanoma. Due to its location and mild exophthalmos, the possibility of local spread to the orbit was considered. Subsequent MRI imaging of the orbit revealed partial to diffuse contrast enhancement in the area, with no signs of invasion into the orbit. Therefore, orbital involvement was ruled out, allowing for further surgical planning, as the condition presented with localized superficial dermal involvement, for which primary treatment is surgical excision. Considerations regarding alternative treatment options included local oncological treatment. The first surgical procedure involved excision of the LMM and reconstruction with a cheek rotation flap. Unfortunately, the excision margins were not free, and the patient developed ectropion og the right lower eyelid. Upon re-excision, this should involve nearly the whole lower limbus edge and a part of the upper limbus edge, which could not be reconstructed using a single flap. The location of the lentigo maligna melanoma (LMM) necessitated comprehensive reconstruction, involving the lower limbal edge, conjunctiva, upper and lower eyelids, as well as the cheek. An important part of the deliberations focused on how to reconstruct these structures. The optimal solution, In this case, involved a tarsconjunctival flap for conjunctival reconstruction, a fascial turn over flap from the temporal muscle to reconstruct the canthus and upper and lower limbal edge, and a skin transposition flap from the temporal region for upper eyelid reconstruction, and a full-thickness skin graft to close the remaining central defect. Particularly with extensive surgery, perioperative complications must always be considered. Therefore, it is crucial to provide comprehensive information and considerations to the patient. In this procedure, there were risks of bleeding, infection, noticeable scarring, incomplete excision necessitating further treatment, flap loss, skin graft failure, wound rupture, vascular and nerve damage, sensory disturbances, re-excision for residual tumor, ectropion, and other eyelid problems.
Step 1: Lentigo maligna melanoma excision and reconstruction using a cheek rotation flap
An excision of lentigo maligna melanoma (LMM) was performed, followed by closure using a local rotational flap from the right cheek, under local anesthesia (LA). The lentigo maligna melanoma (LMM) was located on the right cheek but extended to the lower eyelid, stretching around the lateral canthus to the upper lateral eyelid. The excision was performed with a 10 mm safety margin at an appropriate depth from the musculature. Safety margins were maintained laterally, medially, and caudally as far as possible, but due to functional reasons, it was not possible towards the edge of the eyelid.
Step 2: Histology, re-excision, and a new plan with reconstruction using combined flaps
The histology results showed lentigo maligna melanoma, recurrent. The tumor thickness was 1.3 mm, with dermal mitoses. There were no clear resection margins, with skin involvement seen on both sides. As a result, re-excision with an additional 1 cm margin + sentinel node procedure on the neck was indicated. A new re-excision was planned. Due to the location, re-excision with a 5 mm margin was approved, including the entire limbal edge corresponding to the right lower eyelid, followed by reconstruction using a tarsoconjunctival flap, temporal fascial turnover flap, temporal transposition flap and full-thickness skin graft. Lentigo maligna melanoma re-excision: After identifying the excision area, the LMM was removed with a 5 mm safety margin, ensuring appropriate depth to the fascia and tarsal plate.
Step 3: Reconstruction with Tarsoconjunctival flap. (Hughes tarsoconjuctival flap)
The operation continued with a tarsoconjunctival flap, measuring 2 cm in width, harvested from the upper eyelid, and sutured with Vicryl 4.0 rapid to the conjunctiva on the lower eyelid.
Step 4: Reconstruction with temporalis fascia turnover flap and a temporalis skin transposition flap
The incision was extended laterally into the temporal region, where a 3 cm long temporal fascia was raised/turned. This flap was flipped over and divided into two flaps, forming both the upper and lower limbal edges by suturing them to the remaining medial upper and lower tarsal plates. Laterally, the flap was anchored at the canthus. Superiorly, the skin was reconstructed using a transposition flap from the forehead.
Step 5: Reconstruction with transposition flap, undermining and full-thickness skin graft
Inferiorly, on the cheek, the defect was closed directly after subdermal undermining. This left a clean defect on the lower eyelid of 35×20 mm, with a nice round look imitating the contours of the lower eyelid, which had to be covered with a full-thickness skin graft. The graft was harvested from the right clavicle and sutured to the lower right eyelid margin with nylon 5.0, and the lower limbal edge was sutured with vicryl rapid. Additionally, Jelonet and gauze were applied at the site. Closure has been performed with nylon 5-0 in the skin and flaps throughout the face. Closure on the right clavicle was done with Monosyn 4-0 inverted sutures and intracutaneous sutures. The operation lasted 178 minutes.
Step 6: Two days postoperative
The patient remained admitted to the department for the next two days with unpacking on the second day. The surgery and the postoperative period were uncomplicated, and the patient was discharged on day 2 for a calm recovery at home.
Step 7: Suture removal, day 7 postoperatively
The dressing over the graft was removed, revealing an acceptable result. Loose scabs and sutures were removed, and a thin piece of gauze was applied, secured with micropore.
Step 8: Follow-up
Histological findings revealed no free margin at 3-5 o’clock, with residual in situ melanoma present. The location corresponded to the medial lower right eyelid. At that time, the patient was scheduled for a division of the tarsoconjunctival flap. It was planned that during this operation, re-excision at a 5 mm safety margin could be performed, securing free margins. Alternatively, local oncological or dermatological treatment was considered.
Step 9: Division of the tarsoconjunctival flap
In GA, division of the tarsoconjunctival flap and re-excision of in situ melanoma were performed. Excision: The area was marked for excision with a 5mm margin. Subsequently, local anesthesia with Marcaine and adrenaline was administered. Excision was performed corresponding to the 3-5 o’clock positions, with a small rim of conjunctiva included. The skin was then closed directly with Surgipro 6-0 single knots. Division: The lower eyelids of the two eyes were evaluated for symmetry. Division of the tarsoconjunctival flap was performed using a knife and Stevens scissors and the eye protected using a metal cutting guide. Conjunctiva was sutured forward onto the lower eyelid with 6-0 single sutures, long, which were bent downwards towards the cheek. Corresponding to the upper eyelid, the remaining part of the skin from the skin graft was excised. Finally, the area was bandaged with Micropore and dry gauze.
Step 10: Suture removal
Suture removal followed division of the tarsoconjunctival flap and re-excision of in situ melanoma corresponding to the medial right lower eyelid. The patient experienced pain in the right eye following the surgery. It was assessed that this was due to irritation from threads that had been present inside the eye. Objectively, there was slight swelling but no signs of infection. The flap appeared with pleasing colors and good capillary response.
Step 11: 3 months follow-up
Good postoperative result with intact reconstruction . However, a functional issue arose where the patient couldn’t fully see laterally towards the right side due to the thickness of the flap and the stitching being slightly more medial towards the eye. Consideration could be given to correcting the flap; however, it is too early for that, so the patient will be seen for a follow-up appointment in another 3 months. It is recommended to wait a minimum of 9-12 months before correction to achieve the best possible result.
Post-Operative Plan
The patient was advised to keep the head elevated and avoid hot drinks and foods the following 24-48 hours. A calm regimen was recommended until suture removal, with particular emphasis on avoiding exhausting physical activities including sports and cleaning. Analgesia could be managed by the patient with up to 4 x 1g of paracetamol per day. Seven days after the operation, the patient underwent suture removal and evaluation of the reconstruction. Following the first re-excision, the patient was started on tablet treatment with erythromycin 500 mg twice daily for 5 days prophylactically, and after the second re-excision, the patient started treatment with eye drops (fusidic acid) four times daily for 3 days.
- The temporalis fascia turnover flap serves as a favorable substitute for the lateral palpebral ligament to restore the suspension of both eyelids. (It quickly becomes coated with mucosal epithelium, thus rapidly becoming a viable alternative).
- The transconjunctival flap offers conjunctiva as well as a tarsal strip, which is not always the case in other types of reconstructions.
- Achievement of a favorable functional and aesthetic outcome.
- The eye is closed for 3 weeks which may be challenging for the patient.
- The lateral corner of the eye may end up more medially with affected vision.
- There is a risk of injuring the facial nerve branches (n facialis r temporalis) innervating the frontal muscles during the harvesting of the temporalis fascia flap.