Case 5: Reconstruction of lower right eyelid using a combined tarsoconjunctival flap, temporal fascial turn-over flap, transposition flap and full-thickness skin graft

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.