Hughes Flap: Eyelid reconstruction for large skin cancer of the lower eyelid

Oculoplastic surgeons like myself routinely perform the removal of an eyelid skin cancer and then the reconstruction of the eyelid defect. The most common eyelid skin cancer is basal cell carcinoma but other kinds also include squamous cell carcinoma. The first part of the procedure involves removing the skin cancer and the second part involves eyelid reconstruction. There are two options for the removal of the skin cancer: the first is to remove it directly in the operating room and wait for the pathologist to make sure the margins are clear. This can often take a lot of time so I usually work with a Dermatologist who is trained in Mohs surgery.  Fellowship-trainined Mohs surgeons are dermatologists who have received additional training in treating skin cancers. Once the Dermatologist sucessfully removes the eyelid skin cancer, I then see the patient (usually the same day or next day) to reconstruct the eyelid defect.  There are various techniques that can be employed in the repair of an eyelid defect, and it depends on various factors such as the size of the defect and the laxity of the skin.

If it is a small defect, often local tissue can be rearranged or brought together to repair the eyelid.  If it is a large defect like seen in the photo below, up to 80 percent of the lower lid is mssing along with the tear duct system.  In such instances, tissue from the upper lid is often needed to repair the defect through a procedure called a Hughes flap (aka tarsoconjunctival flap) named after one of the pioneers in Oculoplastic Surgery, Dr. Wendell Hughes. Tissue is taken from the upper lid as seen in this following photo and transfered in the lower lid. Unfortunately, the eyelid is sewn shut for at least one month until the flap takes place. A second surgery is then performed to "take down" the flap and allow for the eyelid to be reconstructed to a normal-appearing eyelid.

 

This photo shows a squamous cell carcinoma of the right lower lid that after its complete excision, was left with a defect that spanned the markings drawn on the photo.  The resection also involved her lower lid tear duct system.  This particular patient did very well after the first stage and went home the same day with little discomfort.

 

The patient underwent a a second stage surgery which was performed several weeks later to detach the flap and reconstruct both upper and lower lids to position them as close to their natural, presurgcial position as possible. She is cancer free, can see from that eye now, and has a good position and contour of her lower lid. Note that she has lost her eyelashes in the lower lid which occured once the tumor was removed in the primary excision. 

 

Ptosis surgery (Droopy eyelid surgery)

Ptosis is the medical term for droopy lids, which can occur in one or both lids. Children with ptosis are often born with it, whereas adults usually get ptosis as a result of aging, prior surgery, or even long term contact lens use. There are various different ways to repair a ptotic lid and it depends on the type of ptosis and the surgeon’s preference. I perform various types of ptosis procedures and each one is catered to the patient’s type and severity of ptosis.  The recovery from ptosis surgery is usually quite rapid, and patients find themselves returning back to work within a few days.

This patient below had a mild ptosis of her right upper eyelid. She had a tired appearance and was unable to see well without having to raise her eyelids manually.

Figure1. Preoperative photograph showing a right upper lid ptosis. Note that her right upper eyebrow is also raised in order to compensate and help raise her right droopy lid.

Figure 2. One month after undergoing a ptosis surgery in the right upper lid. Note the improvement in the lid height, eyebrow position, and the symmetry she has in both eyelids.

Face Transplants

Although I am not direclty involved in performing face transplants, I have been following the procedure's progress over the last several years.   Most recently, a group in Brigham and Woman's Hospital in Boston perfromed a full face transplant and the patient is now doing well and making good recovery. 

People that receive face transplants are those that have full facial burns or trauma which have left them severely disfigured.  They have to undergo a battery of medical and psychiatric tests to make sure they will be good candidates. The procedure itself involves a team of plastic surgeons who transplant the nerves, skin, and facial muscles of a donor onto the recipient.  The surgery takes many hours and involves the use of careful microsurgery.

Unfortunately in this particular case, the patient also lost his eyes from his injury which are not able to be transplanted. 

Read more in LA Times.

Beauty and Fashion Exhibit to Open in LA

This should be an interesting exhibit to check out.  It's the first of its kind--demonstrating beauty in all forms from modeling shoots to photos demonstrating lip and botox injections.  All of these subjects are examined in “Beauty Culture,” the first fashion- and beauty-themed exhibition to be held at the Annenberg Space for Photography in Los Angeles, the heartland of Hollywood goddesses and plastic surgery, which opens on May 21 and runs through Nov. 27.

Read more in NY Times.

An interesting surgery I performed today...

I performed an interesting case today on a patient with constant tearing and irritation in her eyes.  On examination, she has has very lax (or loose) lower lids which do not help in her ability to blink well and drain her tears effectively. You can see this by the rounding to her eyelids in the corner of each eye.  In addition she has small, stenotic openings to her tear drainage system.  The tiny openings you see along the eyelid (close to the nose) actually drain the tears from the ocular surface into the nose and mouth. In order to help her, I had to address both of her problems which were causing her to tear constantly. First, I performed a lower lid resuspension technique to allow for tighter and better positioned lower lids in order to help her blink more effectively. This is also called an ectropion repair.  Next, I attempted to dilate her stenotic tear drainage system to allow for better drainage by placing a baloon dilator to dilate the canaliculi.  My team and I recently published the use of this in a prior medical study (see below link).  Silicone tubes were then placed to intubate the tear drainage system and I will remove those in my office in several weeks. Overall, she tolerated everything well and was home the same day. 

 

See link to my prior blog on our study on canalicular stenois.

 

What are effective scar treatments???

This is a great article summarizing the challenges in scar treatment.  I actually find silicone sheets quite effective for some early scars.  In cases of hypertrophic healing (excessive scarring) or abnormally raised edges, carefully thought-out regimen of low dose steroid injections may be beneficial.  Care must be taken not to inject high doses of steroids around thin skin, such as the eyelids, though.  Laser resurfacing can also be helpful in selected cases.   Read more in LA Times!

Is a Well-Rested Doctor a Better Doctor?

Do better hours for medical students and residents result in better patient care? It's difficult to tell since no real well-controlled study has been published.

Work hour limits have improved the lifestyle of junior doctors, but decreasing their fatigue seems to have had little effect on how patients actually do. Read more in NY Times.