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  5. FP73 : Total or Subtotal Replacement of Tarsal Plate by Autogenous Aricular Cartilage

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Dr. Salil Kumar Mandal, M12531, Dr. Tamojit Chatterjee, Dr. Purban Ganguly

Abstract

Purpose: To evaluate the functional and cosmetic outcome of total or subtotal replacement of tarsal plate by autogenous auricular cartilage. incomplete sentence

Methods: Prospective, interventional case series of 16 patients over a period of three years. All patients had malignant tumors of the upper lid requiring subtotal or total removal of the lid . Lid defects were repaired by Cutler-Beard procedure, using autogenous auricular cartilage for tarsal plate replacement. Patients were followed for one year and photographic documentation was done.Results: Total or subtotal tarsal plate replacement by auricular cartilage was successful in all cases without complications. It maintained excellent architecture and lid motility, and showed good cosmetic and functional outcomes..

Conclusions: Tarsal plate replacement with autogenous auricular cartilage is an effective method for large upper eyelid defects, with good functional and cosmetic results. It is cost effective and easily available. 

Keywords:  eyelid reconstruction, Cutler-Beard procedure, auricular cartilage, malignant lid tumors

Introduction:

Repair of full-thickness, large upper eyelid defects after tumor excision presents a challenge to the eye surgeon, given the goal of restoring both function and cosmesis. Removal of the tumor itself requires an extensive knowledge of the detailed  anatomy of the upper eyelid. In addition, the use of a material to restore stability to the reconstructed upper lid is paramount to the functionality of the eyelid. Flaps without tarsal reconstruction have been studied, and such grafts tend to have inadequate stability, with complications such as entropion.1

Cutler and Beard described the first method of repairing a large upper eyelid defect. Originally introduced in 1955, this procedure involves the creation of an advancement flap from the lower lid that includes skin, orbicularis muscle, and conjunctiva. Notably, the flap excludes tarsal plate, as there is not enough tarsal plate in the lower lid to provide adequate tarsus functionality to both the upper and lower eyelids after the procedure.2 Another study some years later highlighted the general importance of recreating the anterior lamellae with use of skin and muscle rather than skin itself, given the need to maintain structure and provide good vascular supply. In addition, the study alluded to the fact that medial forehead and glabellar flaps, when used, provide an inferior skin source to replace delicate eyelid skin.3

While the Cutler-Beard procedure represented a major advancement in the treatment of large upper eyelid defects, concerns about complications such as ectropion and lid shrinkage began to arise.4 Oculoplastic surgeons started to experiment with grafts that included a tissue element to promote more stability to the upper eyelid flap.  Allan Putterman described a composite upper eyelid graft using skin from the upper eyelid with the defect, as well as tarsus, conjunctiva, and skin taken from the opposite eyelid.5 This procedure, however, included the unenviable manipulation and distortion of an intact contralateral upper eyelid. Nasal septal cartilage grafts have also been used as a tarsal-conjunctival substitute with some success.6

The re-distribution of remaining tarsus, whether in the upper or lower eyelid, has been explored as a means of reestablishing stability to an upper eyelid defect. Leone described a tarsal-conjunctival advancement flap utilizing lower lid tarsus to fill upper lid defects, but the clear disadvantage of possible lower eyelid instability issues persists in this technique.7 Kersten et al described the use of a rotational upper eyelid tarsal flap for upper eyelid defects, but this procedure is effective only if the eyelid defect is small enough that adequate tarsus remains for a flap to bridge the defect.8 Jordan et al. described the advancement of a tarsoconjunctival flap, but only in cases in which at least 3 mm of central upper eyelid tarsus remains.9

In 1997, Yaqub and Leatherbarrow described a technique of using autogenous auricular cartilage as an upper eyelid tarsal substitute in patients with entropion, with good results.10 Holloman et al used Achilles cadaver tendon as a tarsal substitute with successful recreation of the upper eyelid and no complications, but the burden of cost and possibility of disease transmission complicate this technique.11

In general, the  Cutler-Beard procedure has been advocated for repair of large upper eyelid defects, with various materials used to impart stability to the eyelid. Cartilage has been advocated as a tarsal substitute in different situations with success, but has not been studied specifically as a tarsal substitute in combination with Cutler-Beard procedures to correct large upper eyelid defects. In this study, we describe a technique of using autogenous ear cartilage as a means of imparting stability to the traditional Cutler-Beard flap to repair upper eyelid defects greater than 70% with total or subtotal replacement of tarsal plate . It is felt that this technique offers better functionality and cosmesis than other methods for reconstructing upper eyelid defects, particularly those greater than 70% in size.

Materials and Methods:

This is a propective, non-comparative, interventional case series of sixteen patients over a period of three years. Oral consent was obtained from each patient. Six patients were male, and  ten  patients were female. Patient age ranged from sixty- to eighty-six years old. Each patient had an upper eyelid defect created by removal of a large malignant tumor. Defects ranged from 70-100%.  Ethics Committee at the Medical College of Kolkata,  India, approved the study.

Inclusion criteria included any tumor in the upper eyelid (malignancy confirmed by fine-needle aspiration cytology) and upper eyelid defects of 70-100% after removal of the tumor (Figure 1). Patients with involvement of local lymph nodes, distant metastasis in the liver, lung or brain, associated lower eyelid involvement, gross corneal infiltration, or intraorbital extension were excluded.

As for the surgical procedure, the upper eyelid tumor was excised, with a minimum of 4 millimeters of gross macroscopic margins horizontally and vertically, leaving a rectangular eyelid defect. A lower eyelid rectangular flap was then made by making a full-thickness horizontal incision two millimeters below the lower tarsal plate, followed by two vertical full-thickness incisions at the medial and lateral borders of the tarsal plate. The tarsus was dissected from this flap and left to maintain the structure of the lower eyelid (Figure 2). This flap was then advanced into the upper lid defect. It was then split into anterior lamellae (skin and orbicularis muscle) and posterior lamellae (conjunctiva and capsulopalpebral ligament). The remaining upper eyelid was then divided into its own anterior lamellae (skin, orbicularis muscle, and orbital septum) and posterior lamellae (conjunctiva and aponeurosis of the levator palpebrae superioris muscle). The posterior lamellae of the flap and upper eyelid were secured together with interrupted 5-0 polyglactin sutures, creating a cartilage bay.

Figure-1:  Pre-operative image of sebaceous cell carcinoma involving the entirety of the right upper eyelid.

Figure-2:   Steps of operation -autogenously harvested auricular cartilage grafted in upper lid replacing tarsal plate  by modified Cutler-Beard procedure.

Figure -3:  Post-operative lid closure and opening of right upper eyelid of patient who underwent modified Cutler-Beard procedure with auricular cartilage graft

A vertical incision was then made in the back of the pinna on the ipsilateral side of the upper eyelid defect, and a wedge of cartilage was removed (Figure 3). The size of the ear cartilage was measured  to be about 30mm long to appropriately replace the tarsal defect in the upper eyelid. The incision was closed with interrupted 5-0 black silk sutures. The graft was then implanted into the cartilage bay made earlier by attachment of advancement flap posterior lamellae with upper eyelid posterior lamellae, and was secured with 5-0 polyglactin sutures. The anterior lamellae from the advancement flap were then secured to the anterior lamellae of the upper eyelid, sandwiching the autogenous ear cartilage. This bridge flap was maintained for three months. When incised, the bridge flap was maintained with convexity downwards to carefully construct the lid margin, which ideally should be smooth to properly maintain corneal integrity and tear film. The lower lid margin was then smoothed and secured.

Each patient was examined and photographed at every postoperative visit, with patients followed from six months to two years post-operatively.

Observations and Results:

Sixteen  patients underwent the two stage modified Cutler-Beard procedure with autogenous auricular cartilage in the repair of large upper eyelid defects after tumor resection. In this study, half of the patients had a 100% lid defect, while the other half of patients had a 70-90% lid defect. Pre-operative levator palpebrae superior (LPS) action ranged from 0-4 mm, while post-operative LPS action was 12-14 mm. Pre-operative margin-to-reflex distanced (MRD1) ranged from -4 millimeters to -1 mm, while post-operative MRD1 was +3 to +4 millimeters (Table 1).

Tables:Patient Lid Measurements

 

Age    Sex      Original  Created defect (mm) length   Pre-Op       Post-op     Pre-op MRD Post-op MRD

Diagnosis  (Length + Width)     of        LPS action LPS action

harvested cartilage          (mm)
1      75     M        SqCC               30 + 18           30                   0                 14                -4                +4
2      78      M        SeCC              32+  22            28                 0                 13                -4                +3.5
3      80      M       SeCC               30+  20             30                0                 12                -4                 +3
4      74      M       SeCC               26 + 14             32                2                 13                -2                 +4
5      76      M        SeCC              22 +12             30                0                 13                -2                 +4
6      68      M       SeCC              20 + 12             29                3                  14               -1                 +4
7      74      F         SeCC               32 + 24            30                0                  13               -4                 +3
8      68      F        SeCC               25 + 14             29                2                 13               -2                 +3
9.      86      F        SeCC               32+ 18              30                0                 12               -4                 +3
10.    70      F        SeCC               24 + 12            30              2                 13               -2                 +4
11.    72      F        SeCC               24 +18              28               2                  13              -2                 +4
12     71      F         SeCC              22 +12              30              2                  13              -2                 +4
13     68     F         SeCC              22 + 12               28              4                  14              -1                 +4
14     70      F         SeCC               24 + 13             30               3                  14              -2                 +4
15     80      F         SeCC               30 +20              29               0                  14              -4                 +4
16.    82      F         SeCC               30+24                 30              0                  13              -4                 +4

SqCC – Squamous cell carcinoma

SeCC – Sebaceous cell carcinoma

LPS – Levator palpebrae superioris muscle

MRD – Margin to reflex distance

The follow-up period ranged from six months to two years. Every patient had a successful upper eyelid reconstruction. There were no infections, wound dehiscence, cartilage exposure, or wound necrosis in any patient. There was no incidence of ectropion, entropion, lid retraction, lid malposition, ptosis, or lid shrinkage. In this study bandage contact lens was fitted postopratively in all patients. All patients initially had ocular surface irritation due to eyelid margin suture; however, by four months, all patients had adequate eyelid function with a healthy ocular surface. None of the patients required a second surgical procedure. The Cutler-Beard flap and autogenous auricular cartilage used for total or subtotal replacement of  tarsal plate retained good architecture, stability, mobility, functionality, and cosmesis through the entirety of the follow-up period.

Discussion:

As previously described, there are numerous procedures in the literature discussing the repair of complex upper eyelid defects, all with their respective advantages and drawbacks. However, no studies to date have reported the use of the  Cutler-Beard procedure with autogenous ear cartilage replacing tarsal plate with large upper eyelid defects (>70%) after tumor excision. This case series highlights the successful use of this technique in the reconstruction of large, often difficult to repair, upper eyelid defects.

All of the patients did well in this case series following the  Cutler-Beard procedure using autogenous ear cartilage for tarsal replacement. We support this procedure due to its unique advantages. The upper eyelid reconstruction provided excellent functionality with good levator function, allowing adequate clearance of the pupil for good vision. Further, none of the patients in the study had resultant upper or lower eyelid entropion, ectropion, lid shrinkage, lid malposition, or ptosis.

As for cosmetic results, autogenous post-auricular cartilage classically has excellent results. The donor site itself is located in a discreet area one cannot visualize without manipulation of the ear. The experience of multiple institutions, including both at our own and others throughout the world, highlights the excellent cosmetic results at the donor and recipient site in post-auricular graft usage.13,10,16,17,18,25,26,27

This study is particularly unique in that it was performed in Calcutta, India. In resource-poor areas with limited access to donor grafts and expensive synthetic tissue substitutes, the options for repair of very large eyelid defects are few and can be particularly daunting. Achilles tendon grafts cost around $1400, while donor sclera is approximately $650. As for tarSys TM, one 1 cm x 4 cm piece of tarSys TM costs $385. Moreover, aside from the cost of biologic grafts, one must also consider the increased failure rates associated with such grafts. For example, in a study of anterior cruciate ligament repair using allografts and autografts, allografts were 7.7 times more likely to fail than autografts.14 The necessitation of removal of implanted tarSys TM grafts in two cases was previously discussed. Failure rates of allografts and synthetic material simply cannot compare to success rates of autografts. A more highly efficacious procedure, with lower failure rates, and lower cost, the modified Cutler-Beard procedure with auricular cartilage graft is advantageous in both wealthy countries and in those with limited resources.

Finally, the challenges of screening donor tissues thoroughly in certain areas of the world further complicate this issue. If using an autograft, there is no chance of transmission of communicable diseases, as there is no donor tissue involved. Screening for donor tissue infection, including hepatitis B, hepatitis C, and HIV, is expensive and less common in the developing world. In an account on the safety of blood supply in the Caribbean, of 24 countries, 15 reported universal screening. Five did not screen for hepatitis C at all.15,19,20,21,22, The only way that these scenarios can be entirely avoided is by use of autograft, rather than donor tissue when possible.

One minor disadvantage of our technique is that there exists a second surgery site, given that the cartilage graft is autogenous. However, as evidenced above, as cartilage is taken from behind the ear and the site is closed in simple fashion, there is an almost non-existent cosmetic or functional defect. Further as evidenced by this and previous studies, there are no significant functional deficits in the donor flap site of the lower eyelid23.24,.

Conclusion

The  Cutler-Beard procedure with autogenous ear cartilage for tarsal replacement for upper lid reconstruction  is an acceptable procedure for repair of eyelid defects of 70-100%. In addition to providing satisfactory cosmetic results, it is safe and cost-effective. The procedure’s efficacy, cost-effectiveness and low complication rates can make it advantageous everywhere, whether in countries with unimpeded access to varied tissues options, or in those with infrastructure that limits such availability.

 References:

  1. Leone CR. Tarsal-conjunctival advancement flaps for upper eyelid reconstruction. Arch Ophthalmology June 1983; 101: 948.
  2. Cutler NC, Beard C. A Method for partial and total reconstruction. American Journal of Ophthalmology. 1955: 39, 1-7.
  3. Anderson RL, Edward JJ. Reconstruction by myocutaneous eyelid flaps. Arch Ophthalmology 1979; 97: 2358-62.
  4. Carroll RP. Entropion following the Cutler-Beard procedure. Ophthalmology Sep 1983; 90(9): 1052.
  5. Putterman, AM. Viable composite grafting in eyelid reconstruction. American Journal of Ophthalmology 1978; 85: 237-241.
  6. Leone, Charles R. Nasal septal cartilage for eyelid reconstruction. Ophthalmic Surgery Summer 1973; 4(2): 68-71.
  7. Leone, Charles R. Tarsal-conjunctival advancement flaps for upper eyelid reconstruction. Arch Ophthalmology June 1983; 101: 945-48.
  8. Kersten RC, Anderson RL, Tse DT, Winstein GW. Tarsal rotation flap for upper eyelid reconstruction.” Arch Ophthalmology June 1986; 104: 918-22.
  9. Jordan DR, Anderson RL, Nowinski TS. Tarsoconjunctival flap for upper eyelid reconstruction. Arch Ophthalmology April 1989; 107: 599-603.
  10. Yaqub A, Leatherbarrow B. The use of autogenous auricular cartilage in the management of upper eyelid entropion. Eye (1997); 1: 801-805.
  11. Holloman EL, and Carter KD. Modification of the Cutler-Beard procedure using donor Achilles tendon for upper eyelid reconstruction. Ophthalmic Plastic and Reconstructive Surgery 2005; 21(4), 267-70.
  12. Munday WR, Klett Z, McNiff JM, Ko C. Foreign body giant cell reaction to tarSysTM xenograft. J Cutan Pathol 2001; 41: 771-774.
  13. Smith RJ, Malet T. Auricular cartilage grafting to correct lower conjunctival fornix retraction and eyelid, malposition in anophthalmic patients. Ophthalmic Plastic and Reconstructive Surgery Jan-Feb 2008; 24(1); 13-8.
  14. Pallis M, Svoboda SJ, Cameron KL, Owens BD. Survival comparison of allograft and autograft anterior cruciate ligament reconstruction at the United States Military Academy. Am J Sports Med 2012; 40(6):1242-1246.
  15. Cruz JR, Perez-Rosales MD, Zicker F, Schmunis GA. Safety of blood supply in the Caribbean countries: role of screening blood donors for markers for hepatitis B and C viruses. Journal of Clinical Virology Dec 2005 Dec; 34 (suppl 2): S75-S80.
  16. Yoon MK, McCulley TJ. Secondary tarsoconjunctival graft: a modification to the Cutler-Beard procedure.Ophthal Plast Reconstr Surg. 2013 May-Jun. 29(3):227-30.
  17. Wang YC, Dai HY, Xing X, et al. Pedicled lower lid-sharing flap for full-thickness reconstruction of the upper eyelid.Eye (Lond). 2014 Nov. 28(11):1292-6
  18. Matsuo S, Hashimoto I, Seike T, et al. Extended Hair-bearing Lateral Orbital Flap for Simultaneous Reconstruction of Eyebrow and Eyelid.Plast Reconstr Surg Glob Open. 2014 Feb. 2(2):e111.
  19. Gu Y, Guo X, Wang T, Yu H, Yang W, Wang J. Reconstruction of total upper eyelid with prefabricated capsule-lined advancement flaps.J Craniofac Surg.2013;24:1038–41.
  20. Codner MA, McCord CD, Mejia JD, Lalonde D. Upper and lower eyelid reconstructions. Plast Reconstr Surg 2010;126:231e-45e.
  21. Lesavoy MA, Kohan E. Total upper and lower eyelid reconstruction using an expanded forehead flap.Ann Plast Surg.2011;67:502–4.
  22. Saito A, Saito N, Furukawa H, Hayashi T, Oyama A, Funayama E, Minakawa H, Yamamoto Y: Reconstruction of periorbital defects following malignant tumour excision: a report of 50 cases. J Plast Reconstr Aesthet Surg 2012;65:665–670.
  23. Miyamoto J, Nakajima T, Nagasao T, Konno E, Okabe K, Tanaka T, Fujii S, Kobayashi H: Full-thickness reconstruction of the eyelid with rotation flap based on orbicularis oculi muscle and palatal mucosal graft: long-term results in 12 cases. J Plast Reconstr Aesthet Surg 2009;62:1389–1394.
  24. Brusati R, Colletti G, Redaelli V: Upper eyelid reconstruction with forehead galeal flap. J Plast Reconstr Aesthet Surg 2009;62:901– 905.
  25. Mathijssen IM, van der Meulen JC. Guidelines for reconstruction of the eyelids and canthal regions.J Plast Reconstr Aesthet Surg. 2009 Jun 24.
  26. DeSousa JL, Leibovitch I, Malhotra R, O′Donnell B, Sullivan T, Selva D. Techniques and outcomes of total upper and lower eyelid reconstruction. Arch Ophthalmol 2007;125:1601-9.
  27. Scuderi N, Ribuffo D, Chiummariello S. Total and subtotal upper eyelid reconstruction with the nasal chondromucosal flap: A 10-year experience.Plast Reconstr Surg.2005;115:1259–65.  

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