Total upper and lower eyelid replacement following thermal burn using an ALT flap--a case report

Upper and lower eyelid unilateral full thickness reconstruction in a patient with no available adjacent tissues because of burns or trauma sequelae is a surgical challenge. A case of severe thermal burn with unilateral complete defect of both upper and lower eyelids is reported, together with the surgical technique of reconstruction. The patient was a 65-year-old man who sustained deep burns of the head and neck with upper airway burns after falling into a fireplace. After tracheostomy and acute resuscitation, he underwent escharectomy and coverage of his head and neck burns with split thickness skin grafts and with full thickness skin grafts to the eyelids. There was incomplete take of the skin grafts to the upper and lower left eyelids. In these areas, infection and loss of the tarsum and subsequent eyelid retraction led to exposure keratitis and blurred vision. After healing and respiratory rehabilitation, he was referred to our microsurgical unit for upper and lower eyelid reconstruction. A free forearm flap was first considered, but the Allen test was negative. Therefore, a free anterolateral thigh (ALT) flap was chosen to provide skin eyelid coverage. The flap was harvested including fascia and centred on one perforator. The levator muscle stump and conjunctiva from both upper and lower cul-de-sacs were dissected and advanced. Flap vessels were anastomosed to the superficial temporal artery and vein. The conjunctiva and the fascia replaced the new inner upper and lower lamella. To our knowledge, this is the first report of the use of a perforator flap, the ALT flap, in full thickness reconstruction of both upper and lower eyelids and may be a reliable option in such selected and challenging situations.