Single tarsoconjunctival flap (lower eyelid) for upper eyelid reconstruction ("reverse" modified Hughes procedure)

We present a two-stage reconstruction of partial or total full-thickness upper eyelid defects. In the first stage, a single tarsoconjunctival flap from the donor lower eyelid reconstitutes the posterior lamella, and a full-thickness skin graft reconstructs the anterior lamella. In the second stage, 5 to 8 weeks later, the skin tarsoconjunctival flap is severed. The single tarsoconjunctival flap we describe is analogous to the modified Hughes reconstruction for full-thickness lower eyelid defects and thus may be termed a "reverse" modified Hughes procedure. In the lid-sharing Cutler-Beard procedure, the popular alternative, the full-thickness lower lid is advanced into the upper eyelid defect. Our procedure provides greater stability due to the increased amount of vertical tarsus in the reconstructed eyelid. Also, in our procedure, the tarsoconjunctival flap is incised 1.5 to 2 mm from the lower eyelid margin rather than the 4 to 6 mm necessary to preserve the marginal artery in the Cutler-Beard procedure. With a follow up ranging from at least 6 months to over 2 years, the only complications among the 10 patients in our series were pyogenic granuloma at the edge of the donor lower eyelid, and mild, medial upper eyelid blepharoptosis. There were no cases of cicatricial entropion of the upper eyelid, a known complication of the Cutler-Beard procedure.