Zygomatic-palpebral flap: an optional technique for lower eyelid reconstruction

adequate eyelid occlusion and preserved ocular lubrication. Conclusion: The advantages of the zygomatic-palpebral flap are its ease of execution, minimal bleeding, low morbidity of the donor area, and the use of local anesthesia. The reconstruction of eyelid defects aims to restore anatomy and function. This can be a challenging task, especially in cases with larger defects that may be present after oncologic procedures both in young and old patients presenting with scleroatrophic skin and minimal tissue laxity. ■ ABSTRACT

Rev. Bras.Cir.Plást.2019;34 (1):10-14 3. Eyelid stiffness in the canthal ligaments; 4. Functionally active muscles that allow tonus; 5. Adequate eyelid occlusion to maintain eye protection; 6. Acceptable aesthetic result in terms of facial symmetry.In this study, the authors presented the use of zygomatic-palpebral flap, a technique initially described by Hermann Eduard Fritze in 1845, which despite its antiquity has proven to be a safe and versatile option with good results for lower eyelid reconstruction.

OBJECTIVES
This study aimed to present an optional technique for the reconstruction of defects of the anterior lamella of the lower eyelid using the zygomatic-palpebral skin flap.This technique is an excellent alternative in cases of scleroatrophic skin in elderly patients, as well as in young people not presenting upper eyelid skin redundancy, which prevents, for example, the use of upper eyelid grafts

INTRODUCTION
Reconstruction of eyelid defects focuses on two major targets: restoring the anatomy and eyelid function.This can be a challenging task, especially in larger defects, such as those occurring after oncologic procedures in young people with minimal tissue laxity and elderly patients with scleroatrophic skin, and in cases of trauma or burns with significant tissue loss.
Several reconstructive techniques have been developed and the surgical choice usually depends on the affected portion of the eyelid and the extent of the defect.Reconstructive procedures must maintain the function and integrity of the periorbital structures while seeking adequate aesthetic repair.The objectives of eyelid reconstruction should consider the following aspects: 1. Smooth and soft internal conjunctival mucosa -eye lubrication;

METHODS
The flap was indicated in cases of ectropion, reconstruction after resection of neoplasms, and in association with other flaps, such as those of Hughes, in order to cover cartilage grafts and retractions caused by burns.It consisted in a transposition flap composed of skin and underlying subcutaneous tissues, randomized.This technique is based on the use of local flaps with highly similar characteristics to the defect area, allowing it to mimic functions while being safe and feasible.
The procedure for creating the flap was the same in all cases.The limits of the receiving area were evaluated (Figure 1A), and based on the extent of the defect, the donor area was delimited in the ipsilateral malar region.Then, the flap was marked in the zygomatic region (Figure 1B) from the lateral corner of the eyelid, descending perpendicularly to 90° in relation to the lower ciliary margin.The skin flap was raised along with a sufficient thick layer of subcutaneous tissue in order to fill the defect entirely (Figures 1C, 1D).Subsequently, the transposition process took place, followed by closure of the donor and receiving areas using deep subdermal stitches (4-0 polydioxanone) and simple separated stiches (6-0 monofilament nylon) superficially (Figure 1E).

RESULTS
The zygomatic-palpebral flap for lower eyelid reconstruction allowed the restoration of height and palpebral vertical length, preventing and correcting ectropion.The immediate results (Figure 1F) and late results in terms of aesthetics, scar quality and function were satisfactory and well accepted by both patients and surgical team, with adequate eyelid occlusion and preserved eye lubrication.
Lymphatic edema of the flap was the greatest complaint in operated cases, but it resolved spontaneously within approximately 6 months.Infection, surgical dehiscence, hematomas, and other complications were not recorded.Figures 2 and 3 present cases of reconstruction of the lower eyelid due to a skin cancer in a young and in an elderly patient, respectively.Moreover, correction of a scar ectropion in a burn victim is presented in Figure 4.

DISCUSSION
The eyelids cover and protect the eyes.Their function is to protect the eyes against excessive light, trauma, or dryness.Moreover, they contain glands that produce mucus, lubricants, and lipids that make up the tear film.Eyelids are divided into three lamellae.The anterior lamella contains skin and muscle, the middle lamella contains the orbital septum, and the posterior lamella contains tarsus, tarsal plates, and the retractor muscles of the eyelid and conjunctiva.The skin of the eyelids is extremely thin, and the skin of the upper eyelid is thinner than that of the lower eyelid, since there is little subcutaneous fat at the base of the eyelid skin.
Eyelid reconstruction techniques involve the restoration of all lamellae, with at least one of these layers having to be well vascularized.Flaps are preferable when compared to grafts due to the like-to-like phenomenon -similarity with the adjacent skin in texture, color, thickness, and elasticity, besides having intrinsic blood supply, maintenance of tactile sensation, the same surgical field, and durability.However, for partial thickness defects, skin grafts may be highly recommended.A satisfactory reconstruction of the lower eyelid should allow juxtaposition of the eyelid to the eyeball in order to prevent the onset of ectropion.
The eyelid reconstruction technique is chosen based on the thickness and extent of the defect.Direct closure techniques can be used in defects of up to 30% in young patients, and up to 45% in elderly patients.
In borderline cases, a lateral cantholysis may provide additional relaxation for wound closure.
Local and regional flaps are useful for reconstruction of the lamella.Flaps, as described previously by Tenzel, Hughes, Mustardé, and Cutler, are well known among plastic surgeons and are useful for reconstruction of large defects, as well as cartilage grafts 1-6 .Tarsus with free margin associated with myocutaneous flap can be used for reconstruction of the posterior lamella.
A literature review showed that the choice of the technique for lower eyelid reconstruction varied according to the skin texture, scars adjacent to the recipient area, patient's age, probable aesthetic result, size of the defect, and already used alternatives.The zygomatic-palpebral flap technique has some advantages, including the ease of execution, minimal bleeding, low morbidity of the donor area, and the ability to perform it under local anesthesia.Although some authors questioned that the flap design did not consider any of the aesthetic subunits of the face (this being the greatest reservation found in the literature), the scars along the malar region are usually considered as aesthetically acceptable by the patients and surgical teams.

CONCLUSION
Zygomatic-palpebral flap is an alternative technique that can be used in cases of scleroatrophic skin in elderly patients and young patients without sufficient tissue to reconstruct major defects.

Figure 1 .
Figure 1.Technique sequence of the zygomatic-palpebral flap procedure used for correction of senile ectropion.A: Ectropion; B: Flap design; C: Incision and dissection; D: Flap transposition; E: Immediate postoperative period; F: Second postoperative day.

Figure 2 .
Figure 2. Basal cell carcinoma of the lower eyelid.A: Marking of the lesion; B: Defect greater than 50% of the anterior lamella in a young patient without excess skin; C: Immediate postoperative; D: Sixmonth postoperative result.

Figure 3 .Figure 4 .
Figure 3. Squamous cell carcinoma of the lower eyelid.A: Marking of lesion and surgical margin of resection in total plane; B: Reconstruction of posterior and middle lamella with Hughes flap; C: Positioning of the zygomatic-palpebral flap for reconstruction of the defect and closure of the donor area; D: Sixmonth postoperative result.