Orbit, 2014; 33(2): 124126

! Informa Healthcare USA, Inc.

ISSN: 0167-6830 print / 1744-5108 online
DOI: 10.3109/01676830.2013.814681

C ASE REPORT

Sliding Tarsal Advancement Flap for Upper Eyelid

Reconstruction
Adeela Malik and Sabrina Shah-Desai
Ophthalmology Department, Queens Hospital, Barking, Havering and Redbridge University Hospitals NHS
Trust, London, United Kingdom

ABSTRACT
The Sliding Tarsal Advancement Flap, a modification of Hughes procedure has been used for the repair of large
upper eyelid defects in three patients. The procedure yielded both good functional and aesthetic outcomes.
At presentation the defect measured 50% in two cases and 450% in one case.
Keywords: Surgical techniques, upper eyelid reconstruction, upper eyelid flap

CASE REPORT

Reconstruction of large upper eyelid defects pose a

unique challenge to the oculoplastic surgeon, given
the eyelids specialized role in production and smooth
distribution of tears across the ocular surface, globe
protection, and its high visibility as an aesthetic
landmark. To achieve both satisfactory functional
and cosmetic outcomes, eyelid repair requires careful
attention to both the posterior and anterior lamella
anatomy.
Morley et al.1 have reviewed the principles of
upper eyelid reconstruction and the range of techniques available. Popular posterior lamella reconstruction procedures include: free tarsal grafts2;
sliding tarsal conjunctival flaps3; use of tarsal substitutes such as nasal cartilage4; ear cartilage5; tarsal
rotational flap for upper eyelid construction,6 partial
and total upper eyelid construction,7 and banked
sclera, composite grafts from the contralateral eyelid,
and various lower eyelid-sharing procedures.
However, use of these bridging and non-bridging
techniques can be cumbersome. We report the use of a
simple sliding tarsal advancement flap procedure for
the reconstruction of large upper eyelid defects, with
good functional and aesthetic outcomes.

20
14

The Sliding Tarsal Advancement Flap (a modification

of Hughes procedure)8: is particularly suited for the
repair of large upper lid defects such as illustrated in
Figure 1a. This surgical technique involves everting
the upper lid, assessing the defect and amount of
residual tarsus, before marking an appropriate-sized
flap 4 mm from the lid margin of the tarsal remnant
(Figure 1b). The Levator aponeurosis and Mullers
muscle are then recessed from its superior border.
Vertical incisions are made at the medial and lateral
edge of the tarsus and extended superiorly into the
conjunctiva, to fashion a tarsoconjunctival flap of
sufficient width to fill the defect (Figure 1c). The flap
is advanced inferiorly and obliquely to slide into the
upper lid defect, ensuring that there is no tissue
tension. The lateral aspect of the flap is then secured
to the lateral canthal tendon remnant or lateral
periosteum, and the medial aspect is then sutured to
the medial tarsal remnant with buried absorbable
sutures (Figure 1d). Finally, the anterior lamella is
reconstructed by advancing or rotating a myocutaneous flap, or placing a full thickness skin graft.

Received 25 July 2012; Revised 7 January 2013; Accepted 10 June 2013; Published online 16 January 2014
Correspondence: Mrs. Sabrina Shah-Desai, Ophthalmology Department, Queens Hospital, Rom Valley Way, London RM7 0AG,
United Kingdom. E-mail: sabrina.shah-desai@bhrhospitals.nhs.uk

124

Reconstruction of Large Upper Eyelid Defects 125

FIGURE 1. Sliding tarsal advancement flap for upper eyelid reconstruction.

The above sliding tarsal advancement flap reconstruction technique was used for the repair of upper
eyelid defects in three patients with lateral upper
eyelid defects reconstructed during February 2011 to
February 2012. At presentation, the defect measured
50% in two cases and 450% in one case. All patients
had anterior lamellar repair with the use of a local
myocutaneous flap and surgery was performed under
local anaesthesia.
The mean follow-up time was 7 months (range
712 months), with good functional and aesthetic
outcome in 2 out of 3 cases (no lagophthalmos, upper
lid retraction or entropion). One case (with 450%
defect) had post-operative lagophthalmos and a
lateral peak in the lid contour.
Figure 2 shows immediate and late post-operative
outcomes, for a patient with an initial upper eyelid
defect of 50%, using this technique. Figure 2a
shows the immediate post-operative appearance of
left upper lid basal cell carcinoma, repaired with
sliding tarsal advancement flap and a myocutaneous
flap. Figure 2b shows the 3-month post-operative
appearance, with a good position and contour of
the reconstructed eyelid. Figure 2c illustrates
absence of lagophthalmos at 3 months post-operative.
Figure 2d illustrates a stable square reconstructed
lid margin.

2014 Informa Healthcare USA, Inc.

COMMENT
When compared to other procedures for upper lid
reconstruction, such as free tarsal grafts, tarsal rotational flaps or tarsal substitutes, the present sliding
tarsoconjunctival flap procedure is technically easier,
and is essentially a modification of the commonly
used Hughes tarsoconjunctival flap (originally
described by Schinder and Esmaeli8). In addition,
it utilizes ipsilateral preserved tissue, and this avoids
the need for a second stage procedure (i.e., division of
flap) and morbidity associated with more complex
eyelid bridging procedures.
Combining this technique with other supporting
techniques such as lateral canthotomy, cantholysis
and myocutaneous anterior lamellar flaps, very large
medial and lateral eyelid defects may be reconstructed.
We report three cases of patients with large upper
eyelid defects that were repaired with a sliding tarsal
flap after local excision. The positive outcome of these
cases suggests that large upper eyelid defects post
tumour excision can be successfully repaired with a
one stage technique. This maintains eyelid function
compared to the current practice of using eyelid
sharing technique.which require second stage procedures and can result in less favourable outcomes.

126 A. Malik and S. Shah-Desai

FIGURE 2. Comparison of post-surgical outcome of eyelid with initial 50% defect against appearance of contralateral eyelid. (a)
Immediate post-operative appearance of left upper lid with reconstruction of 50% defect following basal cell carcinoma removal
(b) Three month post-operative appearance with a good lid position and contour of reconstructed eye lid (c) Three months postoperative appearance illustrating absence of lagophthalmos (d) Three month post-operative appearance illustrating stable and
square lid margin.

As upper eyelid defects are less common, the

collection of a larger cohort of patients with 450%
upper eyelid defects is difficult, and again the repair
of most of such defects are quite likely to have been
tackled using a variety of traditional eyelid reconstructive procedures and a collaborative study is thus
not a justifiable alternative.
The post-operative complications of lid peak, due
to inadequate flap width and advancement, can result
in poor eyelid closure and cosmesis.
The sliding tarsal advancement flap technique is a
simple and effective method of restoring the posterior
lamella in large upper eyelid defects. The technique is
associated with preservation of eyelid function and
satisfactory cosmesis.

DECLARATION OF INTEREST
All authors declare no support from any organization
for the submitted work; SSD has received honorariums and has been paid for developing and delivering
educational presentations for Alcon; there are no
other relationships or activities that could appear to
have influenced the submitted work.

REFERENCES
1. Morley AMS, Desousa JE, Selva D, Melhotra R. Techniques
of upper Eyelid Reconstruction. Surv Ophthalmol 2010;55:
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eyelid. Am J Opthalmol 1979;87:797801.
3. McCord ECW. Reconstruction of the upper eyelid and
medial canthos. In Oculoplastic Surgery. New York: Raven
Press, 1981, pp 103104.
4. Anderson RL, Edwards JJ. Reconstruction by myocutaneous eyelid flaps. Arch Ophthalmol 1979;97:
23582362.
5. Weinstein GS, Anderson RL, Tse DT, et al. The use of a
periosteal strip for eyelid reconstruction. Arch Ophthalmol
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Reconstructive Surgery. 3rd Edition. Black EH, Nesi FA,
Gladstone GJ, Levine MR, Calvano CJ. eds. New York:
Springer; 2012. Chapter 36, pp 555556.

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