Journal of Cranio-Maxillofacial Surgery (2008) 36, 59e65

Ó 2007 European Association for Cranio-Maxillofacial Surgery

doi:10.1016/j.jcms.2007.08.005, available online at http://www.sciencedirect.com

Case Report
Total lower eyelid reconstruction with a prefabricated flap
using auricular cartilage

Kazuo KOBAYASHI1, Hiroshi ISHIHARA1, Ryuichi MURAKAMI2,

Naoshi KINOSHITA1, Kazuyo TOKUNAGA1
1
Department of Plastic and Reconstructive Surgery (Chief: Dr. K. Kobayashi), Ehime Prefectural Central Hospital,
Matsuyama, Japan; 2 Department of Plastic and Reconstructive Surgery, Yamaguchi Prefectural Central Hospital,
Hofu, Japan

SUMMARY. Introduction: Various methods have been reported for reconstructing the lower eyelid, but there is
still the problem of creating a deep fornix and a supportive eyelid for housing an artificial eye. Case report: A
new prefabricated flap was developed using auricular cartilage and the lateral femoral circumflex vessels as vas-
cular pedicles. This was applied in a 64-year-old male patient with total lower eyelid loss following an extended
maxillectomy for tumour. Conclusion: The prefabricated flap described here showed more flexibility and
a longer vascular pedicle, thus improving the applications for use in patients with limited recipient vessels yet
without major sacrifice or deformity in the donor area. Ó 2007 European Association for Cranio-Maxillofacial
Surgery

Keywords: prefabricated flap, lower eyelid, auricular cartilage

INTRODUCTION Patient and method

After aggressive resection of malignant tumours of the
head and neck, the functional and aesthetic reconstruc-
tion of the involved areas has been difficult and complex.
As for reconstruction following resection for maxillary
cancer with ocular involvement, numerous articles have
been published (Holle et al., 1996; Brown et al., 2002;
Fairbanks and Hallock, 2002; Kakibuchi et al., 2002)
on satisfactory separation between the nasal and the
oral cavities, reconstructing the orbit, lids and socket
and preserving aesthetic appearance as well as filling
the defects.
In reconstructing the orbit, it is of importance to also
create natural appearing eyelids, with a deep fornix,
using robust tissue with little postoperative contracture
(Asato et al., 1993; Altintas et al., 1998; Molnar et al.,
1998; El-Khatib, 2000; Yanaga and Mori, 2001). One
of the reconstructive methods utilizes a prefabricated
flap and has been described by Shen (1982) and
Shintomi and Ohura (1982). In this method, a vascular
bundle is grafted to the site of reconstruction where
there is no existing vascular system and one has to
be formed secondarily. This method can be applied to
various tissue defects (Brent et al., 1985; Khouri
et al., 1991).
This paper describes the reconstruction of the lower
eyelid with a deep fornix using a prefabricated flap in
a patient with an orbital defect following maxillary can-
cer resection.
A 64-year-old man underwent an extended maxillectomy
and cervical lymph node dissection in 1997 for a maxil-
lary tumour, T3N1, M0 squamous cell carcinoma, after
neoadjuvant chemoradiation (ParapratinÒ, 450 mg and
radiotherapy, 40 Gy) which resulted in right mid-facial
contracture and an orbital defect. The patient was referred
to this department in 1998 for repair of this painful defect
(Fig. 1A). On examination, his right palate, maxillary si-
nus, orbital floor, orbital lateral wall, orbital contents and
the zygomatic arch were absent (Fig. 1B). Scar contrac-
ture in the right mid-facial region was noted. Fluid dis-
charge from the right orbit and oral cavity was evident
(Fig. 1C). Reconstruction was aimed at sealing the com-
munication between the oral and nasal cavities and the or-
bit, release of the buccal and intra-oral contracture and
creating an eye socket by using a bone graft and a free
rectus abdominis myocutaneous flap in 1999. However,
since the patient had developed a defect through to the
dura and frontal lobe during debridement of the granula-
tion tissue in the orbit, sealing of the communication with
the intra-cranial cavity was also necessary. First, a rectus
abdominis myocutaneous flap was harvested to seal the
communication between the oral and the nasal cavities
and the orbit. The inferior epigastric vessels were anasto-
mosed with the right facial vessels (Fig. 2A and B). At
the same time, a free groin flap was harvested and trans-
ferred to create the eye socket. The superficial circumflex
iliac vessels were anastomosed to the superficial temporal

59
60 Journal of Cranio-Maxillofacial Surgery

Fig. 1 e Sixty-four-year old patient, preoperatively. (A) Facial deformation with defect right orbit and missing eye globe following radical
maxillectomy. (B) Computed tomography; zygoma, maxilla and orbital floor resected, communication from oral cavity to nasal cavity and orbit. (C)
Oro-nasal fistula (arrow).

vessels (Fig. 2C). Postoperatively the patient was able to
eat with dentures and without a facial prosthesis
(Fig. 2D). However, due to vascular compromise, the
right lower eyelid was lost and the remaining fornix
was shallow. Reconstruction of a supportive lower eyelid
with a deep fornix was required for housing an artificial
eye and the use of an auricular cartilage graft was consid-
ered. However, since the superficial temporal vessels sup-
plying the anterior helix had been used in the previous
operation, it was planned to anastomose the lateral cir-
cumflex femoral vessels to the severed superficial tempo-
ral vessels, to create a prefabricated flap in the anterior
helical region and the temporo-parietal fascia. This flap
was prefabricated in 2000. First, portions of the lateral
circumflex femoral vessels, approximately 10 cm in
length, were harvested with two lobes of fascia and
vastus lateralis muscle measuring 5  5 mm (Fig. 3A).
The fascia was sutured to the right auricular perichon-
drium and the muscle was sutured to the temporo-parietal
fascia, above which a skin graft was transplanted and em-
bedded beneath the skin of the temporal region (Fig. 3B).
By using the lateral circumflex femoral vessels, the
constructed complex had a vessel with sufficient length
capable of being transferred and anastomosed to the
superficial temporal vessels. Seventeen days later the
prefabricated flaps were transferred to the lower eyelid
 Prefabricated ear helix for eyelid reconstruction 61

Fig. 2 e Same first stage reconstruction. (A) Dural defect and brain (white arrow) following debridement of orbital cavity, nasal cavity and
palate. (B) Rectus abdominis flap divided into three portions. The palate and lateral wall of nasal cavity to be reconstructed by two portions
(white arrows). Another portion of the flap (black arrow) was denuded of skin to fill the orbit with adipose tissue. (C) Ribs as supportive
structures grafted between maxilla and anterior nasal spine; the flap was fixed to the ribs to prevent displacement into the oral cavity. (D) CT:
Communications closed between oral and nasal cavities (white arrows), the orbit and anterior cranial fossa contents.

region. The anterior portion of the right auricular helix, DISCUSSION

3 cm in length, with the grafted vascular bundle was el-
evated, and transferred to the lower eyelid (Fig. 4B). The
skin grafted onto the temporo-parietal fascia was also
elevated for reconstructing a deep fornix. As the grafted
vascular bundles adhered to the surrounding tissue and
were shortened, they had to be peeled off. A slight
vascular congestion occurred in the prefabricated flaps,
but the circulation recovered within 5 days (Fig. 4C).
Follow-up evaluation revealed that the reconstructed
lower eyelid was still deep with sufficient support for
housing the artificial globe 4 years, postoperatively
(Fig. 5). The auricular deformity was less than expected
and there were no problems for the patient when wearing
glasses.
There are several goals for reconstruction following re-
section for maxillary cancer:
1. Sealing the communication formed between the oral
and the nasal cavities and the orbit.
2. Release of buccal and intra-oral contractures.
3. Support with hard tissue.
This patient had undergone resection of the whole
right palate, maxillary bone and orbital contents after
radiotherapy and chemotherapy for maxillary carcinoma.
This resulted in facial asymmetry, distortion of the ala
nasi and angle of the mouth as well as buccal depression.
The maxilla and orbit were covered with granulation
62 Journal of Cranio-Maxillofacial Surgery

Fig. 3 e Construction of the prefabricated flap. (A) Lateral circumflex femoral vessels harvested as donor vessels; two lobes of soft tissues (fascia, black
arrow, and muscle, white arrow) were elevated with the distal end of the vascular pedicle. (B) The vascular bundle was approximately 10 cm long,
spanning from the anterior helical region to the lower eyelid and anastomosed to the superficial temporal vessels. One soft tissue lobe (fascia, black
arrow) covered the perichondrium, the other lobe of the flap (muscle, white arrow) was placed upon the temporo-parietal fascia followed by a skin graft
for reconstructing the fornix of the orbit. (C) Schematic drawing of Fig. 3B. The auricular cartilage wrapped by the fascia (black arrow) transfers to the
deficit in the lower eyelid, and the skin grafted muscle on the temporo-parietal fascia (white arrow) transfers to superior orbital fornix.

tissue and mucosa, and extensive debridement and re-
lease of the mucosal contracture were required.
First, it was planned to concurrently perform both the
reconstruction of the eye socket and to seal the commu-
nication formed between the oral and nasal cavities and
the orbit by a free muscle flap. But as injury to the
dura and frontal lobe had occurred during debridement
of granulation tissue in the orbit, the initial plan was al-
tered to repair and prevent infection to the cranial cavity
as a priority. Accordingly the dura mater was repaired
with fascia, the palate and lateral nasal wall were recon-
structed, the orbit was filled with an adipose tissue flap
and bone was grafted between zygoma and the alveolus
during the first operation. At the same time, a free groin
flap was transferred to create the eye socket. However,
whilst eating with dentures was possible and satisfactory
symmetry of the buccal regions was attained, the lower
eyelid was completely lost due to poor perfusion.
The elements considered to be of importance in recon-
structing the lower eyelid have been reported to be carti-
lage covered with thin skin, like a sandwich (Carraway
et al., 1990). In large defects, rotation, advancement or
transposition skin flaps with a composite mucosa and
cartilage graft from the nasal septum have been used
(Mustarde, 1991). However, in a total full-thickness de-
fect of the lower eyelid with a requirement for housing
an artificial eye, reconstruction with numerous skin flaps
usually results in unsatisfactory functional and aesthetic
results. The auricle consists of skin and cartilage which
can be used to reconstruct the eyelid as described by
Koshima et al. (1999), although vein grafting is required
to transfer a major auricular component. For this particu-
lar case, the superficial temporal artery supplying the
anterior helix had already been used during previous sur-
gery. Therefore it was necessary to create a supplying ar-
tery for the auricular component, as a prefabricated flap.

Fig. 4 e Transfer of the prefabricated flap. (A) Deficient right lower eyelid and shallow right orbit prior to the transfer. (B) Auricular cartilage (black
arrow) and skin graft (white arrow) elevated on postoperative 17th day. (C) Both grafts transferred to the lower eyelid (black arrow) and superior orbital
fornix (white arrow), respectively.
This prefabricated flap was constructed in the anterior
helical region and the superficial temporal vessels were
selected as the recipient vessels. A vascular bundle
with fascia and some muscle was grafted onto the auric-
ular cartilage and the temporo-parietal fascia. Thus a new
vascular system was formed, i.e., a newly constructed
axial pattern flap. Studies (Washio, 1971; Erol and Spira,
1980; Hirase et al., 1988) have demonstrated the suc-
cessful formation of a neo-vascular system after grafting
a vascular bundle with fascia or source muscle (Shen,
1982; Shintomi and Ohura, 1982; Sanger et al., 1992;
Costa et al., 1993; Hyakusoku, 1993). The superficial
temporal vessels, thoraco-dorsal vessels and inferior
abdominal vessels are generally selected for their length,
diameter and minimal resulting deformity of the donor
site.
To construct a prefabricated flap, a minimum of two
operations is necessary. The first operation is to construct
Prefabricated ear helix for eyelid reconstruction 63
the new axial pattern flap. In the process of creating the
axial pattern flap, angiogenesis occurs between the small
blood vessels of the fascia and the target tissue (Yao,
1981). The second is to elevate and transfer the flap. It
has been experimentally demonstrated that angiofusion
originates in 3 days at the arteriolar level and blood cir-
culation resumes gradually within 2 weeks following the
grafting procedure (Maitz et al., 1994). There are many
challenges to obtain sufficient angiogenesis between the
fascia or muscle and the target tissue. Some of the
methods described to facilitate angiogenesis are the delay
and expanded techniques and the administration of basic
fibroblastic growth factor (Duffy et al., 1996; Wieslander
and Wieslander, 2000).
The period of prefabrication is reported to last more
than 3 weeks (Maitz et al., 1994; Altintas et al., 1998;
El-Khatib, 2000). Congestion and thrombosis can easily
occur after elevating the flap due to compromise in
64 Journal of Cranio-Maxillofacial Surgery

Fig. 5 e Postoperative appearance of the patient. (A) Improved facial asymmetry. (B) Reconstructed orbit with supportive bony structures and
formation of a deep formix enabling insertion of an artificial eye. (C) Minimal deformity of ear cartilage. Patient is able to wear glasses.

venous return, in other words, venous drainage flows into
the surrounding or adjacent skin prior to elevation but
flows back into the flap after elevation. For success in
elevating and transferring the flap, the use of venous
drainage of the surrounding or adjacent skin and the
use of a silicon tube around the vascular bundle have
been proposed (Karatas et al., 2000).
This is apparently the first reported case of lower eye-
lid reconstruction with a prefabricated anterior helical
flap. The reasons for selection of the lateral circumflex
femoral vessels were as follows: (1) It supplies both
the fascia and muscle. (2) Sufficient length is attained.
(3) Minimal donor site morbidity is to be expected.
The grafted vessels rerouted around the lateral aspect
of the orbit from the superficial temporal vessels to the
anterior helical region. It was planned to cover as wide
an area of the cartilage as possible in order to establish
and facilitate angiogenesis for supplying the anterior
helix.
This prefabricated flap turned out to be extremely use-
ful since it did not depend on preexisting vessels.
CONCLUSION
A lower eyelid was reconstructed using a prefabricated
flap in a patient with facial deformation resulting from ra-
diotherapy and subsequently extended maxillectomy for

malignancy. The use of a prefabricated helical cartilage
flap enabled construction of a lower fornix to house the
artificial globe. Angiogenesis was established between
the newly formed vessels and the 3-cm cartilage/skin
graft in a short period of time, and even a recipient blood
vessel used previously for micro-vascular anastomosis,
was successfully re-used. Auricular deformity was less
than expected and the patient had no problems when
wearing glasses.
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Dr. Kazuo KOBAYASHI, MD
Department of Plastic and Reconstructive Surgery
Ehime Prefectural Central Hospital
83 Kasuga-Machi
Matsuyama
Ehime 790-0024
Japan
Tel.: +81 89 947 1111
Fax: +81 89 943 4136
E-mail: kobak@silver.plala.or.jp
Paper received 11 May 2004
Accepted 28 August 2007