Case 08 2026: A Hella Lamella: A Three-Flap, Full-Thickness Lower Eyelid Reconstruction

Keywords: Eyelid reconstruction, Hughes flap, tarsoconjunctival flap, periosteal flap, periorbital, scc, cheek rotational flap, Z-plasty Authors: Sondre F. Koren (MD), Jette B. Løvenwald (MD). Roskilde, SUH, Denmark. Abstract An 83-year-old male with atrial fibrillation, stage 4 chronic kidney disease, chronic heart failure, monoclonal gammopathy of undetermined significance (MGUS), and glaucoma presented with a 35 × 35 × 15 mm ulcerated squamous cell carcinoma (SCC) of the lateral right lower eyelid. Frozen section-guided full-thickness excision was performed under general anaesthesia. Reconstruction was accomplished in two stages. In the first stage, a combined pedicled tarsoconjunctival flap and a laterally-based periosteal flap (posterior lamella), and a cheek rotation flap (anterior lamella) were used. Frost sutures provided corneal protection during the 4-week inter-stage interval. In the second stage, flap division was performed under general anaesthesia, incorporating Müller's muscle release to prevent upper eyelid retraction. A small dehiscence at the medial flap junction had resulted in a minor notch, which was ultimately resolved with Z-plasty and release of the underlying inferior scar contracture on the cheek. Final histopathology confirmed highly differentiated SCC with clear margins. The multidisciplinary tumour board found no indication for adjuvant therapy. At 23 days following flap division, the patient was satisfied with the functional and aesthetic result. Patient medical history The patient underwent surgery after a 7-week history of a growing tumour of the cheek and lateral lower eyelid. The punch biopsy reported keratoacanthoma/highly differentiated SCC. The tumour had been observed to assess for spontaneous regression, but continued to grow. He had stage 4 chronic kidney disease, treated with Darbepoetin alfa (Aranesp), and glaucoma treated with Latanoprost eye drops, which he had not been taking for several months, with no documented decline