Double-bridge novel modification of Cutler–Beard flap for the reconstruction of full-thickness eyelid deformity

Abstract

Introduction:

Eyelid deformities can come from birth defects or other causes, and they often need full thickness reconstruction. The Cutler–Beard and Hughes techniques are still the best methods for repairing upper eyelid colobomas. However, there are not many choices available when the eyelid margin is still intact. Here, we report the clinical outcomes of a novel modification of the Cutler–Beard flap surgery in eyelid deformity for these difficult cases.

Methods:

Design: Retrospective study. Setting: Tertiary care hospital. Study Population: All patients who presented with significantly deficient full-thickness eyelid tissue and severe exposure keratopathy due to lagophthalmos in the last 6 months were studied. Intervention: Patients underwent double-bridge novel modification of the original Cutler–Beard surgery. Main Outcome Measures: The flap survival, correction of eyelid deformity, lagophthalmos, symptomatic improvement, and patient satisfaction were assessed retrospectively. The patients were also followed up for postoperative complications such as lid contour, margin abnormalities, residual lagophthalmos, lymphedema, and donor site complications.

Results:

Postoperatively, there was satisfactory coverage of the ocular surface in all patients. None of the patients had complications such as flap/bridge necrosis, infection, or excessive secondary contraction of the flap. Chronic lymphedema was observed in one patient due to severe periorbital fibrosis.

Conclusion:

The Cutler–Beard technique remains a cornerstone in the field of eyelid reconstruction due to its versatility and effectiveness in managing large full-thickness defects of the upper eyelid. The described novel modification adds a new indication to the armamentarium of the modified Cutler–Beard procedures for eyelid reconstruction.

Eyelid deformity encompasses coloboma, eyelid retraction, canthal displacement, and margin abnormalities that include distortion, notch, and rotation. Its etiology is broadly classified into congenital and acquired. A wide range of reconstructive eyelid procedures is described for the correction of full-thickness eyelid deformities. The popular techniques for reconstructing a large full-thickness eyelid coloboma, that is, both anterior and posterior lamellae reconstruction/augmentation, are the Cutler-Beard technique and the Hughes flap combined with a skin flap or graft. Both procedures are two-staged and easy to master and produce optimal anatomical, functional, and aesthetic outcomes in patients with large eyelid defects.[1,2] There are limited reconstructive techniques for an eyelid deformity with an intact eyelid margin where augmentation of both the lamellae can be done, especially in patients with extensive periorbital scarring with/without bony fractures of the orbital rim, where mobilization of a periorbital flap and survival of a graft is difficult.[3,4]

The Cutler–Beard bridge flap was classically described for the reconstruction of a full-thickness upper eyelid defect/coloboma with an absent eyelid margin. It is a two-stage procedure where, in stage I surgery, a full-thickness flap of the lower eyelid, sparing its margin and tarsus, is advanced under the bridge and sutured to fill the upper eyelid defect with a single bridge left that consists of the full-thickness lower eyelid with its margin. In stage II, the advanced flap is incised, and both eyelids are formed.[1]

Herein, we describe a novel modification (double-bridge) of the Cutler–Beard surgery for the full-thickness reconstruction/augmentation of the eyelid, where the recipient’s eyelid margin is intact, hence a new indication.

Methods

This is a retrospective case study of three patients in which the double-bridge novel modification of the Cutler–Beard procedure was performed by a single surgeon (NP). Informed written consent was obtained. The study is per the Declaration of Helsinki. The patient who presented with a full-thickness eyelid shortening/defect with an intact eyelid margin, where both lamellae reconstruction was indicated, underwent surgery. The surgeon chose the novel procedure because the conventional method of mobilization of a periorbital flap and graft appeared to be difficult. The data on demography, history, clinical findings, diagnosis, and surgical outcomes are presented.

Case history

Case 1 – The patient was a 15-year-old girl who presented to us with right upper eyelid necrosis following multiple incisions and curettages done elsewhere for recurrent chalazion over 2 years. On examination, there was a full-thickness tissue defect sparing the eyelid margin in the right upper eyelid with discharge, congestion, and exposure keratopathy with a vision of 6/60 [Fig. 1a]. No other significant ocular or systemic abnormality was found. Contrast-enhanced computed tomography revealed mild periostitis in the right frontal bone with minimal soft tissue enhancement. She underwent a biopsy of the superior orbit, which revealed granulomatous inflammation on histopathology. The specimens sent for bacterial, fungal, and tuberculosis testing were negative. The patient was started on a broad-spectrum intravenous antibiotic with no response and was later switched empirically to an anti-tubercular regimen because of granulomatous inflammation on histopathology and mild periostitis on imaging. She was also started on topical antibiotics and lubricants. She responded to the treatment and was taken up for surgery at 2-month follow-up.

Figure 1.

(a): Clinical photograph (case 1) shows full-thickness necrosis of the right upper eyelid, sparing the margin with ocular surface infection. (b): Clinical photograph (case 2) shows severe bony and soft tissue deformity of the right face and orbit with enophthalmos and inferior globe dystopia. The eyelid shows scarred margin laterally with cicatricial retraction, inferior scleral show, and upper eyelid ptosis. (c): Postoperative photograph (case 1) at 5-year follow-up shows right eye ptosis with frontalis overaction. (d): Post-stage 2 procedure (case 2) at 6 months follow-up shows absent scleral show with lymphedema of the reconstructed lower eyelid. The upper eyelid ptosis showed minimal correction with a clear cornea. (e): Post-stage 2 procedure (case 3) at 1-year follow-up shows lateral flare because of loss of the bony support

Case 2 – The patient was a 50-year-old lady who presented with an inability to close the right eye with loss of vision and redness. She underwent a right maxillectomy followed by radiotherapy for adenoid cystic carcinoma of the sinus 7 years ago. She underwent multiple facial and eyelid surgeries in the past, with no records available. On examination, there was a right-sided facial disfigurement with loss of malar prominence and hollowness in the temple, periorbital, and cheek area [Fig. 1b]. The right eyelids and the eyebrow were displaced downward with hypoglobus and enophthalmos. The lateral canthus was displaced inferior-posteriorly with an inability to close the eye because of the severe periorbital soft tissue scarring and loss of orbital bony support. The lower eyelid was tethered to the orbital rim tissues, leading to distortion of the eyelid margins, entropion, and retraction. The bulk of the periorbital soft tissues was grossly reduced and tethered all around, making it difficult to raise a flap or provide a vascular bed for the graft survival. Exposure keratopathy with total cataract was seen. The vision was a perception of light OD and 6/6 OS. The pupillary reactions were normal, and the posterior segment was not visible. The patient underwent the novel double-bridge technique to vertically augment the full-thickness lower eyelid and correct the inferior scleral show and lagophthalmos.

Case 3 – The patient was a 17-year-old girl who presented with an inability to close her left eye with severe craniofacial disfigurement following a road traffic accident 2 years ago. She underwent cranial surgery twice for the large cranial bone defect, with no records available. On examination, there was a severe hollowness in the left parietal, forehead, and periorbital area due to a large bony defect in the frontal and parietal bones. The CSF pulsations could be felt. The upper eyelid was grossly deficient vertically, with an intact eyelid margin. There was severe lagophthalmos due to cicatricial severe upper eyelid retraction with exposure keratopathy. The vision was 6/24 OS with normal anterior and posterior segments. No displacement of the eyeball was seen, and the ocular motility was normal. After seeking neurosurgery clearance, she was taken up for upper full-thickness eyelid augmentation using the double-bridge novel technique.

Surgical technique

Stage 1 [Fig. 2a]: The basic principles of the Cutler–Beard bridge flap were followed for raising the full-thickness eyelid flap from the donor’s eyelid. A horizontal full-thickness incision was given in the donor eyelid, 4–5 mm away from the margin to spare the marginal vascular arcade. Vertical cuts were given along both ends of the horizontal incision, and the full-thickness eyelid bridge flap was advanced as in the Cutler–Beard procedure. Case 1 had an upper eyelid defect sparing the eyelid margin, so a lower eyelid flap was raised and brought beneath the lower eyelid margin bridge and upper eyelid margin bridge and sutured with the cut edges of the upper eyelid defect in two layers, anteriorly skin-orbicularis, and posteriorly tarso-conjunctiva using interrupted 6-0 silk sutures and 6-0 polyglactin sutures, respectively. In cases 2 and 3, a horizontal full-thickness eyelid incision was given 4–5 mm from the donor eyelid margin for full-thickness augmentation of the recipient eyelid. The raised flap from the donor eyelid was advanced under the horizontally incised eyelid margin of both eyelids and sutured with the cut edge of the recipient eyelid in two layers, as already described. Dog ears at the skin edges of the donor bridge flap were excised. The raw surface of the eyelid margin bridge was closed using 8-0 Polyglactin suture taking continuous bites from the skin and conjunctiva. Postoperative antibiotics and analgesics were given. The silk sutures were removed after 1 week. The patients were kept on regular follow-up [Fig. 3a and b]. They were assessed for postoperative complications such as the bridge necrosis, infection, and donor site complications.

Figure 2.

(a): A sketch diagram shows the stage 1 procedure. The full-thickness eyelid flap (yellow shade) is mobilized from the donor lower eyelid and taken beneath both the eyelid margin bridges and sutured to augment the recipient upper eyelid. (b): A sketch diagram shows the stage 2 procedure. The mobilized full-thickness donor eyelid flap is incised and sutured to the recipient eyelid (yellow shade). Two horizontal skin cuts were given on either end of the recipient handle to fit the flap skin. The bridges are sutured to the respective eyelids. Dog ear, if any, was excised

Figure 3.

(a): Post-stage 1 procedure (case 2) shows a metal probe beneath the two eyelid margin bridges. (b): Post-stage 1 procedure (case 3) shows the flap with two eyelid margin bridges on the left side. The patient had loss of frontal and parietal bones on the left side

Stage 2 [Fig. 2b]: The stage II procedure was done after 6–8 weeks. Intraoperatively, the recipient eyelid was gently pulled, and a convex full-thickness incision was placed in the bridging flap starting at its edge. The intraoperative assessment was done to take a sufficient amount of bridge flap tissue for the recipient eyelid reconstruction/augmentation without compromising the vertical height of the donor eyelid. The skin-conjunctival margins of both bridges (eyelid margin) were made raw with sufficient splitting of the anterior and the posterior lamellae to suture the cut edges of the eyelid margin in two layers with the surrounding eyelid tissue to reconstruct. Dog ears were cut, where needed. Postoperative antibiotics and analgesics were given. The skin sutures were removed after 1 week.

The patients were followed up to assess for postoperative complications such as the lid contour, margin abnormalities, residual lagophthalmos, lymphedema, and donor site complications. The flap survival, correction of eyelid deformity, lagophthalmos, symptomatic improvement, and patient satisfaction were assessed retrospectively.

Results

Three patients underwent eyelid deformity reconstruction/augmentation using the double-bridge novel modification of the Cutler–Beard procedure. All these patients had an intact eyelid margin. Following the stage II procedure, case 1 showed right eyelid ptosis, mild lagophthalmos, and a vision of 6/9 at 5-year follow-up. She had no recurrence of the disease. She was not willing to wear crutch glasses. She was advised to continue topical lubricants [Fig. 1c]. Case 2 showed markedly reduced inferior scleral show and lagophthalmos, persistent lymphedema, and minimal keratopathy at 6-month follow-up [Fig. 1d]. The patient underwent cataract surgery with a vision gain of 6/18 OD. She was treated with topical lubricants and was satisfied with the results. Case 3 had residual lateral flare because of the loss of fronto-parietal bone, with minimal lagophthalmos. There was no exposure keratopathy, and the vision was 6/9 at 1-year follow-up [Fig. 1e].

None of these patients had complications such as flap/bridge necrosis, infection, or excessive secondary contraction of the flap. The eyelid margin of the reconstructed eyelid was intact with no entropion/ectropion. Chronic lymphedema of the lower eyelid margin was observed in case 2 due to severe periorbital fibrosis [Fig. 1d].

Discussion

The Cutler–Beard technique for eyelid reconstruction was first described in 1955 by Norman Cutler and Crowell Beard as a method for the reconstruction of full-thickness defects of the upper eyelid.[1] It is a two-stage procedure, and the eye remained closed till the second-stage surgery, which is performed after 4–6 weeks. This approach was groundbreaking as it allowed repair of large defects that could not be managed by primary closure or skin grafting/flaps. The primary reason for the novel technique was the need for a reliable method to reconstruct large upper eyelid defects, often after tumor excision.[1] However, before this technique, there were a few options to repair such defects, such as Hugh’s procedure and raising a rotation/pedicle flap from the periorbital area, which often led to additional scars in the face, especially the latter techniques.[2,5]

The Cutler–Beard technique is versatile and can treat a myriad of clinical scenarios. It reconstructs both the anterior and posterior lamellae, providing optimal functional and esthetic results with a relatively natural appearance of the reconstructed eyelid. Being a flap with good vascularity, the risk of flap necrosis and secondary contraction is less compared with techniques that rely on a combination of flap and graft. Despite its advantages, the Cutler–Beard technique has some disadvantages. The reconstructed donor and recipient eyelids might show entropion, retraction, and lagophthalmos.[4,6,7] Destabilization and ectropion of the donor eyelid have also been reported.[8] A two-staged approach requires an additional surgery to divide the bridge flap. The reconstructed eyelid is floppy, along with the absence of normal eyelid margin structures, as lashes are some of the major esthetic limitations of the procedure. Despite limitations, it is popular among oculoplastic surgeons as it is a simple procedure with acceptable outcomes.[6,7,9,10]

In the literature, there are few modifications of the technique to address its limitations. In a study, authors described the augmentation of the posterior lamella with a free tarsal graft from the contralateral upper eyelid, and the anterior lamella with a lower lid skin flap over the lower eyelid margin, which is divided 2–4 weeks later. This method aims to provide structural integrity to the reconstructed eyelid with a lesser risk of eyelid retraction and entropion.[11] Another modification describes the use of a contralateral transconjunctival graft placed during the second stage of the Cutler–Beard flap to augment the posterior lamella of the recipient eyelid with improved eyelid margin contour.[12] In yet another modification, authors described the use of an inlay graft using auricular cartilage to provide strength to the reconstructed eyelid.[13] Use of sclera has also been described.[14]

In the present cases, authors describe a novel modification of the Cutler–Beard technique with a new indication. The original Cutler–Beard technique was indicated in patients with a deficient full-thickness eyelid with no eyelid margin (coloboma); the present procedure was performed in patients with a deficient full-thickness eyelid with an intact eyelid margin. The described procedure creates two bridges in the first stage, unlike a single bridge of the donor eyelid in the original Cutler–Beard procedure. In the second stage, the eyelid margin bridges were sutured to their respective eyelids with optimal results in all cases.

Conclusion

The Cutler–Beard technique remains a cornerstone in the field of eyelid reconstruction due to its versatility and effectiveness in managing large full-thickness defects of the upper eyelid. The described novel modification adds a new indication to the armamentarium of the modified Cutler–Beard procedures for eyelid reconstruction.

Ethical approval

Approval from the institute ethics committee was taken prior to the commencement of the study, and the study complies with the tenets of the Declaration of Helsinki.

Consent from patients for publication

Taken.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.