Hughes Flap (tarsal-conjunctival flap)
This is Richard Allen at the University of Iowa. This video demonstrates the use of a tarsoconjunctival or Hughes flap to repair a lower eyelid defect.
As is noted, the defect is full-thickness and involves approximately 75% of the width of the lower eyelid. The defect is measured with calipers.
A subciliary incision is then made extending from the lateral edge of the defect to the lateral canthus.
Dissection is then performed between the orbicularis muscle and the orbital septum to the inferior orbital rim. The intent of this dissection is to provide mobilization of a myocutaneous advancement flap to cover the Hughes flap, rather than using a skin graft.
Dissection is carried out in a preperiosteal fashion inferior to the inferior orbital rim.
A 4-0 silk suture is placed through the upper eyelid and the eyelid is everted over a malleable retractor.
A marking pen is used to make a mark 4 mm superior to the eyelid margin. The measured length of the defect is then marked.
A 15 blade is then used to make an incision through the tarsus along the marking.
Dissection is then performed between the anterior surface of the tarsus and the pertarsal orbicularis muscle.
Westcott scissors are then used to make vertical incisions at each end of the flap.
Further dissection is performed with a thermal cautery between the Mullers muscle and conjunctiva.
As you can see, the dissection here is very thin and it is not uncommon to make a button hole in the conjunctiva.
Further dissection is carried out so that the flap can be placed into position to repair the posterior lamella.
The remaining edge of the tarsus medially is then sutured to the flap with interrupted 5-0 vicryl sutures.
Two sutures are placed and then tied.
The flap is then secured to the remaining lateral tarsus, again with two 5-0 vicryl sutures.
The portion of the flap that corresponds to the future lid margin is then sutured with 7-0 vicryl sutures.
Dissection is then carried out with the thermal cautery inferiorly between the conjunctival and lower lid retractors.
Release of the lower lid retractors is important to prevent post-operative lid retraction as it is important to dissect between the Mullers muscle and conjunctiva in the upper lid.
The conjunctiva is then sutured to the inferior edge of the flap with a running 7-0 vicryl suture. This then completes repair of the posterior lamella.
In order to advance the anterior lamella, a preperiosteal midface lid is performed by engaging the SOOF which is then sutured to the periosteum of the inferior orbital rim with 4-0 vicryl sutures.
This results in adequate mobilization of the anterior lamella so that it can cover the tarsoconjunctival flap. The anterior lamella is then sutured to the Hughes flap, and this is performed with a running horizontal mattress suture using 7-0 vicryl suture.
This advanced the flap so that the upper edge of the anterior lamellar flap is at the edge of the Hughes flap.
The subciliary incision is then repaired with the same 7-0 vicryl suture.
Additional 7-0 vicryl sutures are then placed to fixate the upper edge of the anterior lamellar flap to the upper edge of the Hughes flap.
At the conclusion of the case, the eyelid appears to be in good position.
There is a small button hole in the conjunctiva which is of no consequence.
Antibiotic ointment is placed over the repair and the eye is patched for two days.