British Journal of Plastic Surgery (2005) 58, 361 365 Reconstruction of seventeen full-thickness defects of the eyelids with twenty-two Hübner tarsomarginal grafts * G. Dagregorio a, *, V. Huguier b, V. Darsonval b a Department of Plastic Surgery, Centre Hospitalo-Universitaire de Poitiers, CHU Poitiers, rue de la Milétrie, BP 577, 86021 Poitiers cedex, France b Department of Plastic Surgery, Centre Hospitalo-Universitaire d Angers, Angers, France Received 28 December 2003; accepted 12 November 2004 KEYWORDS Eyelid; Hübner technique; Full-thickness defect; Lid margin; Tarsomarginal graft Summary In 1976, Hübner described a new technique to repair full-thickness defects of the eyelids. In 1993, we decided to adopt this simple and easily reproducible technique that guarantees restoration of the normal aspect of the margin. Subsequently, 17 eyelid reconstructions were performed on 13 patients, requiring the harvesting of 22 tarsomarginal grafts. No cosmetic or functional sequelae in the donor eyelids were observed. One or several functional complications were present in seven out of 17 reconstructed eyelids, including two cases of epiphora, one case of lagophtalmos and two cases of lid notch. Loss of the eyelids was observed in three cases out of six upper eyelid reconstructions and in nine cases out of 11 lower eyelid reconstructions. In all cases, the margin integrity was otherwise preserved. Very few simple techniques achieve that level of quality in the eyelid reconstruction process. Q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. In 1976, Hübner described a new technique 1 to repair full-thickness defects of the eyelids. He called it free margin and tarsus transplantation. Two years later, Putterman 2 described the same * Presented in part at the 48th National Congress of the Société française de chirurgie plastique, reconstructrice et esthétique, Paris, France, November 2003. * Corresponding author. Tel.: C33 5 49 44 43 03; fax: C33 5 49 44 39 71. E-mail addresses: verone4@wanadoo.fr (G. Dagregorio), g.dagregorio@chu-poitiers.fr (G. Dagregorio). technique, which he called viable composite grafting. In 1988, Hübner 3 gave a new name to his graft, the tarsomarginal graft. The Hübner technique consists in harvesting a pentagonal full-thickness graft from the contralateral eyelid. Starting from an incision made 2 mm inferior to the lash line of the graft, the anterior lamella (skin and orbicularis oculi muscle) is excised (Fig. 1). The defect is then repaired in layers by first approximating the tarsal edges of the graft and defect at the lid margin (gray line). The lateral edges of the graft are then secured to the remnants S0007-1226/$ - see front matter Q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2004.11.017
362 G. Dagregorio et al. Figure 1 Hübner tarsomarginal graft with lid margin. Excision of the anterior lamella. of the native tarsus and conjunctiva with absorbable sutures. The skin-muscle layer provided by a local flap (rotation, advancement or transposition flap) is closed with 6-0 silk sutures, which are removed in 6 days. If necessary, two or even three grafts may be harvested from the three other eyelids to reconstruct larger defects. Fig. 2 shows how two grafts may be juxtaposed to reconstruct an upper eyelid after excision of a medial canthus tumour. The only limitation to the horizontal dimension of each individual graft is the Mustardé rule: no more than one fourth of each donor eyelid should be harvested, which is consistent with Hübner s recommendations limiting the graft length to 10 mm. Patients and methods Since 1993, 17 eyelid reconstructions have been Figure 3 Keratotic basal cell carcinoma of the right lower eyelid. performed on 13 patients. This group included nine males and four females, aged 26 82 years (mean 54 years). The process involved the harvesting of 22 tarsomarginal grafts. There were two upper eyelid reconstructions, seven lower eyelid reconstructions and four ipsilateral lower and upper eyelid reconstructions. There were six basal cell carcinomas, the most recent case being a 41-year old male patient with keratotic basal cell carcinoma invading the orbicularis oculi muscle and the lid margin of the right lower eyelid (Fig. 3). The series also included one case of morpheic basal cell carcinoma, three cases of lentigo maligna, two traumas and one congenital naevus. Ten tarsomarginal grafts were harvested from the contralateral Figure 2 Example of upper eyelid reconstruction with two juxtaposed tarsomarginal grafts. Figure 4 Keratotic basal cell carcinoma. Results at 2 years.
Twenty-two Hübner grafts 363 Figure 5 Keratotic basal cell carcinoma. Results at 2 years with loss of lashes. upper eyelid and twelve from the contralateral lower eyelid. The average graft length was 9.2 mm, ranging from 7 to 10.6 mm. Results No cosmetic or functional sequelae were observed in the donor eyelids (Fig. 4). The 13 patients were asked to assess the cosmetic results of their reconstructed eyelids. Nine patients rated the final result as very good, two as good, one as fair, and one as poor. Figs. 5 and 6 show one of the very good results, 2 years after excision of a keratotic basal cell carcinoma (Fig. 3). The 21 mm defect in the right lower eyelid had been closed with a 10 mm tarsomarginal graft harvested from the contralateral lower eyelid and a mini rotation cheek flap. The eyelid margin has a very natural aspect, despite the Figure 7 Lentigo malignant melanoma extending to the conjunctiva of the medial fifth of the upper eyelid and of the medial third of the lower eyelid of the right eye. eyelash loss. One or several functional complications were present in seven out of 17 reconstructed eyelids, including two cases of epiphora, one case of lagophtalmos and two cases of lid notch. Loss of the eyelids was observed in three cases out of six upper eyelid reconstructions, and in nine cases out of 11 lower eyelid reconstructions. In all cases the margin integrity was otherwise preserved. Discussion Figure 6 Keratotic basal cell carcinoma. Results at 2 years. Eye closed. Few series have been published on the Hübner technique. In 1988, 3 Hübner himself published a compilation of cases over 16 years. He reported good aesthetic and functional results without complications in the donor eyelids, even in cases of subtotal upper eyelid reconstructions and added that eyelashes were rarely saved. He concluded that his best results were obtained in reconstructing the medial half of the upper or lower eyelid. We disagree with this limiting conclusion: the Hübner technique is remarkably versatile. It may help reconstruct all sections of the eyelids. Shown is an example reconstruction of the lateral third of the lower eyelid (Fig. 5). Other locations of eyelid defects led to remarkable results as well. For
364 G. Dagregorio et al. Figure 8 Lentigo malignant melanoma. Results at 2 weeks postoperatively. Oedema of the medially based flap. Figure 11 eyelid. Avulsion of the central third of the left upper Figure 12 Avulsion. Reconstruction with a 9 mm Hübner graft. Results at 6 months postoperatively. Figure 9 Lentigo malignant melanoma. Results at 1 year postoperatively. example, the central third of the upper eyelid or the medial third of the lower eyelid including the medial canthus as shown in the two following cases. Fig. 7 shows a lentigo malignant melanoma extending to the conjunctiva of the medial fifth of the upper eyelid and of the medial third of the lower eyelid of the right eye. Only the lower eyelid required a 9 mm Hübner graft harvested from the lateral part of the contralateral eyelid. The anterior lamella was reconstructed by a medially based upper lid flap split in half to cover both eyelids. The significant oedema of the flap may be seen 1 month postoperatively (Fig. 8). The result was acceptable Figure 10 Lentigo malignant melanoma. Results at 1 year postoperatively. Figure 13 Avulsion. Reconstruction with a 9 mm Hübner graft. Results at 1 year postoperatively.
Twenty-two Hübner grafts 365 at 1 year postoperatively (Figs. 9 and 10). Another case illustrates the reconstruction of the central third of the left upper eyelid of a young patient after avulsion (Fig. 11). Six months (Fig. 12) and1 year (Fig. 13) after reconstruction with a 9 mm Hübner graft harvested from the contralateral upper eyelid, the patient rated the results as very good. Five years after Hübner s article, Werner et al. 4 published a series on 51 patients. They concluded that cosmetic results and palpebral fissure symmetry were acceptable. They insisted on the importance of the eyelid margin conservation and stressed the value of their 14% eyelash survival rate. Eusterholz 5 published a series of 16 eyelid reconstructions with tarsomarginal grafts in 1997 with comparable results and in 2001 Sayag et al. 6 published a series of 58 tarsomarginal grafts with an average graft length of 9.81 mm and a 92% success rate with very rare complications. We always attempt direct closures when the fullthickness defect is less than one third of the eyelid, especially in older patients with significant skin laxity. When the horizontal length of the defect is well over one half of the eyelid, we normally use a composite flap such as an Abbé-Mustardé flap. In all other indications we use the Hübner technique, as already stated in our 1995 publication. 7 The tarsomarginal graft technique gives better cosmetic results than the usual composite grafts, while being less destructive than full-thickness flaps. Moreover, this one-time procedure leaves no sequelae in the donor eyelid and does not impose closure of the eye following surgery. Lastly, the tarsomarginal graft has a higher take rate than other full-thickness eyelid grafts as a vascularized anterior lamella is provided from adjacent tissue following excision of the anterior lamella of the graft. References 1. Hübner H. Closure of eyelid defects by transplantation of lid margin and tarsus. Klin Monatsbl Augenheilkd 1976;168: 677 82. 2. Putterman AM. Viable composite grafting in eyelid reconstruction. Am J Ophthalmol 1978;85:237 41. 3. Hübner H. Modified full-lid transplants ( tarsomarginal transplants ) in reconstructive eyelid surgery. Klin Monatsbl Augenheilkd 1988;193:647 50. 4. Werner MS, Olson JJ, Putterman AM. Composite grafting for eyelid reconstruction. Am J Ophthalmol 1993;116:11 16. 5. Eusterholz T, Wenzel M. Eyelid reconstruction with tarsomarginal transplant. Ophthalmologe 1997;94:745 50. 6. Sayag D, Ducasse A, Coicaud C, Gotzamanis A, Segal A. Tarsomarginal graft. Indication and results in palpebral surgery. J Fr Ophtalmol 2001;24:724 8. 7. Delahaye JF, Darsonval V, Duly T, Hubault-Marcade P, Dagregorio G. Eyelid repair using the Hübner technique. Ann Chir Plast Esthet 1995;40:169 75.