A Modification to the Hughes Tarsoconjunctival Flap for a Challenging Case of Recurrent Lower Eyelid Retraction

PURPOSE: To present a modification of the Hughes tarsoconjunctival flap to correct a case of refractory lower eyelid retraction. METHODS: The authors report a 49-year-old man with cicatricial right lower eyelid retraction that failed multiple surgical interventions, including ear cartilage grafts to the posterior lamella, tarsal strip, alloplastic implant, and Sub-Orbicularis Oculi Fat (SOOF) lift. A modified Hughes tarsoconjunctival flap was used for repair of a nonmarginal defect of the lower eyelid. A marginal defect was purposely created with a full-thickness blepharotomy that compensated for the amount of lower eyelid retraction. The posterior lamellar defect was filled with the tarsoconjunctival-Muller's flap and the anterior lamella defect covered with a full-thickness retroauricular skin graft. Mueller's muscle was included in the flap to increase the vascular supply to the reconstructed eyelid. Likewise, the authors waited 9 weeks to divide the flap because of concerns that the vascular supply of the surrounding eyelid might be compromised from multiple previous surgeries. RESULTS: A single case of cicatricial right lower eyelid retraction status after multiple failed surgical interventions successfully completed a full-thickness blepharotomy with a modified Hughes tarsoconjunctival flap. Two months after the procedure, the patient had good cosmesis and function with resolution of his signs and symptoms of exposure keratopathy. CONCLUSIONS: The Hughes tarsoconjunctival flap combined with a full-thickness blepharotomy may be a useful technique in selected patients for repair of nonmarginal defects of the lower eyelid when other standard techniques have failed.