title: Modified Hughes procedure for reconstruction of large full-thickness lower eyelid defects following tumor resection.
abstract: BACKGROUND
  Tarsoconjunctival flap advancement, or the Hughes procedure, is among the techniques of choice for reconstructing full-thickness lower eyelid defects so as to restore normal anatomy and function with the best possible cosmetic outcome. The purpose of this study is to report the outcome of a series of patients treated with a modified Hughes procedure following malignant tumor removal.
  
  
  METHODS
  This retrospective study included 45 consecutive cases of modified Hughes procedures performed between January 2013 and October 2015. During Hughes flap creation an incisional plane was chosen in all cases, which left Müller's muscle attached to the superior tarsal margin, while disinserting the levator aponeurosis. All cases were grouped according to the horizontal length of the lower lid defect to be reconstructed, as well as to the type of anterior lamella reconstruction (free graft vs. inferiorly based advancement flap). Grouped data were compared for the rate of surgical success, defined as achievement of normal lid function and satisfactory cosmesis without needing further surgical interventions, and for the frequency of specific complications.
  
  
  RESULTS
  Surgical success was achieved in 39 cases (87 %). The remaining cases required additional surgery for minor complications including lower-lid ectropion (4 %), pyogenic granuloma (4 %), or lower lid margin hypertrophy (2 %). Donor-site complications were not detected apart from one case of mild entropion with focal trichiasis. No case of premature flap rupture was seen. Neither the horizontal length of the lower lid defect (p = 0.489), nor the type of anterior lamella reconstruction (p = 0.349) significantly affected the surgical success. Particularly, there was no increased onset of lower-lid ectropion among patients receiving an advancement flap.
  
  
  CONCLUSIONS
  The modified Hughes procedure remains a well-suited technique for reconstructing lower eyelid defects involving up to 100 % of the horizontal lid length. Leaving Müller's muscle attached to the Hughes flap might prevent premature flap dehiscence without increasing the frequency of upper lid retractions in turn. Whether using a free skin graft or a skin-muscle advancement flap for anterior lamella reconstruction, seems to be insignificant for the functional-aesthetical outcome.
authors.affiliation: Department of Ophthalmology, University of Cologne, Cologne, Germany.
authors.forename: Ahmed M
authors.initials: AM
authors.lastname: Hishmi
authors.affiliation: Department of Ophthalmology, University of Cologne, Cologne, Germany. konrad.koch@uk-koeln.de.
authors.forename: Konrad R
authors.initials: KR
authors.lastname: Koch
authors.affiliation: Department of Ophthalmology, University of Cologne, Cologne, Germany.
authors.forename: Mario
authors.initials: M
authors.lastname: Matthaei
authors.affiliation: Department of Radiology and Radiooncology, University of Duesseldorf, Duesseldorf, Germany.
authors.forename: Edwin
authors.initials: E
authors.lastname: Bölke
authors.affiliation: Department of Ophthalmology, University of Cologne, Cologne, Germany.
authors.forename: Claus
authors.initials: C
authors.lastname: Cursiefen
authors.affiliation: Department of Ophthalmology, University of Cologne, Cologne, Germany.
authors.forename: Ludwig M
authors.initials: LM
authors.lastname: Heindl
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005134:Eye Neoplasms / Q000601:surgery; D005141:Eyelid Diseases / Q000601:surgery; D005143:Eyelids / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D013508:Ophthalmologic Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D019651:Plastic Surgery Procedures / Q000009:adverse effects / Q000379:methods*; D012189:Retrospective Studies; D013524:Surgical Flaps; D016896:Treatment Outcome
keywords: Hughes flap; Lower eyelid tumor; Modified Hughes procedure; Oculoplastic surgery; Tarsoconjunctival flap