Early Flap Division Safe After Modified Hughes

NEW ORLEANS — In lower eyelid reconstruction, early division of a tarsoconjunctival pedicle can be safely performed 7 days after the first stage of a modified Hughes procedure, Igal Leibovitch, M.D., said at the annual meeting of the American Academy of Ophthalmology.

Dr. Leibovitch presented the results of a study showing good functional and cosmetic outcomes in 29 consecutive skin cancer patients (20 men and 9 women) who had surgery between January 2000 and April 2004.

All had their flaps separated 7 days after the first stage of the modified Hughes procedure and were followed for an average of 14 months.

Subjects ranged in age from 39 years to 87 years, with an average age of 69 years. All of the patients had tumors removed by Mohs surgery. Two cases involved squamous cell carcinoma, and the rest had basal cell carcinoma.

The most common complications were mild upper-lid lash ptosis in three patients and lower-lid margin erythema in two patients.

One case with lower-lid margin erythema and hypertrophy required excision and cautery. Another patient had a mild lateral upper-lid retraction that was repaired with an anterior approach levator recession 3 months later.

The overall complication rate was 20.7%, but most events were mild, and many involved the upper eyelid, said Dr. Leibovitch of Tel Aviv Medical Center. "These complications may not be attributable to early division, and all have been reported in other series where the flap was divided later," Dr. Leibovitch commented. No postoperative retraction of the lower eyelid, flap ischemia, or necrosis occurred.

"The authors conclusively demonstrate flap viability at 7 days," said Russell S. Gonnering, M.D., of the Medical College of Wisconsin, Milwaukee.

Lid retraction may still be a problem, he added, and discussion is still open on how best to best handle Müller's muscle when doing the procedure.

Neither factor is related to the timing of the second stage, Dr. Gonnering said. He also noted that while the investigators proposed early division as an option, they did not necessarily advocate it for all patients.

A similar procedure, published in 1911, described an upper-lid tarsoconjunctival flap that was divided with good cosmetic results at 7 days, according to Dr. Leibovitch.

In 1937, however, the initial description of the Hughes procedure called for division after 2-4 months. Although the procedure has since evolved, even a 4- to 6-week interval can preclude it as an option when the patient has only one good eye or a child is at risk for occlusional amblyopia, Dr. Leibovitch said.

A tarsoconjunctival flap is used to repair a large defect in the left lower eyelid after removal of a BCC.

After the flap is secured, a skin graft is sutured in place on the anterior surface to close the defect. Photos courtesy Dr. Mark S. Brown/

NEW ORLEANS — In lower eyelid reconstruction, early division of a tarsoconjunctival pedicle can be safely performed 7 days after the first stage of a modified Hughes procedure, Igal Leibovitch, M.D., said at the annual meeting of the American Academy of Ophthalmology.

Dr. Leibovitch presented the results of a study showing good functional and cosmetic outcomes in 29 consecutive skin cancer patients (20 men and 9 women) who had surgery between January 2000 and April 2004.

All had their flaps separated 7 days after the first stage of the modified Hughes procedure and were followed for an average of 14 months.

Subjects ranged in age from 39 years to 87 years, with an average age of 69 years. All of the patients had tumors removed by Mohs surgery. Two cases involved squamous cell carcinoma, and the rest had basal cell carcinoma.

The most common complications were mild upper-lid lash ptosis in three patients and lower-lid margin erythema in two patients.

One case with lower-lid margin erythema and hypertrophy required excision and cautery. Another patient had a mild lateral upper-lid retraction that was repaired with an anterior approach levator recession 3 months later.

The overall complication rate was 20.7%, but most events were mild, and many involved the upper eyelid, said Dr. Leibovitch of Tel Aviv Medical Center. "These complications may not be attributable to early division, and all have been reported in other series where the flap was divided later," Dr. Leibovitch commented. No postoperative retraction of the lower eyelid, flap ischemia, or necrosis occurred.

"The authors conclusively demonstrate flap viability at 7 days," said Russell S. Gonnering, M.D., of the Medical College of Wisconsin, Milwaukee.

Lid retraction may still be a problem, he added, and discussion is still open on how best to best handle Müller's muscle when doing the procedure.

Neither factor is related to the timing of the second stage, Dr. Gonnering said. He also noted that while the investigators proposed early division as an option, they did not necessarily advocate it for all patients.

A similar procedure, published in 1911, described an upper-lid tarsoconjunctival flap that was divided with good cosmetic results at 7 days, according to Dr. Leibovitch.

In 1937, however, the initial description of the Hughes procedure called for division after 2-4 months. Although the procedure has since evolved, even a 4- to 6-week interval can preclude it as an option when the patient has only one good eye or a child is at risk for occlusional amblyopia, Dr. Leibovitch said.

A tarsoconjunctival flap is used to repair a large defect in the left lower eyelid after removal of a BCC.

After the flap is secured, a skin graft is sutured in place on the anterior surface to close the defect. Photos courtesy Dr. Mark S. Brown/

NEW ORLEANS — In lower eyelid reconstruction, early division of a tarsoconjunctival pedicle can be safely performed 7 days after the first stage of a modified Hughes procedure, Igal Leibovitch, M.D., said at the annual meeting of the American Academy of Ophthalmology.

Dr. Leibovitch presented the results of a study showing good functional and cosmetic outcomes in 29 consecutive skin cancer patients (20 men and 9 women) who had surgery between January 2000 and April 2004.

All had their flaps separated 7 days after the first stage of the modified Hughes procedure and were followed for an average of 14 months.

Subjects ranged in age from 39 years to 87 years, with an average age of 69 years. All of the patients had tumors removed by Mohs surgery. Two cases involved squamous cell carcinoma, and the rest had basal cell carcinoma.

The most common complications were mild upper-lid lash ptosis in three patients and lower-lid margin erythema in two patients.

One case with lower-lid margin erythema and hypertrophy required excision and cautery. Another patient had a mild lateral upper-lid retraction that was repaired with an anterior approach levator recession 3 months later.

The overall complication rate was 20.7%, but most events were mild, and many involved the upper eyelid, said Dr. Leibovitch of Tel Aviv Medical Center. "These complications may not be attributable to early division, and all have been reported in other series where the flap was divided later," Dr. Leibovitch commented. No postoperative retraction of the lower eyelid, flap ischemia, or necrosis occurred.

"The authors conclusively demonstrate flap viability at 7 days," said Russell S. Gonnering, M.D., of the Medical College of Wisconsin, Milwaukee.

Lid retraction may still be a problem, he added, and discussion is still open on how best to best handle Müller's muscle when doing the procedure.

Neither factor is related to the timing of the second stage, Dr. Gonnering said. He also noted that while the investigators proposed early division as an option, they did not necessarily advocate it for all patients.

A similar procedure, published in 1911, described an upper-lid tarsoconjunctival flap that was divided with good cosmetic results at 7 days, according to Dr. Leibovitch.

In 1937, however, the initial description of the Hughes procedure called for division after 2-4 months. Although the procedure has since evolved, even a 4- to 6-week interval can preclude it as an option when the patient has only one good eye or a child is at risk for occlusional amblyopia, Dr. Leibovitch said.

A tarsoconjunctival flap is used to repair a large defect in the left lower eyelid after removal of a BCC.

After the flap is secured, a skin graft is sutured in place on the anterior surface to close the defect. Photos courtesy Dr. Mark S. Brown/