Aim To examine and quantify patients’ satisfaction and correlate with the objective clinical presentation after the treatment and to present a comprehensive literature review on tarsoconjunctival/Hughes flap technique. Methods A review of more than 159 peer-review articles and a combined retrospective-prospective two-centres case series of 17 patients who underwent a two-stage modified Hughes flap procedure (2019-2021) to repair a lower eyelid defect caused by epithelial cancer was conducted. All patients were followed up for a minimum of six months. Patient macroscopic evaluation of redness, lid position, retraction, trichiasis, conjunctival overgrowth, tissue inflammation/infection and hypertrophic scarring were obtained, and findings were graded on a scale of 1 to 5 or binary YES/NO scale. Patients’ satisfaction using a Likert-type scale and correlation with the clinical presentation were analysed. Results Pearson correlation coefficient between patients’ satisfaction and clinical presentation was 0.534. Out of 510 (the highest summed score for patients’ satisfaction), the total score was 479 (93.9%); out of 187 (the highest summed score for clinical presentation), the total score was 162 (86.6%). Although both scores were high, a lower correlation coefficient and the higher satisfaction score can be explained by more realistic expectations in oncological patients compared to cosmetic ones. Conclusion Hughes flaps provide multiple benefits in the reconstruction of selected patients with large defects, especially when poor wound healing is expected, or when local advancement flaps do not provide tension-free reconstruction. The rate of complications is low and manageable, whereas additional therapy is usually observational or symptomatic.
Hawes MJ, Grove AS, Hink EM. Comparison of free tarsoconjunctival grafts and Hughes tarsoconjunctival grafts for lower eyelid reconstruction. Ophthalmic Plast Reconstr Surg. 2011;27:219–23.
2.
Juniat V, Ryan T, O’Rourke M, Ng S, O’Donnell B, McNab AA, et al. Hughes flap in the management of lower lid retraction. Orbit. 2021;23:1–6.
3.
M-SP CYOO, LEE TS. Treatment of recalcitrant orbital implant exposure using upper tarsoconjunctival flap. J Korean Ophthalmo Soc. 2001;1787–92.
4.
Hughes L, Saxby E, Wright M. Tarsoconjunctival ‘Hughes’ flap for repair of globe perforation: A modified technique in the management of severe scleral necrosis. Eur J Ophthalmol. 2021;32:NP60-NP63.
5.
Chen Y, Al-Sadah Z, Kikkawa DO, Lee BW. A Modified Hughes Flap for correction of refractory cicatricial lower lid retraction with concomitant ectropion. Ophthalmic Plast Reconstr Surg. 2020;36:503–7.
6.
Cho RI. Correction of recalcitrant cicatricial lower lid retraction and entropion with transverse tarsotomy and tarsoconjunctival flap. Ophthalmic Plast Reconstr Surg. 2019;35:91–4.
7.
WL H. A new method for rebuilding a lower lid. Arch Ophthalmol. 1937;17(1008):17.
8.
Yano T, Karakawa R, Shibata T, Fuse Y, Suzuki A, Kuramoto Y, et al. Ideal esthetic and functional full-thickness lower eyelid “like with like” reconstruction using a combined Hughes flap and swing skin flap technique. J Plast Reconstr Aesthet Surg. 2021;74:3015–21.
9.
Hughes WL. Total lower lid reconstruction: technical details. Trans Am Ophthalmol Soc. 1976;74:321–9.
10.
Rohrich RJ, Zbar RI. The evolution of the Hughes tarsoconjunctival flap for the lower eyelid reconstruction. Plast Reconstr Surg. 1999;104:518–22.
11.
Cies WA, Bartlett RE. Modification of the Mustardé and Hughes methods of reconstructing the lower lid. Ann Ophthalmol. 1975;7:1497–502.
12.
Hughes WL. Reconstructive surgery of the eyelids. Adv Ophthalmic Plast Reconstr Surg. 1986;5:25–87.
13.
Hishmi AM, Koch KR, Matthaei M, Bölke E, Cursiefen C, Heindl LM. Modified Hughes procedure for reconstruction of large full-thickness lower eyelid defects following tumor resection. Eur J Med Res. 2016;21(7).
14.
Pham CM, Heinze KD, Mendes-Rufino-Uehara M, Setabutr P. Single-stage repair of large full thickness lower eyelid defects using free tarsoconjunctival graft and transposition flap: experience and outcomes. Orbit. 2022;41:178–83.
15.
Bortz JG, Al-Shweiki S. Free Tarsal Graft and Free Skin Graft for Lower Eyelid Reconstruction. Ophthalmic Plast Reconstr Surg. 2020;36:605–9.
16.
Dukes K. Likert Scale. In: Encyclopedia of Biostatistics. 2005. p. 2786–7.
17.
Eye Rounds.org The University of Iowa. 2022;
18.
Mandour SS, Kakizaki H, Farahat HG, Saadany HKAE, AKI I, M. Use of modified Hughes flap versus auricular cartilage graft for replacement of posterior lamella in lower eyelid reconstruction. J Clinic Experiment Ophthalmol. 2011;0:1–4.
19.
McKelvie J, Ferguson R, Ng SGJ. Eyelid reconstruction using the “Hughes” tarsoconjunctival advancement flap: Long-term outcomes in 122 consecutive cases over a 13-year period. Orbit. 2017;36:228–33.
20.
Tenland K, Memarzadeh K, Berggren J, Nguyen CD, Dahlstrand U, Hult J, et al. Perfusion monitoring shows minimal blood flow from the flap pedicle to the tarsoconjunctival flap. Ophthalmic Plast Reconstr Surg. 2019;35:346–9.
21.
Memarzadeh K, Gustafsson L, Blohmé J, Malmsjö M. Evaluation of the microvascular blood flow, oxygenation, and survival of tarsoconjunctival flaps following the modified Hughes Procedure. Ophthalmic Plast Reconstr Surg. 2016;32:468–72.
22.
Berggren J, Tenland K, Ansson CD, Dahlstrand U, Sheikh R, Hult J, et al. Revascularization of free skin grafts overlying modified Hughes tarsoconjunctival flaps monitored using laser-based techniques. Ophthalmic Plast Reconstr Surg. 2019;35:378–82.
23.
Bartley GB, Messenger MM. The dehiscent Hughes flap: outcomes and implications. Trans Am Ophthalmol Soc. 2002;100:61–5.
24.
Seyhan NZT, Keskin M, Savaci N. Lower eyelid reconstruction with tarsoconjunctival flap in a xeroderma pigmentosum patient. Eur J Plast Surg. 2012;35:185–7.
25.
Ibrahim A, Chalhoub RS. 5-fu for problematic scarring: a review of the literature. Ann Burns Fire Disasters. 2018;31:133–7.
26.
Leibovitch I, Selva D. Modified Hughes flap: division at 7 days. Ophthalmology. 2004;111:2164–7.
27.
Aggarwal S, Shah CT, Kirzhner M. Modified second stage Hughes tarsoconjunctival reconstruction for lower eyelid defects. Orbit. 2018;37:335–40.
28.
Ekin MA, Ugurlu SK. Impact of the type of anterior lamellar reconstruction on the success of modified Hughes procedure. Arq Bras Oftalmol. 2020;83:11–8.
29.
Leibovitch I, Huilgol SC, Hsuan JD, Selva D. Incidence of host site complications in periocular full thickness skin grafts. Br J Ophthalmol. 2005;89(219).
30.
Marcet MM, Lau IHW, Chow SSW. Avoiding the Hughes flap in lower eyelid reconstruction. Curr Opin Ophthalmol. 2017;28:493–8.
31.
McNab AA, Martin P, Benger R, O’Donnell B, Kourt G. A prospective randomized study comparing division of the pedicle of modified hughes flaps at two or four weeks. Ophthalmic Plast Reconstr Surg. 2001;17:317–9.
32.
Zaky AG, Elmazar HM, Abd Elaziz MS. Longevity results of modified Hughes procedure in reconstructing large lower eyelid defects. Clin Ophthalmol. 2016;10:1825–8.
33.
Klein-Theyer A, Horwath-Winter J, Dieter FR, Haller-Schober EM, Riedl R, Boldin I. Evaluation of ocular surface and tear film function following modified Hughes tarsoconjunctival flap procedure. Acta Ophthalmol. 2014;92:286–90.
34.
Schiffman RM, Christianson MD, Jacobsen G, Hirsch JD, Reis BL. Reliability and validity of the Ocular Surface Disease Index. Arch Ophthalmol. 2000;118:615–21.
35.
Perry C, Allen R. Repair of 50-75% full-thickness lower eyelid defects: Lateral stabilization as a guiding principle. Indian J Ophthalmol. 2016;64:563–7.
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