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CASE REPORT – OPEN ACCESS

InternationalJournalofSurgeryCaseReports82(2021)105856

ContentslistsavailableatScienceDirect

International Journal of Surgery Case Reports

j o ur na l h o m e p a g e :w w w . c a s e r e p o r t s . c o m

A case report of reconstruction of ocular and complete upper eyelid avulsion with severe facial soft tissue injuries using anterolateral thigh free ﬂap

Yunia Irawati

^a,^∗

, Marsha Alyssa Razief Fitri

^b

, Michelle Eva Rebeca Natalia

^b

, Parintosa Atmodiwirjo

^c

, Mohamad Rachadian Ramadan

^c

, Sara Ester Triatmoko

^c

aPlasticReconstructiveSurgeryDivision,OphthalmologyDepartment,FacultyofMedicineUniversitasIndonesia,Dr.CiptoMangunkusumoNational Hospital,Jakarta,Indonesia

bOphthalmologyDepartment,FacultyofMedicineUniversitasIndonesia,Dr.CiptoMangunkusumoNationalHospital,Jakarta,Indonesia

cReconstructiveMicrosurgerySection,DivisionofPlasticSurgery,FacultyofMedicineUniversitasIndonesia,Dr.CiptoMangunkusumoNationalHospital, Jakarta,Indonesia

a rt i c l e i nf o

Articlehistory:

Received2March2021

Receivedinrevisedform27March2021 Accepted28March2021

Availableonline1April2021

Keywords:

Anterolateralthighfreeﬂap Uppereyelidavulsion Ocularinjury Surgicalintervention Casereport

a b s t ra c t

INTRODUCTIONANDIMPORTANCE:Ocularinjuryissecondmostlycausedbymotorvehicleaccident(MVA) andoftenleadstosevereocularinjuryeventovisuallossandvariousaestheticproblems.Theoutcomeis determinedbythemagnitudeoftheinitialdamageandtreatmentavailability.Treatingocularandfacial injuryduetoMVAischallenginggiventhescopeofthedamageandmayresultinvariousoutcomes.

CASEPRESENTATION:Thiscasepresenteda22-yearsoldwomanwithahistoryofcaraccidentassessed withtotaluppereyelidavulsionwithcornealperforationandinvolvementofmultiplefacialfractures ontheleftside.Thevisualfunctionisirreparableduetotheextensivecornealdefectfromexposureand secondaryinfection,andpossibleopticnervedamage.

CLINICALDISCUSSION:Thiscasepresentedacompleteuppereyelidavulsionwithseverefacialtissue injury.Therefore,thereconstructiveproceduremainobjectivesaretomaintainappropriateprosthetic positionandtoimprovecosmeticfunction.Thiscaseusedanterolateralthighfreeﬂapasthereconstruc- tivesurgerymethodbecauseitisconvenientforlargedefectsandthedonorscarisnotvisible.After completingthesurgeryandseveralfollow-upprocedures,thepatientrecoveredwithoutanysigniﬁcant complications.

CONCLUSION:Despitevisuallossduetotheextentdamageoftheeye,itisimportanttorestorethefacial damages.Visualfunctionisascrucialascosmeticfunctionindeterminingthepatient’squalityoflife.

1. Introduction

Motor vehicle accidents(MVA) is one of the most frequent causes of injury leading to morbidity as well as mortality in Indonesia.Whilethereisnoclearstandardincollectingdataon Indonesian trafﬁc accidents, State Police of Indonesia reported 109,215accidentsalonein2018causingseriousandslightinjuryof 13,315and130,571peoplerespectively[1,2].Ophthalmictrauma duetoMVAisfoundtobethesecondmostcommoncauseofocular injuries[3].Theprognosisofeyeinjuriesishighlydeterminedby theinitialdamageandbytheavailabilityofthetreatment.Although previousliteraturestatedthatmorethan90%ocularinjurieswere mild and didnot threatenthevisualacuity,anepidemiological

∗Correspondingauthorat:JalanKimiaNo.8,CentralJakarta,DKIJakarta,10430, Indonesia.

E-mailaddress:yunia[email protected](Y.Irawati).

studyconductedin1994reportedthat12%ofeyesinvolvedin150 MVArequiredremoval[4].Achoiceforreconstructivesurgeryfor largefacialdefects,asinthiscase,shouldbebasedontherecon- structiveladderwithconsiderationofeachprocedure’sadvantage anddisadvantage.Herewepresentacasewithextensiveocular andadnexalinjurieswithseverefacialsofttissue injuriesusing anterolateralthigh freeﬂap.Thisstudyincludedhumansubject withethicalprinciplestakenintoaccount,asstatedinWMADec- larationofHelsinkiin2013.Thiscasereportiscompliantwiththe SCAREGuidelines2020[5].

2. Casepresentation

A22-years-oldfemalepatientcamebyherselftoourinstitu- tionwiththeappearanceofwhitishlesionthatgrewbiggeronher lefteyeinaweek.Shehadahistoryofbeinginahigh-velocity caraccident.Shesatusingseatbeltinthefrontleftcarpassenger seatonthehighwaywhenanothercarcrashedfromtheleftside

https://doi.org/10.1016/j.ijscr.2021.105856

org/licenses/by-nc-nd/4.0/).

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CASE REPORT – OPEN ACCESS

Y.Irawati,M.A.R.Fitri,M.E.R.Nataliaetal. InternationalJournalofSurgeryCaseReports82(2021)105856

Fig.1.(A)Facialandocularfeaturesoninitialexamination.(B,C)OrbitalCTscanwith3Dreconstructionshowedleftfrontalbonedefectextendingtotheanteriorleftfrontal sinus,leftsuperiororbitalrimandleftzygomaticprocessoffrontalbone,defectofleftlaminapapyraceawithmedialrectusmuscleandorbitalfatherniationtotheleft ethmoidandmaxillarysinus.

Fig.2. Intraoperativepicturesatthefirststepofthesurgery.(A)theeyewaseviscerated;(B)dermis-fat-graft(asterisk)wasusedtofillthesocket;(C)medialandlateral blepharorraphywithsiliconblockandacrylicconformer(yellowarrowheads)wasplacedabovetheDFG.Buccalmucosalgraft(greenarrowheads)wasusedtoaidthe shortageofposteriorlamella;(D)attheendofthefirststep,theconformerwascompletelycoveredwithmucosalgraft.

withhighervelocity.Thenshewascaughtbetweentheroofand left sideof thecar.Patienthad nounderlyinghealth problems, genetic disorders, and nounder medications. Ophthalmological examinationrevealedthevisualacuity(VA)oftherighteye(RE) 6/6sincecorrection,whiletheanteriorandposteriorsegmentwas within normal limits, and VA of the lefteye (LE) had nolight perception(NLP).Therewascompletelossofleftsuperioreyelid (lagophthalmos)withfullcornealandscleralexposureandinfe- riorcicatricial ectropion.Thebulbarconjunctivawashyperemic withconjunctivalchemosisandciliaryinjection.Cornealthinning withinﬁltrate and crustwasfoundinvolvingalmost theentire quadrantofthecornea(cornealabscess).Thefacialwoundwassur- roundedbypusandnecrotictissueextendingtothefrontalregion (Fig.1).

OrbitalCTscanwith3Dreconstructionwasperformedtoeval- uatetheextentoftheinjury(Fig.1).Thepatientwasassessedwith totaluppereyelidavulsionwithimpendingperforationofcorneal abscessinanonfunctionaleyeandinvolvementofmultiplefacial fracturesontheleftside.Thepatientwasconsultedtotheplastic surgeonforcollaborativetreatment.

Thepatientunderwenta simultaneoussurgerywithbackup fromtheneurosurgeonduetothefrontalbonedefect.Tissuenecro- tomyinfrontalareaanduppereyelidwasperformed.Inaddition, thelefteyewaseviscerated,anddermis-fatgraft(DFG)harvested fromtheabdomenwasplacedtoformthesocket.Furthermore, extensivereleaseofcicatricialectropiononlowereyelidandwound adhesionweredone.Buccalmucosalgraftfromthelowerlipwas alsoharvestedtoreplacetheshortageofposteriorlamellaofthe uppereyelid.Attheendoftheevisceration,anacrylicconformer wasplaced,andtheinferioreyelidmargintobuccalmucousgraftto ensurethesocketstabilitywassutured.Intheend,theanterolateral thighfreeﬂapwasperformed(Fig.2).

Twoweeksafterthesurgery,stitchesontheflapweretaken off.Withinsixmonthspost-operative,therewerereductionofthe flapsizewithliposuction,re-insettingoftheflapandthesocket remainsgoodwiththeconformer(Fig.3).Therecipientsitehealed properlywithnosignsoffailure.Thedonorsiteshowednosignsof infectionwithminimalscarring.Thepatient’sconditionremained stableayearafterthesurgery.Thesocketwasstillinagoodcon- dition,butfromtheaestheticandanatomicalpointofview,the horizontalpalpebralfissure(HPF)wassignificantlysmallerthan thefelloweye.Socketreconstructionwithcanthopexywasdone bytheoculoplasticsurgeon,andeyeprosthesiswasusedtoreplace theconformer.Theskinpalpebrawasexcisedtoopentheeye.An excisionwasperformedonthepalpebrafoldandstitchedwitha quiltingsuturetechniquetotheperiosteumunderneathtocreate thefold. Ameasurementprior totheprocedureshouldbecon- ductedtogetasymmetricalandaestheticresult.Thepatientalso underwenthairtransplantationonherlefteyebrowtoreconstruct theanatomicalfeatures.Thepatientrecoveredwithoutanysignifi- cantcomplicationsaftersurgeryandtheinterventionwastolerable (Fig.4).Patientfeltsatisfiedwiththeresultandfeltmoreconfident tosocialize.

3. Discussion

OcularinvolvementinMVAmayinvolvetheeyelids,lacrimal canaliculi,orbitalwall,conjunctiva,cornea,sclera,andextraocu- larmuscles.SeriouseyeinjuriesfromMVAhavearelativelyhigh tendencytocauseapermanentvisuallossandaestheticproblems, affectingpatient’squalityoflife[4,6].Kuhnetal.statedthattissue involvementinocularinjurydeterminedtheprognosisofanatom- icalandvisualfunctionaswellastheinitialdamageandtreatment given.Effectivereconstructionoftheperiorbitalareainitiallyaims 2

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CASE REPORT – OPEN ACCESS

Fig.3. Intraoperativepicturesflap.Thefrontalandsuperioreyeliddefectwereclosedwithanterolateral-thighflap.Vascularanastomosiswassuccessfullyachieved.The patientwasmonitoredcloselyafterthesurgerytoevaluatetheflapintheICUandreceivedheparin.

Fig.4.(A)14-monthsaftertheﬁrstsurgery,theleftHPFwassmallerthanthefelloweye;(B)One-and-halfyearaftertheinitialvisit,thelidcreaseandeyebrowswere surgicallymade.

topreservethevisionandassociatedvisualprotectionmechanism [4,7].

Forcomplexandcompositeperiorbitaldefectsinvolvingmul- tipletissues,multidisciplinaryapproachmustbetakentoachieve optimalfunctionalresults.Eyelidisconsideredacomplexstructure whichprotectstheglobeandcontainsretractormusclestoelevate theeyelid.Asidefromitsaestheticvalue,uppereyelidiscritically importanttoprotecttheglobebecausetheeyecannotsurvivefor longwithoutit.Traumaticeyelidinjuriescouldproduceasignif- icantlossoftissuecausingsigniﬁcantsubsequentdamagetothe globeandcouldmakesecondaryreconstructiveproceduresmore difﬁcult[7–9].

Therearemany methodstoreconstructfull-thicknesseyelid defects.Themainprincipleofeyelidreconstructionisformedof threecomponents:theouterlayerofskin,theinnerlayerofmucosa, and the semi rigid skeleton in the middle. The reconstruction selection isbasedonthereconstructiveladder, witheach ofits advantagesanddisadvantagesshouldbeconsideredbeforethepro-

cedure.Itisimpossiblefordefectswithabonebasetouseaskin graft,whichisthesimplesttechnique.Therefore,aﬂapisanoption.

Locoregionalflaps(e.g.paramedianforeheadorapediclesuperfi- cialtemporalartery-basedscalpislandflap)havethesametexture andcoloradvantagesbuttheseleavemorescarringinthefacial areaandareonlyusedforthereconstructionofsmalldefects.

Thefreeﬂapwasconsideredtobesuperiorbecausethedonor defectdidnotappear inthefaceareaandwiththeapplication ofanterolateralthighfreeﬂap,thedonordefectcouldbehidden.

Debridementwascarriedoutuntilitleftthecraniuminthefrontal areaandtheperiorbitalmusclesaroundtheeye,withinfection- freeandanon-viabletissuewithasizeof10×12cm.Thedefect whichwasthenclosedwiththeanterolateralthighfreeflapwas extendedtoobtainabetteraestheticunitandalsotohidethelateral scarresultedbytheflaponthehairline.Thistechniqueisdifficult becauseitrequiresthetransferofanalivetissuebyabloodvessel sized1−2mmandrequiresathoroughevaluationforasuccessful resultwithin3×24hpostoperatively[10].One-stepreconstruction

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CASE REPORT – OPEN ACCESS

withflapwouldbepossibleafteronestepofadequatedebridement, becauseaflaprichinvascularizationisagoodmodalityindealing withinfection.Inourcase,thisfreeflapwasnotaccompaniedbyan administrationofheparinduetoastrongrecipientarterialflowand smoothrecipientvenousdrainagewithalargeenoughperforator caliber.Thegoalofthecontourcanlaterbeobtainedbyremoving athinflaporbyperformingre-contouringbymeansoffatexcision orliposuctionaftertheflapisstable[11].

Thepatientwasunfortunatetohaveatotaleyelidavulsionwith extensiveskinlossforonemonthbeforebeingbroughttoseek treatmentfromophthalmologist.Thevisualfunctiononthepatient couldnotberestoredduetotheextentofthedamagetothecornea fromexposureandsecondaryinfection,andpossiblyaninjuryto theopticnerve.Thus,thegoalwastomaintainappropriatepros- theticposition.

Duringremovaloftheeyeball,itwasimportanttoformasocket.

Aftertheeyeballremoval,evisceration,andplacementoforbital implant,buccalmucosalgraftwastakentoaidposteriorlamellain theuppereyelid,andacrylicconformerwasplaced.Inferioreyelid marginwasstitchedtothebuccalmucosalgrafttoensurethatthe socketsupportedtheocularprosthesis.Finally,freeﬂapwashar- vestedtoformanteriorlamellaandcoverfullthicknessskinloss onthefrontalregion.

4. Conclusion

Eyelid andfacial injuriesoftenresultin visuallossand vari- ous aestheticproblems,raisingconsiderablecosts.Eventhough thevisualfunctionoftheeyecouldnotberestoredina severe condition,it is principal toimprove thecosmeticfunction. The mainobjectivesofthereconstructiveprocedurearetomakethe reconstructed eyelidstabletosupporttheocularprosthesisand reconstructtheperiorbitalareawithaversatiletissuetoimprove thepatient’squalityoflife.Therearemanymethodstobeapplied toreconstructacompleteeyelidavulsion.Asurgeonhastochoose whichmethodbestsuitseachcase.

DeclarationofCompetingInterest

Theauthorsreportnodeclarationsofinterest.

Funding

All funding is from the author. Authors have no sponsor involved.

Ethicalapproval

Thisstudyisexemptfromethicalapprovalfromtheinstitution.

Consent

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonrequest.

Authorcontribution

Yunia Irawati: main author, contributing in study con- cept/design,datacollection,analysis,andwritingthepaper.

MarshaAlyssaRaziefFitri:contributingindatacollection,analy- sisandwritingthepaper.

MichelleEvaRebecaNatalia:contributingindatacollection,anal- ysisandwritingthepaper.

ParintosaAtmodiwirjo:contributingindatacollection,analysis andwritingthepaper.

MohamadRachadianRamadan:contributingindatacollection andwritingthepaper.

SaraEsterTriatmoko:contributingindatacollectionandwriting thepaper.

Registrationofresearchstudies Notapplicable.

Guarantor YuniaIrawati.

Provenanceandpeerreview

Notcommissioned,externallypeer-reviewed.

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