Total Reconstruction of Lower Eyelid in a Post-traumatic Patient Using Modified Fricke's Cheek Flap
An 22-year-old male patient presented with avulsion injury of the left lower eyelid and lateral periorbital area following a road traffic accident. On examination it was revealed that there was complete loss of the lower eyelid including the skin, subcutaneous tissue, tarsal plate, and palpebral conjunctiva. Few fibers of the orbicularis oculi survived. There was extensive skin loss in the lateral periorbital area. There was no injury to the cornea, sclera, bulbar conjunctiva, lower fornix, and lacrimal apparatus. The upper eyelid was absolutely normal []. The patient was at first treated conservatively with antibiotics and regular dressing of the wound until fresh granulation tissue was formed. Then he was posted for reconstructive surgery with the aim of creating a functional lower eyelid with maximum possible cosmetic result. A strip of cartilage was harvested from the ear concha and inserted in a pocket created within the fibers of orbicularis to serve as tarsal plate []. The remnant of the conjunctiva at the lower fornix was sutured with the orbicularis fibers to form the posterior lamella. The anterior lamella was reconstructed using a modification of the Fricke's flap where the vertical limb of the flap was designed over the cheek. The entire flap design was sketched out on the skin starting from the wound margin with the vertical limb extending over the cheek []. It was slightly longer and wider than the defect to compensate for its retraction and included the totality of the subcutaneous cellular tissue. The length-to-width ratio was roughly 4:1. The whole flap was elevated according to the outline sketched over the skin, and thorough hemostasis was performed []. The apex between the donor and the receptor area is sutured first near the medial canthus; [] followed by the margin with orbicularis oculi fibers, thus completing the anterior lamella. Rest of the defect over the cheek and the lateral temporal area was easily sutured primarily without any tension by adequate undermining of the margins resulting in satisfactory advancement displacement []. The repair was done in two layers. The subcutaneous layer was sutured with 5/0 vicryl and the skin margins opposed by horizontal mattress suture using 5/0 nylon except for the lid margin where simple suture was given avoiding excessive tension. The patient recovered smoothly without any significant postoperative complications. In the subsequent follow-up, the patient did not have major problems like irritation of the eyes, epiphora, synechia, or corneal ulcers [].