
==== Front
JPRAS Open
JPRAS Open
JPRAS Open
2352-5878
Elsevier

S2352-5878(24)00125-6
10.1016/j.jpra.2024.08.005
Original Article
Comparative evaluation of conventional and modified Hughes procedures in reconstructing large full-thickness defects of the lower eyelid
Zhang Lei zhanglei425311@163.com
abcde⁎#
Pan Ye abcde#
Li Jiagen abcde
Zhao Hong 277403716@qq.com
abcde
a Tianjin Eye Hospital, Tianjin, China
b Tianjin Key Lab of Ophthalmology and Visual Science, Tianjin, China
c Nankai University Affiliated Eye Hospital, Tianjin, China
d Clinical College of Ophthalmology Tianjin Medical University, Tianjin, China
e Tianjin Eye Institute, Tianjin, China
⁎ Corresponding author. zhanglei425311@163.com
# These authors contributed equally to this work.

07 9 2024
12 2024
07 9 2024
42 152161
14 5 2024
11 8 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Purpose

To introduce a modified Hughes procedure for the repair of large full-thickness defects of the lower eyelid.

Methods

This retrospective study included 56 patients: 30 in the conventional group treated with a Hughes flap and 26 in the modified group treated with a full-thickness upper eyelid flap pedicled with levator aponeurosis, Muller muscle and conjunctiva. The reconstruction time, period of pedicle division and complication rates were evaluated.

Results

The lower eyelid reconstruction time was 89.2±7.7 minutes in the conventional group and 61.7±7.5 minutes in the modified group, whereas the period of pedicle division was 21.1±3.0 days in the conventional group and 10.8±3.0 days in the modified group, and the differences were statistically significant (p = 0.000 and 0.000). Lower eyelid retraction was 0.4±0.4 mm in the conventional group and 0.1±0.2 mm in the modified group, and the difference was statistically significant (p = 0.001).

Conclusion

The modified Hughes procedure in this study resulted in a shorter lower eyelid reconstruction time, a shorter period of pedicle division, and a lower degree of lower eyelid retraction. This technique is simple and convenient for reconstructing large full-thickness defects of the lower eyelid.

Keywords

Hughes flap
Tarsoconjunctival flap
Modified Hughes procedure
Oculoplastic surgery
Lower eyelid tumour
==== Body
pmcIntroduction

The Hughes procedure is a commonly used reconstruction technique for full-thickness lower eyelid defects.1 A tarsoconjunctival flap from the ipsilateral upper eyelid replaces the posterior lamella, whereas a skin graft, a skin flap, or a skin-muscle flap restores the anterior lamella. The skin graft can be considered when the local anterior lamellar defect is large and the doctor wants to avoid long facial scars due to the use of various flaps.

Skin grafts have contractility, and a premature incision may lead to lower eyelid retraction. Compared to the surrounding normal skin, a skin graft may have poor texture and tone, leading to functional and cosmetic dissatisfaction.2 Another disadvantage of the Hughes procedure is that the operative eye is not exposed until pedicle division, which is extremely inconvenient for patients with blindness or low vision in the other eye.

This study aimed to describe a modified Hughes procedure for large full-thickness defects of the lower eyelid using a full-thickness upper eyelid flap pedicled with levator aponeurosis, Muller muscle, and conjunctiva. Compared to the conventional Hughes procedure, the modified Hughes procedure avoids defects caused by free skin grafting, allows lower eyelid reconstruction in a shorter time, and requires a shorter period of pedicle division.

Materials and methods

Materials

Ethics statement: This retrospective study (surgery on humans) was approved by the Medical Ethics Committee of Tianjin Eye Hospital and was conducted in accordance with the Declaration of Helsinki. Due to the retrospective nature of the study, the requirement for informed consent from a parent or guardian was waived by the Medical Ethics Committees of Tianjin Eye Hospital. Informed consent was obtained from participants to publish the images in an online, open-access publication.

The medical records of all who underwent the Hughes or modified Hughes procedure to repair lower eyelid defects resulting from the resection of malignant eyelid tumours between January 2019 and January 2023 were retrospectively reviewed. This study was conducted from July 2023 until now. The authors had access to information that could identify individual participants after data collection. Patients were examined 3 days, 1 week, and 2 weeks after the first operation. Patients were examined at 1 week, 1 month, 3 months, 6 months, 9 months, 12 months, 18 months, and 24 months after the second operation. Data that were retrieved included age, sex, diagnosis, preoperative and postoperative digital photographs, defect location and size, reconstruction time, period of pedicle division, and related complications, such as retraction, wound dehiscence, infection, necrosis, ptosis, entropion, and ectropion. Images of defects from each patient were selected to assess the defect size using ImageJ version 1.53t (National Institutes of Health, Bethesda, MD, USA).

Inclusion criteria: ① conventional or modified Hughes flap surgery completed between January 2019 and January 2023, ② large full-thickness eyelid defect exceeding half of the total length of the eyelid3 and unable to be repaired with a semicircular temporal flap (Tenzel flap), ③ reconstruction of the anterior lamella with a full-thickness skin graft in conventional Hughes flap surgery, and ④ follow-up period no less than 6 months after division of the Hughes flap.

Exclusion criteria: ① other disease or surgery affecting the eyelid that could influence the structure or blood supply of the eyelid; ② inability to complete follow-up; ③ incomplete patient data; or ④ primary disease recurrence or other eye disease occurring during the follow-up period, thus affecting the observation.

Surgical technique

All surgeries were performed by the same doctor as the chief surgeon, and a conventional margin check by frozen section examination was performed to ensure clean resection before reconstruction of the lower eyelid defect.

Reconstruction technique: The Hughes flaps applied in the two groups were different (Fig. 1). ① In the conventional surgery, after estimating the area of the lower eyelid to be reconstructed, a line was marked along the skin crease of the upper eyelid, and the area needed for skin grafting was marked on this line. The upper eyelid was everted, and a 4 mm marginal strip of tarsus was measured to be preserved. The horizontal length of the posterior lamella needed on this line was marked. Vertical lines were drawn to the superior tarsal border from these horizontal marks to delineate the flap. The tarsal plate was incised through its full-thickness along the horizontal and vertical marks to enter the easily identified postaponeurotic space. Preservation of the marginal strip of the upper tarsus was ensured. The tarsus flap in the postaponeurotic space was dissected and raised to the superior conjunctival fornix to expose the Muller muscle. The vertical tarsal cuts were extended 5 mm into the Muller muscle and conjunctiva to lengthen the tarsoconjunctival flap. The flap was pulled down posterior to the upper eyelid margin and sutured into the lower eyelid defect with 6/0 absorbable sutures to reconstruct the posterior lamella of the lower lid. Finally, the anterior lamella was reconstructed with a full-thickness free skin graft.Figure 1 Schematic diagram showing the Hughes flap. (A) The conventional flap and (B) the modified flap.

Figure 1

② In the modified surgery (Figure 2, Figure 3), the line drawing design on the skin and tarsal plate of the upper eyelid was the same as that in the conventional surgery. The skin and orbicularis muscle were incised in full-thickness along the closed line; however, the tarsal plate, levator aponeurosis, Muller muscle, and conjunctiva were incised in full-thickness only along the lower horizontal line and the vertical lines on both sides to form a full-thickness eyelid flap pedicled with the levator aponeurosis, Muller muscle, and conjunctiva. The incision of the orbicularis muscle coincided with the tarsal incision as much as possible to obtain a better blood supply. The orbital septum was separated from the levator aponeurosis to extend the vertical tarsal cuts ∼5 mm into the levator aponeurosis, Muller muscle, and conjunctiva to lengthen the flap. The flap was sutured into the lower eyelid defect in three layers. The tarsal layer of the flap was sutured with the inferior tarsal plate in the same manner as in the conventional surgery. The muscle and skin layers of the flap were sutured with 6/0 absorbable sutures, in turn, with the same tissues of the lower eyelid.Figure 2 Reconstruction of the lower eyelid with modified flap. (A) Preoperative image of lower eyelid meibomian adenocarcinoma. (B) Severe full-thickness defect of the lower eyelid. (C) Full-thickness incision in the skin and orbicularis muscle along the closed line. (D) Full-thickness eyelid flap pedicled with the levator aponeurosis, Muller muscle and conjunctiva (in front of the marginal strip of the upper tarsus). (E) Advancement of the modified Hughes flap posterior to the eyelid margin into the defect. (F) Layer-by-layer suturing of the modified Hughes flap into the defect. (G) One week after the lower eyelid reconstruction. (H) Three months after the pedicle division.

Figure 2

Figure 3 Reconstruction of the lower eyelid with modified flap. (A) Severe full-thickness defect of the lower eyelid. (B) Draw lines on the upper eyelid skin and palpebral conjunctiva. (C) Full-thickness eyelid flap pedicled with the levator aponeurosis, Muller muscle and conjunctiva (under the marginal strip of the upper tarsus). (D) Layer-by-layer suturing of the modified Hughes flap into the defect. (E) Twelve months after pedicle division.

Figure 3

The period of pedicle division depended on the skin colour, which suggests the condition of the blood supply. When the graft or flap skin colour turned the same colour as the surrounding skin, the pedicle was divided 2 mm superior to the lower tarsal plate. The residual pedicle was dissected so that it could be fully retracted upwards and the upper eyelid could reach a satisfactory height.

Statistical analysis was performed using IBM SPSS Statistics version 19.0. Statistical analysis of age, defect length, defect width, defect size, pre-MRD1 post-MRD1, reconstruction time, division period, follow-up period, retraction, and ptosis of the upper eyelid was performed for both groups with an independent-samples t-test. A χ2 nonparametric test was used to compare sex and the incidence of wound dehiscence, infection, necrosis, ptosis, entropion, and ectropion between the two groups.

Results

Baseline data

In total, 56 eyes of 56 patients with large full-thickness defects of the lower eyelid were repaired by conventional or modified Hughes procedures. The mean (range) age was 65.1±10.6 (45–83) years. Thirty-seven patients were female and 19 were male. Follow-up evaluations were performed postoperatively from 6 months to 4 years, averaging 20.3±12.0 months. No significant difference was found between the conventional and modified flap groups in terms of age, sex, defect length (19–28 mm in the conventional group and 19–26 mm in the modified group), defect width (10–16 mm in the conventional group and 9–1.5 mm in the modified group), defect size, pre-MRD1, or follow-up period (p = 0.328, 0.642, 0.117, 0.957, 0.382, 0.224, and 0.625, respectively).

Reconstruction time

The lower eyelid reconstruction time was 89.2±7.7 minutes in the conventional group and 61.7±7.5 minutes in the modified group and the difference was statistically significant (p = 0.000).

The division period of the upper eyelid pedicle was 21.1±3.0 days in the conventional group and 10.8±3.0 days in the modified group and the difference was statistically significant (p = 0.000; Table 1).Table 1 Distribution of age, sex, defect size, reconstruction time, division period, and follow-up period in the two groups.

Table 1Group	Age (years)	Sex	Follow-up period (months)	Reconstruction time (minutes)	Division period (days)	Defect length (mm)	Defect width (mm)	Defect size (mm2)	Pre-MRD1 (mm)	Total no. of patients	
		M	F									
Conventional	66.4±10.9	11	19	21.0±13.1	89.2±7.7	21.1±3.0	23.0±2.7	12.4±1.5	262.8±58.7	2.3±0.5	30	
Modified	63.6±10.2	8	18	19.4±10.9	61.7±7.5	10.8±3.0	21.9±2.5	12.4±1.2	250.4±44.2	2.5±0.6	26	
p-value	0.328a	0.642b	0.625a	0.000 a	0.000 a	0.117 a	0.957 a	0.382 a	0.224 a		
a Based on the independent-samples t-test.

b Based on the χ2 nonparametric test.

Complications

The lower eyelid retraction was 0.4±0.4 mm in the conventional group and 0.1±0.2 mm in the modified group and the difference was statistically significant (p = 0.001). No significant difference was found between the conventional and modified groups in terms of post-MRD1 or retraction of the upper eyelid (p = 0.104 and 0.219, respectively). Two (6.7%) cases of necrosis developed in the conventional group, in which the compression bandage was dislodged within three days after the operation. Both patients underwent reoperation with a free skin graft after debridement of the necrotic tissue. There were no cases of wound dehiscence, infection, ptosis, entropion, or ectropion in either group (Table 2).Table 2 Complications in the two groups.

Table 2	Conventional group	Modified group	p-valuea	
Post-MRD1 (mm)	2.8±0.6	3.1±0.7	0.104a	
Retraction of the lower eyelid (mm)	0.4±0.4	0.1±0.2	0.001a	
Retraction of the upper eyelid (mm)	0.5±0.3	0.6±0.3	0.219a	
Necrosis (cases)	2	0	0.494b	
Wound dehiscence (cases)	0	0		
Infection (cases)	0	0		
Ptosis (cases)	0	0		
Entropion (cases)	0	0		
Ectropion (cases)	0	0		
a Based on the independent-samples t-test.

b Based on the χ2 nonparametric test.

Discussion

The reconstruction of large, full-thickness eyelid defects involves two steps: the repair of the posterior lamella (tarsal plate and conjunctiva) and anterior lamella (skin and muscle). Because the posterior lamella of the eyelid is in direct contact with the eyeball, the repair material used for the posterior lamella should have good lubricity, compliance and support capability to replace the physiological function of the original tarsal plate and palpebral conjunctiva. At present, common materials for repairing the posterior lamella include allogeneic tarsal plates, allogeneic sclera, ear cartilage, nasal septum cartilage mucosa, hard palate mucosa and autologous tarsoconjunctiva.4

Allogeneic tarsal plates and sclera have good substitutability, but their retraction is obvious, and their sources are limited. Allogeneic sclera and ear cartilage lack a mucosal surface that must be combined with the conjunctival flap, skin, or myocutaneous flap to reconstruct large full-thickness eyelid defects. Ear cartilage and nasal septal cartilage have poor compliance and thus do not easily form good adhesion with the eyeball.5,6

The hard palate mucosa is a good repair material for the posterior lamella of the eyelid, and its autologous source is almost unlimited. The hard palate mucosa consists of two layers. The epithelial layer is composed of partially keratinised stratified squamous epithelium, which has a certain lubricity and can be used to replace the conjunctiva. The lamina propria layer has a dense concentration of collagen fibres, which gives this tissue stability and allows it to act as a replacement for the tarsus. The lamina propria has a loose collagen fibre layer and a dense collagen fibre layer, which makes the tissue supportive and compliant and thus very suitable for repairing the posterior lamella.7

However, because the hard palate mucosa is a free graft, the anterior lamellar repair material must be a flap with a blood supply. Therefore, this method of repairing the posterior lamella with hard palate mucosa is unsuitable in some cases where free flap transplantation of the anterior lamella is considered.8 In this case, the Hughes flap is more suitable for posterior lamellar repair.

The Hughes flap9,10 uses the ipsilateral upper eyelid posterior lamellar pedicle with conjunctiva or conjunctiva-Muller muscle, which can supply blood to repair the lower eyelid posterior lamella, providing a good basis for the survival of free grafts to repair the anterior lamella. As a commonly used method for reconstructing large posterior lamellar defects, the Hughes flap has been continuously improved in clinical applications for >80 years. Several important modifications have been presented, leading to decreased donor-site morbidity and improved recipient-site outcomes. Hishmi et al.11 reported that leaving Muller muscle attached to the Hughes flap can prevent premature dehiscence of the flap without increasing the risk of upper eyelid retraction. Other common complications include ectropion, upper eyelid retraction, lower eyelid retraction, dehiscence of the pedicle and necrosis.12,13 The incidence of complications was closely related to the defect size and follow-up time.

Regarding the repair of the anterior lamella, considering the colour and texture, if the amount of upper eyelid skin is sufficient, the ipsilateral or contralateral upper eyelid is the most common source selected for skin grafts.14 However, skin grafts are less likely to survive than skin flaps with a blood supply. Establishing a blood supply for free skin grafts depends on the close contact of the base and a sterile environment. The risk of poor graft vascularisation, with possible necrosis, is increased if the skin is thick or the fat has been inadequately removed.15 Two patients in the conventional group developed necrosis, which was considered to be related to the large area of skin grafting, the patient's age and insufficient postoperative compression.

There is a contradictory problem in free skin grafting; that is, with decreasing free skin graft thickness, the ease of establishing a blood supply and the chance of graft survival increase, but so does the contractility of the graft, which increases the difficulty of lower eyelid reconstruction. Graft contraction may cause lower eyelid retraction or even ectropion.16 In the conventional group in this study, lower eyelid retraction of 0.4±0.4 mm was observed, which was more severe than that in the modified group. In the modified group, pedicled full-thickness upper eyelid tissue was used to repair full-thickness defects of the lower eyelid; the pedicle supplied blood to the full-thickness eyelid flap to avoid the conflict between the thickness and contractility of the free skin graft.

In addition to avoiding the shortcomings of free skin grafting, the modified surgery also has other advantages, including① Reduced reconstruction time. In the modified group in this study, the reconstruction time was 61.7±7.5 minutes, significantly shorter than that in the conventional group (p<0.05). In the modified group, a full-thickness eyelid flap was used, saving the time to make a free skin graft. In contrast, the conventional pedicle needed to be separated between the levator aponeurosis and Muller muscle. Because the two layers of tissues are closely linked and contain peripheral arcades, they easily bleed and prolong the operation. To make the improved levator complex-conjunctiva pedicle, the orbital septum was opened and the preaponeurotic fat pad was pushed away from the surface of the levator aponeurosis. The above steps are very simple, result in less bleeding and require less time.

② A shorter interval time for the division of the upper eyelid pedicle is another advantage. The pedicle of the original Hughes flap10 is divided after 12 weeks to avoid upper eyelid complications such as retraction and entropion. With continuous improvement, some doctors have shortened the separation time to 3 to 4 weeks.17, 18, 19 McNab et al.20,21 published two reports demonstrating that the tarsoconjunctival pedicle may be safely divided after 2 weeks without any increase in eyelid malposition or complications. Leibovitch et al.22 even reported satisfactory functional and cosmetic outcomes in cases of modified Hughes flap division after 7 days. However, there have been some recent controversies regarding the blood supply of the Hughes flap. A study performed by Memarzadeh et al.23 in pigs showed that blood flow and tissue oxygenation gradually decreased during dissection and advancement of the tarsoconjunctival flap. When the flap was sutured into place, there was virtually no blood flow or oxygenation of the tissue. However, blood flow and oxygenation were only assessed for 12 hours after reconstruction surgery, and there is no research on the assessment of blood flow and oxygenation beyond 12 hours.

Tenland et al.24 monitored perfusion of the tarsoconjunctival flaps in patients with large lower eyelid defects resulting from tumour resection. They found that blood flow gradually decreased from the pedicle base to the end of the Hughes tarsoconjunctival flap. Due to concerns about invasive procedures, this study was limited in that measurements were only performed for detection during the surgical process rather than in the long term. Interestingly, flap survival was not compromised in neither of the studies.23,24

Given the above reports, the optimal timing for the early separation of the pedicle is still worth further exploration. This study attempted to determine the timing of pedicle separation by observing the skin or flap colour. In the modified group in this study, the division period was 10.8±3.0 days SD, significantly shorter than the conventional group (p<0.05). The following reasons were considered for such rapid recovery: the conventional flap based on the Muller muscle-conjunctiva pedicle requires separation between the levator aponeurosis and Muller muscle. These two tissues are closely connected and share a rich blood supply, and these blood vessels are prone to damage during dissection. The production of the improved flap pedicle requires separation between the orbital septum and levator aponeurosis, effectively preserving the blood supply between the levator aponeurosis and Muller muscle. Although the improved flap needed a greater blood supply for the anterior lamellar tissue than the traditional flap, in a postoperative observation, the time for the modified flap to exhibit normal colour restoration was shorter than that of the traditional Hughes flap with skin graft. This may be due to the improved pedicle providing a sufficient blood supply for the full-thickness flap, which is more helpful for improving the quality of life of patients, especially monocular patients.

The modified and conventional procedures have the same two disadvantages:① Retraction of the upper eyelid after the second-stage operation. In the Hughes operation, part of the upper tarsus is advanced into lower eyelid defect, equivalent to tarsomullerectomy of the upper lid. Specifically, this was equivalent to simultaneous levator resection and tarsomullerectomy in the modified group. If only the pedicle is divided without dissection around the pedicle, retraction of the upper eyelid may affect the binocular symmetry. In view of the above, when there was upper eyelid retraction after palpebral fissure incision during the operation, in the conventional and modified groups, full separation around the pedicle was performed during the second-stage operation and placed a downwards traction suture on the upper eyelid for a few days to prevent adhesive retraction. Upper eyelid retraction of 0.5±0.3 and 0.6±0.3 mm SD was observed in the conventional and modified groups, respectively, with no significant difference (p = 0.219). All patients were satisfied with the postoperative binocular symmetry.

② Affecting the functions and tear film stability in the treated eyes. Zaky et al.25 study found that all 11 patients who underwent Hughes reconstruction surgery experienced a decreased BUT. Because the conventional and modified Hughes procedures damage the meibomian gland of the upper eyelid, which may lead to dry eyes after the operation, when other materials can be used as alternatives, the material should be chosen carefully considering the patient's ocular surface and health.

In conclusion, the modified Hughes technique presented in this study is simple and effective in repairing moderate and large full-thickness eyelid defects. The first-stage operation time and the division period are shorter than the conventional procedure, which supports this procedure as a worthy alternative.

Competing interests

The author(s) declare no competing interests.

Appendix Supplementary materials

Image, application 1

Acknowledgements

We thank the clinical investigators Guoge Han, Yatu Guo, Yan Huo and Chenshu Bo for serving as scientific advisers.

Author contributions

L.Z. and H.Z. conceived and designed the study. All authors performed the research and collected the data. L.Z. and Y.P. analysed the data and wrote the paper.

Data availability statement

All relevant data are within the manuscript and its supplementary file section.

Ethical approval statement

This retrospective study (surgery on humans) was approved by the Medical Ethics Committees of Tianjin Eye Hospital (KY-2023043).

Patient consent for photo publication

Written consent has been received.

Funding

This work was supported by the Science and Technology Fund of Tianjin Eye Hospital (YKYB2001 ) and the Tianjin Key Medical Discipline (Specialty) Construction Project (TJYXZDXK-016A ).

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jpra.2024.08.005.
==== Refs
References

1 Dutton JJ Atlas of Oculoplastic and Orbital Surgery 2nd ed. 2018 Lippincott Williams & Wilkins 210 213 Dutton JJ, ed
2 Lee KS Kim JO Kim NG Lee YJ Park YJ Kim JS A comparison of the local flap and skin graft by location of face in reconstruction after resection of facial skin cancer Arch Craniofac Surg 18 2017 255 260 29349050
3 Liu H Zhang H Repair of severe full-thickness eyelid defect Int Rev Ophthalmol 44 2020 207 213
4 Ma Y Eyelid reconstruction options for full-thickness eyelid defect J Clin Ophthalmol 23 2015 431 434
5 Li DM Xu NJ Zhu HM Yang L Luo M Reconstruction of eyelid defects. Ophthalmic Plastic and Cosmetic Surgery 2007 Science and Technology Education Press 193 197
6 Chen B Woo DM Liu J Conjunctival flap with auricular cartilage grafting: A modified Hughes procedure for large full thickness upper and lower eyelid defect reconstruction Int J Ophthalmol 14 2021 1168 1173 34414079
7 Zhang J Jin HJ Sun Y Zhang T Application of hard palate mucosa combined nasolabial flap in repairing large area inferior eyelid full-thickness defect Chin J Aesthet Med 28 2019 85 87
8 Hendriks S Bruant-Rodier C Lupon E Zink S Bodin F Dissaux C The palatal mucosal graft: The adequate posterior lamellar reconstruction in extensive full-thickness eyelid reconstruction Ann Chir Plast Esthet 65 2020 61 69 30795932
9 Hughes WL A new method for rebuilding a lower lid Arch Ophthalmol 17 1938 315
10 Hughes WL Total lower lid reconstruction: Technical details Trans Am Ophthalmol Soc 74 1976 321 329 867633
11 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 21 2016 27 27364344
12 Aggarwal S Shah CT Kirzhner M Modified second stage Hughes tarsoconjunctival reconstruction for lower eyelid defects Orbit 37 2018 335 340 29333918
13 Ooms LSS Beets MR Grosfeld EC Reconstruction of the lower eyelid using Hughes’ tarsoconjunctival flap: follow up of 28 cases J Plast Reconstr Aesthet Surg Jpras 67 2014 e177 e179 24534131
14 Tyers AG Collin JRO Basic techniques in ophthalmic plastic surgery Colour Atlas of Ophthalmic Plastic Surgery 3rd ed. 2008 Elsevier St. Louis 38 39 Tyers AG, Collin JRO
15 Triana JRJ Murakami CS Larrabee JWF Skin grafts and local flaps Papel ID Facial Plastic and Reconstructive Surgery 2002 Thieme Medical Publishers 38 54
16 Papel ID Frodel JL Holt GR Facial plastic and reconstructive surgery Wound Healing 2016 10.1055/b-004-135545
17 Cies WA Bartlett RE Modification of the Mustardé and Hughes methods of reconstructing the lower lid Ann Ophthalmol 7 1975 1497 1502 1200561
18 Tyers AG Collin JRO Basic techniques in ophthalmic plastic surgery Tyers AG Collin JRO Colour Atlas of Ophthalmic Plastic Surgery 3rd ed. 2008 Elsevier St. Louis 410 411
19 Ekin MA Ugurlu SK Impact of the type of anterior lamellar reconstruction on the success of modified Hughes procedure Arq Bras Oftalmol 83 2020 11 18 31691727
20 McNab AA Early division of the conjunctival pedicle in modified Hughes repair of the lower eyelid Ophthal Surg Lasers 27 1996 422 424
21 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 Ophthal Plast Reconstr Surg 17 2001 317 319
22 Leibovitch I Selva D Fracs F Modified Hughes flap: division at 7 days Am Acad Ophthalmol 2004 2164 2167
23 Memarzadeh K Gustafsson L Blohmé J Malmsjö M Evaluation of microvascular blood flow, oxygenation, and survival of tarsoconjunctival flaps following the modified Hughes procedure Ophthalmic Plast Reconstr Surg 32 2016 468 472 26669289
24 Tenland K Memarzadeh K Berggren J Perfusion monitoring shows minimal blood flow from the flap pedicle to the tarsoconjunctival flap Ophthalm Plast Reconstr Surg 35 2019 346 349
25 Zaky AG Elmazar HMF Abd Elaziz MS Longevity results of modified Hughes procedure in reconstructing large lower eyelid defects Clin Ophthalmol 10 2016 1825 1828 27695287
