Ophthalmic Surgery, Lasers and Imaging Retina

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Case Report 

Complications of Cicatricial Ectropion Repair with Pre-Auricular Wolfe Graft

Yajati K. Ghosh, FRCSEd, FRCSOphthal; Mohammed Rashid, MRCOphth; Harpreet S. Ahluwalia, MS, MRCOphth, FRCS

Abstract

An 85-year-old lady presented with a severe cicatricial ectropion several months after a fall. The abnormality was corrected with a procedure that involved the use of a retroauricular skin graft. This provided resolution of her ocular symptoms. Several months later, she had noted significant hair growth on the graft, but elected for this to be managed conservatively. Careful harvesting of the graft from the non-hairy area between the ear and the hairline is essential to prevent unwanted transplantation of terminal hairs. Surgical success is also dependent on the final aesthetic outcome.

Abstract

An 85-year-old lady presented with a severe cicatricial ectropion several months after a fall. The abnormality was corrected with a procedure that involved the use of a retroauricular skin graft. This provided resolution of her ocular symptoms. Several months later, she had noted significant hair growth on the graft, but elected for this to be managed conservatively. Careful harvesting of the graft from the non-hairy area between the ear and the hairline is essential to prevent unwanted transplantation of terminal hairs. Surgical success is also dependent on the final aesthetic outcome.

Complications of Cicatricial Ectropion Repair with Pre-Auricular Wolfe Graft

From the Department of Ophthalmology, University Hospital Coventry & Warwick, Coventry, United Kingdom.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Yajati K Ghosh, FRCSEd, FRCSOphthal, Department of Ophthalmology, University Hospital, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom.

Accepted: July 22, 2009
Posted Online: March 09, 2010

Introduction

Growth of unwanted hair in grafted skin has been reported in different parts of the body, including the eyelids.1 We describe the management of an elderly woman with a full-thickness retroauricular skin graft to cover a lower eyelid defect. The graft in this case had an additional cosmetic complication of hair growth.

Case Report

An 85-year-old myopic Caucasian lady was referred with a left lower lid ectropion. She had previous history of laceration of her eyelid which had been managed conservatively. She was noted to have moderate horizontal lower lid laxity, conjunctival hypertrophy, and a severe cicatricial ectropion (Fig. 1).

Cicatricial Ectropion.

Figure 1. Cicatricial Ectropion.

She underwent excision of the lower lid cicatrix, had a tarsoconjunctival diamond, combined with a full thickness retroauricular skin graft and a lateral tarsal strip, under general anesthesia. Subsequent postoperative follow-ups demonstrated good ectropion correction and bedding of the graft. Follow-up 6 months later showed slight thickening of the graft (Fig. 2) and unexpected significant hair growth on the graft (Fig. 3). The hairs were trimmed and she was advised to continue massaging of the graft. The patient was unconcerned about this unexpected hair growth as her ocular symptoms had completely resolved. She declined any further surgical intervention.

Good Ectropion Correction and Bedding of the Graft. Significant Hair Growth Identifiable on the Graft.

Figure 2. Good Ectropion Correction and Bedding of the Graft. Significant Hair Growth Identifiable on the Graft.

Slight Thickening of the Graft. Hair Growth Seen Extensively Along the Graft.

Figure 3. Slight Thickening of the Graft. Hair Growth Seen Extensively Along the Graft.

Discussion

Trauma is the most common cause of cicatricial ectropion and can be difficult to manage. A large proportion of patients may require excision of the scar tissue with the resultant defect being covered with full thickness skin grafts (FTSGs). Different host sites have been tried to reconstruct anterior lamella of eyelids. Growth of unwanted hair has been a major problem in most of them as they are from hair bearing areas.1

It is a common practice in oculoplastic surgery to supplement the anterior lamella of eyelids with FTSGs harvested from the retroauricular space,2 a region with few hair follicles and minimal sun exposure. This is usually done after excision of periocular tumors, for lid reconstruction and also to manage cicatricial ectropion.2–4 Retroauricular skin grafts provide ample, appropriately matched tissue, and the harvested site heals both quickly and inconspicuously5,6 and avoids an unsightly scar at the graft site.7

Grafts of considerable size can be obtained from the postauricular area. Appropriate harvesting of the graft provides an area of skin which is normally devoid of hair follicles. Although it is not possible to totally eradicate unwanted hair growth on the graft, it may be minimized by careful graft defatting.8 However, the hairline is not far-off and it is quite easy to include an area of skin within the graft which contains hair follicles. This seems to be the case in our patient. Hence careful harvesting of the graft from the nonhairy area between the ear and the hairline is essential to prevent unwanted transplantation of terminal hairs9. Management of this unwanted hair could involve periodic trimming, topical hair removing agents, electrolysis, or laser ablation.

Unwanted hair growth in skin grafts using the arm as a donor site for full-thickness skin grafts used in eyelid and facial reconstruction has been previously reported.1 To the best of our knowledge, hair growth in postauricular skin graft, following eyelid reconstruction has not been reported previously.

The surgeon should be careful when harvesting a retroauricular graft as large grafts could have margins running very close to the hairline. This case demonstrates a situation in which complete surgical success in managing the initial problem was achieved, but with an undesirable aesthetic outcome.

References

  1. Hauben DJ, Baruchin A, Mahler A. On the history of the free skin graft. Ann Plast Surg. 1982;9:242–245. doi:10.1097/00000637-198209000-00009 [CrossRef]
  2. Vallabhanath P, Carter S R.Ectropion and entropion. Curr Opin Ophthalmol. 2000;11:345–351. doi:10.1097/00055735-200010000-00010 [CrossRef]
  3. Cartwright MJ, Elner V M.Retroauricular skin grafts: preferred location of donor site. Plast Reconstr Surg. 1992;89:378–379. doi:10.1097/00006534-199202000-00045 [CrossRef]
  4. Mendez-Eastman S. Full-thickness skin grafting: a procedural review. Plastic Surgical Nursing. 2004;24:41–45.
  5. Adams DC, Ramsey ML. Grafts in dermatologic surgery: review and update on full- and split-thickness skin grafts, free cartilage grafts, and composite grafts. Dermatol Surg. 2005;3:1055–1067.
  6. Edgerton MT, Hanson FC. Matching facial color with split thickness skin grafts from adjacent areas. Plast Reconstr Surg. 1960;25:455–464. doi:10.1097/00006534-196005000-00001 [CrossRef]
  7. Tuncali D, Ates L, Aslan G. Upper eyelid full-thickness skin graft in facial reconstruction. Dermatol Surg. 2005;31:65–70
  8. Leibovitch I, Huilgol SC, Hsuan JD, Selva D. Incidence of host site complications in periocular full thickness skin grafts. Br J Ophthalmol. 2005;89:219–222. doi:10.1136/bjo.2004.052639 [CrossRef]
  9. Custer PL, Harvey H. The arm as a skin graft donor site in eyelid reconstruction. Ophthal Plast Reconstr Surg. 2001;17:427–430. doi:10.1097/00002341-200111000-00008 [CrossRef]
Authors

From the Department of Ophthalmology, University Hospital Coventry & Warwick, Coventry, United Kingdom.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Yajati K Ghosh, FRCSEd, FRCSOphthal, Department of Ophthalmology, University Hospital, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom.

10.3928/15428877-20100215-59

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