INTRODUCTION
Periorbital defects are especially challenging to reconstruct because the thin eyelid skin, orbicularis oculi muscle, lacrimal drainage system, and canthal tendons are intricately interwoven, necessitating simultaneous restoration of both function and appearance [1,2]. Although full‑thickness local flaps, skin grafts, and free flaps have long been used, they are frequently associated with shortcomings such as mismatch in thickness or color, conspicuous donor scars, and the requirement for multistage surgery [2]. Accordingly, local flaps are generally favored in periorbital reconstruction due to their superior skin color and thickness match [3]. In fact, a recent comparative study reported that aesthetic outcomes (e.g., color and contour) were higher with local flaps than with skin grafts for medial canthal defects [3].
The orbicularis oculi myocutaneous (OOMC) flap transposes a composite of skin and muscle from the same region, providing robust vascularity and an optimal match in color, thickness, and texture. OOMC flaps are supplied by the subdermal–muscular plexus formed by the medial and lateral palpebral arterial arcades, in addition to the angular, supraorbital, supratrochlear, and superficial temporal branches [4]. With design options including V‑Y advancement, unipedicle or bipedicle switch, and pivot flaps, the OOMC flap can reconstruct upper‑ and lower‑lid as well as medial‑ and lateral‑canthal defects in one or two stages [5-8]. Several small series have reported high survival and low complication rates with this technique [1,5], but large, homogeneous, single‑cohort analyses reflecting recent trends remain lacking. Therefore, the present study was designed to investigate temporal trends in indications, flap‑design preferences, and outcomes of OOMC flaps by comparing an early practice phase (2001–2017) [9] with a contemporary phase (2018–2024).
METHODS
This single-institution retrospective study reviewed all periorbital reconstructions performed with OOMC flaps between November 2001 and December 2024. An interim report published in 2018 detailed the initial 36 flaps performed from 2001 to 2017; the current analysis incorporates those earlier cases and an additional 42 flaps completed from 2018 to 2024. To evaluate practice evolution, cases were stratified by operative date into Group A (2001–2017) and Group B (2018–2024). Electronic medical records and operative photographs were analyzed for age, sex, etiology (basal cell carcinoma [BCC], squamous cell carcinoma [SCC], xanthoma), defect location (upper/lower eyelid, medial/lateral canthus), number of defects, flap design (V-Y advancement, unipedicle switch, bipedicle switch, pivot), and adjunctive procedures. Complications were defined as venous congestion lasting >24 hours, partial or total necrosis, infection, eyelid malposition (entropion/ectropion), hematoma, or tumor recurrence.
Operative procedure
Flap‑selection considerations were based on primary assessment of defect position (medial, central, or lateral), horizontal width, and eyelid laxity, as follows: (1) the V‑Y advancement was the first choice for defects located at the medial or lateral edge of either eyelid when adjacent tissue can advance without excessive tension; (2) the pivot flap was preferred for lower‑eyelid defects spanning the central‑to‑lateral region when a pedicled orbicularis flap can rotate safely; and (3) the switch flap was selected when a pivot flap cannot reach the defect or when the gap is too wide. A unipedicle switch suffices for moderate widths; a bipedicle switch is reserved for broader defects requiring maximal perfusion during the two‑stage transfer.
V-Y advancement
After selecting the direction of advancement based on defect size and location, a V-shaped flap is designed. The skin and orbicularis oculi muscle are completely separated from surrounding tissues, with submuscular undermining extended medially and laterally to achieve mobility. The flap is advanced to cover the defect, and the donor site is closed primarily in a Y configuration. When simple advancement is inadequate, rotational advancement is incorporated. For example, in a 52-year-old woman with bilateral upper eyelid xanthoma (Fig. 1A and B), a total skin-muscle block was isolated, the medial and lateral muscles were gently freed, and bilateral V-Y flaps were advanced to restore symmetrical folds.
Switch flap
Three variants were employed, as follows: (1) the unipedicle switch flap, which was transposed on a single pedicle and divided 3 weeks later as a second stage; (2) the bipedicle switch flap, in which both pedicles were preserved during transposition and sequentially divided at the same 3‑week interval; and (3) the pivot flap, a semicircular, single‑pedicle flap adjacent to the defect that was rotated into position.
RESULTS
Findings from Group A (2001–2017) are summarized in Table 1, and those from Group B (2018–2024) are summarized in Table 2. In total, 57 patients were analyzed (Table 3). Group A comprised 25 patients with 30 defects reconstructed with 36 OOMC flaps, while Group B comprised 32 patients with 40 defects repaired with 42 flaps. The mean age increased from 64.0 years in Group A to 67.4 years in Group B, and the sex ratio shifted toward women: 12 men and 13 women (48% male) in Group A versus 9 men and 23 women (28% male) in Group B (Table 3).
BCC was the predominant etiology in both groups—19 out of 25 patients (76%) in Group A and 25 out of 32 (78%) in Group B. Xanthoma accounted for 12% (3/25) versus 19% (6/32), and SCC for 8% (2/25) versus 3% (1/32). One congenital coloboma was observed only in Group A (Table 4).
Of the 78 OOMC flaps, Group A utilized 18 V-Y advancement flaps (50%), 10 switch flaps (7 unipedicle, 3 bipedicle), six pivot flaps (17%), and two simple advancement flaps (6%). In Group B, V-Y advancement increased to 35/42 flaps (83%), including 20 bilateral V-Y (×2) cases; switch flaps totaled 6 (14%), five of which were bipedicled, and one pivot flap (2%) was performed (Table 5).
Complications occurred in two patients in Group A (8%): one case of venous congestion lasting >24 hours and one transient entropion. Both resolved with observation alone. No flap necrosis occurred. Local tumor recurrence was seen in one patient in Group A, whereas no complications or recurrences were reported in Group B.
DISCUSSION
The use of OOMC flaps increased from 36 cases over 17 years in Group A (2001–2017) to 42 cases over 7 years in Group B (2018–2024). Notably, 83% of flaps in the recent 7-year interval were V-Y advancement designs, establishing this as the most frequently employed technique. Simultaneously, the overall complication rate fell to 0%, confirming that the OOMC flap— particularly the V-Y advancement variant—is a safe and reproducible option for periorbital reconstruction [1,5]. Likewise, re‑cent clinical reports have documented periorbital reconstructions with local flaps achieving complete defect coverage without postoperative eyelid malposition even after wide tumor excisions [10].
The increase in V-Y advancement usage from 50% to 83% without any reported complications underscores the anatomic and technical advantages of this approach [11]. The dense subdermal– muscular plexus between the eyelid skin and orbicularis muscle, supplied by the medial and lateral palpebral arcades as well as angular and supraorbital branches, ensures reliable perfusion even on a short pedicle [4]. Direct advancement minimizes suture-line tension, thereby reducing venous congestion and eyelid malposition [6,12]. Whereas venous congestion and transient entropion in Group A were seen exclusively with switch flaps, the absence of complications in Group B suggests that simplification of technique shortens the learning curve [2].
Small- to medium-sized lower-lid defects are effectively managed with a single V-Y advancement flap, as demonstrated in Case 2 (a 76-year-old woman) who maintained a symmetrical scar and lid position 7 months postoperatively [1,12]. In Case 1 (a 52-year-old woman with bilateral upper-lid xanthomas), complete skin–muscle isolation and careful medial-to-lateral undermining enabled bilateral V-Y advancement and maintenance of symmetric folds at 14 months (Fig. 1).
For larger defects, a single OOMC flap may be insufficient in thickness, blood supply, or arc of rotation. When the defect is extensive, a single OOMC flap may not provide adequate thickness, perfusion, or tension relief; as shown in Case 3 (Fig. 2), combining an OOMC V-Y flap with a nasolabial V-Y advancement flap produces a safer reconstruction and a superior aesthetic result [13,14]. Likewise, for extensive composite defects involving both medial and lateral canthal tendons, reconstructing the canthal angle with OOMC flaps and covering the residual area with a full-thickness skin graft—as in Case 4 (Fig. 3)— effectively preserves ocular contour [15]. Patients should be advised that upper-lid OOMC flaps may enlarge the supratarsal fold or cause minor asymmetry, which could later necessitate revisional blepharoplasty [16].
When additional reach or tension relief is required beyond what advancement alone allows, a bipedicled switch flap is a practical alternative. In Case 5 (Fig. 4), a large defect adjacent to the palpebral fissure was reconstructed with a bipedicled switch flap; pedicle division at 3 weeks and follow-up at 8 months revealed no ectropion or exposure keratopathy. Bipedicled switch flaps have been reported to maintain long-term perfusion, and our findings support this [7,8].
Local tumor recurrence occurred in only one Group A patient after immediate OOMC reconstruction, mirroring previous reports of oncologic safety for OOMC flaps [1,5] and aligning with multicenter outcome data [17]. Across all 57 cases, no flap necrosis occurred, indicating high flap survival regardless of patient age or comorbidities.
This study is limited by its single-surgeon, single-institution design, absence of quantitative defect measurements, and lack of objective aesthetic assessment tools such as the FACE-Q Eye module. Nonetheless, 24 years of continuous data demonstrate that simplification of technique and deeper anatomical understanding translate into zero complications and excellent cosmetic outcomes—an observation of clear clinical significance.
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