Sebaceous carcinoma is a rare but aggressive malignancy that frequently affects the periocular region, ranking as the third most common eyelid cancer after basal cell carcinoma and squamous cell carcinoma.1) Surgical excision with adequate margins, followed by appropriate eyelid reconstruction, is essential for achieving optimal oncologic control and restoring eyelid function and appearance. However, substantial marginal defects of the lower eyelid can be challenging to repair due to the region’s complex anatomy and the need for both structural and functional restoration. The eyelid’s unique composition—comprising anterior and posterior lamellae—necessitates careful selection of tissue substitutes for each layer. The Tripier flap, a bipedicled orbicularis oculi myocutaneous flap harvested from the upper eyelid, is a reliable and well-vascularized option for anterior lamella reconstruction, offering excellent color and texture match. When combined with an appropriate posterior lamellar graft, this technique enables effective restoration of eyelid integrity and mobility.

Here, we present the case of an 83-year-old woman with sebaceous carcinoma involving two-thirds of the right lower eyelid, who underwent a two-stage reconstructive procedure using a Tripier flap and a palatal mucosal graft. We also describe the surgical approach, clinical outcomes, and advantages of this reconstructive strategy in managing complex marginal eyelid defects.

An 83-year-old woman presented with a slow-growing, asymptomatic reddish swelling on her right lower eyelid that had been present for three years. Examination revealed a 13 × 3 mm reddish plaque along the lower eyelid margin, extending to the palpebral conjunctiva (Fig. 1A). Pathologic assessment of an incisional biopsy performed 18 months earlier suggested sebaceous carcinoma. Although surgical excision was initially recommended, the patient declined further treatment until the lesion increased in size.

Preoperative planning included delineation of a 3-mm safety margin around the lesion and the design of a bipedicled flap on the upper eyelid. The inferior incision line was placed 6 mm above the lash line, with the superior line drawn parallel to create a 9-mm-wide flap (Fig. 2A). Tapered medial ends were designed to facilitate future revision and closure.

Under general anesthesia, a 1 × 2.5 cm mucosal graft was harvested from the right hard palate, with preservation of the periosteum. Hemostasis was achieved, and a double-layer Mepilex® dressing (Mölnlycke Health Care, Gothenburg, Sweden) was applied to the palatal donor site and secured with a tie-over dressing.

A 0.5% lidocaine solution with 1:200,000 epinephrine was infiltrated around the surgical sites of the upper and lower eyelids to achieve hemostasis. The lower eyelid lesion was excised en bloc, resulting in a 19 × 7 mm defect. Frozen section analysis confirmed clear margins. Postoperatively, permanent pathology revealed that all surgical margins were free from carcinoma (lateral and deep margins, 0.1 cm), with no evidence of tarsal plate, lymphovascular, or perineural invasion. A myocutaneous flap was elevated from the upper eyelid along the marked design, with the underlying orbicularis oculi muscle dissected slightly broader than the skin width to preserve cutaneous vascularity (Fig. 2B). Most of the donor defect was closed primarily, except for the medial portion. To maintain upper eyelid symmetry, a comparable amount of skin and muscle was excised from the contralateral side.

The defatted palatal mucosal graft was inset as the posterior lamella and secured using continuous 6-0 Ethilon and interrupted 6-0 Vicryl sutures. Additional mucosa was preserved for later placement along the upper edge of the anterior lamella. The bipedicled flap was then transposed and inset into the eyelid defect.

Postoperatively, an occlusive eye dressing was applied, and antibiotic ointment was administered. The intraoral dressing was removed after three days, and the wound was managed with 0.3% Tantum gargles for one week. By postoperative day 2, the transposed flap demonstrated good vascularity and minimal swelling (Fig. 3A). Two weeks postoperatively (Fig. 3B), the flap pedicles were divided and the wounds were revised. The palatal donor site healed by secondary intention within four weeks without complications.

A comprehensive evaluation for distant metastasis was performed using neck computed tomography and positron emission tomography/computed tomography scans, which revealed no evidence of metastasis. At her six-month follow-up visit, the patient demonstrated good postoperative outcomes without complications such as ectropion, lagophthalmos, epiphora, or cancer recurrence (Fig. 1B).

Lower eyelid reconstruction following tumor excision is vital for restoring both the functional integrity and aesthetic appearance of the eyelid. The choice of reconstruction technique is primarily determined by the size, location, and depth of the defect. Small full-thickness defects (<25% of the lid) can often be closed primarily. Defects involving up to one-third of the lid width may require lateral canthotomy and cantholysis. Tenzel semicircular flaps can address defects involving one-half to three-fourths of the lid.2)

However, when the defect requires additional tissue supplementation, reconstruction becomes more complex. The eyelid comprises two functional layers: the anterior (skin and muscle) and posterior (tarsus and conjunctiva) lamellae. Typically, one lamella is reconstructed with a vascularized flap, while the other can be replaced with a free graft.3) Full-thickness reconstructions using a single flap have also been described.4)

For larger defects (up to two-thirds), options include the two-stage Hughes tarsoconjunctival flap or Mustardé cheek advancement combined with grafts. The Hughes flap is particularly effective for vertical defects of 4-5 mm, as it allows direct integration of the transposed tarsus and conjunctiva with the existing tarsal “skeleton.” However, for complete lower eyelid defects, these techniques may offer insufficient tarsal support, necessitating more comprehensive approaches. In such cases, the Anderson-Weinstein technique can simplify total lower eyelid reconstruction by creating a single-stage, full-thickness bipedicled flap, thereby eliminating the need for separate anterior or posterior lamellar support.4)

When addressing substantial marginal defects, a combination of flaps and grafts is often required to achieve optimal outcomes. In particular, when the lower eyelid defect spares the medial and lateral canthi or leaves a small eyelid remnant—as seen in this case—the bipedicled orbicularis oculi myocutaneous flap (Tripier flap) is preferable to the Anderson-Weinstein technique.4) This approach provides an excellent match for the lower eyelid’s texture and color, enhancing aesthetic outcomes, while its bipedicled design ensures robust vascularity and reduces the risk of ischemic complications. In cases of full-thickness defects, the flap requires a graft to reconstruct the posterior lamella. Chondromucosa or palatal mucosa is commonly used as a substitute for this purpose. While nasal septal chondromucosa is the preferred donor tissue for posterior lamellar reconstruction, it presents several donor site challenges, including poor accessibility, limited tissue availability, risk of septal perforation, and delayed healing. Additionally, composite grafts do not integrate as well as single-layer grafts. In contrast, palatal mucosa serves as an excellent graft for moist tissue reconstruction, as it is relatively abundant, easy to harvest, integrates well, and undergoes minimal shrinkage.5) In our case, the palatal mucosal graft retained much of its original size and stiffness over time, effectively functioning as a single-layer graft to replace both the tarsus and the conjunctiva. The Tripier flap has also been used for anterior lamella reconstruction in the repair of cicatricial6) or paralytic ectropion.7)

However, the Tripier flap has some limitations. The procedure requires a two-stage approach, necessitating a secondary operation to divide the pedicles, which may increase patient morbidity and prolong recovery time. Donor site morbidity is another consideration; however, in this case, primary closure of most of the donor defect minimized this issue. There is also a risk of postoperative complications such as flap bulkiness, asymmetry, and eyelid malposition, including ectropion or entropion—although none of these complications were observed in our patient.

Although the patient showed no evidence of local recurrence or distant metastasis during the 6-month follow-up period, sebaceous carcinoma is known for its potential for delayed recurrence and metastasis.8) Therefore, long-term surveillance with regular ophthalmologic and systemic evaluations is essential to ensure early detection of tumor relapse or spread. Continued follow-up of this patient is planned, and extended observation will further validate the durability and oncologic safety of the described reconstructive approach.

In conclusion, a bipedicled orbicularis oculi myocutaneous (Tripier) flap combined with a palatal mucosal graft offers a reliable, aesthetically favorable, and functionally effective approach for reconstructing substantial marginal defects of the lower eyelid. With careful surgical planning and technique, this method can yield excellent outcomes with minimal morbidity.