Treatment of Divided Eyelid Nevus using Single Split-Flaps: Clinical Experience and Systematic Review.

Abstract

A Divided eyelid nevus is a rare congenital condition that poses complex reconstructive challenges. This study reports our experience with single split-flaps for medium and large-sized lesions, complemented by a systematic review of flap-based techniques. We retrospectively analyzed 26 patients treated between 2005 and 2024. Eleven patients with broad foreheads underwent reconstruction using superficial temporal artery frontal branch (STA-Fbr)-based flaps, and fifteen underwent reconstruction using distally based brachial artery perforator (dBAP) flaps. Intraoperative indocyanine green angiography (ICGA) was used for vessel mapping, flap splitting, and perfusion assessment. Depending on medial canthus involvement, the flaps were split distally in a fish-mouth or window pattern to enable simultaneous reconstruction of both eyelids. A systematic review was conducted on August 12, 2024, across four major databases. Six medium and five large lesions were reconstructed using STA-Fbr-based flaps, whereas six medium and nine large lesions were reconstructed using dBAP flaps. The mean tissue expansion periods were 5 and 6 months, respectively. ICGA accurately guided flap splitting and confirmed adequate perfusion. All STA-Fbr-based and 12 dBAP flaps were split in a fish-mouth pattern, while the remaining dBAP flaps were split in a window pattern. All flaps survived without venous congestion or necrosis. The systematic review identified 27 studies supporting the reliability of pre-expanded forehead and medial arm flaps for large lesions. The single split-flap technique using pre-expanded STA-Fbr-based or dBAP flaps under ICGA guidance is a reliable approach for the simultaneous reconstruction of both eyelids in medium and large lesions, achieving favorable functional and aesthetic outcomes.