Hughes procedure is a surgical technique often used to reconstruct the lower eyelid, especially after removal of a cancerous tumor. The procedure restores normal function and anatomical structure. It also aims to improve cosmetics as best as possible. 

Dr. Wendel Hughes was the oculoplastic surgeon who first presented and popularized the procedure in 1937.

However, monocular patients who require lower eyelid reconstruction on the seeing eye should not undergo the Hughes procedure since it can lead to temporary obstruction of vision. Hughes procedure is performed on patients with sebaceous cell carcinoma, squamous cell carcinoma, basal cell carcinoma, Merkel cell carcinoma, melanoma, and eyelid malignancies. Patients who have also experienced eye trauma may undergo the Hughes procedure.

Also Known As

  • Tarso-conjunctival flap advancement

Preparation & Expectation Before Surgery

Before surgery, any malignant eyelid tumor is excised repeatedly if need be, until the affected area is tumor-free. The specimens are sent for histopathological analysis (microscopic examination to establish the manifestations of the concerned disease).

A complete history and ophthalmological examination are conducted. The surgeon explains the details of the operation, including risks and benefits.

Types, Purpose & Procedure

General anesthesia is administered in complete aseptic conditions (free from contamination. Hughes procedure is a two-stage procedure. In the first stage, the posterior lamella is reconstructed by advancing the tarso-conjunctival flap from the upper eyelid to the lower eyelid. The second stage involves severing the flap approximately two weeks following the first-stage procedure depending on patient factors. The procedure can also be performed using the modified Hughes procedure, where the marginal upper lid tarsus is spared. In this procedure, the levator muscle aponeurosis is disengaged from the tarso-conjunctival flap.

  • The patient is intravenously sedated with a mixture of lidocaine with epinephrine, Marcaine with epinephrine, hyaluronidase, and sodium bicarbonate.
  • The surgeon preps and drapes the patient in the usual sterile fashion.
  • S/he places a silk suture through the central upper lid margin. The Desmarres retractor is then used to evert (turn outwards or inwards) the upper eyelid.
  • The surgeon uses a 15 blade to make an incision on the tarsus and conjunctiva.
  • The surgeon vertically cuts the tarsus’ superior edge on either side of the original horizontal incision using a 15 BP blade.
  • Next, using forceps, the surgeon elevates the flap. S/he divides the tarsal-conjunctival flap from the underlying tissues using a Colorado blade.
  • The surgeon then uses Steven scissors to extend the incision on the conjunctiva to the superior fornix. Muller’s muscle is then dissected off the conjunctiva.
  • The surgeon removes the Desmarres retractor and rotates the tarsal-conjunctival flap inferiorly into the lower eyelid defect.
  • Next, the surgeon attaches the tarsal conjunctival flap to either side of the remaining lower eyelid tarsus. The surgeon uses polyglactin suture to attach the tarsal-conjunctival to the remaining lower eyelid retractors inferiorly.
  • If there is sufficient lid laxity, the surgeon will create the lid’s anterior lamella by using a myocutaneous advancement flap. The surgeon can also use a myocutaneous transposition flap from the upper eyelid to create the lid's anterior lamella
  • The surgeon then performs a full-thickness skin graft using the upper eyelid skin, supraclavicular, or postauricular.
  • S/he places an antibiotic ointment (prophylactic) on the incision, even twice, until the dissolution of the sutures or there is evidence of flap severance.
  • Approximately two weeks later, the surgeon will separate the eyelids when S/he cuts across the flap at the intended lower eyelid margin. S/he bevels (reduce to a sloping edge) the scissors to prevent the conjunctiva from creeping onto the reconstructed eyelid's anterior surface.


Risks, Side Effects & Complications

The procedure generally records a low rate of complications; however, entropion (eyelid folds inward), lower lid ectropion (eyelid folds outward), eyelid retraction, lagophthalmos (eyelids can’t close completely), and lower lid margin erythema (redness of the skin), may arise. Others include pyogenic granuloma (bloody red skin growths), flap suture dehiscence (separation), trichiasis (in-growth of eyelashes), and infection. 

Sometimes a revision is necessary when buckling occurs or when conjunctival creeps onto the lid margin. Eyelid resection can also occur, but it can be avoided if the surgeon dissects the advanced Muller's muscle back into the superior cul de sac (tube open at only one end) when the flap is severed.

There are more donor site complications recorded in the Hughes procedure than in the modified one. The modified Hughes procedure has less upper lid complications like trichiasis, entropion, and upper lid retraction. This is because the procedure spares the marginal upper lid tarsus. It also removes the levator muscle aponeurosis from the tarso-conjunctival flap.

After Care, Recovery & Outcome

The eyelid will be patched for two days. Patients are to continue with systemic antibiotics, topical antibiotics, and anti-inflammatory medications for a week. Follow up can range from 12 to 48 months. 

The Hughes procedure is most often performed successfully. After surgery, a patient achieves normal lid function with a successful cosmesis or aesthetic rate without the need for another surgical procedure.