Case report of Wolfe grafting for the management of bilateral cicatricial eyelid ectropion following severe burn injuries

INTRODUCTION: Eye lid reconstruction followed by severe, extensive body and facial burns represents a surgical challenge due to difficulties to obtain proper, healthy skin graft, tissue ischemia and necrosis. PRESENTATION OF CASE: We present a reconstructive lid surgery of cicatricial bilateral lower eyelid ectropion in a case of 31-year-old man who sustained thermal injuries, affecting more than 60% of total body surface area, causing severe, deep dermal burns. Reconstruction was made using the technique of skin cantus-to-cantus incision, contracture release, orbicularis liberation and lid elevation; and oversizing free full-thickness skin graft (FTSG) (Wolfe technique) from the left inguinal region, as the only healthy skin on the entire body surface. Residual lower left lid laxity was addressed by pentagonal wedge resection, not interrupting marginal arcade vessels, thus minimizing ischemia. DISCUSSION: Method of choice of the graft type has been much debated question; however, significantly less reoccurrence rate of ectropion was observed using FTSG. Time of grafting should be balanced to avoid excess granulation and, thus scaring caused by delayed grafting time, or poor graft adherence caused by premature grafting. An interruption of the marginal arcade vessels should not be performed due to already severe ischemic process and increased risk for lid necrosis. CONCLUSION: Major issues when addressing cicatricial ectropion followed by severe burns are: right donor site selection, appropriate graft thickness with the least possible disturbance of the affected place vascularisation, followed by immediate grafting after debridement of scaring and unhealthy tissue, with generous preservation of the orbicularis muscle.