Histopathologic alterations in the eyelid after Hughes tarsoconjunctival flap: loss of Meibomian glands with preservation of accessory lacrimal glands.

A 71-year-old female with invasive squamous cell carcinoma of the lower eyelid involving the ocular surface underwent surgical excision with negative margins and a subsequent reconstruction. The posterior lamellar defect was reconstructed with a Hughes tarsoconjunctival flap, and the anterior lamellar defect was reconstructed by advancing the lower eyelid skin. Three years later, the patient presented with signs suspicious for recurrence involving the tarsoconjunctival graft: a nodule along the mucocutaneus junction, symblepharon, and forniceal shortening. Repeat scouting biopsies showed variable degrees of moderate to severe squamous dysplasia so the patient underwent a staged full thickness excision of the lower eyelid and involved conjunctiva followed by reconstruction. Direct immunofluorescence was not diagnostic for ocular cicatrcial pemphigoid. Permanent histopathologic sections did not show any carcinoma, but the full thickness excisions involving the prior Hughes tarsoconjunctival flap highlighted two notable alterations: the Meibomian glands were absent and the accessory lacrimal glands of Wolfring were transposed to the mucocutaneous junction of the reconstructed lower eyelid.