PMC8016385_01
Right periocular zone prior to reconstruction. A: Preoperative photograph showing the basal cell carcinoma located laterally on the lower eyelid. B: Intraoperative photograph showing the periocular defect after the first tumour excision with positive section margins. A corneal protector is in place. C: Intraoperative photograph showing the periocular defect after the second tumour excision with negative section margins. Whilst passively elevating the upper eyelid, a full thickness defect of the lower and upper eyelid, and a defect of the lateral canthus is shown
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F1
The final histopathological examination confirmed the absence of tumour cells in the section margins, allowing reconstruction (Figure 1). 
First stage of the periocular reconstruction. A: Intraoperative photograph showing the modified myocutaneous Tenzel flap advanced into the defect of the upper eyelid to reconstruct the anterior lamella. Posterior to this flap lie the superior component of the Y-shaped periosteal and temporal fascia sling, as well as the advanced palpebral mucosa which is sutured to the inferomedial border of the flap. B: Intraoperative photograph showing the inferior component of the medially hinged periosteal and temporal fascia sling (arrow) by elevating the modified Tenzel flap with forceps. C: Intraoperative photograph showing the autologous cartilage graft from the right concha sutured into the defect of the lower eyelid to reconstruct the posterior lamella. The modified Tenzel flap is elevated with forceps. Posterior to the cartilage graft lies the advanced palpebral mucosa which is sutured to the superior border of the graft. D: Intraoperative photograph showing the interpolated paramedian myocutaneous forehead flap transposed onto the cartilage graft to reconstruct the anterior lamella of the lower eyelid. Conventional closure of all donor sites with a small frontal defect remaining, left open to heal secondarily
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F2
Then the myocutaneous Tenzel flap was advanced into the defect in de upper eyelid and was sutured subcuticular with antibacterial Monocryl Plus  poliglecaprone 25 5-0 (Ethicon US, LLC) and with Vicryl Rapide  polyglactin 910 6-0 (Ethicon US, LLC) sutures for the skin (Figure 2). It was sutured into place with Ethilon  nylon 6-0 (Figure 2). The later was also applied daily into the right eye (Fig. 2).
First stage of the periocular reconstruction with intraoperative marking of the forehead flap
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F3
In order to reconstruct the anterior lamella of the lower eyelid; an ipsilateral myocutaneous paramedian forehead flap was created, after design of a template (Figure 3). 
Second stage of the periocular reconstruction. A: Intraoperative photograph prior to release of the pedicle of the forehead flap showing an adequate flap ingrowth and a favourable healing of the donor site. B: Intraoperative photograph after release of the pedicle and lateral inset of the forehead flap after subcutaneous thinning and fixation to the lateral canthal ligament. The palpebral mucosa of the lower eyelid is advanced and sutured to the superolateral border of the flap. The frontal donor site is closed with a V-Y plasty. C: Intraoperative photography showing the passive aperture of the right eye after partial lateral canthotomy for scar release
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F4
All wounds were further closed with Prolene  polypropylenesutures 6-0 (Ethicon US, LLC) sutures and were covered again with nitrofural or tobramycine/dexamethasone ointment and a grease gauze (Figure 4).
Postoperative photographs two months after the second stage of the periocular reconstruction. A: Frontal view. B: Oblique view. C: Lateral view
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F5
An ancillary corrective canthopexy was offered to the patient (Fig.5).