A 48-year-old male, a long-standing diabetic, poorly controlled, who presented to the Emergency Department of our hospital with a 5-day history of pain, oedema and increased temperature in the left upper and lower eyelid,
according to the patient, secondary to blunt trauma that initially caused a minor dermabrasion.
On admission, he was assessed by Ophthalmology and diagnosed with preseptal cellulitis. Eight hours after admission, he developed a necrotic eschar in the involved tissue. On the first day of hospitalisation he underwent surgical cleaning and debridement of all the necrotic tissue. Material was sent for bacteriological culture, identifying Streptococcus Pyogenes. Based on this result, the patient was assessed by Infectious Diseases and treatment was started with Meropenem, Vancomycin, Clindamycin and Amphotericin.

On the second day of hospitalisation, he was assessed by the Wound Clinic of the Dermatology Department and treatment was started with negative pressure therapy at 125 mmHg continuously, with the aim of controlling exudate, promoting granulation and reducing dead space. This therapy was suspended 3 days later (on the fifth day of hospitalisation) due to progression of the erythema towards the contralateral palpebral portion. The patient continued in the care of Ophthalmology and Dermatology, being treated with physiological solution and isodine-based dressings and covered with alginate patches, a procedure which managed to control the infectious process.

Fifteen days after hospitalisation, he was assessed by Plastic and Reconstructive Surgery, who observed skin loss of the entire upper eyelid, partial loss of the orbicularis oculi and levator muscle (the latter was disinserted), good granulation tissue and focal loss of conjunctiva.

One month after the initial assessment, the patient underwent surgery and the granulation tissue was debrided until partial closure of the eyelid was achieved, identifying an intact tarsal plate. We performed local flaps to close defects in the conjunctiva, lateral canthotomy, full-thickness graft in the medial canthus and right frontalis musculocutaneus flap, which we attached to the superoexternal remnant of the orbicularis oculi muscle of the eyelid.

Four weeks later, we performed the pedicle section and frontalis flap thinning, seeing that the patient presented palpebral movement dependent on frontalis myorrhaphy with the orbicularis oculi remnant.

The patient persisted with greater volume and eversion of the reconstructed eyelid, so 2 months later we thinned the flap again and corrected the lagophthalmos by lateral canthopexy, freeing the palpebral ligament and reinserting it into the orbital rim.

After 2 years of evolution, the eyeball was covered with complete closure and opening of the eyelid, with no visual repercussions. No new surgical treatment was required.