Fig. 1

Diagram illustrating the basic steps of the modified Hughes procedure. a Left eye with a full-thickness lower eyelid defect involving >50 % of the horizontal lid length. b Approximation of the temporal and nasal wound margins using two pairs of forceps to measure the required width of the Hughes flap. c Everting the upper lid to expose the conjunctiva and measuring 4 mm of the marginal tarsus to be preserved. d Tarsoconjunctival flap is cut and extended down to cover the defected area. e Suture fixation of the Hughes flap (posterior lamella) and of a free skin graft (anterior lamella), which has been harvested from the contralateral upper eyelid. f Division of the pedicle about 0.5 mm above the lower lid margin, performed 6 weeks after Hughes flap fixation