Abstract Background The standard technique used for full-thickness reconstruction of the lower eyelid is the Hughes tarsoconjunctival flap. Despite its widespread use, objective postoperative assessments of eyelid morphology and tension remain rare. Methods This cross-sectional clinical study included patients who underwent the Hughes procedure at the Department of Ophthalmology, University of Cologne. Eyelid morphology was evaluated using the VECTRA M3 stereophotogrammetry system in neutral position, manual downward traction, and standardized hook distraction with a 15.9 g eyelid hook. Seventeen anatomical landmarks were identified per eye, measuring eight linear distances, two angles, and eyelid area. Operated and non-operated eyes were compared. Results Sixteen patients were included; 75% had basal cell carcinoma. In neutral position, operated eyes showed significantly larger lateral lid distances ( p = 0.004), upper lateral lid distances ( p = 0.008), and lateral canthal angles ( p = 0.010). Under manual distraction, the lateral canthal angle remained larger ( p = 0.003), while lateral lid mobility was reduced ( p = 0.039). Hook distraction revealed smaller length and area changes in operated eyes ( p ≤ 0.023, respectively), indicating increased tension. Subgroup analysis showed these differences were more pronounced in patients with defects >50% of eyelid length. In small defects, differences persisted but were less marked. Conclusions The Hughes procedure increases lower eyelid tension and reduces tissue compliance, particularly in the temporal region and in large defects. Standardized tension testing, such as weighted hook distraction, may improve postoperative assessment and guide surgical refinements. Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Ju et al. (2026) studied this question.