The skin defect after eyelid tumor resection is not an inverted triangle, but a horizontal rectangle in most cases. This skin defect shape may be due to the reason that many lower eyelid malignancies originate at the eyelid margin [10].

In turn, resection with a safety margin often results in a rectangular or trapezoidal defect that includes the eyelid margin.

For this type of anterior lamellae tissue defect involving the lower eyelid margin, reconstruction by cheek rotation flap is commonly performed [9]. However, when a cheek rotation flap is used, the healthy skin tissue below the tissue defect is usually excised with wide resection to correct the dog ear deformity. Furthermore, a large skin flap must be elevated and rotated from the entire buccal area, including the outer ocular area and anterior ear area. Therefore, it must be said that reconstruction with a cheek rotation flap is relatively invasive.

Moving the cheek skin upward below the defect with a V–Y advancement lower eyelid flap is relatively easier and quicker to perform than a cheek rotational skin flap [11]. And then, because subcutaneous pedicle of V–Y flap contains direct cutaneous perforators as opposed to the random pattern of the cheek rotation flap, it has a better blood supply [11].

However, in this case, the two longitudinal oblique scars are likely to cause the skin flap to droop due to contraction and gravity, resulting in an ectropion formation [11]. In addition, the triangular scar is more likely to cause trapdoor deformity, and the scar is also more visible because the incision line intersects the RSTL [12].

To solve this problem, we developed a reconstruction method using a Step ladder V–Y advancement flap. The step ladder V–Y advancement flap is a skin flap commonly used for hand and foot reconstruction [13,14,15]. However, as far as we could find, there are no reports of its use in lower eyelid reconstruction.

The step ladder shape minimizes drooping of the skin flap, and by making the first step slightly lengthwise-wider than the defect, a sufficient amount of tissue can be placed at the eyelid margin to prevent ectropion. In fact, no cases of ectropion occurred. Furthermore, moving the direction of the flap slightly more oblique than vertical can also minimize drooping, because the flap is less likely to be pulled downward.

On the other hand, this flap is inferior to the cheek rotation flap in some respect. In the cheek rotation flap, the scar is only noticeable in the outer ocular area [9]; in the step ladder V–Y advancement flap, the V-shaped scar is in the front of the face. However, because of the zig-zag incision of the step ladder, the scar is not a problem, as shown in the case presentation.

The most significant disadvantage of this flap over the cheek rotation flap is that lymphatic dissection of the parotid region cannot be performed in the same surgical field at the same time.

In conclusion, reconstruction with a Step ladder V–Y advancement flap is very useful for anterior lamellae defects of the lower eyelid. This technique provides a very satisfactory cosmetic result without sacrificing healthy tissue. In addition, the operative time is reduced.