Exenteration with placement of a split thickness skin graft
This is Richard Allen at the University of Iowa. This video demonstrates an exenteration with placement of a split thickness skin graft. The patient has a biopsy proven sebaceous carcinoma which involved much of the upper eyelid as well as the conjunctival surface. Two 4-0 silk tarsorrhaphy sutures are placed which will also act as traction sutures throughout the case. A monopoloar cautery is then used to make an incision through the skin and orbicularis muscle at the orbital rim 360 degrees. Dissection is the carried out to the orbital rim laterally as well as inferiorly. The superior orbital rim is identified and the periosteum is elevated. The lateral orbital rim is incised along the periosteum. Superiorly, the periosteum is elevated from the orbital rim. Laterally the periosteum is elevated from the lateral orbital rim and lateral wall. In this area one will usually encounter structures corresponding to the zygomatico facial and zygomatico maxillary neurovascular bundles. The supraorbital neurovascular bundle is identified and transected with the monopolar cautery. Medially, the anterior ethmoidal neurovascular bundle is identified and cauterized. It is important to not compromise the thin bone of the medial orbital wall to prevent sino-orbitl fistula formation. Posteriorly, the posterior ethmoidal neurovascular bundle is identified and cauterized. After transection of the infraorbital fissure as well as the nasolacrimal duct, the curved scissors are used to transect the posterior obit. In doing this, the ophthalmic artery is transected and there is significant bleeding. One can apply a snare prior to transection, but I do not find this useful. Inspection of the excised orbit shows that the periosteum is largely intact other than the posterior orbit. Hemostasis is attained with the bipolar cautery. A posterior orbital biopsy can be obtained if needed. The area is then packed for hemostasis prior to harvesting of the split thickness skin graft. Other options for covering the defect or reconstruction include granulation, use of local flaps such as a cheek lift and median forehead flap, and use of a free flap. In this case, the patient has opted for a split thickness skin graft.