Full Thickness skin graft
This is Richard Allen at the University of Iowa. This video demonstrates full thickness skin grafting. The patient is s/p Mohs excision of a basal cell carcinoma of the left lower lid. It has been determined that adequate skin is available on the ipsilateral upper lid to cover the defect on the lower lid. A blepharoplasty has been marked to insure that adequate skin remains for closure postoperatively. A monopolar cautery is used to excise the skin, a blade and scisssors could be used if desired.
4-0 Silk is placed at the level of the meibomian glands. These sutures will be used as Frost sutures later. I will usually tighten the lower lid in these cases in order to add to the post-operative stability of the lid. This will be peformed with your standard lateral tarsal strip. Canthotomy, cantholysis, dissection between the anterior and posterior lamella, excision of the mucocutaneous junction, scraping the tasal conjunctiva, shortening the strip, and suturing the strip to the lateral orbital rim at the level of Whitnall's tubercle. The suture used here is a 4-0 mersilene suture on an S2 needle. These sutures are placed relatively superior and posterior. The sutures are tied.
The skin graft is then placed into the lower lid defect. Prior to doing this, any remaining orbicularis is excised from the back side of the graft so that only dermis and epidermis remain. Usually I would make a template of the defect prior to harvesting the skin graft. In this case, the maximal amount of skin was removed from the upper lid, so the graft is trimmed to fit the defect. The graft is then sutured into position. 7-0 Vicryl is used in this case. I will also use 5-0 fast absorbing gut suture or a permanent monofilament suture such as a 6-0 prolene or nylon suture. Interrupted sutures are placed in 4 cardinal positions followed by a running suture to complete the closure.
The upper eyelid incision is then closed. In this case it is performed with a 6-0 prolene suture. This can be placed in an interrupted or running fashion as is noted in this case.
6-0 silk sutures are then used to fixate the subsequent bolster into position. Depending on the size of your graft anywhere from 2 to 4 sutures may be needed. Two are used in this case. Some surgeons will place these sutures to incorporate the edge of the graft. In this case sutures are placed outside the graft. Antibiotic ointment is then placed on the surface of the graft, followed by the bolster which has underlying telfa and a sponge. I like to use a sponge from a sterile scrub sponge without soap. The sutures are then tied to place adequate pressure on the graft. The graft should remained undisturbed for one weak so that it establishes its vascular supply. The frost sutures are then taped to the patient's forehead to keep the eyelid on stretch. This is then followed with placement of a double eye pad. The patient returns in one week for removal of the eyepad and bolster.