Repair of large cheek defect with a combination of a Mustarde flap and skin graft
This is Richard Allen at the University of Iowa. This video demonstrates repair of a large shallow cheek defect with a combination of a Mustarde a flap and a full-thickness skin graft. An incision is made from the superior lateral portion of the defect to extend superiorly to begin the Mustarde flap. A 4-0 silk suture is then placed through the lower lid at level tarsus in order to provide traction. The lower lid will be tightened using a lateral tarsal strip. This is performed in the standard fashion and fixated to the lateral orbital rim with a double-armed 4-0 Mersilene suture. I think it is important to stabilize the lower lid in any reconstruction which involves anterior lamella of the lower lid.
The Mustarde flap is then lifted. Inside the lateral orbital rim, dissection is carried out between the orbital septum and the orbicularis muscle. Outside lateral orbital rim, the dissection is carried out in the subcutaneous fat layer. Transposition of the flap shows that more needs to be lifted. This is performed with the needle tip cautery. Again transposition shows that progress is being made however, additional dissection needs to be performed. The incision is extended to the tragus. Transposition now shows reasonable coverage of the defect. Wide undermining is performed outside the flap. Hemostasis is assured. Transposition is then performed. This appears to be adequate to cover much of the defect. An incision is then made along the nasolabial fold in order to get elevation of this area to aid in coverage of the defect. This dissection again is carried out in the subcutaneous fat plane. Transposition now results in a relatively small defect. The decision was made at this point to cover the remaining defect with a skin graft rather than continue with elevation of a larger flap.
The posterior surface of the flap is then sutured to the inferior lateral orbital rim for fixation. This takes tension off the flap which allows it to lay into position without tension. The posterior surface of the flap is then sutured to the medial portion of the defect. This results in coverage of much of the lower eyelid defect. The flap is then sutured into position with deep interrupted 4–0 and 5–0 Vicryl sutures. The inferior portion of the flap from the nasolabial fold is elevated and sutured into position with deep 4–0 Vicryl sutures. The superficial portion the flap is closed with interrupted and running 5-0 fast-absorbing sutures. A small Burrow's triangle is removed inferiorly. This should be conservative so that the flap is not compromised.
A template will then be made of the resulting defect with Telfa. This is transferred to the preauricular area on the left. A full-thickness skin graft is harvested with the 15 blade and Westcott scissors. The flap will be thinned of the subcutaneous fat so that only the dermis and epidermis remain. The donor site is then closed with deep interrupted 4–0 Vicryl sutures followed by 5–0 Prolene sutures for the skin. The skin graft is then placed into position. This is sutured into position with running and interrupted 5-0 fast-absorbing sutures. The remaining portions of the flap are closed with 5–0 Prolene sutures. 6-0 silk sutures are placed along the skin graft for placement of a bolster. The defect is repaired well. Erythromycin ophthalmic ointment is placed over the skin graft followed by Telfa and a bolster. Frost sutures are placed followed by an eye pad. The patient will follow-up in approximately 1 week for removal of the bolster and reevaluation.
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