Rotational flap for medial defect
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This is Richard Allen at the University of Iowa. This video demonstrates reconstruction of a medial defect of the lower lid. I think one could perform a skin graft or even potentially widely undermine and repair this defect. But due to the risk of medial ectropion, it was decided to perform an advancement flap with a lateral tarsal strip. A 4-0 silk suture is placed through the lower lid to provide traction. The needlepoint cautery is then used to make a subciliary incision which extends from the defect laterally to the lateral canthus. Dissection is then carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. Care is taken to preserve the pretarsal orbicularis muscle. Additional dissection is carried out laterally in order to completely mobilize the flap which can the transposed to cover the defect. A lateral tarsal strip is performed to stabilize the lower lid. A lateral canthotomy and inferior cantholysis are performed followed by dissection between the anterior posterior lamella. The mucocutaneous junction is excised. The posterior surface of the strip is scraped. The strip is then shortened by approximately 3-4 millimeters. The strip is then engaged with a double-armed 4-0 Mersilene suture. The suture then engages the lateral orbital rim at the level of Whitnall's tubercle. Periosteal bites are demonstrated and the suture is tied. The flap is then transposed into position. 5–0 Vicryl sutures are then used to engage the deep tissue medially followed by the orbicularis muscle of the flap. This should place the flap into position with little tension at the skin edges. The lateral canthotomy is then closed with interrupted 5-0 fast-absorbing suture which reapproximates the anterior and posterior lamella. The subciliary incision is then closed with a running 5-0 fast-absorbing suture. The skin is then closed with mattress sutures medially. At the conclusion of the case, antibiotic ointment will be placed over the repair and the patient will return approximately one week for reevaluation.