Combination glabellar and rotational flaps for repair of medial canthal defect
If video fails to load use this link: https://vimeo.com/218702681
This is Richard Allen at the University of Iowa. This video demonstrates repair of a medial canthal defect with a combination of Mustarde and glabellar flaps. The patient also has a small defect along the lateral portion of the lower lid. Inspection of the canaliculus of the lower and upper eyelid with a Bowman probe shows that the lacrimal system has not be violated. A marking pen is used to outline the glabellar flap. The proposed Mustarde flap is also marked. The area has been anesthetized with lidocaine with epinephrine. A 15 blade is then used to make an incision along the marking of the glabellar flap. A needle tip cautery is then used to raise the flap. This dissection is just beneath the subcutaneous fat. Transposition of the flap shows that it covers the upper portion of the defect well. The donor site is then closed with deep interrupted 4-0 Vicryl sutures which are placed in a buried fashion. Two sutures are placed. The periosteum of the medial canthus is then engaged with the 4-0 Vicryl suture followed by the underside of the glabellar flap. Tying the suture places posterior tension on the flap to seat it into the medial canthus. An additional suture is placed inferiorly in the same fashion. An additional deep suture is placed to close the donor site. The flap appears to be in good position. A portion of the superior portion of the flap is thinned where it will be sutured to the thin eyelid skin. The donor site is then closed with superficial 5-0 Prolene sutures which are placed in a vertical mattress fashion. A deep 5-0 Vicryl suture is placed. Superficial 5-0 fast absorbing sutures are then placed to complete the reconstruction of the superior portion of the defect. The apex of the flap is excised and additional superficial 5-0 fast absorbing sutures are placed. The glabellar flap appears to be in good position covering the upper portion of the defect.
A 4-0 silk suture is then placed through the lower eyelid margin to provide traction during the case. A subciliary incision is made with the needle tip cautery extending from the defect medially to the smaller defect laterally. This incision then continues along the portion of the proposed Mustarde rotational flap. Dissection is then carried out between the orbicularis muscle and the orbital septum medial to the lateral orbital rim. The dissection continues to the inferior orbital rim. Lateral to the lateral orbital rim dissection is performed just beneath the subcutaneous fat to avoid damaging branches of the facial nerve. A lateral tarsal strip will be performed to stabilize the lower eyelid. The strip will be sutured to the lateral orbital rim at the level of Whitnall's tubercle with a double armed 4-0 Mersilene suture. Inspection of the position of the lower eyelid shows that it is at appropriate tension and in good position.
The flap is then transposed medially and is shown to cover the remaining portion of the medial canthal defect with minimal tension. A 4-0 Vicryl suture then engages the deep portion of the lateral flap. This suture then engages the periosteum of the lateral orbital rim to elevate, stabilize, and transpose the flap. A small dimple is noted and desired; it will resolve with time. Another deep suture is placed through the medial portion of the flap to complete transposition of the flap.
The subciliary incision is then closed with interrupted and running 5-0 fast absorbing sutures. The flap is sutured to the lateral tarsal strip to recreate the lateral canthus. Additional sutures are placed laterally and medially. The medial portion of the Mustarde flap is then sutured to the lateral portion of the glabellar flap with 5-0 fast absorbing sutures. This results in repair of the defect with the lower eyelid in good position. The silk suture is removed. Antibiotic ointment is placed over the repair and the patient will return in one week for reevaluation.