Second stage median forehead flap with lid crease creation
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This is Richard Allen at the University of Iowa. This video demonstrates a second stage median forehead flap. The patient has a poor lid crease after placement of the flap and the flap somewhat thick. A lid crease will be created with the repair. An incision is made along the proposed lid crease. The thick portions of the flap have been marked. Scissors are then used to debulk the inferior medial portion of the flap. An incision is then made along the junction of the flap with the host tissue. The scar in this area is excised with the scissors. The flap is then raised with scissors. The goal here is to raise the flap, thin it, and then place it back into position. Superiorly the incision is widely undermined. A thick portion of the superior incision is excised. The thick portions of the flap are also excised. This usually consists of subcutaneous fat from the forehead. The goal here is to attain a concave shape to the medial canthus. The flap appears to be in good position. Attention is then directed to the upper eyelid where the orbital septum is opened. The underlying preaponeurotic fat is identified. The levator aponeurosis is then disinserted from the anterior surface of the tarsus. Dissection is then carried out between the levator aponeurosis and the underlying Mueller's muscle. Attention is then directed to lid crease formation. This is performed by engaging the skin, followed by the levator aponeurosis, followed by the skin of the flap. This is performed with a 6-0 Prolene suture. Additional sutures are placed along the lid crease in the same exact fashion. By incorporating the levator aponeurosis, a strong lid crease should be created. This is performed along the length of the proposed lid crease. The superior incision is then closed with 6-0 Prolene sutures placed in a horizontal mattress fashion. This is performed in order to gently evert the wound edges to attain a cosmetically acceptable scar. At the conclusion of the case, the flap is in good position. The patient will use Erythromycin ophthalmic ointment 3 times a day and follow-up in approximately 1 week for suture removal.