Placement of Enduragen graft with inverting sutures
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This is Richard Allen at the University of Iowa. This video demonstrates repair of lower lid retraction with placement of an Enduragen graft. In addition, inverting sutures are placed in order to stabilize the tarsus to prevent postoperative ectropion. A lateral canthotomy and inferior cantholysis are performed. 4-0 silk sutures are then placed through the lower lid at the level of the tarsus in order to provide traction. A trans-conjunctival incision is then made inferior to the inferior border the tarsus extending from the punctum medially to the lateral canthotomy incision laterally. Dissection is then carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. The conjunctiva is then dissected from the lower lid retractors. In the placement of these synthetic grafts, I feel it is important to cover the graft with conjunctiva. The thinness of the dissection is demonstrated. The acellular porcine dermis is then placed between the inferior border the tarsus and the cut end of the lower lid retractors/orbital septum. This is sutured into position with interrupted and running 5–0 fast absorbing sutures. The inferior border of the Enduragen is then sutured to the cut end of the lower lid retractors and septum. This is performed with the same 5-0 fast-absorbing sutures. The position of the eyelid is then noted. There is a slight tendency towards ectropion in some patients with placement of the Enduragen graft. Therefore, the inferior border of the tarsus will be stabilized with inverting sutures.
A 5–0 Vicryl suture is placed transcutaneously. The suture then engages the inferior border the tarsus. The suture is then placed back through the orbicularis and skin. 2-3 sets of sutures are placed along the lower lid. These are left untied. The trans-conjunctival incision is then closed with interrupted and running 7–0 Vicryl sutures. Sometimes, it is best to place these in a buried fashion in order to prevent postoperative irritation. A lateral tarsal strip is then performed by dissecting between the anterior posterior lamella. The mucocutaneous junction the posterior lamella is excised. The posterior surface of the posterior lamella is scraped. The strip is shortened. The lash follicles are then excised. The strip is then engaged with a double-armed 4-0 Mersilene suture on an S2 needle. The suture then engages the periosteum of the lateral orbital rim at the level of Whitnall's tubercle. The suture is left untied. The mucocutaneous junction of the upper lid has been excised. The upper denuded mucocutaneous junction is then engaged with a 5–0 Vicryl suture. The suture will then engage the lateral tarsal strip. This is performed in order to stabilize the lateral canthus. The lateral tarsal strip sutures are then tied. A small medial tarsorrhaphy will be performed. A V-shaped incision is made with the needle tip cautery followed by dissection between the anterior and posterior lamella. The posterior lamella is then sutured together with a 6–0 Vicryl suture. The anterior lamella is then closed with the 7–0 Vicryl suture. This provides medial stabilization of the eyelid. The lateral canthotomy incisions are then closed with interrupted 5-0 fast-absorbing sutures. The tarsus stabilization sutures are then tied over a cotton bolster. These sutures will be removed at the one-week follow-up.