Mustarde rotational flap
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This is Richard Allen at the University of Iowa. This video demonstrates the use of a Mustarde rotational flap to repair a defect of the lower lid and cheek. The patient is status post Mohs excision of a basal cell carcinoma. A 4-0 silk suture is placed through the lower lid at the level of the Meibomian gland orifices to provide traction during the case. A lateral canthotomy and inferior cantholysis are performed. A subciliary incision is performed extending from the lateral portion of the defect to the lateral canthus and then extending superiorly and laterally. Dissection is carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. Lateral to the lateral orbital rim, the dissection is performed just beneath the subcutaneous fat in order to not compromise the facial nerve. Inspection of the rotation of the flap shows that it appears to be adequate. Hemostasis is assured. Additional incisions are then performed along the nasolabial fold and the ala of the nose. This will assist in subsequent rotation and elevation of the flap in order to close the defect. Dissection is performed in this area just beneath the subcutaneous fat. The inferior portion of the nasolabial fold is elevated and closed with deep interrupted 5-0 Vicryl sutures. A lateral tarsal strip is then performed to tighten the lower lid. The flap is then rotated into position. It appears to be positioned without much tension. Redundant tissue inferiorly will be excised. A lateral 4-0 vicryl suture is then placed through the underside of the flap and then engages the periosteum of the lateral orbital rim. This is a mandatory suture to elevate and rotate the flap medially. An additional suture is placed with 4-0 vicryl suture along the medial portion of the flap to the periosteum of the inferior orbital rim. Additional deep interrupted 5-0 vicryl sutures are placed medially in a buried fashion. The flap now appears to be able to be closed with little tension. The lateral portion of the flap can then be closed with a combination superficial interrupted and running 5-0 fast and 6-0 prolene sutures. The lateral canthotomy is closed with the fast absorbing sutures. The medial portion of the flap is then trimed at the apex and the skin is closed with interrupted 6-0 prolene sutures. The medial portion along the nose is closed with interrupted 5-0 prolene sutures. At the conclusion of the case there appears to be minimal tension along the skin. The lower eyelid is in good position. The patient will return in approximately one week for removal of the sutures.