Repair of 50% Central Full-Thickness Lower Eyelid Defect
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This is Richard Allen at the University of Iowa. This video demonstrates repair of central full-thickness lower lid defect which would traditionally be repaired with a Hughes flap. In this case, the defect will be repaired with a combination of flaps and free tarsal graft. The defect measures at least 50% of the width of the lower eyelid. A subcialiary incision is made extending from the defect both laterally and medially. Dissection is then carried out between the orbicularis muscle and orbital septum to the inferior orbital rim. The inferior orbital rim is identified. Dissection will then be carried out inferior to the inferior orbital rim in a preperiosteal plane with the freer periosteal elevator. This will allow advancement of the anterior lamella so that a skin graft will not be needed. This is performed along the length of the inferior orbital rim. Elevation of the anterior lamella shows that it is redundant enough so that it can repair the defect.
A lateral canthotomy and inferior cantholysis are peformed. This is performed to swing the remaining tarsus medially to the medial portion of the defect. A 5-0 vicryl suture is used to engage the lateral tarsus followed by the remnant of the medial tarsus. Two such sutures are placed and the sutures are tied. This results in transposition of the remaining lateral tarsus medially. This essentially shifts the defect in the posterior lamella laterally. A 7-0 vicryl suture is placed in a vertical mattress fashion at the lid margin. This results in a lateral defect in the posterior lamella which will be addressed with a periosteal strip and a free tarsal graft.
A periosteal strip is developed along the lateral orbital rim. This periosteal strip is then elevated from the bone and reflected medially. This anchor the free tarsal graft which will fill in the lateral portion of the posterior lamellar defect. I think it is important for the free tarsal graft to be lateral in the reconstruction so that the anterior lamella has minimal tension of the graft with lateral fixation. The defect is measured and the contralateral upper lid is everted and marked. The free tarsal graft can then be harvested with a 15 blade followed by Westcott scissors. I always take the free tarsal graft from the opposite lid so that a Hughes would always be an option if needed. The free tarsal graft is dissected from the underlying pretarsal orbicularis muscle. The graft is then excised and light cautery is used to stop any bleeding.
The free tasal graft is then sutured into position with 5-0 Vicryl suture to the medial tarsus. A 7-0 vicryl suture is then placed at the lid margin in a vertical mattress fashion at the meibomian gland orifices. The free tarsal graft is then reflected laterally to engage the periosteal strip. A 5-0 vicryl suture on a taper needle is then used to be placed in a mattress fashion so that the periosteal strip is anterior to the free tarsal graft. Tying the suture results in repair of the posterior lamellar defect. It also directs the free tarsal graft posteriorly and superiorly and results in lateral stabilization of the graft.
A preperiosteal cheek lift is then performed. A 4-0 vicryl suture is used to engage the soft tissue of the cheek followed by the periosteum of the inferior orbital rim. An additional suture is placed centrally, followed by a lateral suture which liberally elevates the lateral portion of the cheek, engaging the periosteum at the level of the periosteal strip. This results in support of the cheek and lateral canthus so that the anterior lamella can be transposed over the posterior lamellar repair without any tension.
5-0 Vicryl suture is the used to secure the anterior lamella to the free tarsal graft, using a mattress suture. The suture is placed through the skin and orbicularis followed by a lamellar bite of the free tarsal graft, and then back through the orbicularis and skin. Two sutures are placed so that the graft is well covered by the vascularized flap. These sutures are then tied over bolsters. The remaining subciliary incision is closed with interrupted 7-0 vicryl suture. The canthotomy incision is then closed with the 7-0 vicryl suture. At the conclusion of the case, the eyelid appears to be in good position. Antibiotic ointment is used three times per day and the patient returns in one week for reevaluation and suture removal.