Repair of 50% lower eyelid defect with a periosteal strip
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This is Richard Allen at the University of Iowa. This video demonstrates repair of a full thickness lower lid defect using a periosteal strip to repair the posterior lamella. The defect is demonstrated. A lateral canthotomy incision is made with the needle tip cautery followed by a subciliary incision medially. This essentially separates the anterior and posterior lamella. Dissection is then carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. The rim is identified and further dissection is carried out in a preperiosteal plan inferior to the inferior orbital rim. The anterior lamella is then transposed superiorly to show that it will cover the posterior lamellar reconstruction. Looking at the ability of primary closure shows that this would not be possible. The periosteum of the lateral orbital rim is exposed using the freer periosteal elevator. The lateral remnant of tarsus is mobilized with an inferior cantholysis. The remnant is transposed medially and sutured to the remaining medial tarsus with 5-0 Vicryl suture, which unfortunately is not shown in the video. The lid margin is repaired with two 7-0 vicryl sutures placed in a vertical mattress fashion. This results in a lateral lower defect in the posterior lamella, which will be repaired with a periosteal strip.
A 15 blade is used to make an incision through the periosteum of the lateral orbital rim. The incision should be at a level relatively superior. A freer periosteal elevator is then used to elevate the periosteum from the underlying lateral orbital rim. This periosteum is reflected medially. This elevation is performed to where the lateral orbital rim becomes intraorbital. Examining the defect now shows that the periosteal strip will stretch to the lateral tarsus. This is sutured into position with a 5-0 vicryl suture on a taper needle which is placed in a mattress fashion so that the periosteal strip is anterior to the tarsus. This is then tied which results in repair of the posterior lamella. A 7-0 vicryl suture is used to support the superior portion of the strip to the tarsus.
The anterior lamella is then transposed into position. This is secured by engaging the cheek laterally with a 4-0 vicryl suture which then engages the periosteum at the level of the periosteal strip. I feel that it is very important to have lateral stabilization of the cheek. The subciliary incision is then closed wth interrupted 7-0 vicryl suture. The anterior lamella will then engage the lateral remnant of the tarsus with a 5-0 suture placed in a mattress fashion. An additional suture is placed laterally through the periosteal strip, again in a mattress fashion. The lateral canthotomy incision is closed with a deep 5-0 vicryl suture. The mattress sutures are then tied over bolsters. The canthotomy incision is then closed with interrupted 7-0 vicryl sutures. At the conclusion of the case the eyelid appears to be in good position with good lateral tension and minimal vertical tension. Antibiotic ointment will be placed over the repair, and the patient will return in one week for reevaluation and suture removal.