Repair of 50% lateral full-thickness lower eyelid defect
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This is Richard Allen at the University of Iowa. This video demonstrates repair of a lateral full-thickness eyelid defect involving approximately 50% of the eyelid using a free tarsal graft and periosteal strip. This defect could also be repaired with a Hughes flap, but there are disadvantages to the Hughes flap in some instances. A subciliary incision is made extending from the punctum medially to the defect laterally. Dissection is then carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. The inferior orbital rim is palpated and additional dissection is carried out inferior to the inferior orbital rim in a preperiosteal plane as well as along the lateral orbital rim. This is performed to fully mobilize the anterior lamella so that it can be transposed superiorly to cover the posterior lamellar repair. Dissection is then performed laterally to expose the periosteum of the lateral orbital rim. A periosteal strip is then developed using the 15 blade. The strip started at a level relatively superior and directed in a superior lateral direction. The freer periosteal elevator is then used to elevate the strip. This is performed in order to reflect the strip medially. The strip is reflected medially, and the distance between the strip and the native tarsus is measured.
Attention is then directed where the contralateral upper lid is everted. The proposed area of the free tarsal graft is measured. A 4 mm bridge of tarsus should remain at the lid margin of the donor lid. The 15 blade and Westcott scissors are used to harvest the graft. I always take the free tarsal graft from the contralateral lid in case I need to do a Hughes flap later. Light hemostasis is applied.
A preperiosteal cheek lift is then performed using a 4-0 vicryl suture. The suture engages the soft tissue of the cheek, followed by the periosteum of the inferior orbital rim. Approximately 3 sutures will be placed along the inferior rim. Transposition of the anterior lamella shows that it will be able to be positioned without significant tension. The edge of the remaining tarsus is freshened. The free tarsal graft is then placed into position and sutured to the medial tarsus with 5-0 Vicryl suture. Two sutures are placed followed by a 7-0 Vicryl suture that is placed in a vertical mattress fashion at the meibomian gland orifices to evert the lid margin. The free tarsal graft is then sutured to the periosteal strip with a 5-0 vicryl suture on a tapered needle. I like the taper needle to prevent cutting the periosteal strip. The suture is placed in a mattress fashion so that the periosteal strip is anterior to the free tarsal graft. This concludes reconstruction of the posterior lamella with good lateral fixation of the free tarsal graft. The conjunctiva is then sutured to the edge of the free tarsal graft – I am not sure that this is necessary.
The canthotomy incision is then closed with a deep 4-0 vicryl suture which engages the cheek and the periosteum. A mattress suture is then placed full thickness though the myocutaneous flap followed by a lamellar bite of the free tarsal graft. Approximately 2-3 sutures are placed in this fashion in order to provide a vascular supply to the free tarsal graft. These sutures are then tied over cotton bolsters. The canthotomy incision is then closed with interrupted 5-0 fast absorbing sutures, and the subciliary incision is closed with interrupted 5-0 fast absorbing sutures.
At the conclusion of the case, the eyelid appears to be in good position. Antibiotic ointment will be placed over the repair three times a day and the patient will return in one week for reevaluation and suture removal.