Lower lid elevation with ear cartilage graft
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This is Richard Allen at the University of Iowa. This video demonstrates the use of an ear cartilage graft to address lower eyelid retraction. 4-0 silk sutures are placed through the lower eyelid at the level of the meibomian glands in order to provide traction during the case. The needle tip cautery is then used to make a subciliary incision extending from the lateral cantus laterally to the punctum medially. Dissection is then carried out between the orbicularis muscle and orbital septum inferiorly to the inferior orbital rim. The anterior lamella appears to be freely mobile. The needle tip cautery is then used to disinsert the confluence of the lower lid retractors and orbital septum from the inferior border of the tarsus. Dissection is then carried out between the lower lid retractors and underlying conjunctiva with the thermal cautery. The ear cartilage will be placed in this space. The eyelid appears to be free from the inferior pull of the retractors. It is determined that an ear cartilage graft measuring approximately 30 mm in width and 12 mm in height will be used. Attention is then directed to the ear where an incision is made with the 15 blade, following the curvature of the helix. Dissection is the carried out along the surface of the cartilage with Westcott scissors. This dissection is carried out to expose the appropriately sized amount of cartilage needed. This is demonstrated with the calipers and ruler. A 15 blade is then used to make an incision along the appropriately sized cartilage. Westcott scissors are used to complete the incision. Dissection is then carried out along the surface of the cartilage in order to harvest it. Care is taken not to go full-thickness through the ear. Hemostasis can be attained with bipolar cautery. After the graft is harvested, it is set aside in saline soaked gauze.
The ear is then closed with 6-0 prolene sutures. These are placed in an interrupted fashion. Attention is then redirected to the graft. As on can see, there is some difficulty in getting it to conform to the curvature of the eyelid due to the stiffness of the graft. Therefore, the graft is scored with a 15 blade to make it more flexible.
The graft is then placed in the space between inferior border of the tarsus and the cut end of the confluence of the lower lid retractors and orbital septum. The graft is the sutured into position with a combination of interrupted and running 5-0 fast absorbing sutures.
The eyelid will then be tightened horizontally with a lateral tarsal strip. A lateral canthotomy and inferior cantholysis are performed followed by fashioning the strip. Dissection is performed between the anterior and posterior lamella followed by excision of the mucocutaneous junction and scraping the posterior surface of the strip. The strip is sutured to the lateral orbital rim at the level of Whitnalls tubercle with a double armed 4-0 mersilene suture. Prior to tying the sutures, the lateral portion of the mucocutaeous junction of the upper lid is excised in order to include the upper lid into the canthoplasty. This is sutured to the lateral tarsal strip with a 5-0 Vicryl suture. The mersilene is then tied to place the eyelid into position.
In this case a medial tarsorrhaphy is also going to be performed to support the medial portion of the eyelid. This is performed by making a V shaped incision extending from the lower lid to the upper lid. The posterior lamella is then sutured together with 5-0 vicryl suture. Two sutures are placed. The anterior lamella is the closed with 7-0 Vicryl suture. The subciliary incision is then closed with the 7-0 vicryl suture. The cathotomy is closed with interrupted sutures. A running suture is place for the subciliary incision. At the conclusion of the case, antibiotic ointment is placed over the incisions and into the eye. The Frost sutures are taped to the forehead in order to place the eyelid on stretch. The eye is then patch for one week.