Repair of 50% medial full-thickness lower eyelid defect
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This is Richard Allen at the University of Iowa. This video demonstrates repair of a medial full-thickness lower lid defect with a combination of flaps and a free tarsal graft. The defect involves the lower canaliculus. The upper punctum is dilated and a Crawford stent is placed through the upper canaliculus and down the nasolacrimal duct. It is retrieved from the nose with a Crawford hook. The other end of the Crawford stent is then placed through the cut end of the lower canaliculus and retrieved from the nose. A 4-0 silk suture is place through the lateral tarsus. A subciliary incision is then made extending from the medial edge of the defect to the lateral canthus. Dissection is then carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. Dissection is continued inferior to the inferior orbital rim in a preperiosteal plane with a freer periosteal elevator. This appears to mobilize the anterior lamella adequately to cover the defect.
A lateral canthotomy and inferior cantholysis is performed to mobilize the lateral tarsus. The tarsus is then transposed medially. A 4-0 Vicryl suture on a P-2 needle then engages the periosteum of the posterior lacrimal crest. This suture then engages the medial edge of the tarsus. Tying the suture results in repair of the medial defect in the posterior lamella, but shifts the defect now laterally. The Crawford stent should exit from the cut end of the lower punctum posterior to the tarsus.
Attention is then directed to the lateral orbital rim where a periosteal strip will be raised. This is performed with a 15 blade to incise the periosteum followed by elevation of the periosteum with a freer. The flap is reflected medially. There is still a defect between the periosteal strip and the tarsus. This will be filled with a free tarsal graft.
The ipsilateral upper lid is everted and the free tarsal graft is harvested with a 15 blade and Westcott scissors. Usually I would prefer the free tarsal graft from the contralateral eyelid, but the patient refused that in this case. The free tarsal graft is then placed into the defect and sutured to the lateral edge of the tarsus with 5-0 vicryl suture. Two sutures are placed. A 7-0 vicryl suture is then used to repair the lid margin by placing a vertical mattress suture at the level of the meibomian gland orifices to evert the lid margin.
The periosteal strip is then sutured to the free tarsal graft with a 5-0 vicryl suture on a taper needle. This is placed with a mattress suture in order to place the periosteal strip anterior to the free tarsal graft. Tying the suture results in repairing the posterior lamellar defect with lateral fixation of the free tarsal graft.
A cheek lift is then performed to elevate the anterior lamella by engaging the soft tissue of the cheek with a 4-0 vicryl suture followed by the periosteum of the inferior orbital rim. Two sutures are placed to elevate the medial anterior lamella. A final suture is placed laterally. The anterior lamella appears to be able to be placed into position without any significant vertical tension.
A 5-0 vicryl suture is then placed through the myocutaneous flap followed by a lamellar bite of the free tarsal graft. The suture is turned around to exit the myocutaneous flap. The suture is then tied over a cotton bolster to provide vascularized support to the free tarsal graft.
The lateral canthus is repaired with a deep 5-0 vicryl suture to provide adequate support. The anterior lamella appears to cover the posterior lamella without tension. A 5-0 fast absorbing suture is then used to close the subciliary incision with interrupted sutures. The lateral canthotomy is then closed with superficial 5-0 fast absorbing sutures.
The stents are tied and allowed to retract into the nose. At the conclusion of the case, the defect is repaired with the eyelid in good position. Antibiotic ointment is placed over the repair three time per day and the patient returns in one week for suture removal and reevaluation.