Combination of myocutaneous flaps for lower eyelid defect:
Anterior lamella reconstruction
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This is Richard Allen at the University of Iowa. This video demonstrates repair of a lower eyelid anterior lamellar defect using a combination of flaps. 4-0 Silk sutures are placed through the eyelid margin to provide traction during the case. The 15 blade is then used to make an incision extending from the lateral portion of the flap laterally and then superiorly to create a Mustarde type incision. An incision is then made from the medial aspect of the defect medially to the level of the punctum. Dissection is then carried out medially between the orbicularis muscle and orbital septum to the inferior orbital rim. Attention is then directed laterally where dissection is carried out along the under surface of the subcutaneous fat. Dissection should not be performed deeper than this to prevent injury of the branches of the facial nerve. Transposition of the flaps show that they appear to be adequately mobilized and not under too much tension.
A lateral tarsal strip will be performed to stabilize the lower eyelid. A lateral canthotomy is performed followed by an inferior cantholysis. Dissection is then carried out between the anterior and posterior lamella along the strip with Westcott scissors. This patient has significant lower lid laxity and a generous strip will be developed. The mucocutaneous junction of the strip is excised with Westcott scissors. The posterior surface of the strip is scraped with a 15 blade. The lashes along the dissected anterior lamella are excised. The strip is shortened the appropriate amount and then engaged with a double armed 4-0 Mersilene suture. Each arm of the suture then engages the periosteum of the lateral orbital rim at the level of Whitnalls tubercle. Tying the sutures results in tightening and, therefore, stabilization of the lower lid.
The posterior surface of the flap is then engaged with a 4-0 Vicryl suture. This suture then engages the periosteum of the lateral orbital rim. This suture will sometimes create a small dimple which will go away with time. This suture is important to place, not only mobilize the flap into position, but also support it. The orbicularis muscle of the lateral flap is then sutured to the orbicularis muscle of the medial flap with a 5-0 Vicryl suture. This results in adequate transposition of the flaps with minimal tension on the skin. The skin is then closed in this case with 5-0 fast absorbing sutures. This is performed in an interrupted fashion. Laterally, the incision is closed with interrupted 6-0 Prolene sutures. At the conclusion of the case, the defect is repair with minimal tension. Antibiotic ointment is placed over the repair three times per day and the patient will return in one week for reevaluation and suture removal.