Hughes flap with skin graft
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This is Richard Allen at the University of Iowa.
This video demonstrates repair of a full-thickness lower lid defect with a Hughes flap and a skin graft.
Examination of the defect shows that it involves approximately 75% of the lower eyelid. Dissection is carried out inferiorly between the orbital septum and the orbicularis muscle to the inferior orbital rim. The inferior orbital rim and lateral orbital rim are exposed. Dissection is carried out inferior to the inferior orbital rim in a preperiosteal plane. A periosteal strip will be raised from the lateral orbital rim. A 15 blade is used to make incisions through the periosteum corresponding to the periosteal strip. The strip is then raised with a Freer periosteal elevator. The periosteal strip is reflected medially. A 4-0 silk suture is placed through the upper eyelid. Calipers are used to measure the defect between the remaining tarsus medially and the periosteal strip.
The upper eyelid is everted over a shoe horn speculum. The proposed length of tarsus is marked for the Hughes flap. A 15 blade is used to make an incision 4 mm superior to the inferior border of the tarsus. Westcott scissors are then used to raise the Hughes flap. Dissection is performed along the anterior surface of the tarsus. Dissection proceeds superiorly between the conjunctiva and the Muller muscle. The high temperature cautery is used to dissect further between the conjunctiva and the Muller muscle.
The flap is placed in to position. Dissection is carried out inferiorly between the conjunctiva and lower lid retractors. The tarsus of the Hughes flap is sutured to the native tarsus medially with 5-0 Vicryl suture which is placed partial thickness through the anterior surface of the tarsus. Two such sutures are placed. Laterally, the tarsus of the Hughes flap is sutured to the periosteal strip so that the strip is situated anterior to the Hughes flap.
A preperiosteal midface lift is performed by engaging the soft tissue of the cheek with a 4-0 Vicryl suture. This suture then engages the periosteum of the inferior orbital rim.
The conjunctiva is sutured to the inferior border of the tarsus with 7-0 Vicryl suture. This completes the repair of the posterior lamella.
The anterior lamella is fixated to the lateral orbital rim laterally. An anterior lamellar defect remains. This will be repaired with a full-thickness skin graft. A template of the defect is made with Telfa. The graft is harvested from the retroauricular area and placed into the defect. 7-0 Vicryl suture is used to suture the graft to the skin of the cheek. The upper border of the graft is sutured to the superior border of the tarsus of the Hughes flap. Additional 7-0 Vicryl sutures are used to complete the repair and close the canthotomy incision.
Antibiotic ointment is placed over the graft. A bolster fashioned from a scrub sponge is placed over the graft. An eye pad is the placed. The patient returns in one week for reevaluation and removal of the patch and bolster.