Free tarsal graft for repair of central lower lid defect
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This is Richard Allen at the University of Iowa.
This video demonstrates repair of a full-thickness central lower lid defect with a free tarsal graft and myocutaneous advancement flap.
Numerous different procedures could be performed in cases that involved approximately 50% of the lower eyelid. In this case, the patient had poor vision in the contralateral eye and did not want a Hughes flap performed. A subciliary incision is performed extending from the defect medially to the lateral canthus laterally. Dissection is then carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. This results in mobilization of the anterior lamella. The dissection is carried out along the width of the inferior orbital rim. Advancement of the flap shows that it covers the posterior lamellar defect adequately.
Attention is then directed to the posterior lamellar defect. The defect is measured. The upper lid is everted over a shoe horn speculum and the amount of tarsus needed is marked. A 15 blade is then used to make an incision 4 mm superior to the inferior border of the tarsus. Westcott scissors are then used to harvest the graft. The pretarsal orbicularis muscle is dissected from the anterior surface of the tarsus. The donor site does not need to be repaired. Hemostasis is assured with cautery.
The free tarsal graft is then placed into the lower lid defect. The graft is sutured into position laterally with a 5-0 Vicryl suture on a spatula needle that is placed partial thickness through the anterior surface of the tarsus. Two sutures are placed. The same is performed medially. The canalicular system was not involved in the defect. The lid margin is then addressed by placing a 7-0 Vicryl suture in a vertical mattress fashion. This results in eversion of the junction of the graft and the native tarsus. This is performed medially as well.
Attention is then directed to the inferior edge of the graft which is sutured to the edge of the conjunctiva with 7-0 Vicryl suture placed in a running fashion. This completes repair of the posterior lamellar defect, and the tension of the eyelid appears to be adequate.
The anterior lamella is then draped over the posterior lamella. A 5-0 Vicryl suture is placed through the anterior lamella followed by a partial thickness bite of the anterior surface of the tarsus. The suture is then placed back through the anterior lamella. This is essentially a mattress suture. An additional suture is placed medially. Tying the suture adheres the myocutaneous advancement flap to the free tarsal graft. These sutures can be placed over bolsters if preferred. The subciliary incision is then repaired with the suture of the surgeon’s choice, in this case the same 7-0 Vicryl suture. The superior edge of the myocutaneous flap is sutured to the superior edge of the free tarsal graft with the 7-0 Vicryl suture. At the conclusion of the case the eyelid appears to be in good position. Antibiotic ointment will be placed over the repair three times per day and the patient will return in 1 week for reevaluation.