Repair of anophthalmic deformity with mid-face left, orbital augmentation, and periosteal strip
This is Richard Allen at the University of Iowa. This video demonstrates the use of the headlight mounted video camera in a patient undergoing a drill hole cheek lift, orbital augmentation, and a periosteal strip.
The patient has a history of anophthalmia. A 4-0 silk suture is placed through the lower lid at the level of the tarsus in order to provide traction during the case. The 15 blade is then used to make a transcutaneous subciliary incision. The needle tip cautery is then used to dissect between the orbicularis muscle and the orbital septum to the inferior orbital rim. The inferior orbital rim is then identified. The needle tip cautery is then used to make an incision through the periosteum of the inferior orbital rim. The Freer periosteal elevator is then used to elevate periosteum along the face of the maxilla. This dissection is carried out laterally first. This should be lateral to the infraorbital nerve. The dissection continues to the level of the gingival-buccal sulcus. The drill is then used to make drill holes through the inferior orbital rim. A 3-0 nylon suture is then placed through the inferior orbital rim. The needle then engages the soft tissue of the cheek inferiorly which has been elevated from the maxilla. The suture is left untied. An additional drill hole is then made centrally along the infraorbital rim. This usually is made in 2 passes. The suture is again placed through the drill hole. The suture then engages the soft tissue of the cheek which is the elevated periosteum. Tightening the suture demonstrates elevation of the cheek. The suture is left untied and an additional hole is then made laterally. Again the suture is backed through the hole. The needle that comes with the suture is too big to be placed through the hole. The needle then engages the soft tissue of the cheek. This can be difficult with this big needle and another option is to make stab incisions full-thickness through the cheek which is demonstrated in another video.
Attention is then directed to the orbital floor where the periosteum is elevated from the orbital floor. A small Medpor wedge implant is then placed along the orbital floor to augment the volume of the orbit in this patient. This will be fixated to the infraorbital rim. The drill is used to make a hole through the implant followed by the bone of the infraorbital rim. A 1 millimeter screw is then placed to hold the implant into position. The sutures of the mid facelift are then tied to elevate the cheek.
Attention is then addressed laterally where a lateral canthotomy and inferior cantholysis are performed. The periosteum of the lateral orbital rim is identified. A periosteal strip is going to be raised in this patient due to the fact that patient has had a previous lateral tarsal strip performed. The periosteal strip will allow extra-support in this area. The 15 blade is used to make an incision through the periosteum. A Freer periosteal elevator is then used to elevate the periosteum from the lateral rim. This is then reflected medially. The periosteal strip is demonstrated. The periosteal strip is then engaged with a 5–0 Vicryl suture on a taper needle. The suture then engages the lateral tarsus. This is a mattress suture so that the periosteum lays on top of the lateral tarsus. Tightening the suture results in an overlap of the periosteal strip over the lateral tarsus with good support. A conformer is placed prior to tying the sutures. The sutures are tied. The eyelid appears be in good position. The cheek appears to be in good position. An additional Vicryl suture is then placed which engages the soft tissue of the lateral cheek followed by the periosteum superior to the periosteal strip. The suture is then tied to give additional lateral support. The subciliary incision is then closed with interrupted 5-0 fast-absorbing sutures. At the conclusion of the case, the eyelid appears be in good position. Frost sutures will be taped to the patient's forehead. The patient will be patched and return for reevaluation in approximately 1 week.