Repair of lower lid/cheek defect with a full-thickness skin graft
This is Richard Allen at the University of Iowa. This video demonstrates placement of a skin graft to a relatively large lower eyelid/cheek defect. The patient also has involvement of the lateral lower eyelid. The skin in this patient is relatively tight due to actinic damage therefore a regional flap would be difficult. A periosteal strip will be raised from the lateral orbital rim to cover the posterior lamella of the lower lid defect. This is incised with a 15 blade followed by elevation with a Freer periosteal elevator. Inspection of the defect shows that it should be able to be covered with the periosteal flap. The anterior lamella is excised from the most lateral portion of the tarsus. Residual tarsus is removed. The periosteal strip and the lateral tarsus are opposed. A 5–0 Vicryl suture is then placed in a mattress fashion to overlap the periosteal strip onto the lateral tarsus. This completes the repair of the lower lid posterior lamella.
A small flap will be raise laterally in order to make the anterior defect smaller. Wide undermining is performed with the needle tip cautery around the defect. Again, the skin is relatively tight and a complete Mustarde flap will not be performed. The posterior surface of the flap is engaged with 4–0 Vicryl suture which then engages the periosteum of the lateral orbital rim. The suture is then tied which places the flap into position. The superior medial portion the flap is then sutured to cover the periosteal strip. The closure of the flap is then performed with deep interrupted 4–0 Vicryl sutures. Superficial 5–0 Prolene sutures are then placed on the skin. A template of the defect is made. In this case, a supraclavicular graft was harvested. This is sutured into position with 5-0 fast-absorbing sutures. These are placed in a running and interrupted fashion. 6-0 silk sutures will then be placed around the graft so that a bolster can be fixated. Erythromycin ophthalmic ointment is placed over the graft. A bolster of Telfa with a surgical sponge is then placed into position. The patient will be patched. The patient will follow-up in approximately 1 week for patch removal and reevaluation.
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