Placement of Enduragen graft with pillar tarsorrhaphy
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This is Richard Allen at the University of Iowa. This video demonstrates placement of an Enduragen graft with a pillar tarsorrhaphy. This is performed in order to maximize the correction of the lower lid retraction by placing the lower lid in an upward position for as long as possible postoperatively. The patient has a history of exposure keratopathy. A 4–0 silk suture is placed through the lower lid to provide traction. A trans-conjunctival incision is made extending from the punctum medially to the lateral canthus laterally. A lateral tarsal strip will not be performed in this case, which is somewhat uncommon. Dissection is then carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. The inferior orbital rim is visualized. Dissection is then carried out between the conjunctiva and the lower lid retractors. This is performed so that the Enduragen graft can be covered with the conjunctiva. I think this is very important for these grafts that are not lined with mucous membrane. The graft will then be placed between the cut end of the lower lid retractors/orbital septum and the inferior border the tarsus. The graft is first sutured to the cut end of the lower lid retractors with a 5-0 fast-absorbing suture placed in a running and interrupted fashion. The graft is then placed into position and sutured to the inferior border of the tarsus. The shape of this graft is different compared to if one would perform a lateral tarsal strip at the same time. This is sutured into position with the same 5-0 fast-absorbing suture. The conjunctiva is then reapproximated to the inferior border the tarsus with a running 7–0 Vicryl suture.
Again, success of this procedure will depend on placing the lower lid in upward traction postoperatively. I think the longer that this can be performed the better the repair of the retraction. Therefore, in this case, a pillar tarsorrhaphy will be placed with 2 pillars. The upper lid is everted over a shoehorn speculum. A 15 blade is then used to develop the pillars. Westcott scissors are then used to raise the pillars. This is just a tongue of tarsus with conjunctiva. The lower lid margin is denuded at the area where the pillar will be placed. This is performed right at the mucocutaneous junction. This is performed with the Wescott scissors. The pillar tarsorrhaphy is then engaged with a double-armed 5–0 Vicryl suture. Each arm the suture is then placed through the lower lid at the area of the denuded epithelium. This is performed in the exact same manner for each pillar. The sutures will then be tied over cotton bolsters. The bolsters will be removed at the one-week follow-up. At the conclusion of case, the eyelid is in good position. Antibiotic ointment will be used over the area three times per day for one week.