Repair of large cheek defect with a rotational flap
This is Richard Allen at the University of Iowa. This video demonstrates repair of a relatively large defect in the cheek and lower lid.
The patient had Mohs excision of cutaneous carcinomas. A lateral tarsal strip will be performed to stabilize the lower eyelid. A lateral canthotomy and inferior cantholysis are performed. The strip is then fashioned and sutured to the lateral orbital rim at the level Whitnall's tubercle. A Mustarde flap is then planned. A 15 blade is used to make an incision which extends superior lateral. The incision then follows the hairline to the ear. This incision will extend behind the ear in order to get maximal rotation of the flap. Dissection is then carried out in the subcutaneous fat plane. This plane is relatively superficial to avoid any damage to the branches of the facial nerve. This is performed with the needle tip cautery. This could be performed with scissors if the surgeon prefers. As these are 2 separate defects there will be some consideration with regards the repair of this. Again, the incision is extended behind the ear in order to get a maximal rotation of the flap. The amount of rotation is then evaluated. It is determined that the flap will be separated between the 2 defects in order to aid in repair of this. The patient's subcutaneous fat will be elevated in order to prevent any depression at the inferior orbital rim. Dissection is carried out along the surface of the subcutaneous fat. Dissection is then carried out in a subperiosteal plane under the subcutaneous fat. The fat is then elevated to the inferior orbital rim with 4-0 Vicryl suture to the periosteum of the inferior orbital rim in order to provide volume to this space. Further undermining is performed in order to get mobilization of the flap. The posterior surface of the flap is engaged with a 4–0 Vicryl suture. The suture then engages the periosteum of the lateral orbital rim. This will provide support laterally. Deep sutures are then placed with 5–0 Vicryl suture along the flap. Sutures on the skin are then placed with 5–0 and 6–0 Prolene. Additional deep sutures are placed with 5–0 Vicryl suture. A drain is placed. This will be connected to suction. Skin closure is then completed with interrupted 5–0 and 6–0 Prolene suture. At the conclusion of the case, the defects are repaired. The patient has good volume. The lower lid is in good position. The drain will be removed in 1-2 days depending upon the drainage. The patient will then return in one week for reevaluation.
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