Repair of lower lid retraction with a hard palate graft and medial pillar tarsorrhaphy
Richard C. Allen, MD, PhD
Additional Notes: Length 02:45
Posted March 20, 2017
This is Richard Allen at University of Iowa. This video demonstrates placement of a hard palate graft with a medial pillar tarsorrhaphy in a patient with a history of lower eyelid retraction, status post multiple previous failed attempts at lower eyelid elevation. The tarsorrhaphy is being placed in order to assist in elevation of the lid postoperatively. The lower eyelid is inspected and a lateral canthotomy and inferior cantholysis are performed. 4-0 silk sutures are placed through the lower eyelid at the level of the tarsus. A trans-conjunctival incision is then made inferior to the inferior border of the tarsus extending from the punctum medially to the lateral canthotomy incision laterally. Dissection is then carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. Scarring is encountered in this patient due to the previous surgeries. The eyelid appears to be released of the cicatricial bands.
The hard palate is harvested and placed in the space between the cut in of the lower eyelid retractors/orbital septum/conjunctiva and the inferior border the tarsus. This is sutured into position with a combination of running and interrupted 7–0 Vicryl sutures. A lateral tarsal strip is then fashioned by dissecting between the anterior and posterior lamella. The posterior surface of posterior lamella scraped with a 15 blade.
Attention is then directed to the upper eyelid which is everted over a shoehorn speculum. A medial pillar is then developed with the 15 blade and Westcott scissors. The conjunctiva of the lower eyelid is excised in the area where the pillar will be sutured. The pillar is then engaged with a double-armed 5–0 Vicryl suture. Each arm is then placed full-thickness through the eyelid.
Attention is then redirected to the lateral tarsal strip where the strip is engaged with a double-armed 4-0 Mersilene suture. The suture then engages the periosteum at the level of Whitnall's tubercle. The sutures are then tied. The eyelid appears be in good position. Elevation of the eyelid is demonstrated with tightening of the medial pillar. The Vicryl sutures are then sutured over a cotton bolster. The pillar will be released approximately 2 months post-operatively.
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