Median forehead and rotational flap for medial canthal defect
Richard C. Allen, MD, PhD, FACS
Additional Notes: Length 06:57
This is Richard Allen at the University of Iowa. This video demonstrates the repair of a relatively large medial canthal defect with a combination of a median forehead flap and a lateral rotational or Mustarde flap. The defect is inspected. The lacrimal system is then assessed by placing the Bowman probe through the upper and lower canaliculi. No defect in the lacrimal system is identified. Attention is then directed to the median forehead flap. A 15 blade is used to make an incision along the marking. The monopolar cautery is then used to elevate the flap in the pre-galeal plane. This is connected with the upper border of the defect. At an area approximately 1 centimeter above the brow, the dissection is carried deeper to avoid transecting neurovascular structures. The flap is then rotated into position and inspected. Additional wide undermining is performed along the edges of the defect. Attention is then directed to the donor site of the median forehead flap. Wide undermining is performed to mobilize the edges of the donor site. The donor site is then closed with deep interrupted 4–0 Vicryl sutures. These are placed in a buried interrupted fashion. This results in adequate closure of the donor site. The skin is then closed with interrupted 5–0 Prolene sutures placed in a vertical mattress fashion. Attention is then redirected to the defect. The flap is rotated into position. The closure of the defect is inspected. The inferior portion of the flap is thinned by excising the subcutaneous fat. This is then sutured into position with deep interrupted 5–0 Vicryl sutures. The posterior surface of the flap is then engaged and sutured to the underlying periosteum of the medial canthus with a 4–0 Vicryl suture. This results in preservation of the concave shape of the medial canthus. The flap is thinned additionally and the skin is then closed with interrupted 5–0 Prolene sutures. The flap is inspected and a portion is excised. This is then laid into position along the superior portion of the defect. The posterior surface of the flap is engaged with a 4-0 Vicryl suture. This is then sutured to the underlying periosteum, again to encourage the concave contour of the medial canthus.
Attention is then directed to the lower eyelid. A 4–0 silk suture is placed through the eyelid margin for traction. A subciliary incision is then made with the needle tip cautery to extend from the medial portion of the defect to the lateral canthus. This is then extended superior temporally in order to raise a rotational or Mustarde flap. Dissection is carried out in the sub-cutaneous fat plane lateral to the lateral orbital rim. Inferiorly, dissection is carried out between the orbicularis muscle and the orbital septum. The lower lid will be tightened. This is performed with a lateral tarsal strip. A lateral canthotomy and inferior cantholysis are performed. The strip is then fashioned, shortened and engaged with a double-armed 4-0 Mersilene suture on an S2 needle. The periosteum of the lateral orbital rim is then engaged. The suture is tied and the lid is adequately tightened. Attention was then directed to the rotational flap which is engaged with a deep 4–0 Vicryl suture. The suture then engages the periosteum of the lateral orbital rim in order to support the flap. Rotating the flap shows that it is placed into position with minimal tension. The flap is sutured into position medially with deep interrupted 5–0 Vicryl sutures. This results in adequate closure of the defect. The subciliary incision is then closed with interrupted 5–0 fast absorbing sutures. Attention is directed laterally where the suture is used to engage the lateral tarsal strip. Along the Mustarde flap, deep interrupted 5–0 Vicryl sutures are used. The skin is then closed with a combination of 5-0 fast-absorbing sutures and 6–0 Prolene sutures. At the conclusion of the case, the eyelid appears to be in appropriate position and there is minimal tension on the edges of the flap. Erythromycin ophthalmic ointment will be placed over the incisions and the patient will return in approximately one week for reevaluation.
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