Repair of large, lateral full-thickness upper lid defect
Richard C. Allen, MD, PhD, FACS
Length: 05:14
This is Richard Allen at the University of Iowa. This video demonstrates repair of a relatively large lateral upper eyelid defect which extends to the lateral canthus. The patient had Mohs excision of a recurrent basal cell carcinoma. The patient had a previous Hughes flap on the same side for reconstruction of a lower eyelid defect. In addition, a free tarsal graft had been taken from the contralateral upper lid. The defect involves a full-thickness section of the upper eyelid. Attention is directed to the lateral lower lid initially. A lower cantholysis is performed. Attention is then directed to the upper anterior lamella where a bipedicle flap will be planned. A 4-0 silk suture is placed through the lower lid. The periorbita of the lateral orbital wall is exposed. The posterior lamella defect is measured and a periosteal strip is planned and raised from the lateral orbital rim. This periosteal strip extends inferiorly in order to gain as much length to the strip as possible. This will be reflected medially to reconstruct the posterior lamella of the upper eyelid. Since upper lid tarsus is not available on either side and the patient preferred to not have a Cutler Beard procedure, the periosteal strip is used to recreate the posterior lamella. The periosteal strip is demonstrated along with the remaining conjunctiva.
A superciliary incision is extended along the remaining portion of the upper eyelid. This will enable the posterior lamella to be reconstructed independently of the anterior lamella. A 5–0 Vicryl suture is then placed in a mattress fashion to engage the periosteal strip and the lateral portion of the remaining tarsus. The suture is then tied. Attention is then directed to the remaining conjunctiva. Aggressive dissection should not be performed along the conjunctiva in order to preserve the lacrimal gland ductules. A 15 blade is used to make an incision along the marking for the bipedicle flap. The needle point cautery was then used to raise the bipedicle flap. This will be reflected inferiorly in order to cover the new posterior lamella. The edge of the conjunctiva is then sewn to the periosteal strip. This also engages the bipedicle flap. The bipedicle flap is then sutured to the edge of the periosteal strip. Elevation of the bipedicle flap results in the creation of an anterior lamellar defect superiorly which will be repaired with a skin graft. Attention is redirected to the lower lid where the lateral tarsus will engage the lateral orbital rim at the level Whitnall's tubercle. This is essentially at the area where the upper periosteal strip was reflected. The apposition of the bipedicle flap to the periosteal strip is finished with interrupted 7–0 Vicryl sutures. The lateral canthotomy incision is closed with interrupted 5-0 fast-absorbing sutures. The anterior lamella defect is then measured. A blepharoplasty is then performed on the contralateral eyelid so that a full-thickness skin graft can be performed. This is sutured into position with interrupted and running 5-0 fast-absorbing sutures. At the conclusion of case, the eyelid appears be in good position. A bolster will be placed over the skin graft and the patient will return in approximately one week for reevaluation.
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