Forehead flap for medial canthal defect
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This is Richard Allen at the University of Iowa. This video demonstrates repair of a high medial canthal defect with a forehead flap. The patient is status post Mohs excision of a basal cell carcinoma. The forehead flap is planned. This is relatively high vertically just due to the width of the medial canthal defect. An incision is made with the 15 blade and the flap is raised in the subgaleal plane with the needle tip cautery. Transposition of the flap shows that it will adequately cover the defect. The flap is mobilized completely. The flap is transposed into position and the donor site is then widely undermined with the needle tip cautery. This is extended with Metzenbaum scissors. This should go to the level of the conjoint tendon. Potentially, the conjoint tendon could be lysed if the additional mobilization as needed. Additional blunt dissection is performed with a finger. This results in adequate mobilization of the donor site. Additional wide undermining is then performed around the defect with the needle tip cautery between the orbicularis muscle and the orbital septum. The posterior surface of the flap is then engaged with a 4–0 Vicryl suture. This then engages the periosteum to seat the flap. The flap is transposed easily. The flap is thinned where it will join the thinner eyelid skin. Attention is then directed to the donor site which is closed with deep interrupted 4–0 Vicryl sutures. Closing the donor site should essentially transposed the flap into position. The flap is then inspected. It is trimmed inferiorly. Sutures are then placed deep with 5–0 Vicryl suture. The flap is then trimmed laterally. Inspection of the flap shows that additional trimming will need to be performed. Is important to be conservative in trimming the flap. One can always trim more, but it is difficult to put some back. This can be performed with scissors or a blade. Closure is then completed with interrupted superficial 5-0 fast-absorbing sutures inferiorly. Additional deep sutures are placed superiorly. The donor site is then closed superficially with 5–0 Prolene sutures placed in a vertical mattress fashion. The flap is then closed superficially with a combination of 5-0 and 6-0 Prolene sutures. At the conclusion of the case, the flap appears be in good position with appropriate tension. The patient will use erythromycin ophthalmic ointment over the area 3 times a day and return in approximately 1 week for reevaluation.