Myocutaneous flap for lateral lower lid defect
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This is Richard Allen at the University of Iowa. This video demonstrates repair of a lateral lower anterior lamellar defect with the use of a myocutaneous flap. A 15 blade is used to make an incision extending from the flap laterally and superiorly. This incision curves to outline a small Mustarde type flap. Westcott scissors are then used to undermine the flap in the plane just beneath the subcutaneous fat. Dissection should not be deeper than this to avoid injury to the facial nerve branches. Mobilization of the flap shows that it is still under too much tension. Additional undermining is performed with the needle tip cautery in the same plane. The mobilization appears adequate.
A lateral tarsal strip will be performed to stabilize the lower eyelid. A canthotomy and lower cantholysis has been performed followed by fashioning the strip by dissecting between the anterior and posterior lamella. The mucocutaneous junction is excised and the posterior surface of the strip is scraped with a 15 blade. The strip is then engaged with a double armed 4-0 Mersilene suture followed by engaging the periosteum of the lateral orbital rim at Whitnalls tubercle. The sutures are tied. The lateral anterior lamella of the strip is reassociated to the strip with a 5-0 fast absorbing suture. The flap is again mobilized and a deep 5-0 Vicryl suture is used to close the defect. An additional deep suture is placed laterally to further transpose the flap. The apex of the flap is excised. An additional deep suture is placed laterally. The skin is then closed with interrupted 6-0 Prolene suture. An additional 5-0 fast absorbing suture is placed in the area of the lateral canthotomy incision. A small dog-ear is excised to prevent a standing cone deformity. The final sutures are placed. At the conclusion of the case, antibiotic ointment is placed which will be used three times per day. The patient returns in one week for suture removal.
