Repair of 100% lower eyelid defect
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This is Richard Allen at the University of Iowa.
This video demonstrates the repair of the entire lower eyelid.
The patient is s/p a Mohs excision of a basal cell carcinoma. The lower canaliculus is involved. A Crawford stent is introduced into the cut end of the lower canaliculus, down the nasolacrimal duct, and retrieved from the nose. The other end of the Crawford stent is then placed through the upper system and retrieved from the nose. Attention is then directed to the defect. Examination shows that there is no evidence of any tarsus left. However, there does appear to be adequate anterior lamella. Dissection is then carried out between the orbicularis muscle and orbital septum to the inferior orbital rim. A lateral canthotomy is performed with further dissection to the lateral orbital rim between the orbicularis muscle and orbital septum. The lateral orbital rim is exposed. Mobilization of the anterior lamella shows that it should be able to cover any posterior lamellar reconstruction.
The upper eyelid is everted over a shoe horn speculum. The tarsus is inspected. A mark is made 4 mm superior to the inferior border of the tarsus. As much tarsus as possible will be taken along the length of the eyelid. A 15 blade will then be used to make an incision along the length of the tarsus of the upper lid to take as much tarsus as possible. Westcott scissors are then used to raise the flap. Dissection is carried out along the anterior surface of the tarsus. The flap is then mobilized by dissecting between the conjunctiva and the Muller muscle. It is important to keep Muller muscle out of the flap to prevent post-operative upper lid retraction. Further dissection is carried out along the surface of the conjunctiva to the superior fornix. The thinness of the flap is demonstrated. This will be transposed medially and sutured to the remnant of the medial canthal tendon. This is sutured into position with 5-0 Vicryl suture. Two sutures are placed. The stent is positioned to exit posterior to the Hughes flap.
Attention is then directed laterally where a significant defect is still apparent in the posterior lamella. Realistically it is difficult to use a Hughes flap alone to repair a defect of the entire lower eyelid. Dissection is then carried out inferiorly between the conjunctiva and lower lid retractors. The dissection plane is demonstrated. This conjunctival will be sutured to the inferior border of the posterior lamellar reconstruction.
A periosteal strip will then be elevated laterally. A 15 blade is used to make an incision through the periosteum. To elevate the strip, a Freer periosteal elevator is used. The strip is raised and reflected medially. Measuring between the Hughes flap and the strip shows that there is still a significant defect. This will be filled with a free tarsal graft from the contralateral upper eyelid. This is harvested with a 15 blade and Westcott scissors. Dissection is carried out similar to the Hughes flap along the anterior surface of the tarsus. The graft will be excised. Hemostasis is assured, but no repair needs to be done for the donor site.
The free tarsal graft is then sutured to the Hughes flap. This is performed with the same 5-0 Vicryl suture on the spatula needle. The free tarsal graft is sutured with a mattress suture to the periosteal strip with a 5-0 Vicryl suture on a taper needle so that the periosteal strip is situated anterior to the free tarsal graft. This results in repair of the posterior lamellar. A 7-0 Vicryl suture is placed at the junction of the free tarsal graft and the Hughes flap at the proposed lid margin. An additional suture is placed at the junction of the graft and the periosteal strip. The conjunctiva will then be sutured to the inferior border of the posterior lamellar repair. This is performed with a 7-0 Vicryl suture placed in a running fashion. Retractors have been dissected from the conjunctiva to prevent post-operative lid retraction. This is performed along the length of the repair.
A 4-0 Vicryl suture is used to engage the lateral soft tissue of the cheek and this is then sutured to the periosteum of the lateral orbital rim to provide lateral support of the myocutaneous advancement flap.
The myocutaneous advancement flap is then sutured to the anterior surface of the free tarsal graft with a 5-0 Vicryl suture in a mattress fashion. A similar suture is placed through the Hughes flap. These sutures are tied over bolsters. The superior edge of the myocutaneous advancement flap is then sutured to the superior boarder of the Hughes flap with interrupted and running 7-0 Vicryl sutures. This fixates the superior edge of the flap to the superior edge of the future lid margin. The lateral canthotomy incision is closed with the same 7-0 Vicryl suture.
At the conclusion of the case, an eye pad is placed for approximately two days. Antibiotic ointment is placed over the repair. The patient will return in one week for reevaluation. The second stage of the procedure will likely be performed in 3-4 weeks.
