Composite flap for medial full-thickness eyelid defect
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This is Richard Allen at the University of Iowa.
This video demonstrates repair of a medial lower lid defect using a composite flap.
Examination of the defect shows that it involves the lower canalicular system. Therefore, a Crawford stent will be placed through the cut end of the canaliculus, down the nasolacrimal duct and retrieved from the nose. The upper portion of the system is then intubated. Examination of the defect shows that the anterior lamellar defect is extensive enough that cheek recruitment would not be adequate to cover the anterior lamellar defect. Therefore, the defect is measured and a composite flap is planned by measuring the area laterally with the plan to advance it medially. The area is marked and the needle tip cautery is used to make an incision along the marking. Dissection is then carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. Transposition of the eyelid medially shows that there is too much tension. Therefore, a lateral cantholysis is performed which allows release of the lateral composite flap. Transposition of the composite flap medially shows that it covers the defect well. However, in doing so, a defect is now created laterally.
The medial canthal tendon is engaged with a 5-0 Vicryl suture which then engages the medial edge of the composite flap. Additional deep sutures are used to place the flap into appropriate position.
Attention is then directed to the newly created lateral defect.
Before addressing the lateral defect, the medial portion of the eyelid is repaired with deep 6-0 Vicryl sutures. Redundant skin is excised.
A lateral canthotomy is performed followed by dissection between the orbicularis muscle and the orbital septum to the lateral orbital rim. The lateral orbital rim is exposed and a periosteal strip is elevated with the freer periosteal elevator. The strip is reflected medially. There still appears to be a gap within the posterior lamellar repair. A free tarsal graft is harvested and placed into position. The free tarsal graft is then suture into positon to the tarsus of the composite graft with 5-0 Vicryl sutures which are placed partial thickness through the anterior surface of the tarsus. Two sutures are placed. The lid margin is then reapproximated with a 7-0 Vicryl suture placed in a vertical mattress fashion. The free tarsal graft is then sutured to the periosteal strip. This results in repair of the posterior lamella.
The anterior lamellar defect laterally will then be repaired with a myocutaneous advancement flap. A preperiosteal dissection is carried out inferiorly. The soft tissue of the cheek is then engaged with a 4-0 Vicryl suture. The suture then engages the periosteum of the inferior orbital rim. Tying the suture performs a preperiosteal midface lift. An additional suture is placed followed by a final suture to the lateral orbital rim to provide lateral support.
The myocutaneous flap is then positioned over the free tarsal graft and fixated to it with a 5-0 Vicryl suture that is placed in a mattress fashion. Two sutures are placed. The sutures are then tied over bolsters. Redundant anterior lamella is excised. The remainder of the anterior lamellar repair is completed with interrupted and running 7-0 Vicryl and 5-0 fast absorbing sutures. At the conclusion of the case, the eyelid appears to be in good position. A patch is placed for 2 days and the patient will return in one week for reevaluation.
