This is Richard Allen at the University of Iowa. This video demonstrates repair of a large full-thickness upper eyelid defect after excision of a skin cancer. The defect is inspected. The posterior lamellar portion of the defect is noted. The upper and lower lacrimal system are involved. There is no remnant of the upper canaliculus. Therefore, a mono-canalicular stent will be used to repair the lower canalicular defect. This is placed through the proximal end of the canaliculus and punctum. The mono-canalicular stent is then placed through the defect in the lacrimal sac and down the nasolacrimal duct. A 4–0 Vicryl suture is then used to engage the periosteum of the posterior lacrimal crest. This then engages the medial portion of the lower lid defect in the posterior lamella. Tying the suture places the lower lid in appropriate position. The canaliculus is then repaired over the mono-canalicular stent with 7–0 Vicryl sutures.
The upper lid is inspected. The medial edge of the defect is unable to be stretched to the medial canthus. Therefore, a lateral canthotomy and superior cantholysis are performed. This results in mobilization of the eyelid but not enough to transposed the posterior lamella to the medial canthus. Therefore, a free tarsal graft will be harvested from the contralateral upper eyelid. This is performed with Westcott scissors.
Attention is then redirected to the posterior lamellar defect. The edge of the medial tarsus is squared off. The pretarsal graft is then sutured to the tarsus. This is performed with 5–0 Vicryl sutures. The length of the eyelid appears be appropriate. The lid margin is then repaired with a vertical mattress suture with 7–0 Vicryl suture. A 5–0 Vicryl suture is then used to engage the periosteum of the posterior lacrimal crest. This then engages the medial edge of the free tarsal graft. Tying the suture results in adequate positioning of the upper eyelid and repair of the posterior lamellar defect. The cut edge of conjunctiva is sutured to the superior border of the free tarsal graft. This is performed 7–0 Vicryl sutures.
Attention is then directed to the anterior lamellar defect. This will be repaired with a small median forehead flap. A15 blade is used to make an incision along the markings. The needle tip cautery is then used to elevate the flap in the subgaleal plane. Wide undermining is then performed in the donor area. Closing the donor site results in adequate transposition of the flap. The donor site will then be closed with deep interrupted 4–0 Vicryl sutures. Wide undermining is performed around the area of the anterior lamellar defect superiorly. The posterior surface of the median forehead flap is then engaged with 4-0 Vicryl suture. This then engages the periosteum of the medial canthus. Tying this suture results in seating of the median forehead flap. Additional sutures are then used to close the anterior lamellar defect inferiorly. The flap will need to be thinned along the portion which corresponds to the pretarsal anterior lamella. The flap is trimmed of subcutaneous fat. Redundant portion of the flap is then marked. This is excised. The flap is then sutured to the free tarsal graft with mattress sutures with 5–0 Vicryl sutures. 2 sutures are placed in order to oppose the flap to the free tarsal graft. The lid margin is inspected. The flap is then closed with superficial 7–0 Vicryl sutures at the lid margin placed in a vertical mattress fashion. Attention is then directed to the donor site which is closed with interrupted 5–0 Prolene sutures placed in a vertical mattress fashion. Superficial sutures are placed along the remainder of the flap. The patient will follow-up in approximately 1 week for suture removal.
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