This is Richard Allen at the University of Iowa. This video demonstrates repair of a left upper lid full-thickness medial defect with a combination of a free tarsal graft to reconstruct the posterior lamella and a myocutaneous flap for the anterior lamella. The lacrimal system is inspected and the upper canaliculus has been resected. Stretching the eyelid medially shows that a primary closure could not be performed. The lower punctum is dilated with a punctal dilator. A pigtail probe is then used to identify the cut end of the upper canaliculus. A 6-0 nylon suture is placed through the eye of the pigtail probe. This is to allow identification of the cut end of the canaliculus. A Crawford stent is then placed through the cut end of the upper canaliculus and down the nasolacrimal duct. This is then retrieved from the nose. The same is then performed for the lower canalicular system. A hard stop is palpated and the stent is then placed down the nasolacrimal duct and retrieved from the nose. This completes intubation of the remaining portions of the canalicular system.
A free tarsal graft will then be harvested from the right upper lid. The length of the graft needed is measured. This is then marked with a marking pen. The graft is then harvested with a 15 blade followed by Westcott scissors. The harvesting of the graft is then completed. This area is allowed to granulate on its own. No sutures are needed for repair of the donor site. The lateral portion of the upper eyelid crease is then identified and incised with the needle tip cautery. This will allow mobilization of the anterior lamella later. The free tarsal graft is then engaged with a double-armed 5–0 Vicryl suture. The suture then engages the posterior lacrimal crest medially. The lacrimal stent exits posterior to the free tarsal graft. The lateral edge of the free tarsal graft is then sutured to the medial edge of the remaining tarsus. This is performed with 5–0 Vicryl suture. 2 sutures are placed. The medial suture is then tied. This will complete reconstruction of the posterior lamella.
Attention is then directed to the anterior lamella. Dissection is carried out between the orbicularis muscle and the orbital septum. A myocutaneous flap is then planned. Originally, a bilobe flap was planned so the donor site of the myocutaneous flap could be filled with the glabellar flap. The marking is incised with a 15 blade. The flap is then elevated by dissecting between the orbicularis muscle and the orbital septum. This is performed medially to fully mobilize the flap. The flap is then placed into position to cover the free tarsal graft. The flap will be sutured to the anterior surface of free tarsal graft with a 5–0 Vicryl suture which is placed in a mattress fashion. The first suture is left untied, and the second suture is then placed in the same manner. The sutures are then tied to appose the myocutaneous advancement flap to the free tarsal graft. At this point, attention is directed to the anterior lamella defect superiorly. Is determined that this will be able be closed primarily, without elevation of a second flap. The edge of the anterior lamellar flap is then sutured to the edge of the free tarsal graft. An additional wide undermining is performed to fully mobilize the anterior lamella. The flap is then sutured into position with superficial 6–0 Prolene sutures. The redundant portion of the anterior lamella laterally is excised with the Westcott scissors. The skin is then closed with interrupted 6–0 Prolone sutures. At the conclusion of case, the defect is closed well without significant tension. Erythromycin ophthalmic ointment will be placed over the repair. The patient will follow-up in approximately 1 week for suture removal.
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