Key notes on plastic surgery/Adrian M. Richards

3
140 THE HEAD AND NECK
• They should then pass backwards through the conjunctiva and tarsal plate.
• The knot should be buried deeply within the eyelid anterior to the tarsal plate.
• The eyelid margin should be repaired with a non-absorbable 6/0 suture passing
through the grey line.
• The grey line lies between the anterior and posterior lamellae on the eyelid
margin.
• The eyelid skin should be closed with interrupted non-absorbable everting
sutures.
Defects between one-quarter and one-third of the horizontal width
• The lesion should be excised as a wedge or a pentagon.
• A lateral cantholysis is then performed to mobilize the lower lid sufficiently to
allow direct closure of the defect.
• Lateral cantholysis involves division of the lower limb of the lateral canthal
tendon.
• It is performed in the following way:
1 Medial traction is applied to the lateral part of lower lid.
2 The lower limb of the lateral canthal tendon can then be felt as a tight
band.
3 The lower limb is then dissected by spreading scissors along its edges.
4 It is then divided allowing the lower eyelid to advance medially.
Defects greater than one-third of the horizontal width
• These defects are usually repaired by a combination of:
• A cheek-advancement flap to reconstruct the anterior lamella, and
• A septomucosal graft to reconstruct the posterior lamella.
• Septomucosal grafts are harvested from the nasal septum.
• A lateral rhinotomy incision is usually required to gain adequate access to the
septum.
• A lateral rhinotomy incision is a full-thickness incision in the alar groove.
• A strip of septum with overlying mucosa is harvested.
• Care is taken to preserve the integrity of the contralateral septal mucosa in order
to avoid creating a septal perforation.
• The septomucosal graft is then scored and secured to the tarsal plates or canthal
ligaments.
• A cheek-rotation flap is then advanced over the graft and secured.
• Superiorly, the mucosa of the septomucosal graft should slightly overlap the
underlying graft so that the eyelid margin is reconstructed with mucosa.
• Cheek-advancement flaps may include a Z-plasty superiorly (McGregor pattern),
alternatively it can be omitted (Mustardé pattern).
Alternatives for reconstructing the anterior lamella
• A Tripier flap from the upper lid can be transposed to the lower lid.
• Superiorly based transposition flaps from the cheek or lateral border of the nose
are sometimes used to reconstruct the lower lid.
• Glabella flaps may be useful in reconstructing defects around the medial canthus.