Surgery: Lower Lid Repair with Hughes Tarsal Conjunctival Flap

So this is a patient who had trauma, and, he had his entire lower eyelid avulsed. So the whole eyelid the whole lower eyelid is gone.

And so, we’re going to try to reconstruct the lower eyelid.

The first thing you want to do is try to loosen this up.

What we’re doing at the moment is trying to free up scarring from the lower eyelid to make room for for this tarsal conjunctival graft.

So you can see that he’s lost a lot of conjunctiva.

You can see that all of his lower eyelid is gone. So what we’re going to do is we’re going to borrow part of the upper eyelid, and we’re going to bring it down and suture it into the lower avulsed eyelid as a tarsoconjunctival flap, and then we’re going to borrow some skin from the upper eyelid to reconstruct the the outer part, the anterior lamella.

So right now, it’s just trying to freshen up these edges so that we can get a tarsal conjunctival flap to actually have something to to suture to. What we’re going to do next is evert the upper eyelid.

And remember that the tarsal plate up here in the upper eyelid is about ten millimeters, whereas in the bottom, it’s about four. So what we’re going to do is borrow from the upper eyelid.

What I’m doing here is just marking where my incision’s going to be.

And then what I’m going to do is mobilize this flap.

What we’re going to do is put this flap down inside the lower eyelid to reconstruct it.

And, now you may ask, why don’t you just cut this off and use it as a free tarsal graph?

And in some cases, we’ll do that. But like with any flap, if we leave it attached, then it brings its own blood supply.

So then it’s much more likely to get a good take.

So we’ll just do a little cautery.

So now what I want to do is pull this down and I want to suture this.

There’s a little tiny stump of tarsus that you can see here, and we’re going to suture to that.

I’m going to mobilize this just a little bit more.

We’ll take this edge of our tarsus and suture it right here.

And I like using a Vicryls uture because Vicryl dissolves, but it takes a long time to dissolve. It dissolves over a period of of months, not in days.

We’re going to cut these tails really short.

I put one more in here.

Now, unfortunately, on the medial half of his eyelid, he doesn’t have any discernible tarsus left, but he does have a medial canthal tendon. So I’m going to suture to that.

So we’re getting our flap anchored.

So this is called a fused tarsoconjunctival flap. Do use it a lot. It’s used a lot for all types of lower eyelid reconstruction.

If this patient only had vision in one eye and if this was his only seeing eye, I would probably not be using this particular technique for reconstruction.

I would be doing something different.

But it’s nice when they have good vision in the other eye because this is a technique that just tends to work pretty well.

You can see the conjunctiva there. So what I’m going to do is suture right to the edge of that.

So I’m going to take the bottom edge of my tarsal flap here and suture that to the conjunctiva.

I’m trying to be careful to just get the very edge here because I don’t want to have, suture rubbing the cornea, obviously.

Remember, we think of the eyelid as two halves. The outer half is skin and muscle. We call that the anterior lamella.

The inner half, which is the ttarsal plate and conjunctiva, we call that the posterior lamella. So we’ve now or given him a posterior lamella.

Now we need to give him an anterior lamella. We need something to take the place of all this missing skin and muscle, and that’s what we’re going to do next.

And we can see I’ve marked the upper eyelid here.

So I’m going to incise this flap here.

One of the things I like about using the Bovie instead of a knife is a knife drags through the tissue and pulls it. And a bovie, it’s like drawing.

It just cuts so smoothly.

This is called a transposition flap because we’re moving something from the upper eyelid down into the lower eyelid.

So this is the same sort of type of incision we use when we’re doing a blepharoplasty.

So it’s a very common type of incision that I do.

If I’m just doing a blepharoplasty, I only take the skin.

But here, I want to take the orbicularis muscle layer as well.

Now one of the things we want to do is as we get out further lateral, we want to make sure we go deep because we want to have good vascularity to this flap.

So now we’re just going to suture this into position down here.

So when I do a skin graft or flap, I typically like to use a type of suture that’s going to dissolve and go away on its own.

That’s why I’m using this chromic suture.

So right now, I’m just anchoring this down.

And the best way to avoid infection, is to clean the wound every day, which is good old regular soap and water. Nothing fancy, just soap and water.

And then, to put some, antibiotic ointment on, I rarely ever give oral antibiotics unless I’m putting in an implant.

It’s almost always just topical ointment.

If a patient washes their face, when they, every day, like, when they’re in the shower or whatever or in the sink, the chances of them getting infected are very small.

Other than that, really, I just tell them to kinda just leave it alone.

Don’t, try not to touch it.

I’m trying to take very shallow bites here, so, I stay away from the from the globe.

One of the interesting things about chromic sutures is that when they start getting dried out, they don’t pull very well. If you get them wet, they’re they pull really nicely.

We brought down tarsus, but we also brought down conjunctiva with it. So now all this conjunctiva is still attached to the tarsus, so that’s feeding it.

Whereas if I just took a a free graft, there’s nothing feeding it, and it’s less likely to take well.

So now all we’re doing is just closing the skin up here.

What I’m going to be doing now is called a running suture.

The way you do a running suture is if you have a locking needle driver is you unlock it, and you go skin to skin, and then you grab it and go again.

So this part can go quickly.

I want you to notice what I’m not doing. If you suture with this technique, you say you it’s safer in that you never have to touch the needle with your hands. And as you can see, it just goes a lot faster.

You can use absorbable in the upper lid, and and I will sometimes do that.

For example, in children, I always use absorbable. And if I have a patient that I think is not going to follow-up or come back and see me again, then I use the absorbable. The the problem with the absorbable is that the absorbable sutures break more easily.

So if a patient rubs their eye really hard, when it itches, they rub it, and then they break their stitch.

How long do we keep the eye closed? Usually, about three to four weeks because we want this flap to have good vascularity to take well. And then the second step that we do here is to open it up. And to do that, we just take scissors and open it up all the way across.