Propeller flap, tarsal graft and periosteal flap
Propeller or subcutaneous island skin flap provide a versatile options for anterior lamellar reconstruction. They can support a posterior lamellar graft facilitating one stage reconstruction of big eyelid defects 타카네노 하나 다운로드.
This narrated video demonstrates the repair of a large defect with a free tarsal graft harvested from the contralateral upper eyelid and a periosteal flap to secure the lateral margin of the tarsal graft 다운로드. The anterior lamella is reconstructed with a propeller flap, which will support the graft, allowing this to be a one stage reconstruction of the lower lid in contrast to the more widely used Hughes procedure 피크닉 다운로드.
The propeller flap is positioned to recruit tissue from an area of sufficient laxity with an appropriate skin match and preferably siting scars along relaxed skin tension lines or on borders of cosmetic subunits 레고마인드스톰 ev3. It is also positioned to minimize the amount of rotation required although unlike conventional skin pedicle flaps it can be rotated 180 degrees or even slightly more if required 구글 플레이스토어.
The location of the pedicle is determined by the site of the defect and the positioning of the flap, but is typically one quarter of the flap diameter away from the defect 다운로드. In general, an inferior pedicle is preferred, to enhance lymphatic drainage and possibly reduce the risk of postoperative oedema or trapdooring.
The full circumference of the flap is incised and the flap is dissected free in either the subcutaneous or suborbicularis plane as per the desired flap thickness 다운로드. As the pedicle area is approached dissection is in the sub-orbicularis plane and an orbicularis pedicle is fashioned. A wide pedicle is created initially and it is gradually reduced whilst checking the rotation after each reduction, until a pedicle is created with the maximum diameter that will will allow adequate rotation without excessive torque 다운로드. The pedicle length can be increased by dissecting out more orbicularis, but again should be the minimum length required to allow the flap to reach the defect without tension on the pedicle 알피스 네오 다운로드. Typically a pedicle of diameter 6-10mm diameter and length 10-14mm is created. The flap is rotated and transposed into the defect, taking care not to accidentally rotate the pedicle any more than required 다운로드. The flap can be rotated and transposed slowly or in stages to maintain perfusion; the donor site can be sutured during this time. The flap is sutured into position and the placement of tacking sutures to secure the base of the flap is advisable.
The technique of propeller flap creation is discussed in more detail in another video on this website.
The upper eyelid is everted over a desmarres retractor. A free tarsal graft is harvested, ensuring at least 4 to 5mm of inferior tarsal plate is left in situ to maintain upper lid stability. The size of the graft is estimated according to the defect size with the edges of the defect held together on tension. The medial edge of the tarsal graft is sutured to the residual medial tarsal plate. The entire lateral tarsal plate and lateral canthal tendon has been excised. Therefore a periosteal flap is raised. It is secured to the lateral edge of the tarsal graft.
The flap is rotated and transposed into the defect, taking care not to accidentally rotate the pedicle any more than required. The flap can be rotated and transposed slowly or in stages to maintain perfusion; the donor site can be sutured during this time. The flap is sutured into position and the placement of tacking sutures to secure the base of the flap is advisable.
Trapdooring or persistent oedema under the flap is one complication that may be encountered which may settle in time or require further intervention.