Exenteration with split graft

This video demonstrates an exenteration with placement of a split thickness skin graft. The patient has a biopsy proven sebaceous carcinoma which involved much of the upper eyelid as well as the conjunctival surface. Two 4-0 silk tarsorrhaphy sutures are placed which will also act as traction sutures throughout the case. A monopolar cautery is then used to make an incision through the skin and orbicularis muscle at the orbital rim 360 degrees. Dissection is carried out to the orbital rim laterally as well as inferiorly. The superior orbital rim is identified and the periosteum is elevated. The lateral orbital rim is incised along the periosteum. Superiorly, the periosteum is elevated from the orbital rim. Laterally the periosteum is elevated from the lateral orbital rim and lateral wall. In this area one will usually encounter structures corresponding to the zygomatico facial and zygomatico maxillary neurovascular bundles. The supraorbital neurovascular bundle is identified and transected with the monopolar cautery. Medially, the anterior ethmoidal neurovascular bundle is identified and cauterized. It is important to not compromise the thin bone of the medial orbital wall to prevent sino-orbitl fistula formation. Posteriorly, the posterior ethmoidal neurovascular bundle is identified and cauterized. After transection of the infraorbital fissure as well as the nasolacrimal duct, the curved scissors are used to transect the posterior obit. In doing this, the ophthalmic artery is transected and there is significant bleeding. One can apply a snare prior to transection, but I do not find this useful. Inspection of the excised orbit shows that the periosteum is largely intact other than the posterior orbit. Hemostasis is attained with the bipolar cautery. A posterior orbital biopsy can be obtained if needed. The area is then packed for hemostasis prior to harvesting of the split thickness skin graft.

The dermatome blade is placed over the defect to determine the appropriate width to use. The anterior surface of the thigh is then anesthetized with 1% lidocaine with epinephrine. The area is then covered with mineral oil. The dermatome is then used to harvest the graft. Adequate pressure is placed on the thigh with the dermatome, and the motor is engaged and the dermatome is advanced. Forceps then are used to hold the split thickness graft and the dermatome is advanced further to acquire the graft. A number 15 blade is then used to cut the skin from the dermatome and the graft is transferred to the recipient site. The graft can be meshed to expand the graft if needed. In this case we did not mesh the graft. The donor site is then covered with epinephrine soaked gauze to stop bleeding. This is kept on the donor site as the graft is sutured to the recipient site.

The graft is then placed into the area of the recipient site and sutured into position with 5-0 fast absorbing sutures. Antibiotic ointment is then placed over the graft. Packing is then placed over the graft followed by an eye pad to place pressure on the graft to the recipient bed. The patch stays on for at least one week.

The leg is then dressed with tedgaderm. This dressing should stay on for approximately 3 days.

[Other options for covering the defect or reconstruction include granulation, use of local flaps such as a cheek lift and median forehead flap, and use of a free flap. In this case, the patient has opted for a split thickness skin graft.]