|Lower eyelid retraction without need for significant volume augmentation|
|Posterior lamellar and/or middle lamellar shortening|
|Desire for use of autologous graft|
|Quantify amount of eyelid retraction according to MRD2|
|Assess adequacy of anterior lamella; may need cheek lift or skin graft if severe shortening is present|
|Assess eyelid laxity|
|Assess globe and inferior orbital rim position for presence of negative vector|
|Assess orbicularis strength; weakness on closure may portend high risk of recurrence|
|Prior eyelid, facial surgery or trauma|
|Examination of oral mucosa and hard palate donor site for history of prior oral malignancies|
The indications and clinical assessment for posterior lamellar grafting with hard palate mucosa are similar to Chapters 34 and 35 . The decision to proceed with hard palate mucosa is made on several factors. Some patients only prefer using an autologous graft. From a consumable standpoint, there is also no additional expense of using a commercially prepared implant. These are personal decisions that should be discussed with the patient and surgeon. The remote possibility of a transmissible agent from either allografts or xenografts should also be disclosed. Other autologous grafts that can be used as posterior lamellar grafts are ear cartilage and nasal cartilage. Our preference is for hard palate mucosa as this is easy to harvest, has an epithelial surface and undergoes minimal post operative contraction.
The greatest downside of hard palate grafting is donor site morbidity. It can be painful and possible side effects can be palatal fistulas and oral candidiasis. A preoperative examination of the hard palate should be performed prior to considering its use. The presence of atypical lesions, ulceration, bony protrusions (torus palatinus) should be noted and, if present, alternate grafts such as acellular dermal matrix or dermis fat are discussed ( Chapter 34 and 35 ). Postoperative fitting with a palatal obturator can reduce discomfort and aid healing. Patients can be directed to a dentist or orthodontist for fabrication of an obturator preoperatively and this is placed immediately after graft harvesting. Hard palate grafting also provides minimal volume and a limited amount of surface area and if additional soft tissue volume and graft size is desired, consideration should be given to dermis fat.
Surgical principles for all lower eyelid retraction are similar. Complete release of the retracted eyelid is mandatory. Placement of the posterior lamellar graft with buried fine sutures, canthoplasty and, in severe cases, midface lifting with mild overcorrection and use of a Frost suture are necessary steps.