Lower eyelid retraction repair with hard palate grafting







Table 36.1

Indications for surgery









Lower eyelid retraction without need for significant volume augmentation
Posterior lamellar and/or middle lamellar shortening
Desire for use of autologous graft


Table 36.2

Preoperative evaluation

















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


Introduction


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.




Surgical Technique





Figures 36.1A–D


Harvesting of hard palate graft

Hard palate serves as an excellent posterior lamellar spacer graft owing to its epithelialized surface and autologous nature. The harvest is best performed under local anesthesia with IV sedation as the endotracheal tube may interfere with surgical access. The hard palate is marked on either side of the midline, while avoiding the nasopalatine and anterior palatine neurovascular branches and the soft palate ( Figure 36.1A ). Local anesthetic is then infiltrated. A Yankauer suction tip is available on standby to evacuate blood that may irritate the oropharynx. A #69 or #15 blade is used to make the mucosal incision ( Figure 36.1B ). A crescent blade is then used to make a lamellar incision along the hard palate to free it from the underlying tissue ( Figure 36.1C ). Care is taken to remove the graft intact as the hard palate has limited availability. Hemostasis is then obtained using a combination of bipolar cautery, fibrin glue, and/or cellulose polymer dressing ( Figure 36.1D ). A pre-fashioned hard palate obturator is then placed after achieving complete hemostasis. The graft is inspected, thinned and placed in wrapped saline gauze for subsequent usage.



Figures 36.2A and 36.2B


Lateral canthotomy and inferior cantholysis

A corneal shield is preplaced before the start of surgery. Access to the lower eyelid is facilitated by a small lateral canthotomy and inferior cantholysis ( Figures 36.2A and 36.2B ). The inferior crus of the lateral canthal tendon should be completely released to allow full access to the lower eyelid and midface. Hemostasis is achieved with bipolar cauterization.

May 16, 2019 | Posted by in Reconstructive surgery | Comments Off on Lower eyelid retraction repair with hard palate grafting
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