- Email: [email protected]
Complications at Mucous Membrane Donor Sites
C O M P L I C A T I O N S AT M U C O U S M E M B R A N E D O N O R
SITES
RUSSELL W. NEUHAUS, M . D . , H E N R Y I . BAYLIS, M . D . , AND NORMAN SHORR, M . D . Los Angeles, California
Full-thickness mucous membrane is an acceptable autogenous graft to replace deficient conjunctiva resulting from intrinsic disease, surgical resection for carcinoma, or reconstruction of contracted sockets. The mouth provides an excellent source of mucous membrane graft material with few donor site complications. However, we encountered four cases of donor site complications after full-thickness mucous membrane grafting. All cases involved submucosal scarring with contracture. Because the inner aspect of the mouth is a multicontoured surface, the submucosal scarring resulted in web formation and limitation of movement of the mandible or lip. In two cases, we resected submucosal fibrotic scar tissue and designed a standard or multiple Z-plasty to release mucosal tension. This allowed a return to normal oral function. During surgical reconstruction of the orbit a mucous membrane lining is often needed on the inner aspect of the eyelid to protect the cornea, provide adequate mobility of the globe with respect to adjacent supporting structures, or provide a nonkeratinized epithelium to line a socket cavity for optimal prosthesis appearance. Full-thickness mucous membrane from the mouth, although somewhat thicker than conjunctiva, undergoes minimal contraction in the recipient bed and is readily available. Various areas in the mouth have been used as donor sites, including the internal aspect of the upper lip, lower lip, or buccal area. To facilitate removal and minimize hemorrhage, full-thickness mucous membrane is obtained after ballooning with 1% lidocaine with epinephrine.
Enough mucous membrane must be left adjacent to the mucocutaneous border and parotid duct papilla to avoid possible dysfunction of these structures. In general this technique results in minimal, transient discomfort to the patient, with reepithelialization of the defect within seven days. We have observed four cases, how-
1,2
Accepted for publication Feb. 18, 1982. From the UCLA Center for the Health Sciences, Jules Stein Eye Institute, Los Angeles, California. Reprint requests to Russell W. Neuhaus, M.D., Jules Stein Eye Institute, Los Angeles, CA 90024.
Fig. 1 (Neuhaus, Baylis, and Shorr). Case 1. Vertical cicatricial scarring of the buccal area after mucous membrane harvesting (arrows).
©AMERICAN JOURNAL OF OPHTHALMOLOGY 93:643-646, 1982
643
644
AMERICAN JOURNAL OF OPHTHALMOLOGY
MAY, 1982
Fig. 3 (Neuhaus, Bay lis, and Shorr). Case 3. Cicatricial scarring adjacent to the upper lip frenulum after mucous membrane harvesting (arrow).
CASE REPORTS Fig. 2 (Neuhaus, Baylis, and Shorr). Case 2. Vertical cicatricial scarring of the buccal area after mucous membrane harvesting.
ever, in which severe submucosal scar formation occurred with cicatricial mucous membrane bands and webs, resulting in mild to moderate oral dysfunction.
Case 1—A 4-year-old girl underwent an uncomplicated socket reconstruction with a mucous membrane graft from her buccal area. Her immediate postoperative course was uneventful, and the mucous membrane donor site gradually healed. One month after surgery the patient could not open her mouth fully. Examination at that time showed a dense, vertically oriented submucosal scar band in the buccal area, causing limitation of mandibular movement (Fig. 1). The patient was observed for one year, but she showed minimal improvement. Recon-
Fig. 4 (Neuhaus, Baylis, and Shorr). Case 3. Postoperative appearance of the upper lip sulcus after Z-plasty.
Fig. 5 (Neuhaus, Baylis, and Shorr). Case 4. Vertical cicatricial scarring of the buccal area after mucous membrane harvesting (arrows).
VOL. 93, NO. 5
MUCOUS MEMBRANE GRAFTS
645
structive surgery was advised but the patient's mother declined it. The patient has continued to be followed up and has had limited improvement during the past year. Case 2-—A 45-year-old man underwent successful socket reconstruction with full-thickness mucous membrane grafting. He developed mild submucosal scarring similar to that in Case 1 (Fig. 2). Because the functional impairment was minimal, no surgical intervention was needed. In the subsequent 18 months the cicatricial changes have improved slightly. Case 3—A 30-year-old man underwent socket reconstruction with a mucous membrane graft from the upper lip. Postoperatively he developed a mucosal scar band that limited mobility of his upper Up and
rotated the Up inward (Fig. 3). We performed a standard reconstructive Z-plasty because no spontaneous improvement was noted after several months of observation. The patient now has normal Up function (Fig. 4). Case 4—A 51-year-old woman developed cicatricial scarring in the buccal area after a full-thickness mucous membrane graft was taken. The vertical orientation of the scar limited the mobility of the mandible and her abüity to open her mouth (Fig. 5).
Fig. 7 (Neuhaus, Baylis, and Shorr). Case 4. Submucosal scar band is exposed (arrows).
Fig. 8 (Neuhaus, Baylis, and Shorr). Case 4. Scar band is removed with sharp dissection.
After several months of observation, we saw no spontaneous improvement. Because of the particular conformation of this scar, we performed a multiple Z-plasty. This allowed a maximum of vertical lengthening and a minimum of anteroposterior shortening (Fig. 6). We incised the mucous membrane along the length of the submucosal scar band. After undermining the mucous membrane, we exposed the scar band and removed it with sharp dissection (Fig. 7 and 8). Normal tissue elasticity returned immediately after scar removal. We then cut the Z-plasty flaps along the previous ink Unes and transposed them, relaxing the vertically shortened mucous membrane (Fig. 9). DISCUSSION
The use of full-thickness mucous membrane grafts from the mouth to augment deficient conjunctiva during reconstructive surgery is well established and successful in ophthalmic plastic surgery. Small areas of oral mucous membrane may be obtained with minimal postoperative complications at the donor site. However, when large areas of buccal or
labial mucous membrane are needed for socket reconstruction, the incidence of donor site complications increases. Our four cases all occurred after relatively large amounts of mucous membrane were taken from the mouth during reconstruction of contracted sockets. All the patients had varying amounts of mucosal contracture with submucosal scar band formation, limiting oral function. Two patients underwent successful surgical reconstruction to improve or eliminate oral mucosal contracture. The use of standard Z-plasty techniques with submucosal resection of fibrotic scar tissue improved the function and appearance of the mouth. REFERENCES 1. Callahan, M. A., and Callahan, A.: Ophthalmic Plastic and Orbital Surgery. Birmingham, Aesculapius Publishing Co., 1979, pp. 134-141. 2. McCord, C. W.: Oculoplastic Surgery. New York, Raven Press, 1981, pp. 327-347.
SITES
RUSSELL W. NEUHAUS, M . D . , H E N R Y I . BAYLIS, M . D . , AND NORMAN SHORR, M . D . Los Angeles, California
Full-thickness mucous membrane is an acceptable autogenous graft to replace deficient conjunctiva resulting from intrinsic disease, surgical resection for carcinoma, or reconstruction of contracted sockets. The mouth provides an excellent source of mucous membrane graft material with few donor site complications. However, we encountered four cases of donor site complications after full-thickness mucous membrane grafting. All cases involved submucosal scarring with contracture. Because the inner aspect of the mouth is a multicontoured surface, the submucosal scarring resulted in web formation and limitation of movement of the mandible or lip. In two cases, we resected submucosal fibrotic scar tissue and designed a standard or multiple Z-plasty to release mucosal tension. This allowed a return to normal oral function. During surgical reconstruction of the orbit a mucous membrane lining is often needed on the inner aspect of the eyelid to protect the cornea, provide adequate mobility of the globe with respect to adjacent supporting structures, or provide a nonkeratinized epithelium to line a socket cavity for optimal prosthesis appearance. Full-thickness mucous membrane from the mouth, although somewhat thicker than conjunctiva, undergoes minimal contraction in the recipient bed and is readily available. Various areas in the mouth have been used as donor sites, including the internal aspect of the upper lip, lower lip, or buccal area. To facilitate removal and minimize hemorrhage, full-thickness mucous membrane is obtained after ballooning with 1% lidocaine with epinephrine.
Enough mucous membrane must be left adjacent to the mucocutaneous border and parotid duct papilla to avoid possible dysfunction of these structures. In general this technique results in minimal, transient discomfort to the patient, with reepithelialization of the defect within seven days. We have observed four cases, how-
1,2
Accepted for publication Feb. 18, 1982. From the UCLA Center for the Health Sciences, Jules Stein Eye Institute, Los Angeles, California. Reprint requests to Russell W. Neuhaus, M.D., Jules Stein Eye Institute, Los Angeles, CA 90024.
Fig. 1 (Neuhaus, Baylis, and Shorr). Case 1. Vertical cicatricial scarring of the buccal area after mucous membrane harvesting (arrows).
©AMERICAN JOURNAL OF OPHTHALMOLOGY 93:643-646, 1982
643
644
AMERICAN JOURNAL OF OPHTHALMOLOGY
MAY, 1982
Fig. 3 (Neuhaus, Bay lis, and Shorr). Case 3. Cicatricial scarring adjacent to the upper lip frenulum after mucous membrane harvesting (arrow).
CASE REPORTS Fig. 2 (Neuhaus, Baylis, and Shorr). Case 2. Vertical cicatricial scarring of the buccal area after mucous membrane harvesting.
ever, in which severe submucosal scar formation occurred with cicatricial mucous membrane bands and webs, resulting in mild to moderate oral dysfunction.
Case 1—A 4-year-old girl underwent an uncomplicated socket reconstruction with a mucous membrane graft from her buccal area. Her immediate postoperative course was uneventful, and the mucous membrane donor site gradually healed. One month after surgery the patient could not open her mouth fully. Examination at that time showed a dense, vertically oriented submucosal scar band in the buccal area, causing limitation of mandibular movement (Fig. 1). The patient was observed for one year, but she showed minimal improvement. Recon-
Fig. 4 (Neuhaus, Baylis, and Shorr). Case 3. Postoperative appearance of the upper lip sulcus after Z-plasty.
Fig. 5 (Neuhaus, Baylis, and Shorr). Case 4. Vertical cicatricial scarring of the buccal area after mucous membrane harvesting (arrows).
VOL. 93, NO. 5
MUCOUS MEMBRANE GRAFTS
645
structive surgery was advised but the patient's mother declined it. The patient has continued to be followed up and has had limited improvement during the past year. Case 2-—A 45-year-old man underwent successful socket reconstruction with full-thickness mucous membrane grafting. He developed mild submucosal scarring similar to that in Case 1 (Fig. 2). Because the functional impairment was minimal, no surgical intervention was needed. In the subsequent 18 months the cicatricial changes have improved slightly. Case 3—A 30-year-old man underwent socket reconstruction with a mucous membrane graft from the upper lip. Postoperatively he developed a mucosal scar band that limited mobility of his upper Up and
rotated the Up inward (Fig. 3). We performed a standard reconstructive Z-plasty because no spontaneous improvement was noted after several months of observation. The patient now has normal Up function (Fig. 4). Case 4—A 51-year-old woman developed cicatricial scarring in the buccal area after a full-thickness mucous membrane graft was taken. The vertical orientation of the scar limited the mobility of the mandible and her abüity to open her mouth (Fig. 5).
Fig. 7 (Neuhaus, Baylis, and Shorr). Case 4. Submucosal scar band is exposed (arrows).
Fig. 8 (Neuhaus, Baylis, and Shorr). Case 4. Scar band is removed with sharp dissection.
After several months of observation, we saw no spontaneous improvement. Because of the particular conformation of this scar, we performed a multiple Z-plasty. This allowed a maximum of vertical lengthening and a minimum of anteroposterior shortening (Fig. 6). We incised the mucous membrane along the length of the submucosal scar band. After undermining the mucous membrane, we exposed the scar band and removed it with sharp dissection (Fig. 7 and 8). Normal tissue elasticity returned immediately after scar removal. We then cut the Z-plasty flaps along the previous ink Unes and transposed them, relaxing the vertically shortened mucous membrane (Fig. 9). DISCUSSION
The use of full-thickness mucous membrane grafts from the mouth to augment deficient conjunctiva during reconstructive surgery is well established and successful in ophthalmic plastic surgery. Small areas of oral mucous membrane may be obtained with minimal postoperative complications at the donor site. However, when large areas of buccal or
labial mucous membrane are needed for socket reconstruction, the incidence of donor site complications increases. Our four cases all occurred after relatively large amounts of mucous membrane were taken from the mouth during reconstruction of contracted sockets. All the patients had varying amounts of mucosal contracture with submucosal scar band formation, limiting oral function. Two patients underwent successful surgical reconstruction to improve or eliminate oral mucosal contracture. The use of standard Z-plasty techniques with submucosal resection of fibrotic scar tissue improved the function and appearance of the mouth. REFERENCES 1. Callahan, M. A., and Callahan, A.: Ophthalmic Plastic and Orbital Surgery. Birmingham, Aesculapius Publishing Co., 1979, pp. 134-141. 2. McCord, C. W.: Oculoplastic Surgery. New York, Raven Press, 1981, pp. 327-347.