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Use of the palatal mucosal graft for reconstruction of the eye socket
Use of the palatal mucosal graft for reconstruction of the eye socket Yohko Yoshimura, Tatsuo Nakajima, Kei Yoneda
Department of Plastic and Reconstructive Surgery (Head: Prof. Tatsuo Nakajima), School of Medicine, Fujita Health University, Japan
S U M M A R Y . Hard palate mucosa is thick and rigid. Grafted with its periosteal layer, it can be a supportive material. Simultaneously, wound healing of the palatal donor site is very rapid and the patient does not experience any pain. Such characteristics of the palatal mucosal graft have led to its use in reconstruction of the eyelids, including the tarsal plate. Nevertheless, there have been very few reports on its use in this area of the face. Herein we report the use of the palatal mucosal graft in reconstruction of the eye sockets.
surrounding mucosa. Therefore, palatal mucosa, including the healed donor site, was harvested to reconstruct the socket. Palatal mucosa was used to resurface the deepened fornix, both the palpebral and bulbal sides. Very slight contracture of the palatal graft was seen after the second operation. Although donor site healing was slightly slower than the first time, no morbidity was detected at the donor site (Fig. 3).
CASE REPORTS Case 1 A 53-year-old male was severely injured in a road traffic accident. The globe of his right eye was ruptured, along with laceration of the lower eyelid, extending to the cheek. After extirpation of the right eye, reconstruction of his lower eyelid was performed with an advancement flap. After lid reconstruction, he was fitted with an artificial eye. Several months later, scar contracture of the eyelid made support of the prosthesis impossible. We incised the residual conjunctiva and turned it down to the palpebral side. Then, palatal mucoperiosteum was harvested and grafted to reconstruct the posterior wall of the socket. Eighteen months later, the reconstructed socket has retained its depth sufficiently to support the prosthesis (Fig. 1).
DISCUSSION
Castroviejo (1956) reported conjunctival reconstruction with split thickness buccal mucosa along with his innovative keratotome. However, eyelid and eye socket reconstruction requires not only mucosal lining but also supportive tissue, mimicking the tarsus. Fullor split thickness skin grafts without any supportive tissue sometimes undergo severe contracture, and resultant keratotic debris necessitates repeated cleansing of the eye socket, a n d / o r irritates the remaining conjunctiva and cornea. Traditionally, the composite nasal cartilage-mucosa graft (Millard, 1962; Mustardd, 1980) has been used. However, access to the nasal septum is not simple. Moreover, there is a risk of septal perforation. Use of the palatal mucosa for reconstruction of the eyelid was reported by Siegel (1985), who focussed on the fact that the palatal mucosa is moist and stiff. He also mentioned that 'surprisingly' he could not find the use of palatal free grafts described for eyelid reconstruction. We agree with Siegel. Palatal mucosal graft had been used for reconstruction of the lip (Vaccione, 1983), and gingiva (Morgan et al., 1973). We reported its use for nasal vestibular lining (Nakajima and Yoshimura, 1990) and tracheal wall (Yoshimura and Nakajima, 1990). Recently, Khoo Boo-Chai (1992) introduced the technique of Taik-jong Lee et al. in which they reported their experience of two cases of palatal mucosal graft for lower eyelid reconstruction, and, comparing it with the nasal septum, concluded that palatal mucosa can be used when the nasal septum is destroyed.
Case 2 A 20-year-old male had congenital left microphthalmos with a hypoplastic zygoma and temporal bone. In the first-stage operation, expansion of his left orbit was performed by osteotomy of the zygoma and a calvarial bone graft for augmentation of the orbital rim and temporal region was used. Lateral canthotomy to lengthen the palpebral fissure was included. Six months after the first operation, the eye socket reconstruction was carried out. Palatal mucosa was grafted to line the elongated portion of the fissure of both the upper and lower eyelids. One year postoperatively, his eye prosthesis still fits well (Fig. 2).
Case 3 A 35-year-old female had congenital left microphthalmos. After she had worn an artificial eye for a long time, it became difficult to fit it into its socket because of inflammatory adhesion of the inferior fornix. We cut the fornix and grafted a split-thickness oral mucosa graft from the inside of the lower lip to the bulbal conjunctiva and additional palatal mucosa to the palpebral mucosa to deepen the fornix. Although the result was satisfactory three months after surgery, it again became difficult to wear the prosthesis because ofcontracture of the grafted oral mucosa. Six months after the first operation, additional surgery was performed. At that time, the donor site in the palate had healed well and we could not find any difference from the 27
28
Journal of Cranio Maxillo-Facial Surgery
B
A
PER I OSq ELI~I UPPER
EYELID REMNANT CONJUNCTIVA
INCIS1
~ P A L A T A L MUCOSA
LOWER E Y E L I D
C
D
Palatal mucosa is a suitable material for reconstruction of mucosal defects, together with its supportive tissue such as the tarsal plate, nasal cartilage, and tracheal rings. Palatal mucosal graft takes very well, even when it is combined with periosteum. Siegel (1985) stated that there will of course be a 1 to 2 mm postoperative shrinkage. In our experience with 18 cases over a 5-year period, however, there were some cases in which the graft showed 20 to 30 % contracture in the early postoperative period. In such cases, recovery from contracture began 2 to 3 months after surgery and regained dimensions to their final extent of about 10 to 20 % smaller than the original size. We do not use any device to support the graft. As shown in Figure 1C, stay sutures to deepen the fornix are essential to keep the maximum dimensions of the graft
Fig. 1 - Case 1. (A) Three months after injury. Right lower eyelid was severely damaged. (B) Six months after reconstruction of the lower eyelid with local advancement flaps. Conjunctival sac had become too shallow to accommodate the prosthesis. (C) Schemati.c___ drawing of socket plasty. (D) 18 months postoperatively. Eye prosthesis fits well. (E) Reconstructed socket.
Use of the palatal mucosal graft for reconstruction of the eye socket
29
epithelialized, it might have been better for secondary wound healing if the periosteal layer had been preserved throughout the procedure. Moreover, there is no other part of the body which can provide such thick and rigid mucosa more than twice. Therefore, we can conclude that the palatal mucosa is an ideal material for reconstruction of the eyelid and eye socket.
A
A
B Fig. 2 - Case 2. (A) Preoperative view. (B) One year after socket reconstruction.
during the healing period. These sutures are removed 10 to 14 days postoperatively and then an artificial eye or a silastic rubber ball is inserted to maintain the newly formed socket. Of course, the contracture rate depends on the condition of the graft bed. When grafted to a well vascularized recipient site, this graft may maintain its original size with minimum shrinkage. Therefore, one should assume there will be some postoperative shrinkage of the graft and make it slightly larger than the final size. The donor site of the palatal mucosa heals very well and causes no discomfort to the patient. Although the donor site can be left open postoperatively, we put a piece of gelatine sponge into the donor defect and suture over the sponge. The dressing can be removed 4 to 5 days postoperatively. As shown in case 3, the healed donor site can be used as a secondary donor site. Although it took a little longer time to be fully
REMNANT EYEBALL
\ V_,Ncrs,o PALATAL
SPLIT
FH I C K N E S S
I OWF=R l . I P
HUCOSA
711.1
B Fig. 3 - Case 3 (A) Preoperative view. (B) Schema of the first operation. See p. 30 for Fig. 3 (C), (D), (E), (F).
30
Journal of Cranio Maxillo-Facial Surgery
@ ~ P L
1T-TH 1CKNES[A LOWER LIP PIUCO~A
|'RE'v'[OUSLY GRAP'['ED |)A[ A I'AL
C
D
E
F
MUCOSA
P~DD | ]- | O N A I I'AI.AIAi PI[I('().~A
Fig. 3 - Case 3 (C) Condition of the lower fornix 6 months after the first operation. (D) Schema of the second operation. (E) Condition the lower fornix eighteen months after the second operation. (F) Prosthesis fits well.
Siegel, R. J. : Palatal graft for eyelid reconstruction. Plast. References
Castroviejo, R. : Plastic and reconstructive surgery of the
conjunctiva. Plast. Reconstr. Surg. 24 (1959) 1-12. Khoo Boo-Chai. : Abstract: Comparison of nasal septal mucochondral graft with palatal mucosal graft in reconstruction of the inner layer of the lower eyelid. (TaikJong Lee et al. J. Korean Soc. Plast. Reconstr. Surg. 17: 210.) Plast. Reconstr. Surg. 89 (1991) 1189. Millard, D. R. : Eyelid repairs with chondromucosal graft. Plast. Reconstr. Surg. 30 (1962) 267-271. Morgan, L. R., Gallegos, L. T., Frileck, S. P. : Mandibular vestibuloplasty with a free graft of the mucoperiosteal layer from the hard palate. Plast. Reconstr. Surg. 51 (1973) 359-363. Mustard#, J. C. : Repair and reconstruction in the orbital region. 2nd ed. Edinburgh, Chirchill Livingstone, 1980. Nakajima, T., Yoshimura, Y. : Secondary correction of bilateral cleft lip nose deformity J. Craniomaxillofac. Surg. 18 (1990) 63-67.
Reconstr. Surg., 76 (1985) 411-414. Veceione, T. R. : Palatal grafts for lip reconstruction. Ann. Plast.
Surg. 10 (1983) 301-305. Yoshimura, Y., Nakajima, T. : Tracheoplasty with palatal
mucoperiosteal graft. Plast. Reconstr. Surg. 86 (1990) 558-560.
Yohko Yoshimura, M D
Dept. of Plastic and Reconstructive Surgery Fujita Health University 1-98 Dengakugakubo Kutsukake Toyoake Aichi 470-11 Japan Paper received: 17 September 1993 Accepted: 4 July 1994
Department of Plastic and Reconstructive Surgery (Head: Prof. Tatsuo Nakajima), School of Medicine, Fujita Health University, Japan
S U M M A R Y . Hard palate mucosa is thick and rigid. Grafted with its periosteal layer, it can be a supportive material. Simultaneously, wound healing of the palatal donor site is very rapid and the patient does not experience any pain. Such characteristics of the palatal mucosal graft have led to its use in reconstruction of the eyelids, including the tarsal plate. Nevertheless, there have been very few reports on its use in this area of the face. Herein we report the use of the palatal mucosal graft in reconstruction of the eye sockets.
surrounding mucosa. Therefore, palatal mucosa, including the healed donor site, was harvested to reconstruct the socket. Palatal mucosa was used to resurface the deepened fornix, both the palpebral and bulbal sides. Very slight contracture of the palatal graft was seen after the second operation. Although donor site healing was slightly slower than the first time, no morbidity was detected at the donor site (Fig. 3).
CASE REPORTS Case 1 A 53-year-old male was severely injured in a road traffic accident. The globe of his right eye was ruptured, along with laceration of the lower eyelid, extending to the cheek. After extirpation of the right eye, reconstruction of his lower eyelid was performed with an advancement flap. After lid reconstruction, he was fitted with an artificial eye. Several months later, scar contracture of the eyelid made support of the prosthesis impossible. We incised the residual conjunctiva and turned it down to the palpebral side. Then, palatal mucoperiosteum was harvested and grafted to reconstruct the posterior wall of the socket. Eighteen months later, the reconstructed socket has retained its depth sufficiently to support the prosthesis (Fig. 1).
DISCUSSION
Castroviejo (1956) reported conjunctival reconstruction with split thickness buccal mucosa along with his innovative keratotome. However, eyelid and eye socket reconstruction requires not only mucosal lining but also supportive tissue, mimicking the tarsus. Fullor split thickness skin grafts without any supportive tissue sometimes undergo severe contracture, and resultant keratotic debris necessitates repeated cleansing of the eye socket, a n d / o r irritates the remaining conjunctiva and cornea. Traditionally, the composite nasal cartilage-mucosa graft (Millard, 1962; Mustardd, 1980) has been used. However, access to the nasal septum is not simple. Moreover, there is a risk of septal perforation. Use of the palatal mucosa for reconstruction of the eyelid was reported by Siegel (1985), who focussed on the fact that the palatal mucosa is moist and stiff. He also mentioned that 'surprisingly' he could not find the use of palatal free grafts described for eyelid reconstruction. We agree with Siegel. Palatal mucosal graft had been used for reconstruction of the lip (Vaccione, 1983), and gingiva (Morgan et al., 1973). We reported its use for nasal vestibular lining (Nakajima and Yoshimura, 1990) and tracheal wall (Yoshimura and Nakajima, 1990). Recently, Khoo Boo-Chai (1992) introduced the technique of Taik-jong Lee et al. in which they reported their experience of two cases of palatal mucosal graft for lower eyelid reconstruction, and, comparing it with the nasal septum, concluded that palatal mucosa can be used when the nasal septum is destroyed.
Case 2 A 20-year-old male had congenital left microphthalmos with a hypoplastic zygoma and temporal bone. In the first-stage operation, expansion of his left orbit was performed by osteotomy of the zygoma and a calvarial bone graft for augmentation of the orbital rim and temporal region was used. Lateral canthotomy to lengthen the palpebral fissure was included. Six months after the first operation, the eye socket reconstruction was carried out. Palatal mucosa was grafted to line the elongated portion of the fissure of both the upper and lower eyelids. One year postoperatively, his eye prosthesis still fits well (Fig. 2).
Case 3 A 35-year-old female had congenital left microphthalmos. After she had worn an artificial eye for a long time, it became difficult to fit it into its socket because of inflammatory adhesion of the inferior fornix. We cut the fornix and grafted a split-thickness oral mucosa graft from the inside of the lower lip to the bulbal conjunctiva and additional palatal mucosa to the palpebral mucosa to deepen the fornix. Although the result was satisfactory three months after surgery, it again became difficult to wear the prosthesis because ofcontracture of the grafted oral mucosa. Six months after the first operation, additional surgery was performed. At that time, the donor site in the palate had healed well and we could not find any difference from the 27
28
Journal of Cranio Maxillo-Facial Surgery
B
A
PER I OSq ELI~I UPPER
EYELID REMNANT CONJUNCTIVA
INCIS1
~ P A L A T A L MUCOSA
LOWER E Y E L I D
C
D
Palatal mucosa is a suitable material for reconstruction of mucosal defects, together with its supportive tissue such as the tarsal plate, nasal cartilage, and tracheal rings. Palatal mucosal graft takes very well, even when it is combined with periosteum. Siegel (1985) stated that there will of course be a 1 to 2 mm postoperative shrinkage. In our experience with 18 cases over a 5-year period, however, there were some cases in which the graft showed 20 to 30 % contracture in the early postoperative period. In such cases, recovery from contracture began 2 to 3 months after surgery and regained dimensions to their final extent of about 10 to 20 % smaller than the original size. We do not use any device to support the graft. As shown in Figure 1C, stay sutures to deepen the fornix are essential to keep the maximum dimensions of the graft
Fig. 1 - Case 1. (A) Three months after injury. Right lower eyelid was severely damaged. (B) Six months after reconstruction of the lower eyelid with local advancement flaps. Conjunctival sac had become too shallow to accommodate the prosthesis. (C) Schemati.c___ drawing of socket plasty. (D) 18 months postoperatively. Eye prosthesis fits well. (E) Reconstructed socket.
Use of the palatal mucosal graft for reconstruction of the eye socket
29
epithelialized, it might have been better for secondary wound healing if the periosteal layer had been preserved throughout the procedure. Moreover, there is no other part of the body which can provide such thick and rigid mucosa more than twice. Therefore, we can conclude that the palatal mucosa is an ideal material for reconstruction of the eyelid and eye socket.
A
A
B Fig. 2 - Case 2. (A) Preoperative view. (B) One year after socket reconstruction.
during the healing period. These sutures are removed 10 to 14 days postoperatively and then an artificial eye or a silastic rubber ball is inserted to maintain the newly formed socket. Of course, the contracture rate depends on the condition of the graft bed. When grafted to a well vascularized recipient site, this graft may maintain its original size with minimum shrinkage. Therefore, one should assume there will be some postoperative shrinkage of the graft and make it slightly larger than the final size. The donor site of the palatal mucosa heals very well and causes no discomfort to the patient. Although the donor site can be left open postoperatively, we put a piece of gelatine sponge into the donor defect and suture over the sponge. The dressing can be removed 4 to 5 days postoperatively. As shown in case 3, the healed donor site can be used as a secondary donor site. Although it took a little longer time to be fully
REMNANT EYEBALL
\ V_,Ncrs,o PALATAL
SPLIT
FH I C K N E S S
I OWF=R l . I P
HUCOSA
711.1
B Fig. 3 - Case 3 (A) Preoperative view. (B) Schema of the first operation. See p. 30 for Fig. 3 (C), (D), (E), (F).
30
Journal of Cranio Maxillo-Facial Surgery
@ ~ P L
1T-TH 1CKNES[A LOWER LIP PIUCO~A
|'RE'v'[OUSLY GRAP'['ED |)A[ A I'AL
C
D
E
F
MUCOSA
P~DD | ]- | O N A I I'AI.AIAi PI[I('().~A
Fig. 3 - Case 3 (C) Condition of the lower fornix 6 months after the first operation. (D) Schema of the second operation. (E) Condition the lower fornix eighteen months after the second operation. (F) Prosthesis fits well.
Siegel, R. J. : Palatal graft for eyelid reconstruction. Plast. References
Castroviejo, R. : Plastic and reconstructive surgery of the
conjunctiva. Plast. Reconstr. Surg. 24 (1959) 1-12. Khoo Boo-Chai. : Abstract: Comparison of nasal septal mucochondral graft with palatal mucosal graft in reconstruction of the inner layer of the lower eyelid. (TaikJong Lee et al. J. Korean Soc. Plast. Reconstr. Surg. 17: 210.) Plast. Reconstr. Surg. 89 (1991) 1189. Millard, D. R. : Eyelid repairs with chondromucosal graft. Plast. Reconstr. Surg. 30 (1962) 267-271. Morgan, L. R., Gallegos, L. T., Frileck, S. P. : Mandibular vestibuloplasty with a free graft of the mucoperiosteal layer from the hard palate. Plast. Reconstr. Surg. 51 (1973) 359-363. Mustard#, J. C. : Repair and reconstruction in the orbital region. 2nd ed. Edinburgh, Chirchill Livingstone, 1980. Nakajima, T., Yoshimura, Y. : Secondary correction of bilateral cleft lip nose deformity J. Craniomaxillofac. Surg. 18 (1990) 63-67.
Reconstr. Surg., 76 (1985) 411-414. Veceione, T. R. : Palatal grafts for lip reconstruction. Ann. Plast.
Surg. 10 (1983) 301-305. Yoshimura, Y., Nakajima, T. : Tracheoplasty with palatal
mucoperiosteal graft. Plast. Reconstr. Surg. 86 (1990) 558-560.
Yohko Yoshimura, M D
Dept. of Plastic and Reconstructive Surgery Fujita Health University 1-98 Dengakugakubo Kutsukake Toyoake Aichi 470-11 Japan Paper received: 17 September 1993 Accepted: 4 July 1994