Download Mucous Membrane Graft

Surface
Disorder
Ocular Ocular
Surface
Disorder
Mucous Membrane
Graft
Vishnukant Ghonsikar
MS, DNB,FICO,FAICO
Vishnukant Ghonsikar MS, DNB, FICO, FAICO, Neelam Pushker MD, M.S. Bajaj MD
Dr. Rajendra Prasad Centre for Ophthalmic Sciences,
All India Institute of Medical Sciences, New Delhi
I
n ophthalmology mucous membrane graft (MMG) has
unique application in reconstruction of ocular surface,
posterior lamella of lid, contracted socket and as a spacer for
lid retraction. Today ophthalmologists are keen to explore
these applications of MMG. Detailed knowledge about its
various application, graft harvesting, surgical techniques &
postoperative care is very essential for providing successful
and safe outcome1,2.
Grafts in lid reconstruction
Free grafts are often needed for large lid defects which
cannot be closed by direct suturing or advancement flaps.
•
•
For anterior lamella of the lid, full thickness skin grafts
taken from ipsilateral or contralateral upper lid is the
best match. If enough upper lid skin is not available
as in young patients, full thickness skin grafts can be
taken from post auricular region, inner upper arm,
supraclavicular region and nasolabial fold.
For posterior lamella, tarsoconjunctival free graft is the
best option. Other options include buccal mucosa,
lip mucosa, nasal or hard palate mucoperichondrium,
auricular cartilage.
Mucous membrane graft [Lip/ Buccal mucosa]3
A mucous membrane graft can be removed free-hand or
with the aid of a mucotome. It is generally easier and safer
to remove such a graft free hand. The donor sites are the
lower lip (Figure 1), upper lip, and the buccal mucosa. The
lower lip is preferred. The access is easier and no sutures are
required to close the donor site wound which epithelialises
spontaneously over the course of 2 to 3 weeks. The buccal
mucosa yields more graft material but normally has to be
sutured and is not as accessible. Great care must be taken
to avoid damage to the parotid duct, whose opening is
opposite the upper second molar tooth, when harvesting
a buccal graft.
Indications
• Ocular surface reconstruction e.g. symblepharon
release and reconstruction or excision and replacement
of keratinised conjunctiva in Steven Johnson’s
Syndrome (SJS).
• Lid reconstruction as posterior lamella
• Contracted socket
• As a spacer for lid retraction
• Severe eyelid cicatricial entropion
• Conjunctival replacement following an enucleation
• With minor salivary gland in dry eye treatment
Any patient who is to undergo an enucleation and who
has conjunctival scarring from previous surgery or trauma
may require a mucous membrane graft. The patient should
be counseled about this possibility prior to surgery and
the anesthetist should be informed. The anesthetist should
place a throat pack after induction of anesthesia and should
place the endotracheal tube to one side of the mouth. The
donor site is injected with xylocaine and adrenaline before
the patient is prepared and draped for surgery.
Hard palate graft4
Hard palate mucosa (Figure 2) is more rigid than lip or buccal
mucosa as it has perichondrium. It has a rougher surface
because of keratinized epithelium unlike lip mucosa. It
does not tend to shrink more than 10% postoperatively.
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Ocular Surface Disorder
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Figure 1: The mucous membrane graft is harvested
Figure 2: The area of the hard palate from which a graft can be safely harvested (shown with arrows)
Figure 3: Position of the nasal septal cartilage to be removed
Its use in upper eyelid should be avoided where it may
abrade the cornea except in the anophthalmic socket. The
anesthetist should place a throat pack after induction of
anesthesia. The donor site is injected with 3 to 5 ml of 0.5%
Bupivacaine with adrenaline before the patient is prepared
and draped for surgery.
Indications
• Spacer in lower lid retractor recession.
•
Posterior lamellar graft in lower eyelid reconstruction.
• Graft in severe lower eyelid cicatricial entropion
surgery.
Other Grafts
Auricular cartilage graft
The auricular cartilage graft has a number of indications
but its use is limited by the anatomical size and shape of
an individual patient’s pinna. In contrast to the hard palate
graft, the auricular cartilage graft has the disadvantage of
lacking a mucosal surface.
Indications
• A tarsal replacement in upper eyelid reconstruction.
• A tarsal replacement in upper eyelid entropion surgery.
• Graft for the reconstruction of a contracted socket.
•
Upper eyelid tarso-conjunctival graft
Nasal septal cartilage graft
A free tarso-conjunctival graft is harvested from the upper
eyelid. Caution should be exercised, however, in the use of
such a graft as the tarsus provides structural support for the
upper eyelid and the adjacent conjunctiva. It is important
to evert the upper eyelid preoperatively to ensure that the
height of the tarsus is adequate. A minimum of 3.5 mm of
tarsus from the eyelid margin should be left undisturbed.
A nasal septal cartilage graft (Figure 3) makes an
ideal posterior lamellar replacement for lower eyelid
reconstruction where the whole of the lower eyelid has
been resected. It is usually used in conjunction with a
Mustardé cheek rotation flap.
Indications
A posterior lamellar mucous membrane graft is typically
used for patients with a severe entropion with marked
symblephara, severe lagophthalmos and eyelid retraction.
A graft is indicated if the patient requires a subsequent
penetrating keratoplasty. Amniotic membrane may be used
as an alternative graft if the patient agrees to the use of donor
material. It is preferable to avoid the use of a hard palate
• A posterior lamellar graft in eyelid reconstruction
• A graft in severe upper or lower eyelid cicatricial
entropion surgery
• A spacer in lower lid retractor recession
32 l DOS Times - Vol. 19, No. 4 October, 2013
A tarsal replacement in lower eyelid reconstruction.
Mucous Membrane Graft
Ocular Surface Disorder
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Figure 4: Extensive keratinization of posterior lamella of eyelid following severe Stevens–Johnson syndrome
Figure 5: Excision of the keratinized area avoiding damage to eyelashes
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Figure 6: The lip mucosa has been marked and injected with local anaesthetic followed by careful
dissection for the removal of a mucous membrane graft
Figure 7: Observe for bleeders and if required bipolar cautery is used to cauterize any bleeding vessels
graft for use in the upper eyelid as the corneal surface,
which is often already compromised, can be damaged by
its rougher surface. The procedure is usually performed
under appropriate anesthesia as per the patients age and
co-operation.
Surgical steps
For reconstruction of posterior lamella after
symbhlepharon release in post SJS / Chemical injury
•
The lower lip is everted with fingers or atraumatic
forceps. The lip mucosa is dried with a swab. The
template is transferred to the lower lip mucosa or
the required lip mucosa is marked with avoiding the
vermillion border and frenulum. This is outlined with a
sterile gentian violet.
•
The marked incision line is gently incised with a no.
15 scalpel blade and the graft removed very carefully
using blunt-tipped Westcott scissors and small-toothed
forceps (Figure 6). The Westcott scissors should be
kept just under the surface of the graft with the edge of
the graft drawn horizontally to ensure that the graft is
not inadvertently perforated and that the dissection is
not taken too deep. Dissection in a deeper plane risks
leaving areas of the lip with sensory loss.
•
The graft donor site is compressed with topical
adrenaline on a swab. Bipolar cautery is used to
cauterize any bleeding vessels (Figure 7).
The graft is carefully shaped with Westcott scissors
(Figure 8) and graft is then placed ensuring that the
original graft surface faces upward, on the recipient
bed and interrupted 7/0 Vicryl sutures are placed
from the graft edge to the recipient conjunctival edge
(Figure 9).
The graft must be maintained in position with the use of
a symblepharon ring when the graft is placed onto the
• Two to three milliliters of bupivacaine with adrenaline
mixed with lidocaine is injected along the upper lid
skin crease.
• A 4/0 Silk traction suture or a cotton suture is placed
horizontally through upper eyelid margin centrally
and the eyelid is everted over a Desmarres retractor
(Figure 4).
• All symblephara are divided with Westcott scissors.
•
The conjunctiva at the upper border of the tarsus is
incised and dissected free from all subconjunctival
scar tissue into the superior fornix and onto the bulbar
surface of the globe (Figure 5).
•
Next, a template is taken of the conjunctival defect or
the size of the defect is measured.
•
The lower/upper lip mucosa is injected with local
anesthetic.
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Figure 8: The graft is carefully thinned with Westcott scissors removing any fibro-fatty tissue
Figure 9: The graft is then placed ensuring that the original smooth graft surface faces upward
References
10
1. Brian Leatherbarrow: Oculoplastic Surgery Second Edition 2011.
Informa Healthcare Ltd.
2. Henderson HW, Collin JR. Mucous membrane grafting. Dev
Ophthalmol. 2008; 41: 230–42.
3 . Putterman (1980): Basis oculoplastic surgery in Peyman GA:
Principles and practice of ophthalmology, Vol. 3. Philadiphia: WB
Saunders Company, 2246-2333.
Figure 10: The graft must be maintained
in position with the use of full thickness
anchoring sutures tied over pegs
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globe or a conformer of an appropriate size and shape
when the graft is placed centrally in an anophthalmic
socket.
If the graft is used to reconstruct a conjunctival fornix
it should be held in place with a silicone retinal band
and 4/0 Nylon fornix-deepening sutures (Figure 10).
Topical antibiotic ointment is instilled into the eye. A
compressive dressing is applied.
Postoperative Care of donor site
The patient is instructed to avoid any hot drinks or hot food
for a period of 1- 2 weeks. The patient is discharged on a
broad spectrum oral antibiotic for a week and an oral antiseptic mouth wash for 2 weeks. Topical preservative free
antibiotic drops are instilled into the eye four times a day
for 2 weeks. A preservative free topical lubricant is used.
The patient is instructed to sleep with the head elevated for
1-2 weeks. The symblepharon ring is maintained in place
for a minimum period of 6 to 8 weeks. The patient has to
be reviewed twice weekly to ensure that the symblepharon
ring does not cause any corneal problems.
34 l DOS Times - Vol. 19, No. 4 October, 2013
4. Bartley GB, Kay PP. Posterior lamellar eyelid reconstruction with a
hard palate mucosal graft. Am J Ophthalmol 1989; 107: 609–12.