13 The use of autologous grafts in ophthalmic plastic surgery

introduction

Autogenous grafts have widespread application in ophthalmic plastic surgery. By contrast, homologous material such as donor sclera, although very convenient to use, is no longer acceptable to the vast majority of patients because of the small risk of transmissible disease. For this reason, the use of homologous material should be avoided if possible. If the surgeon feels it is in the best interests of the patient to use homologous material, the risks must be explained to the patient and fully informed consent for its use obtained.

skin grafts

Skin grafts may be full-thickness or split-thickness grafts. A split-thickness skin graft contains only a portion of the dermis and the graft is harvested using a dermatome (Fig. 13.1), the thickness of the graft being varied by adjustments made on the device. By contrast, a full-thickness skin graft is harvested free hand using a surgical blade. Split-thickness skin grafts contract and have a poor color match with adjacent skin. Full-thickness skin grafts show less of a tendency to contract and are much more commonly utilized in ophthalmic plastic surgery.

Indications

Full-Thickness Skin Graft

●Repair of cicatricial ectropion

●Eyelid/facial reconstruction

●Scar revision surgery

Partial Thickness Skin Graft

●Reconstruction of the exenterated socket

●Skin coverage of large facial skin defects (Fig. 13.2)

Full Thickness Skin Graft

There are a number of potential donor sites for full-thickness skin grafts:

●Upper eyelid

●Postauricular area

●Preauricular area

●Upper inner arm

●Supraclavicular fossa

The choice of donor site is influenced by a number of factors, e.g. the patient’s age, the size of graft required, the degree of solar damage of the donor skin.

The upper eyelid skin is easy to harvest, provides an ideal color and texture match for eyelid defects and has no subcutaneous fat. This site does not yield much skin, however, except in older patients with marked dermatochalasis. Removing too much skin may cause lagophthalmos and may exacerbate a brow ptosis. It may also leave the patient with an asymmetrical

appearance. The skin above the skin crease is removed in a similar fashion to a blepharoplasty ensuring that the skin to be removed is marked very carefully ensuring that the patient can still close the eyelids passively and ensuring that a minimum of 12 mm of skin is left between the uppermost skin marking and the lowermost part of the eyebrow.

Postauricular skin provides a relatively good color and texture match for eyelid and canthal defects. Its use may be precluded by solar damage in older patients or the use of a hearing aid. The skin to be removed is shared between the ear and the scalp in the mastoid area. The removal of large grafts can leave the ear closer to the skull. Preauricular skin is more readily accessible but may not yield sufficient skin for large defects. It is also a poor site to use in patients who have very greasy skin with prominent sebaceous glands. Such skin is more prone to contracture and a “pin cushion” effect (Fig. 13.3), particularly when used for medial canthal defects.

Surgical Procedure

Meticulous attention to detail is required in order to obtain a good result from a skin graft without complications.

1.The recipient bed must be prepared carefully and all bleeding stopped. The defect should be exaggerated in the eyelids by placing traction sutures through the gray line and placing the eyelid on traction. It must be remembered that it is frequently necessary to tighten the lower eyelid, e.g., with a lateral tarsal strip procedure before placing a skin graft.

2.A piece of Steri-Drape is placed over the defect and outlined with a marker pen (Fig. 13.4). This is cut to the exact size and shape of the defect and used as a template.

3.The template is then transferred to the donor site, where it is outlined with the marker pen (Fig. 13.5A).

4.The donor site is then injected subcutaneously with 0.5% Bupivacaine with 1:200,000 units of adrenaline.

5.The marked incision line is incised with a no. 15 scalpel blade and the graft removed using forceps and the scalpel blade (Fig. 13.5B). The skin should be held under tension as the blade is used to stroke across the skin maintaining a constant depth which should be as shallow as possible, alternatively, Westcott scissors may be used. The defect may need to be converted to an ellipse to effect adequate closure of the wound or to the typical shape of a blepharoplasty incision when the upper eyelid is used.

6.The graft is protected in a gauze swab moistened with saline. This must be stored carefully to avoid inadvertent loss of the graft.

Figure 13.3 A “pin-cushioned” skin graft.

7.The donor site is closed with a 4/0 Nylon suture, either as a continuous simple or blanket suture when the preor post-auricular area is used as a donor site. An upper lid defect should be closed with interrupted 7/0 Vicryl sutures.An upper inner arm wound should be closed with interrupted subcutaneous 4/0 Vicryl sutures followed by interrupted 4/0 Nylon sutures for the skin placed in a vertical mattress fashion.A supraclavicular fossa donor site wound can be closed with a subcuticular 6/0 Novafil suture or with interrupted 4/0 Nylon sutures if the wound is under tension.

8.All subcutaneous tissue is completely removed with blunt-tipped Westcott scissors while holding the graft over the index finger of the non-dominant hand (Fig. 13.6). It is important to spend time meticulously thinning the graft in this way until no more tissue can be removed. Large skin grafts are perforated at several points with the tip of the scalpel blade.

9.The graft is then placed on the recipient bed and four interrupted 6/0 silk sutures are placed. The sutures are passed from graft to recipient skin edge. Interrupted 7/0 Vicryl sutures are placed between the silk sutures (Fig. 13.7). The graft should fit snugly into the recipient bed with a slight degree of tension.

10.A piece of sterile sponge is then cut to the size and shape of the graft using the original template. This is covered with Vaseline gauze and placed onto the graft. The silk sutures are tied to each other over the sponge to act as a bolster (Fig. 13.8). This prevents the accumulation of serous fluid or blood under the graft, which will act as a barrier to vascularization. This sponge can be omitted in the case of small lower lid or upper lid grafts which can be covered with Vaseline gauze alone.

11.In the case of an eyelid skin graft, the gray line silk suture is left in place and used to keep the graft stretched and the globe protected. The skin of the cheek or forehead is treated with a small amount

of tincture of benzoin applied with a swab to dry the skin. The silk suture is taped to the cheek in the case of an upper lid graft or to the forehead in the case of a lower lid graft using Steri strips.

12.A pressure dressing consisting of a sheet of Jelonet covering the orbital area and two eye pads is applied and taped into place with Micropore® tape and this is reinforced with a head bandage.

Postoperative Care

The bandage is removed by the patient after 48 hours but the underlying dressing is maintained in place for 5 days. The dressing is then removed along with the silk sutures. The Vicryl sutures are left in place and removed no later than 2 weeks postoperatively. The sutures are also removed from the donor site at this time.

Aftercare of the skin graft is very important. The patient should avoid sun exposure for a period of a few weeks to minimize color changes in the graft. Antibiotic ointment should be applied to the graft three times per day for 2 weeks

and massage of the graft commenced after 2 weeks. Massage should be performed in several directions over the graft for a minimum period of 3 to 4 min three times per day Massage prevents contracture and thickening of the graft and should be continued for 2 to 3 months. Lacrilube (liquid paraffin) ointment is applied to the graft prior to massage. The application of silicone gel, e.g., Kelocote or Dermatix, may also help to prevent contracture and thickening of the graft, but this adds expense. If the graft does thicken, it can be injected with tiny quantities of Triamcinolone (Kenalog®) at several different sites in the graft.

Split-Thickness Skin Graft

The usual donor site for a split-thickness skin graft is the thigh.

Surgical Procedure

1.The thigh is prepared with undiluted iodine solution and the area prepped and draped. The area is injected subcutaneously at several sites using

Figure 13.7 The skin graft is sutured to the recipient skin using 7/0 Vicryl sutures; 6/0 Silk sutures are used as bolster sutures.

15 to 20 ml of 0.25% Bupivacaine with 1:200,000 units of adrenaline.

2.A light coating of glycerine is applied to the thigh for lubrication.

Figure 13.8 The 6/0 silk sutures are tied over a sponge bolster.

3.The dermatome is prepared with a blade of an appropriate size and the desired thickness of the graft set on the dermatome (usually 1/16 inch). The dermatome is checked to ensure that it is working correctly.

4.The assistant places a small wooden board across the thigh in front of the dermatome in order to flatten the contour of the thigh (Fig. 13.9).

5.The dermatome is applied to the thigh at a shallow angle and slowly advanced while counter traction is applied to the skin of the thigh in the opposite direction.

6.An assistant holds the skin as it emerges from the dermatome. Once the desired amount of skin has been harvested, the dermatome is stopped and the skin attachment to the thigh is cut with Stevens tenotomy scissors.

7.The skin graft is then cut and shaped according to the defect and sutured into place as described for a full-thickness skin graft.

8.The patient should be prescribed appropriate postoperative analgesia to be administered as soon as the effects of the local anesthetic agent begin to wear off.

9.Most split-thickness skin grafts in oculoplastic surgery are used to line an exenterated socket (Fig.13.10).

10.Such grafts are first placed in a skin graft mesher and enlarged 1:2 (Fig. 13.11).

This effectively enlarges the area of the graft, reducing the size of the donor site. It also ensures egress of serosanguinous fluid. Any remaining skin is returned to the donor site, which aids the rapid healing of the donor site.

Postoperative Care

The thigh wound is covered with an Allevyn Non-Adhesive® (Smith and Nephew) foam dressing and attached using adhesive Opsite Flexifix®(Smith and Nephew) transparent film covering. A piece of Gamgee® (3M), a highly absorbent cotton roll padding with a non-woven cover, and a bandage are also applied to aid hemostasis and to reduce the amount of exudate. This dressing should be changed if any exudate leaks from it. As the wound continues to heal a less absorbent dressing may be considered and an Allevyn Thin® or Compression® (Smith and Nephew) dressing can be used to protect the area from clothing and allow the wound to completely heal. Once healed the area should be then be massaged with Vaseline.

mucous membrane graft

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, upper lip, and the buccal mucosa. The lower lip is preferred. The access is easier and no sutures are required to close the 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

●Conjunctival replacement following an enucleation

●Fornix reconstruction

●Severe upper eyelid entropion

●Symblepharon division and reconstruction

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 0.5% Bupivacaine with 1:200,000 units of adrenaline before the patient is prepared and draped for surgery.

Surgical Procedure

1.The recipient bed must be prepared carefully and all bleeding stopped.

2.A piece of Steri-Drape is placed over the defect and outlined with a marker pen. This is cut to the exact size and shape of the defect and used as a template much in the same way as for a full thickness skin graft.

3.Two Babcock’s bowel clamps are placed over the edge of the lower lip, which is protected with gauze swabs moistened with saline. The vermillion border of the lip is included in the clamps, ensuring

Figure 13.11 A meshed split-thickness skin graft placed into an exenterated socket.

that this area cannot be included in the area used to harvest the graft.

4.The template is then transferred to the donor site, where it is outlined with the marker pen after the mucosa has been dried with a dry swab.

Figure 13.12 The lower lip has been marked and injected with local anaesthetic and then saline in preparation for the removal of a mucous membrane graft. The vermillion border has been protected with a saline-soaked swab and the lip is being retracted with the use of atraumatic Babcock’s bowel clamps. A further swab has been placed over the tongue to soak up any blood.

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. Alternatively, a mucotome may be used.

7.The graft is protected in a gauze swab moistened with saline. This must be stored carefully to avoid inadvertent loss of the graft.

8.A swab gently moistened with 1:1000 units of adrenaline is held over the donor site for 5 min and then any bleeding vessels are cauterized using bipolar cautery.

9.The graft is carefully thinned with Westcott scissors removing any fibro-fatty tissue while holding the graft over the index finger of the non-dominant hand (Fig. 13.14).

10.The 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 (Fig. 13.15).

11.The graft must be maintained in position with the use of a symblepharon ring when the graft is placed onto the 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 240 silicone retinal

band and 4/0 Nylon fornix-deepening sutures (see chap. 22).

Postoperative Care

The patient should be prescribed an antiseptic mouthwash for 7 to 10 days and should have a soft bland diet until the donor site has healed. The donor site usually re-epithelializes within 2 to 3 weeks.

hard palate graft

Hard palate mucosa is more rigid than lip or buccal mucosa but has a rougher surface. It does not tend to shrink more than 10% postoperatively. As a general rule it should not be used in the upper eyelid where it may abrade the cornea except in the anophthalmic patient. 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 1:200,000 units of adrenaline before the patient is prepared and draped for surgery.

Indications

●A spacer in lower lid retractor recession

●A posterior lamellar graft in lower eyelid reconstruction

●A graft in severe lower eyelid cicatricial entropion surgery

●A graft for the reconstruction of a contracted socket

Surgical Technique

1.A Boyle–Davis (or similar) retractor is carefully placed, ensuring that the endotracheal tube is not displaced. The patient should be placed in a reverse Trendelenburg position. The surgeon should stand at the side of the patient and should wear a headlight. The anesthetist should tilt the head posteriorly to improve access to the hard palate.

2.The hard palate is dried with a dry swab.

3.The graft size to be harvested is measured and the margins marked on the hard palate, avoiding the gingival border, the midline and the soft palate (Fig. 13.16A).

4.An incision is made with a no. 15 Bard Parker blade through the surface epithelium and into the adipose layer beneath. The periosteum should not be disturbed.

5.The graft is then removed using a no. 66 Beaver blade keeping the dissection plane within the firm adipose layer (Figs. 13.16B and 13.17). Westcott scissors may aid the dissection once the plane has been established with the no. 66 blade.

6.The graft is protected in a gauze swab moistened with saline. This must be stored carefully to avoid inadvertent loss of the graft.

7.A patty gently moistened with 1:1000 units of adrenaline is held over the donor site for 5 min and any bleeding vessels are cauterized using bipolar cautery. The wound is left to heal by secondary intention.

8.Excess adipose tissue is removed with blunt-tipped Westcott scissors while holding the graft over the index finger of the non-dominant hand.

9.The graft is then placed on the recipient bed and interrupted 7/0 Vicryl sutures are placed from the graft edge to the recipient conjunctival edge, ensuring that the sutures are buried.

Postoperative Care

The patient should be prescribed an antiseptic mouthwash for 7 to 10 days and should have a soft bland diet until the donor site has healed. Edentulous patients may replace clean dentures after 2 days. This increases patient comfort and provides a mechanical barrier for the healing area. The donor site usually granulates and re-epithelializes within 2 to 3 weeks.

upper eyelid tarsal graft

A free tarsal 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 contains accessory lacrimal tissue. 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.

Indications

●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

Surgical Procedure

1.One to two ml of 0.5% Bupivacaine with 1:200,000 units of adrenaline mixed 50:50 with Lidocaine with 1:80,000 units of adrenaline are injected subcutaneously into the central aspect of the upper eyelid. A 4/0 Silk traction suture is then passed through the gray line of the upper eyelid and the eyelid is everted over a medium Desmarres retractor and a further 1 ml of 0.5% Bupivacaine with 1:200,000 units of adrenaline is injected subconjunctivally at the superior border of the tarsus.

2.The tarsus is dried and a horizontal incision marked 3.5 mm from the eyelid margin with a sterile gentian violet marker pen.

3.The required width of the graft is also marked on the tarsus (Fig. 13.18A).

4.The tarsus is incised centrally along the horizontal mark with a no. 15 Bard Parker blade and the remainder of the incision is made with blunt-tipped Westcott scissors.

5.Vertical relieving incisions are made and the tarsus dissected from the underlying orbicularis muscle with blunt-tipped Westcott scissors. The graft is then cut free and removed (Fig. 13.18B).

6.The donor area is left to heal by secondary intention.

7.The graft requires no thinning or other preparation prior to its use (Fig. 13.19).

Postoperative Care

Antibiotic ointment is instilled in the eye for a week.

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.

Figure 13.19 The tarsal graft has been used to reconstruct a posterior lamellar defect in the opposite upper eyelid.

Indications

●A tarsal replacement in upper eyelid reconstruction, e.g., as part of a Cutler–Beard procedure (Fig. 13.19).

●A tarsal replacement in upper eyelid entropion surgery, e.g., following an overly aggressive tarsal excision during a Fasanella–Servat procedure.

●A tarsal replacement in lower eyelid reconstruction.

Surgical Procedure

1.The pinna is injected subcutaneously with 0.5% Bupivacaine with 1:200,000 units of adrenaline mixed 50:50 with Lidocaine with 1:80,000 units of adrenaline, both anteriorly and posteriorly.

2.Babcock’s bowel clamps are placed on the edge of the pinna (Fig. 13.20A).

3.A skin incision is made with a no. 15 Bard Parker blade over the posterior aspect of the pinna centrally. This is deepened to the auricular cartilage with blunt-tipped Westcott scissors.

4.The overlying tissues are dissected from the cartilage until sufficient cartilage has been exposed to enable a graft of sufficient size to be harvested.

5.Next, the graft size is measured and marked out with a gentian violet marker (Fig. 13.20A).

6.An incision is made with a no. 15 Bard Parker blade through the cartilage and the rest of the excision is completed with blunt-tipped Westcott scissors (Fig. 13.20B).

7.The graft is stored carefully in a moistened swab to prevent inadvertent loss.

8.The skin incision is closed with a continuous 6/0 Nylon suture.

9.Two 4/0 Nylon sutures are then passed through the pinna and tied over two dental rolls covered in Jelonet to prevent a hematoma (Fig. 13.21).

10.The graft is then cleaned of any overlying soft tissue and sutured into its recipient bed with interrupted

Figure 13.21 Two dental rolls are used to compress the ear to prevent a haematoma.

5/0 Vicryl sutures. Any undulations in the graft can be improved by gentle partial-thickness vertical scoring of the graft with a no. 15 Bard Parker blade.

Postoperative Care

The Nylon sutures are removed after 1 week. Antibiotic ointment is applied to the wounds for 2 weeks.

nasal septal cartilage graft

A nasal septal cartilage graft 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.

Surgical Procedure

1.An injection of 0.5% Bupivacaine with 1:200,000 units of adrenaline is given submucosally on one side of the nasal septum to aid separation of the mucosa from the perichondrium. This facilitates removal of the graft without the risk of perforation of the mucosa. Perforation should be avoided as this can lead to whistling and nasal crusting. The same solution is injected submucosally just above the base of the nasal septum on the opposite side in the region of the planned incision.

2.A nasal epistaxis tampon is placed into each nostril and moistened with 5% cocaine solution. This is removed after 5 min.

3.The aim is to harvest a graft measuring approximately 10 to 15 mm × 5 to 8 mm. It is important to leave approximately 0.8mm of cartilage anteriorly to avoid collapse of the nasal strut (Fig. 13.22).

4.Using a 0.4 mm nasal endoscope and a crescent blade, a superficial incision is made through the nasal mucosa at the inferior aspect of the nasal septum, leaving a strut measuring approximately 5 mm above the columella. This incision is then extended through the nasal septum using the sharp end of a Freer periosteal elevator, taking care not to perforate the mucosa on the opposite side.

5.The blunt end of the Freer elevator is then slipped between the nasal septal cartilage and the overlying mucoperichondrium on the opposite side. The elevator is kept against the cartilage and used to sweep the mucosa away. This maneuver is greatly assisted with the use of the nasal endoscope.

6.Vertical cuts are then made with straight blunttipped scissors and the most superior attachment of the mucosa and cartilage is severed with a no. 66 Beaver blade.

Figure 13.23 A nasal septal cartilage graft. A frill of mucosa has been left proud on the superior surface of the graft and the cartilage has been scored vertically with a blade.

7.The graft is stored carefully in a moistened swab.

8.If an endoscope is not available, the procedure can be undertaken using a nasal speculum and a headlight. If access to the nasal septum is restricted, a nasal alar incision can be made to improve the exposure. The nasal alar incision is then sutured internally with 5/0 Vicryl and the skin closed with interrupted 6/0 Nylon sutures.

9.A fresh nasal epistaxis tampon, lightly coated with antibiotic ointment is inserted into each nostril and left overnight.

10.The graft is very carefully prepared. The nasal cartilage is gently thinned by shaving excess cartilage away using a no. 15 Bard Parker blade. A small strip of cartilage is removed from the border, which will lie against the globe, enabling a strip of mucoperichondrium to be carried over the edge of the cartilage, thereby creating a new eyelid margin (Fig. 13.23).

11.The cartilage may be gently scored vertically to enable the graft to bend towards the globe.

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Postoperative Care

The nasal epistaxis tampon is soaked with saline before being gently removed the following day. The nose is gently irrigated with a nasal saline douche or Sinurinse® twice a day for 2 weeks.

dermis fat graft

Fat can be used to replace volume and to prevent/manage subcutaneous adhesions. Dermis is left attached to the fat to provide a blood supply, but postoperative fat atrophy is very variable and unpredictable. Dermis fats in infants, used in the management of the congenital anophthalmic socket, can be seen to grow and may even need to be debulked. This is not seen in adults. Hair follicles and sebaceous units which may be left within the graft usually atrophy but may rarely be responsible for the formation of cysts and the growth of hair. The graft is usually harvested from the upper outer quadrant of the buttock but it is easier and more comfortable for adult patients for the graft to be taken from the lower lateral abdominal wall. In anophthalmic socket reconstruction, the graft may be completely buried but the surface can be left partially exposed when it is used in a volume-deficient socket, which also lacks conjunctival lining. The exposed dermis epithelializes spontaneously over a period of 3 to 4 weeks.

Figure 13.24 The typical donor sites for a dermis fat graft.

OCULOPLASTIC SURGERY

Indications

●A primary or secondary orbital implant

●A primary or secondary orbital implant when socket lining is also required

●A replacement orbital implant in the management of an extruding orbital implant

●Prevention/management of subcutaneous adhesions following periorbital surgery/trauma/infection

●Camouflage of upper eyelid sulcus deformity in post-enucleation socket syndrome

Surgical Procedure

1.The size of graft required is outlined on the skin with a gentian violet skin marker pen (Fig. 13.24). A graft to be used as an orbital implant is taken as a circular graft, whereas one to be used within the eyelid is taken as an ellipse (Fig. 13.25).

2.Ten to fifteen milliliters of 0.5% Bupivacaine with 1:200,000 units of adrenaline are injected subcutaneously in the marked area.

3.Saline is injected into the epidermis under pressure using a 10 ml syringe and a fine-gauge needle to create a “peau d’orange” appearance (Fig. 13.26). This is repeated at intervals as required.

4.An incision is made through the epidermis with a no. 15 Bard Parker blade. The edge of the epidermis is grasped with toothed Adson forceps and drawn away as the blade is used to sweep under the epidermis, separating it from the dermis (Fig. 13.27A). The dermis should appear quite pale with multiple bleeding points (Fig. 13.27B). No fat should be visible. The epidermis should ideally be removed in a single sheet.

5.Asmallincisionismadethroughoneedgeof thedermis with the blade and the rest of the incision completed with Stevens tenotomy scissors (Fig. 13.28A). The fat is dissected to an approximate depth of 2 to 3 cm and removed with the overlying dermis (Fig. 13.28B). The graft is stored safely in a moistened swab.

6.The donor site is closed with interrupted subcutaneous 4/0 Vicryl sutures and interrupted 4/0 Nylon sutures passed in a vertical mattress fashion for the skin closure.

7.The graft iscompressed in adry swab beforeit issutured into the recipient site. In the socket the extraocular muscles are sutured to the edges of the graft and the

Figure 13.26 Saline is injected into the skin to create a ‘peau d’ orange’ appearance.

conjunctiva either closed over the graft or sutured to its surface, leaving part of the dermis exposed. In the eyelid the dermis is positioned against the periosteum to which it is sutured with interrupted 5/0 Vicryl sutures. The fat is positioned to mimic the anatomical location of the preaponeurotic fat (Figs. 13.29 and 13.30).

Postoperative Care

The skin sutures are removed after 10 to 14 days.

structural fat grafting

Structural fat grafting is a procedure in which fat cells are harvested from the patient and re-injected into his/her facial subcutaneous tissues. In this procedure fat is harvested by syringe liposuction and the aspirated material centrifuged. This

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separates into three layers: the uppermost layer is composed primarily of oil, the middle layer is composed of fat, and the bottom layer is composed of blood, serum, and local anesthetic solution. The oil, blood, serum, and local anesthetic solution are removed and the separated fat cells are used for injection.

Indications

Structural fat grafting is used primarily for the cosmetic improvement of facial lines, depressions, and fat atrophy, although it is also used for the cosmetic improvement of depressions and volume loss that are seen following trauma or tumor resections, or following the development of disease states, e.g., Romberg’s hemifacial atrophy. It can also be used to treat the post enucleation socket syndrome. In facial rejuvenation, it has the following indications:

●Augmentation of nasolabial folds

●Augmentation of temple hollowing

●Augmentation of the mid-face

●Cosmetic improvement of lower lid tear trough defects

●Volume enhancement of the upper eyelid

●Volume enhancement of the lateral eyebrow

Selection of the Donor Site

Although the lower abdominal wall can be used as a donor site, it is safer to use the “love handle” area, the upper outer quadrant of the buttock or the lateral aspect of the upper thigh.

Figure 13.29 A dermis fat graft prepared and ready to be implanted into an anophthalmic socket.

OCULOPLASTIC SURGERY

Surgical Procedure

1.The areas of the face to be injected are meticulously marked out using gentian violet marker pen with the patient sitting upright.

2.The donor site area is marked out with gentian violet.

3.The areas of the face to be injected are anesthetized using regional nerve blocks. A mixture of 0.5% Bupivacaine with 1 in 200,000 adrenaline mixed 50:50 with 2% Lidocaine with 1:80,000 units of adrenaline is used. Care should be taken not to exceed the maximum safe limit of local anesthetic solution taking into account the weight of the patient.

4.Five milliliters of the same solution are injected subcutaneously into the inferior aspect of the donor site.

5.A local anesthetic solution for the donor site is prepared using a 50 ml syringe. The following are used:

●30 ml of saline for injection

●10 ml of 0.5% Bupivacaine

●10 ml of 2% Lidocaine

●0.25 ml of 1:1000 adrenaline

6.The patient is prepared and draped to allow a meticulous sterile technique.

7.A single stab incision is made through the skin at the inferior aspect of the donor site using a no. 15 Bard Parker blade in a crease, stretch mark or hair bearing area if possible to camouflage the small resulting scar.

8.Using a long blunt-tipped injection cannula attached to a 20 ml Luer lock syringe containing the anesthetic solution transferred from the 50 ml syringe, the cannula is inserted through the stab incision and advanced into the subcutaneous fat, gradually injecting the solution. A further 10 to 20 mls are injected. Ten minutes are allowed for this anesthetic solution to take effect.

9.A few tiny stab incisions are then made in preparation for the fat injections, using a no. 15 Bard Parker blade within skin creases or behind the hairline in the face or temple, depending on the sites of injection. Pressure is applied to these incisions to prevent bleeding.

10.A blunt tipped harvesting cannula is attached to a 10 cm3 Luer lock syringe.

11.The cannula is inserted through the donor site stab incision.

12.The plunger of the syringe is gently manipulated with the thumb and forefinger to provide approximately

1 to 2 cm3 of negative pressure space in the barrel of the syringe while the cannula is pushed forward through the subcutaneous fat plane.

13.The cannula is quickly moved back and forth through the fat plane while maintaining the negative pressure on the plunger.

14.After the fat has been harvested, the cannula is removed from the syringe and replaced with a cap.

15.The Luer lock cap is secured to create a seal to prevent any spillage of contents of the syringe during the centrifuging process.

16.The plunger is then removed from the proximal end of the syringe.

17.The syringe is then placed into the sterilized central rotor of a centrifuge.

18.More fat is then harvested in the same way.

19.Each 10 cm3 syringe is placed into an individual sleeve of the centrifuge. The syringes are placed evenly so that each syringe is balanced on the opposite side (Fig. 13.31).

20.The lid on the centrifuge is then closed and locked.

21.The timer is set to 3 min. The recommended centrifugation is 3000 rpm for 3 min. Some surgeons have expressed concern about the possibility of the centrifugation causing damage to the fat cells and some surgeons undertake the centrifugation for as little as 15 secs.

22.The donor site incision is closed with a 6/0 Nylon suture.

23.The cover of the centrifuge is opened only after the rotor has stopped completely.

24.The scrub nurse then removes the centrifuged syringes, taking care to avoid touching the cover or any other non-sterilized parts of the centrifuge.

25.The appearance of the syringe with the separated layers is shown in Figure 13.32.

26.The top oily layer is poured into a sterile glass container and can be used to lubricate the insertion site incisions.

27.The plug is then removed from the Luer lock connection and the blood and fluid is allowed to pour out into a kidney dish or gallipot (Fig. 13.33).

28.The syringes are placed into a sterile rack and a neurosurgical patty is gently inserted into the top of the syringe and used to soak any remaining oil.

29.Any fat, which adheres to the neuropatties or becomes exposed to air, should be discarded.

30.The plunger is replaced and advanced to remove air.

31.A metal Luer lock connector is attached to the 10-ml syringe and a 1 cm3 Luer lock syringe is attached to the other end of the metal connector (Fig. 13.34).

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32.By gently depressing the plunger on the 10 cc syringe and withdrawing the plunger on the 1 cm3 syringe, the fat is carefully transferred from the 10 cm3 to the 1 cm3 syringe.

33.The 1 cm3 syringe is filled to the 0.8 cm3 mark and any air is expelled before an injection cannula is attached.

34.The fat is now ready for injection into the face, eyelids, temples (or anophthalmic socket) (Fig. 13.35).

The fat should be used as soon as possible after it has been centrifuged. It should be injected using a variety of cannulae, whose tips are especially tailored to the different demands of the tissues to be injected. The tips of the cannulae are blunt to minimize the risk of intravascular injection. The cannula should be inserted while stabilizing the tissues with the opposite hand and 0.1 cm3 of fat only should be injected slowly as the cannula is withdrawn. The process is somewhat tedious, as the fat should be injected gradually and meticulously with multiple passes in different directions. The aim is to place the fat cells in contact with vascularized tissue and not to inject large quantities of fat, most of which will be sequestered and will inevitably atrophy.

Figure 13.35 Syringes of fat prepared for injection.

OCULOPLASTIC SURGERY

In the upper eyelid, if the patient is undergoing an upper lid blepharoplasty or a levator aponeurosis advancement, the fat can be injected directly into the preaponeurotic space before the skin sutures are placed.

The temple is a relatively easy area to begin injections. As experience is gained, the surgeon can then move to the more challenging areas of the face (Fig. 13.36).

The eyelids require meticulous attention to detail and this area should not be overcorrected. The results of mid-face injections, which can be placed at a deeper level than elsewhere in the face, are particularly pleasing in patients who have midface fat atrophy with little mid-face ptosis. In the patient with a significant mid-face ptosis, the injections can be combined with mid-face lift surgery.

The tiny stab incisions are closed with interrupted 7/0 Vicryl sutures. No dressings are required. Topical antibiotic ointment is applied to the wounds.

Postoperative Care

The patient should sleep with the head raised at least 30° for the first few days following surgery. Sufficient analgesia should be provided to control pain at the donor site, which can be significant. Clean cool packs should be applied to the recipient sites intermittently for 48 hours. Topical antibiotic ointment to the wounds is continued for a week. Gentle massage to any

Figure 13.37 A skin incision has been made just below the umbilicus to access subcutaneous fat.

Figure 13.36 The fat is being injected into areas of facial fat atrophy in this patient via a small stab incision.

Figure 13.38 Very small “pearls” of fat have been prepared ready to insert into the preaponeurotic space of the upper eyelid.

irregular areas of fat can be commenced after a few days. The patient is advised to avoid vigorous exercise for 3 to 4 weeks.

fat pearl graft

Fat can be harvested via a small semicircular incision just below the umbilicus (Fig. 13.37). The fat can be divided into very small fat “pearls” and placed into the eyelids e.g., following an over-resection of upper eyelid fat during a previous blepharoplasty (Fig. 13.38). The fat should not be harvested until the recipient site has been prepared. The fat should be handled meticulously and placed into the recipient site without any delay to reduce the risk of postoperative fat atrophy.

fascia lata graft

Fascia lata is harvested from the lateral aspect of the thigh. Its use can lead to some herniation of the vastus lateralis muscle and an obtrusive scar. It is usually harvested via an incision in the lower aspect of the thigh, although it may be removed via an incision in the superior aspect of the thigh.

Indications

●Frontalis suspension surgery

●Lower eyelid suspension

●Mid-face fascial sling in facial palsy

●Patch grafting of an exposed orbital implant

●Wrapping of an orbital implant

Surgical Technique

1.A 4 to 5 cm incision is marked approximately 10 cm above the knee joint along a line drawn from

The anterior superior iliac spine

Figure 13.39 The incision for the removal of fascia lata lies on a line running between the anterior superior iliac spine and the head of the fibula.

the head of the fibula to the anterior–superior iliac spine (ASIS) (Fig. 13.39).

2.The incision site and the lateral thigh at several sites along the line extending from the incision site towards the ASIS are injected subcutaneously with 10 to 15 ml of 0.25% Bupivacaine with 1:200,000 units of adrenaline. The volume used depends on the age and the weight of the patient. This is particularly important in children.

3.A skin incision is made with a no. 15 Bard Parker blade. The subcutaneous fat is bluntly dissected using Stevens scissors with a horizontal spreading action until the fascia is exposed. A dry swab is used to clean the surface of the fascia.

4.The fascia first encountered runs circumferentially in contrast to the fascia lata which runs in a vertical direction. The horizontal investing fascia is grasped with Paufique forceps and bluntly stripped in a vertical direction revealing the glistening vertical fibers of the underlying fascia lata.

5.Next a long straight Nelson scissor is inserted between the edge of the horizontal fascia and the fascia lata and pushed up the thigh for a distance of 12 to 15 cm.

6.Two small vertical incisions are made 1 cm apart in the fascia lata with a no. 15 blade. The incisions are continued along fascia up into the thigh using the long straight Nelson scissors. Small blunt-tipped straight scissors are then passed beneath the fascia and the fascia is separated from the underlying muscle along the length of the skin incision.

7.The inferior aspect of the fascia is then cut and the cut end is introduced into a Crawford fascia lata stripper (Figs. 13.40 and 13.41).

8.The stripper is passed along the line of the fascia lata, ensuring that the end of the stripper is passed under the horizontal investing fascia. It is imperative to ensure that the cutting mechanism is locked before the stripper is passed along the fascia.

9.Once the stripper has been passed along the fascia lata to the desired length, as measured on the stripper, the cutting mechanism is unlocked and activated to cut the superior aspect of the fascia.

10.The fascia and the stripper are removed and external pressure applied to the thigh for a few minutes (Fig. 13.42).

11.The fascia is carefully stored in a moistened swab.

12.The thigh wound is closed with interrupted subcutaneous 4/0 Vicryl sutures and the skin is closed

with interrupted 4/0 Nylon sutures passed in a vertical mattress fashion.

13.A pressure dressing and bandage are applied.

14.The fascia is then cleaned of any attached fat or fibrous tissue by bluntly rubbing a wet gauze swab along the length of the fascia in a vertical direction.

temporalis fascia graft

Temporalis fascia is readily accessible and its removal leaves a scar hidden behind the hair. This site does not, however, yield the quantity of fascia which is obtainable from the thigh. It does, however, yield more than enough tissue for use in patch grafting of an exposed orbital implant.

Indications

●Patch grafting of an exposed orbital implant

●Lower eyelid suspension

●Surface wrapping of an orbital implant

Surgical Technique

1.The patient’s hair is thoroughly cleaned over the temporal fossa with Chlorhexidine (Hibiscrub®) and parted with a comb posterior to the superficial temporal artery.

2.5 to 10 ml of 0.5% Bupivacaine with 1:200,000 units of adrenaline are injected subcutaneously into the area of the proposed incision.

Figure 13.43 The placement of the incision for a temporalis fascia harvest.

3.A 3 to 4 cm incision is made with a No. 15 Bard Parker blade through the skin (Fig. 13.43).

4.The incision is deepened with Stevens tenotomy scissors using a spreading action until the glistening fibres of the deep temporal fascia are visible (Fig. 13.44).

5.The fascia is widely exposed with blunt dissection.

6.Desmarres retractors are inserted and the wound edges moved around to expose the fascia as required.

7.The fascia is incised with a no. 15 Bard Parker blade. The fascia is then dissected from the underlying temporalis muscle with Stevens tenotomy or blunttipped Westcott scissors (Fig. 13.45).

Figure 13.45 The wound is closed with staples.

8.The fascia is stored carefully in a moistened swab.

9.The wound is closed with subcutaneous 5/0 Vicryl sutures and the skin is closed with staples. These are removed after 7 to 10 days.

eyelid composite graft

Approximately one-third of the upper eyelid in an older patient may be resected without altering the appearance and function of the eyelid. In patients with marked eyelid laxity an even greater proportion may be removed. The tissue can be used for the reconstruction of a contralateral upper eyelid defect which cannot be closed directly with a lateral canthotomy and cantholysis. The same technique can be used for the lower eyelid. The technique can yield very good cosmetic and functional results but the eyelashes rarely survive (Fig. 13.49).

Surgical Technique

1.The eyelids are injected with 1 to 2 ml of 0.5% Bupivacaine with 1:200,000 units of adrenaline.

2.A full-thickness wedge resection of the upper eyelid is performed (Fig. 13.46). The defect is closed directly.

3.The skin and orbicularis muscle are removed from the tarsus with Westcott scissors (Fig. 13.47).

4.The remaining tarsus with its lid margin and eyelashes are transplanted into the opposite upper eyelid defect. The tarsus is sutured edge to edge with 5/0 Vicryl sutures (Fig. 13.48).

5.The lid margin is sutured with 6/0 Silk sutures placed in a vertical mattress fashion.

6.A local skin–muscle flap is fashioned to advance or rotate over the graft to provide a blood supply.

bone graft

With the improvement of alloplastic materials now available for the reconstruction of orbital bony defects there is rarely an indication to use bone grafts. The following sites may be used for harvesting bone:

●Calvarium

●Rib

●Iliac crest

●Anterior face of the maxilla

The outer table of the skull yields bone that does not tend to show much resorption. It has the disadvantage, however, of being rigid and brittle. It is very difficult to contour when used for orbital wall defects. It can, however, be stacked piecemeal for simple orbital volume augmentation. The bone can be split from the outer table of the skull in the parietal area using a burr and a curved osteotome. Alternatively, the inner table can be split from a full-thickness piece of calvarium, e.g., following a frontal craniotomy, and used to reconstruct the orbital roof following its removal to gain access to the orbital apex.

Rib grafts can be split, curved, and contoured but show more resorption. The potential donor site morbidity must be considered.

The iliac crest can yield relatively large quantities of corticocancellous bone. The bone does not contour well, however, and also may show resorption. The patient may also experience considerable postoperative pain at the donor site.

The anterior face of the maxilla can yield a small quantity of bone which can be used in the repair of modest-sized orbital floor fractures but this is very rarely justified.

further reading

1.Bartley GB, Kay PP. Posterior lamellar eyelid reconstruction with a hard palate mucosal graft. Am J Ophthalmol 1989; 107: 609–12.

2. Geary PM, Tiernan E. Management of split skin graft donor sitesresults of a national survey. J PlastReconstr Aesthetic Surg 2008; 62(12): 1677–83.

3. Hawes MJ. Free autogenous grafts in eyelid tarsoconjunctival reconstruction. Ophthal Surg 1897; 18: 37–41.

4. Henderson HW, Collin JR. Mucous membrane grafting. Dev Ophthalmol 2008; 41: 230–42.

5. Leone CR Jr. Nasal septal cartilage for eyelid reconstruction. Ophthal Surg 1973; 4: 68–71.

6. Levin PS, Stewart WB, Toth BA. The technique of cranial bone grafts in the correction of posttraumatic orbital deformities. Ophthal Plast Reconstr Surg 1987; 3: 77–82.

7. Lisman RD, Smith BC. Dermis-fat grafting. In: Smith BC, ed., Ophthalmic plastic and reconstructive surgery. St. Louis: CV Mosby Co, 1987; 1308–20.

8.Putterman AM. Viable composite grafting in eyelid reconstruction: a new method of upper and lower eyelid reconstruction. Am J Ophthal 1978; 85: 237–41.