Hard Palate Graft

Description

The hard palate is composed of variably keratinized stratified squamous epithelium, a lamina propria made up of densely packed collagen fibers, a submosal layer with adipose and glands, periosteum, and the maxillary and palatine bones. The covering layers are used to replace posterior lamella (Fig. 5). This can be done under local or intravenous sedation. A bite block is used to keep the mouth wide open. The soft palate, midline of the hard palate, and arteries should be avoided (the greater and lesser palatine adjacent to the third molar, and the nasopalatine artery just posterior to the central incisors). The graft is oversized by 30% and prepared by removing fat J

and thinning the thick submucosa. A clear plastic palate stent custom-fit preopera-

tively at the dental office or dentures can be used for pain relief. Viscous lidocaine can also help, and soft foods should be eaten for 3 weeks. s„

Indications

Hard palate grafts are indicated for defects between 60 and 100% of the length of the |

eyelid of any depth.

Figure 5 A hard palate graft used to resurface the posterior lamella.

Advantages

The mucosal surface minimizes ocular irritation postoperatively. Hard palate is often rigid enough to support the reconstructed eyelid without the use of cartilage or other rigid grafts (e.g., conchal cartilage). Additional rigidity may be afforded by the use of a composite nasal septal graft consisting of mucoperiosteum and underlying cartilage.

Disadvantages

Because the hard palate is variably keratinized, it may take up to 6 months for metaplasia to nonkeratinized mucosal epithelium causing prolonged ocular irritation, foreign body sensation, and excess lacrimation. In rare cases, keratinization may persist. Postoperative shrinkage between 10 to 60% (mean of 25%) total surface area has been reported, usually by 1 month (6).

Tarsoconjunctival (Hughes) Flap (for Lower Eyelid Repair) |

Description |>

The Hughes tarsoconjunctival flap is a staged lid-sharing procedure that transfers a posterior lamellar flap from the upper eyelid to a lower eyelid defect (Fig. 6). The >3

technique involves everting the upper eyelid and incising through tarsus at least

4 mm above the eyelid margin, equal in width to the lower eyelid defect. Vertical o superior cuts are created to allow the flap to reach the inferior edge of the defect in the lower eyelid. The flap is composed of a portion of the height of the superior

Hughes Flap

Eyelids joined

Figure 6 Step by step depiction of a Hughes flap for repair of a lower eyelid margin defect.

Eyelids joined

Figure 6 Step by step depiction of a Hughes flap for repair of a lower eyelid margin defect.

tarsus and conjunctiva (a tarsoconjunctival flap). To enhance the blood supply to the flap, Muller's muscle or both Muller's muscle and the levator muscle may be included (7). The flap is composed of conjunctiva, tarsus, Muller's muscle, levator aponeurosis, and orbital septum. The flap is left in place 6-8 weeks for delay and for upward traction to minimize postoperative cicatricial ectropion. The second stage consists of flap division allowing excess conjunctival tissue to drape over the lower lid margin. The anterior lamella must be reconstructed independently using a skin graft or local flap.

Indications

The indication for this flap is for marginal lower eyelid defects involving greater than 60% of the lid margin and limited to 7 mm in height (4).

Advantages

The main advantage to this flap is that it replaces the posterior lamella with similar tissue.

Disadvantages

The main disadvantage to this procedure is that the size of the graft is limited to approximately 5x25 mm and tapered nasally and laterally. It may result in 0.5-1.0 mm upper eyelid retraction. To minimize eyelid retraction, avoid cautery to the surgical area after removing the graft and use corticosteroid drops for 2-3 weeks. Eye irritation can result from the tarsal scar (8,9).

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