Orbit: Eye Socket Reconstruction with Mucous Membrane Graft

Abstract

Contracture of the conjunctiva of an anophthalmic socket is a common complication following enucleation (Klein, Menneking, Bier Int J Oral Maxillofac Surg 29(2):96–98, 2000; Molgat, Hurwitz, Web Ophthal Plast Reconstr Surg 9(4):267–272, 1993; Tyers, Collin (2008) Colour atlas of ophthalmic plastic surgery, 3rd edn. Butterworth-Heinemann/Elsevier, Boston). The lower fornix is typically affected before the upper fornix (Klein, Menneking, Bier Int J Oral Maxillofac Surg 29(2):96–98, 2000; Molgat, Hurwitz, Web Ophthal Plast Reconstr Surg 9(4):267–272, 1993; Tyers, Collin (2008) Colour atlas of ophthalmic plastic surgery, 3rd edn. Butterworth-Heinemann/Elsevier, Boston). Loss of forniceal depth can make it impossible for an ocularist to fit a prosthetic. In such cases, forniceal reconstruction may be necessary (Klein, Menneking, Bier Int J Oral Maxillofac Surg 29(2):96–98, 2000; Molgat, Hurwitz, Web Ophthal Plast Reconstr Surg 9(4):267–272, 1993; Tyers, Collin (2008) Colour atlas of ophthalmic plastic surgery, 3rd edn. Butterworth-Heinemann/Elsevier, Boston). If the conjunctiva is sufficiently elastic, fornix-deepening sutures can be used to recreate the upper and lower fornices. However, if the conjunctiva is scarred and inelastic, mucous membrane grafting may be considered (Tyers, Collin (2008) Colour atlas of ophthalmic plastic surgery, 3rd edn. Butterworth-Heinemann/Elsevier, Boston). Buccal mucosa is similar in consistency to conjunctiva, consisting of non-keratinized squamous cell epithelium and a thin lamina propria (Markiewicz, Margarone, Barbagli, Scannapieco EAU-EBU Update Ser 5(5):179–187, 2007). When harvesting buccal mucosa, care must be taken to avoid the parotid (Stensen) duct, located on the inner cheek, across from the second superior molar tooth. Additionally, damage to the underlying buccinator muscle should be avoided. Buccal mucosal grafts from below the lower lip have been associated with a high rate of permanent lip anesthesia and should be avoided. When choosing the size of the graft to harvest, one should overestimate the amount of mucosa required, as oral mucosal grafts can shrink up to 20% from their original size (Markiewicz, Margarone, Barbagli, Scannapieco EAU-EBU Update Ser 5(5):179–187, 2007). After harvesting the graft, it is important to soak the graft in 10% Betadine solution and use a second set of sterile surgical instruments and surgeons’ gloves in order to prevent contamination of the eye socket with oral bacteria (Markiewicz, Margarone, Barbagli, Scannapieco EAU-EBU Update Ser 5(5):179–187, 2007).