Surgery: Fornix Reconstruction with Mucous Membrane Graft

This video demonstrates an inferior fornix reconstruction surgery using a mucous membrane graft. The patient had previously undergone an evisceration and presented with a contracted socket, which was unable to retain an ocular prosthesis.

Surgery Location: on-board the Orbis Flying Eye Hospital, Kingston, Jamaica
Surgeon: Dr. Bradford Lee, Bascom Palmer Eye Institute, USA

 

Transcript

DR LEE: This is our patient, and she was assaulted with a bottle, I believe, which caused lower lid laceration here, as well as an upper lid laceration. It also damaged her eye, and she had an evisceration. She hasn’t really gotten an ocular prosthetic. She’s a young mother, and would like to be aesthetically rehabilitated. So what we’re gonna do — we’ve already injected anesthetic into the lower lid here. We’ve already numbed up her lower lip as well. And we’re gonna be harvesting some mucous membrane from inside there. We’re gonna release this scar band, and recreate a fornix for her, with a mucous membrane. So let’s explore here now. This is our cicatricial band that we have to release. I can feel it. So here’s this tight band that I’m grasping here. I’m just kind of feeling that this is all scar. So I’m just trying to release that, little by little. So here you can see it starting to open. And I’m just feeling for any more cicatricial bends here. I think that’s okay now. So I’m gonna extend my incision a little bit now. We try to be very conservative with the cautery. Both for blood supply and we don’t want to induce more scar. Sometimes when the patients have this loss of the fornix, it’s very extensive, and it’s across the entire lid. In her case, it looks like maybe it was more focal, and she really had that one band really causing a very focal loss of the fornix. And perhaps in the conjunctival closure, after the evisceration, too big of a bite of conjunctiva was taken, and when you sew it up, then it foreshortens the fornix. So I would say when you’re closing the conjunctiva, it’s like 1 millimeter from the conjunctival edge, so you don’t accidentally shorten the fornix. We didn’t have the operative report of what was done with her prior surgery. Clinically, when we saw her on evaluation, she didn’t look that hollow. Palpation is one way to do it. You could use a B scan to try to see if there’s implants inside. A CT scan would show you as well. We decided that her volume is sufficient for her not to look too hollow. 18 millimeters this way. Maybe we’ll go a little bit more. I would say 20 millimeters. We always like to oversize our grafts just a little bit, because they inevitably cataract to some degree. So we already gave her about — maybe 4CCs of our local anesthetic in the lip, and you can see it’s blanching, and it’s gonna help with her hemostasis. I also like to inject it with just injectable saline. This really just blows up the lip, and makes it very turgid, and it facilitates your mucous membrane grafts. You can easily put 10, 20CCs in the lip, and it’s no problem. It’s just saline, and it’ll go down very quickly afterwards. I always tell people that the lips are like the eyelids of the mouth. So everything that can happen to eyelids can happen to the lips too. So if you totally overdo it, and take out way too much tissue in your graft, you can actually cause lip entropion. This is the wet/dry junction. So this is the wet part of the lip, the mucosal side. This is the more keratinized dry part. So the wet/dry junction is about here. And then the vermillion border is where the pink of the lip meets with the skin. So this is kind of central here. So we had said 20, so let’s just go a little bit bigger. And when you do a mucous membrane graft, there’s various options. You can leave it to just heal by secondary intention, and patients do just fine like that. But you can also close it. A little bit more comfortable for patients. Now, mucous membrane grafts are more delicate than skin grafts, so you want to be very careful when you handle the tissue here. You can see our graft is still fully within the wet zone of the lip. So we’ll take the 15 blade here, and there’s also an option — you can do what’s called split thickness mucous membrane graft or full thickness mucous membrane graft. In general, I typically will do a full thickness. The split ones tend to have more contracture. And so that’s why I typically like to do the full thickness. So now we’re gonna very delicately excise this. Again, it’s just like a blepharoplasty here. And the submucosal tissue of the lip — it looks kind of glandular, because there’s probably mucous glands and goblet cells and all of that stuff. If patients have pain after the surgery, sometimes they have these oral mouthwashes that have — kind of like anesthetic in them. And that can sometimes help with the pain. But like I said, because we’re gonna be closing the donor site, she really shouldn’t have much pain afterwards. So typically, we like to thin the graft very carefully, and I like to do this over my finger. Trying not to buttonhole the graft. When you debulk this submucosal tissue, it reduces the metabolic needs of the graft. So we’ll put this in the gentamicin solution here, and we did prep inside the mouth before surgery. So this is 4-0 chromic gut, which is kind of one of the more popular types of sutures to use in closing. I’m gonna do a buried interrupted stitch here, to try to prevent the tails from irritating her lip. If patients have really bad dentition, which she doesn’t, and you just know that their oral hygiene is terrible, you could have them do chlorhexidine mouthwashes. Which are used for gingivitis and gum disease, and that can kind of help to make you feel better about the risk of infection or problems in the mouth. So we’re gonna sew the mucous membrane graft into our recipient site that we created from releasing the scar, undermining, and then we’re gonna give her a little injection of 5FU, to kind of help modulate her wound healing response, and to help to prevent graft contracture. We’ll put a conformer in, and then do a tarsorrhaphy, and that’s gonna help maintain that pressure in the fornix.

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April 15, 2019

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