Hard Palate Graft for Lower Eyelid Retraction Repair

Abstract

Lower eyelid retraction secondary to thyroid eye disease or prior lower eyelid blepharoplasty can be addressed by disinserting the lower eyelid retractors and employing a spacer graft between the tarsus and lower eyelid retractors (Colour Atlas of Ophthalmic Plastic Surgery, Boston, 2008). Graft materials include hard palate, ear cartilage, sclera, or alloplastic materials. When using ear cartilage or sclera, the graft must be covered with conjunctival epithelium (Colour Atlas of Ophthalmic Plastic Surgery, Boston, 2008). Hard palate has the benefit of combining the structural rigidity of tarsus with the mucous membrane epithelium similar to that of the conjunctiva. The biggest disadvantage of hard palate grafting is donor site morbidity. Preoperative fitting of a palate protector and postoperative oral viscous lidocaine (2 %) gel can be used to improve patient discomfort. Anesthesia during hard palate grafting can be obtained with a greater palatine nerve block (Ophthalmic Plastic and Reconstructive Surgery 8:183–195, 1992) and direct infiltration of the hard palate. Local anesthesia is injected by the greater palatine foramen, medial to the alveolar process by the third molar. The hard palate is composed of epithelium, lamina propria, and submucosa. Hard palate harvesting is done in the submucosal plane and the submucosa is removed from the graft before implantation. The area of the alveolar process and midline raphe are devoid of submucosa and should therefore be avoided (Ophthalmic Plastic and Reconstructive Surgery 8:183–195, 1992). After harvesting the graft, the graft is rinsed in a 10 % betadine solution, a second set of sterile surgical instruments are opened, and the surgeon’s gloves are changed in order to prevent contamination of the eye socket with oral bacteria.