Spacer Graft Research Articles

Correction of Upper Eyelid Retraction Using Deep Temporal Fascia Spacer Grafts

Upper eyelid retraction may occur as a manifestation of infiltrative disease, previous surgery, or trauma. It is associated with dry eye syndrome and corneal compromise. The authors evaluate a lid-lengthening procedure performed through a lid crease incision that uses modified levator recession coupled with autologous deep temporal fascia upper lid spacer grafting. Records of 15 patients (22 lids) treated by a single surgeon were reviewed retrospectively. Dry eye symptoms, scleral show, lagophthalmos, and keratopathy were evaluated. Each patient underwent slit lamp examination and a Schirmer's test. Degrees of preoperative scleral show and lagophthalmos were 1.6 +/- 0.7 mm and 1.9 +/- 0.7 mm, respectively. Every patient experienced complete resolution of dry eye symptoms, scleral show (p < 0.001), and lagophthalmos (p < 0.001) following repair. Symmetry was achieved in 73 percent of patients. Overcorrection occurred in four lids (18 percent) and required lid-shortening operations in three. There were no instances of undercorrection or recurrence. No major complications were noted. Graft resorption, extrusion, and infection did not occur. Lid margin contour was consistently excellent. Mean follow-up was 30 months. The authors' technique is efficacious, durable, and safe. Autogenous deep temporal fascia is easy to harvest and manipulate. Complications associated with other repairs including recurrence and contour irregularities are avoided. Asymmetry, in this series, resulted solely from overcorrection, and the authors' reoperation rate (13.6 percent) compares favorably with that of other methods of repair. Overall patient satisfaction remains excellent. Deep temporal fascia interposition is a powerful technique for the repair of upper lid retraction.

Aesthetic and Functional Management of Eyelid and Orbital Reconstruction

Major head and neck resections may result in ocular defects that are functionally and/or aesthetically incapacitating. Restoration of the eyelid and orbit must address lateral canthal laxity, midface ptosis, eyelid retraction and ptosis, globe malposition, and dysfunctional lacrimal drainage. Here we discuss lateral canthal reconstruction, midface-lifting, eyelid spacer grafts, gold weight placement, surgical approaches to the orbit, free flap options for orbital reconstruction, and endoscopic lacrimal surgery. Successful outcomes in eyelid and orbital reconstruction depend upon proper knowledge, planning, and multidisciplinary management.

Reconstruction of Contracted Anophthalmic Socket with Acellular Dermal Allograft

Purpose: To study the use of acellular dermal allografts for the reconstruction of contracted anophthalmic sockets. Methods: A retrospective analysis was performed on 12 patients with contracted sockets who underwent reconstructive surgery using acellular dermal allografts from 2002 to 2006. Results: The mean age of the patients was 44.4 years. The mean duration of conjunctival sac contracture after removal of the eyeball was 21.4 years. In 4 patients, acellular dermal allografts were used as spacer grafts to elevate the eyelids, and in 8 patients the allografts were used as a conjunctival grafting material. All patients were able to wear ocular prostheses comfortably 2.2 months after surgery with acceptable cosmesis. There were no serious complications, such as infections or graft rejections during follow-up period. Conclusions: When used as conjunctival grafting materials and tarsal substitutes to elevate patients’ eyelids, acellular dermal allografts gave cosmetically and functionally acceptable results in the surgical rehabilitation of contracted sockets.

Influence of vascularized transplant bed on fat grafting

Recent advances in regenerative medicine have opened up the option of materials used for transplantation. However, only a few studies have examined the take of transplanted tissues. We attempted to establish a functional bed for transplanted tissues using growth factors. A cylinder-type silicone substrate (spacer) was coated with a photoreactive gelatin containing basic fibroblast growth factor. This spacer was transplanted into the dorsal subdermal layer in a rabbit. After 2 and 4 weeks, the capsule formed around the spacer was histologically assessed for use as a transplant bed. In addition, after 2-4 weeks of spacer grafting, autologous fat was transplanted into the capsule. After 4 more weeks, the grafted fat was assessed immunohistochemically to evaluate the capsule as a functional bed for transplantation. In the groups pretreated with growth factors, proliferation of blood vessels was observed in the capsules. After fat grafting, a pattern of overall necrosis was observed in controls. However, good proliferation of blood vessels and favorable fat take were observed in the groups pretreated with growth factors. Necrosis, however, was found at the center of the grafted fat. We conclude that a vascularized transplant bed was useful for promoting take of the grafted fat.

Eyelid reconstruction with acellular human dermal allograft after chemical and thermal burns

Objective To evaluate the efficacy of eyelid reconstruction with acellular dermal allograft in patients with eyelid defect after chemical and thermal burns. Method Eyelid reconstruction was performed in 15 eyelids of 13 patients during the period of June 2001–October 2004 by a single senior surgeon (Chen). Among them five patients had thermal burns, and eight patients had chemical burns. The acellular dermal allograft was used as a tarsus substitute that was sutured into the place between the levator aponeurosis in upper lid or retractor in lower eyelid and the remaining tarsus. Results After a mean follow-up of 9 months, satisfactory function and cosmesis were obtained. No implant rejection or severe complications were observed. Conclusion Acellular dermal allograft may be used safely as a posterior lamellar spacer graft after chemical and thermal burns; the allograft appears to be biocompatible and does not aggravate the inflammation in the injured eyelid.

Comparison of the Efficacy of Hard Palate Grafts with Acellular Human Dermis Grafts in Lower Eyelid Surgery

The Madame Butterfly procedure of lower eyelid reconstruction addresses lower eyelid retraction after blepharoplasty caused by middle lamellar tethering. After scar lysis and subperiosteal midface lift, the surgical procedure uses a lower eyelid spacer graft to prevent further postoperative contraction of the middle and posterior lamellae. Different graft materials have been used, including autogenous hard palate and AlloDerm. The preoperative and postoperative photographs of consecutive patients who had undergone the Madame Butterfly procedure were analyzed retrospectively. Thirty-five patients undergoing AlloDerm grafting were compared with 25 patients undergoing hard palate grafting. Their lower eyelid heights were digitally measured and analyzed statistically for differences between the two groups. No statistically significant difference was found in the amount of eyelid elevation between the AlloDerm and hard palate groups, although a trend was seen that hard palate grafts resulted in both better elevation (p = 0.121) and a lower failure rate (p = 0.092). Female patients in both groups were found to experience significantly greater eyelid elevation than male patients (p = 0.018). Both AlloDerm and hard palate were found to be successful grafting materials for lower eyelid elevation in patients with postblepharoplasty lower eyelid retraction. Each has advantages and disadvantages, and surgeons should tailor their choices according to each patient.

Current Treatment Strategies for the Painful Lumbar Motion Segment

Review of the literature. We discuss the indications and contraindications for posterolateral lumbar fusion and posterior approaches to lumbar interbody fusion. We also review the advances in minimal access surgical techniques, graft materials, and osteobiologics. Previously published data and our own surgical experience form the basis of this report. A Pub Med online internet search for the keywords was performed. The pertinent articles were then cited. Posterior interbody fusion techniques have theoretical and demonstrable advantages over posterolateral fusion, but the former is also associated with greater morbidity. There are several approaches one may use to perform posterior interbody fusion, as well as multiple minimally invasive techniques and interbody spacer graft options. Bone morphogenetic protein offers an attractive alternative for achieving fusion. Fusion of painful motion segments is widely used to treat patients with degenerative low back pain. Successful arthrodesis may be achieved using either posterolateral fusion with pedicle screw fixation or posterior interbody fusion, depending on the patient's situation. These techniques may be accomplished with a variety of minimal access strategies and various graft and spacer technologies. The modern spine surgeon should be proficient in using all these options to treat the painful lumbar motion segment.

Combined Hard Palate Spacer Graft, Midface Suspension, and Lateral Canthoplasty for Lower Eyelid Retraction: A Tripartite Approach

Eyelid retraction is an unfortunate consequence of cosmetic surgery, trauma, and disease states. It is frequently symptomatic and may be associated with dry eye syndrome and corneal compromise. The pathophysiology of lower eyelid retraction usually involves some degree of lateral canthal tendon laxity, middle lamella scarring, and malar descent. The authors describe for the first time a series of patients whose lid retraction was treated with a tripartite procedure that addresses all three pathophysiologic components simultaneously and rehabilitates the patients cosmetically and functionally. The authors retrospectively reviewed the records of 17 patients (24 eyelids) operated on between 1999 and 2003 by one senior surgeon. The age of the patients ranged from 26 to 77 years (mean, 50.3 years), and all presented with significant scleral show (average, 2.0 mm) and symptomatic corneal exposure from a variety of causes. Preoperatively, all patients were noted to have a combination of lower eyelid laxity, middle lamellar contracture, and malar descent. Preoperative and postoperative examinations included Shirmer's test, a measurement of scleral show, and a slit-lamp examination. Mean follow-up time was 13 months. All patients underwent a triad of hard palate spacer grafting, lateral canthal suspension, and midface elevation. All 17 patients (representing 24 retracted eyelids) had complete resolution of scleral show (2.5-mm average correction) and were uniformly satisfied with their cosmetic and functional outcome at last follow-up. Preoperative dry eye symptoms resolved in all patients in the series. There were no major complications and only two minor complications (corneal irritation from graft sutures in one patient and an oronasal palatal fistula in another), both of which resolved in the early follow-up period. The combination of hard palate spacer grafting, lateral canthoplasty, and midface suspension is an effective, aesthetic, and functional treatment for moderate to severe lower eyelid retraction resulting from multiple causes. This tripartite procedure is associated with predictable results, a low morbidity rate, and high patient satisfaction.

Free Tarsus Autogenous Graft Struts for Lower Eyelid Elevation

Free tarsus autogenous graft (FTG) has emerged as a useful biological spacer in lower eyelid elevation. However, it has limited use where a spacer of greater than 4 mm height is required, because at least 4 mm of upper tarsal height must be preserved to maintain upper eyelid rigidity. We describe an augmentation of FTG in its use as a spacer, by way of creating 2 parallel-placed vertical FTG struts, in contrast to interpositioning the FTG horizontally. This case series describes the technique of harvesting and interpositioning FTG struts. Nine eyelids in 6 patients in whom FTG struts were used for lower eyelid elevation are reported. The patients ranged in age from 41 to 80 years. Underlying diagnoses included thyroid orbitopathy, previous blepharoplasty, and previous facial and eyelid thermal burns. FTG struts achieved an effective spacer height of up to 7 mm, and follow-up of 9 to 20 months revealed a good outcome in all 3 cases, with no complications. FTG struts provide an effective and lasting lower eyelid elevation when used as a spacer. A spacer graft of up to 7 mm in vertical height may be harvested from a long strip of upper eyelid tarsus that is 4 mm in vertical height. This technique would allow autogenous upper eyelid tarsus to be harvested with maximum conservation of tissue.

Polytetrafluoroethylene as a Spacer Graft for the Correction of Lower Eyelid Retraction

To evaluate the efficacy of porous expanded polytetrafluoroethylene (e-PTFE, Goretex) containing large pores made with a 21-gauge needle as a graft for the correction of lower lid retraction. e-PTFE grafts were implanted between the tarsus and lower lid retractor via a transconjunctival approach with/without amniotic membrane transplantation, or via a transcutaneous approach. Rabbits were examined and assessed for comeal and conjunctival complications and for e-PTFE graft status. Rabbits were sacrificed for a histological study at 8 weeks postoperatively. e-PTFE grafts were uniformly extruded 3 weeks postoperatively in eyelids operated on via the transconjunctival approach. However, rabbits operated on via the transcutaneous approach demonstrated e-PTFE graft retention; in addition, dense fibrovascular ingrowths into the large pores of e-PTFE were observed histologically. e-PTFE is a good substitute for other graft materials as a spacer in lower lid retraction operations, especially as an interpositional graft using a transcutaneous approach.

Graft Contraction

In Brief Purpose To compare graft contraction rates of acellular dermis versus hard palate mucosa when used as free spacer grafts in lower eyelid surgery and to provide clinical outcome data. Methods A prospective, nonrandomized clinical trial involving the placement of 19 spacer grafts in the lower eyelids of 14 patients was performed. Indications for spacer graft placement included lower eyelid retraction and mildly contracted socket. Patients with lower eyelid retraction also underwent an endoscopic subperiosteal midface lift. For all procedures, the height of each graft was measured during and after surgery. The amount of contraction was measured for each graft, and a mean was calculated for each spacer material. The clinical success was evaluated for all procedures, based on improvement of the functional concern being addressed. Results The mean graft contraction rate was 57% for the acellular dermis and 16% for the hard palate mucosal grafts (P <0.005). Of the 7 procedures using acellular dermis for lower eyelid retraction, 6 were considered a success, and 1 was considered a partial success. Of the 6 procedures using hard palate for lower eyelid retraction, 5 were considered a success, and 1 was considered a failure unrelated to the graft. Of the 5 procedures with acellular dermis used for mildly contracted socket, 2 were considered a success, 2 were considered a partial success, and 1 was considered a failure because of graft contraction. The one case using hard palate for mildly contracted socket was considered a success. Conclusions Acellular dermis contracts significantly more than hard palate mucosa when used as a lower eyelid spacer graft. Acellular dermis and hard palate mucosa were both associated with a high rate of clinical success in all categories except for patients with a mildly contracted socket who received acellular dermis; more than 60% of these patients (n=5) had only partial success or failure caused by graft contraction. Acellular dermis has a significantly greater contraction rate than hard palate mucosa in lower eyelid surgery, although clinical success may be achieved with both materials.

Endoscopic Subperiosteal Midface Lift

To review the surgical technique of the endoscopic subperiosteal midface lift and present our clinical outcome in 22 consecutive patients.We retrospectively evaluated the clinical outcomes of 39 endoscopic subperiosteal midface lifts in 22 consecutive patients. Of the 39 sides, 21 had a lower eye conjunctival spacer graft inserted (15 hard palate mucosal graft, 6 AlloDerm). The success of the procedure was graded based on the aesthetic and functional results. Subjective and objective assessments were made using history, examination, and photos.Results for the clinical outcome were graded as excellent, good, fair, or poor. Among the 39 sides, indications for the procedure included facial rejuvenation (41%), postblepharoplasty lower eyelid retraction (26%), eyelid retraction secondary to midfacial ptosis (15%), severe cicatricial ectropion (13%), and paralytic ectropion secondary to 7th nerve palsy (5%). The operating surgeons evaluated the clinical outcome as "excellent" in 24 sides (61%), "good" in 10 sides (26%), "fair" in 2 sides (5%), and "poor" in 3 sides (8%). The procedure was successful at increasing malar projection, improving lower eyelid fullness, and elevating the lower eyelid in cases of lower eyelid retraction. The procedure was less effective in decreasing the prominence of the deep nasolabial fold.The endoscopic subperiosteal midface lift is an effective method for elevating the midface. A more youthful appearance is achieved with the procedure, and when necessary, recruitment of anterior lamella allows elevation of the lower eyelid to correct retraction.

Evolution of Lower Lid Support Following Lower Lid/Midface Rejuvenation: The Pretarsal Orbicularis Lateral Canthopexy

An 18-month experience with an endoscopically assisted "closed" technique of modified transblepharoplasty lower lid and midface rejuvenation is presented. In the modified approach, preseptal dissection in the body of the lower lid is eliminated to decrease the incidence of septal scarring and lower lid retraction. The technique also leaves intact the connection between the orbicularis and septum, resulting in tightening of the septum and better support of lid with redraping of the muscle. By providing more secure support of the lower lid and lateral canthus, the need for direct canthal manipulation has been reduced significantly. This experience confirms, however, that an occasional patient with significant exophthalmus occasionally might need additional lower lid support (spacer graft or more direct lateral tendon fixation) to obtain ideal lower lid position. Conversely, an occasional older patient with relative enophthalmus and horizontal lower lid laxity will be best served by canthoplasty with correction of excess laxity. So far, the quality of aesthetic results compared with the "open" approach has not been compromised, and morbidity seems to have been decreased.

The safety and applications of acellular human dermal allograft in ophthalmic plastic and reconstructive surgery: a preliminary report.

To describe the uses and determine the safety of a commercially available acellular dermal allograft in ophthalmic plastic and reconstructive surgery. The existing literature regarding current applications and results using acellular dermal allograft is reviewed. The study design was a retrospective, noncomparative case series. Participants consisted of 63 consecutive patients undergoing ophthalmic plastic and reconstructive surgery using an acellular dermal matrix graft. The main intervention was placement of a dermal allograft. Outcome measures included the degree of clinical improvement and complications for each patient. We used AlloDerm (LifeCell Corporation, The Woodlands, TX, U.S.A.) as a posterior lamellar conjunctival spacer graft, a soft tissue interpositional graft, and an orbital implant wrapping material. Clinical improvement was noted in all cases. There were no complications attributable to the acellular dermal matrix material. We describe several novel ophthalmic plastic and reconstructive surgical applications using acellular dermal allograft tissue. This material may be used safely as a posterior lamellar conjunctival spacer graft, a soft tissue interpositional graft, and a wrapping material. Clinically, the allograft appears to be biocompatible, nontoxic, and nonallergenic in the orbit, eyelid, and midfacial tissues. Long-term data and studies comparing the efficacy of acellular dermal allograft with conventional materials are necessary.

Ophthalmic plastic applications of acellular dermal allografts

Purpose Clinical problems of contracted conjunctival fornices, superior sulcus defects, and soft tissue contour defects in the periorbital region have not shown good, sustained results with a range of autologous and alloplastic implants. AlloDerm (Lifecell Corp., Woodlands, TX) is an acellular dermal graft processed from human donor tissue. The authors sought to assess the efficacy of AlloDerm as a soft tissue replacement in a variety of oculoplastic applications. Design Retrospective, noncomparative case series. Participants Twenty-three patients. Methods Applications were broadly classified as barrier/scaffolding (i.e., primary and secondary implant coverage, lid spacer graft) and volume augmentation (i.e., superior sulcus and other periorbital soft tissue contour defects). Barrier grafts were applied as single sheets. Stacked sheets or rolled grafts were used for augmentation. Collectively, this material was used in 29 cases with 3 to 16 months’ follow-up. Main outcome measures Clinical evaluation of outcome and complications. Results As a soft tissue scaffolding and barrier implant, AlloDerm persisted sufficiently to permit repopulation with native tissue. Rolled/stacked implants demonstrated unpredictable resorption. Upper eyelid grafts seemed to have higher resorption rates than lower eyelid grafts. One case of anophthalmic superior sulcus augmentation required two revision surgeries to provide sufficient volume augmentation. The grafts were well tolerated, with no cases of infection or explanation. Conclusion Acellular human dermis is an excellent barrier and reconstructive grafting material that provides an alternative to autologous grafts and other alloplastic material, avoids harvesting autologous tissue, possesses excellent handling properties, and is associated with minimal inflammation. Long-term follow-up is required to evaluate persistence.

Lower-lid dynamics: Influence on blepharoplasty and management of lower-lid retraction

Lower-lid dynamics play an important role in the preoperative planning and postoperative management of lower-eyelid blepharoplasty. Patients at risk for lower-lid retraction are best identified before surgery to allow customization of the procedure. Lower-lid laxity, eye prominence, and skin excess must be taken into consideration to optimize surgical results and patient satisfaction. Lateral canthoplasty with horizontal tightening of the lower-lid posterior lamellae (tarsoligamentous sling) is necessary in most cases. Prominent eyes require loosening and supraplacement of the lower lid to prevent clotheslining and scleral show. Skin removal is dependent on laxity. If lower-lid retraction is present, supplemental procedures are necessary. The orbicularis strap procedure is useful for recruiting skin vertically and giving anterior lamellae support to the lower lid. More severe lid retraction and skin shortage may require the use of lower-lid slings, spacer grafts, or full-thickness skin grafts. Lower-eyelid management can be challenging, and a systematic approach that considers lower-lid dynamics may be helpful.

Lower Eyelid Recession Combined with Ptosis Surgery in Patients with Poor Ocular Motility

The authors treated ten patients (13 eyelids) with visually significant blepharoptosis and compromised corneal protective mechanisms resulting from paresis of ocular motility and absent Bell phenomenon. Traditional upper eyelid surgery consisting of frontalis suspension (6 eyelids) or levator aponeurosis advancement (7 eyelids) was used. In all patients, the ptosis repair was combined with maximum recession of the lower eyelid, using a posterior lamellar scleral spacer graft. The goal was to maintain a narrow, vertical, interpalpebral fissure to allow for eyelid closure, but to reposition this opening centrally over the pupil. Postoperatively, all patients achieved significant improvement in superior visual field, with no associated keratopathy. Complications were few, minor, and transient. The postoperative cosmetic appearance was acceptable in all patients. This combined procedure allows repair of fair- to poor-function ptosis in patients in whom ptosis surgery previously has been considered risky. For the authors, this technique has been proven safe and effective and should be considered in any patient population with compromised corneal protective mechanisms.

Management of Lower-Lid Retraction With Hard-Palate Mucosa Grafting

Lower eyelid retraction is frequently managed by recession of the lower-lid retractors and interposition of a "spacer graft." We have used hard-palate mucosa as our spacer material in 25 eyelids of 18 patients. A graft twice the height of the measured amount of lid retraction was used and resulted in predictable, satisfactory results. The hard-palate mucosa was easily obtained and the donor site healed well in all patients, with minimal care.