Int. J. Oral Maxillofac. Surg. 2000; 29: 96–98 Copyright C Munksgaard 2000Printed in Denmark . All rights reserved

ISSN 0901-5027

Martin Klein, Horst Menneking,Ju rgen BierReconstruction of theBerlin Center of Facial Prostheses, Oral &Maxillofacial Surgery, Charite, CampusVirchow Clinic, Medical Faculty of thecontracted ocular socket with Humboldt University, Berlin, Germany

free full-thickness mucosa graftM. Klein, H. Menneking, J. Bier: Reconstruction of the contracted ocular socketwith free full thickness mucosa graft. Int. J. Oral Maxillofac. Surg. 2000; 29: 96–98. C Munksgaard, 2000

Abstract. Patients who have undergone enucleation of the eye can be treated withglass eye prostheses, provided retention is adequate. Inadequate retention due tocontraction of the conjunctival mucosa is a common problem which frequentlyaffects the lower fornix first. This can be corrected using a free full-thicknessbuccal mucosa graft. Indications, operative procedures and postoperative resultsare presented.Zusammenfassung. Nach Enukleation eines Auges konnen Patienten mitAugenprothesen aus Glas rehabilitiert werden. Voraussetzung ist allerdings einausreichender Halt der Prothese. Unzureichender Halt bedingt durch dieKontraktion der Konjunktiva ist ein haufiges Problem, welches die untere

Key words: contracted socket; mucosa graft;konjuktivale Umschlagsfalte meist zuerst betrifft. Der Halt kann durch ein freies socket reconstruction.buccales Mukosatransplantat verbessert werden. Indikationen, operativesVorgehen, postoperative Ergebnisse werden dargestellt. Accepted for publication 23 November 1999

If the eyelids are intact and the volumewithin the orbit has been filled afterenucleation, an adequate cosmetic re-sult can be obtained with a glass eyeprosthesis which has been custom-madeto resemble the healthy eye. To hold theeye prosthesis in the socket, the lowerand upper fornices of the conjunctivamust have sufficient depth. Inadequateretention due to contraction of the con-junctival lining is a common problemwhich can occur several weeks or yearsafter enucleation and usually affects thelower fornix first (Fig. 1). Before con-sidering surgery, one should considermodification of the prosthesis. The pa-tient should be seen by a competentocularist for the best fitting artificialeye. If modification of the prosthesisdoes not solve the problem, surgerywith a free full-thickness mucosa graftmight be carried out to improve the re-tention for the prosthesis (Fig. 2)7.

Material and methodsPatients

Twenty four patients, 14 women and 10 menranging in age from 23 to 71 years, weretreated with this technique. All suffered froma shortened lower fornix and had alreadyundergone an unsuccessful effort by an ocu-larist to fabricate a prosthesis which wouldstay in the shallow socket. In each case, thelower fornix was reconstructed using a freefull-thickness buccal mucosa graft.

Surgical procedure

With the patient under general anesthesia, afull-thickness mucosal graft was harvested ina rhomboid form. The graft was deliberatelytaken too large to fit the defect in order toallow for some contraction. The donor sitewas closed primarily with sutures. Before thegraft was applied, any submucosal tissue wasremoved with scalpel or scissors.

A horizontal incision was made throughthe contracted conjunctiva of the lower for-

nix, after which the wound was deepened andwidened with scissors throughout the lengthof the fornix. During this procedure, carewas taken not to injure the orbicularismuscle. The graft was adapted in size to thedefect and sutured to the surrounding con-junctiva with absorbable sutures, withouttension on either side of the incision. Thegraft was kept in place by a conformer (Fig.3). In two cases the conformer was insertedwithout suturing, permitting the overlappingedges of the graft to be resected later. Thelids were loosely sewn closed with sutures sothat the conformer and the graft could notslip out. Any wound secretion could drainfreely through holes in the conformer andthrough the palpebral fissure. The orbit wasprotected by a sterile dressing. The woundswere rinsed daily with saline until the lidswere opened again after ten days.

Follow-up

After about four weeks, the conformer wasremoved and the ocularist fitted a new eye

Reconstruction of the contracted ocular socket 97

Fig. 1. Contracted lower conjunctival fornix.

Fig. 2. Restored lower conjunctival fornix with free full-thickness mucosalgraft.

Fig. 3. Thinned-out free full-thickness mucosal graft around conformer.

Fig. 4. Eye prosthesis with short lower margin due to shortened lowerconjunctival fornix.

Fig. 5. New eye prosthesis manufactured after operation. Note elongatedlower margin, adapted to the newly formed lower conjunctival fornix.

prosthesis. The improvement in retention wasthen evaluated. The criteria to measure thesuccess were that it slipped snugly and satsecurely in the reconstructed fornix when theeye was open and that it held firmly duringvoluntary and involuntary closure of the eye-lids. Two weeks later, when the patients camefor follow-up, they were asked for their sub-jective opinions.

Results

From 1993 until the present time, 24patients with a contracted lower fornixof an anophthalmic socket underwentlower fornix reconstruction. There wereno serious intra- or postoperative com-plications and no infections. Postopera-

tive pain was minimal. All grafts werevital when the conformer was removed.Four patients had some dehiscence inthe cheek and three patients minimaldehiscence at the edges of the graft. Inboth locations, healing by secondary in-tention took place. Repeated contrac-tion of the sockets was not seen.

98 Klein et al.

The lower half of all new prostheseswas at least 3 mm longer than the oldones (Figs. 4 and 5). All patientsshowed adequate retention at rest andduring eyelid motion. Only one patientwas not satisfied with the result whenasked.

Discussion

If the eyelids and lid function are intactand the orbital tissues have sufficientvolume after enucleation, adequate cos-metic results may easily be obtainedwith a custom-made eye prosthesis. In-ability to retain a cosmetically accept-able ocular prosthesis can result from avariety of factors including socket in-fection, orbital radiation, severe chemi-cal or thermal injury, orbital trauma,multiple socket surgeries, ill-fitting androughened artificial eyes and refusal towear an artificial eye1,2.

A conjunctival lower fornix which istoo shallow reduces retention of the eyeprosthesis. Full-thickness mucosalgrafts, which have a structure similar tothat of the conjunctiva, are to be pre-ferred because they are less susceptibleto shrinkage and contraction3. Con-siderable experience has been reportedon the use of mucosal grafts from thecheek for vestibuloplasties12. Skinshould preferably not be used in a moistenvironment such as the orbital socket,as this could lead to desquamation andthe possibility of foul smelling dis-charge, most likely caused by Candidainfection5. It is important to use an ap-propriate conformer to hold the graftin place. One function of the conformeris to press the graft to the underlyingtissue to avoid hematoma and toguarantee nourishing through dif-fusion. Its other function is to maintainthe shape of the new fornix.

The operation described is safe, easyto perform and improves prosthesis re-tention. Compared to moderate socketcontraction, a totally contracted ocularsocket is more difficult to reconstruct8.

If there is volume loss together witha contracted socket, it must be replacedusing a hydroxyapatite implant, adermofat graft or, if the volume deficitis moderate, a mucous membrane fatgraft4,6,10,11,14. Socket volume can alsobe augmented with a subperiosteal or-bital floor implant3. To optimize cos-metic rehabilitation, it is important tocorrect any other lid abnormalities suchas ectropion, entropion or ptosis withthe appropriate surgical techniques13.

If the eyelids are cosmetically andfunctionally severely damaged, it maybe cosmetically preferable to cover theorbital defect with an implant-anchoredfacial prosthesis9.

References

1. B H, S N. Correction of prob-lems of the anophthalmic socket. In:MC CD J., ed.: OculoplasticSurgery. New York: Raven Press, 1981:327–47.

2. C A, D RK. Socketreconstruction advances. In: MJC, J L, C A, eds.: Ophthal-mic Plastic Surgery Up-to-Date. Bir-mingham, AL: Aesculapius PublishingCo, 1970: 125–38.

3. C JRO. Surgical techniques for thecontracted socket. Orbit 1987: 6: 101–3.

4. D JJ. Coralline hydroxyapatite asan ocular implant. Ophthalmology 1991:98: 370–7.

5. H S, H-H E,E E, S B. Influence of skingraft pathology on residual ridge reduc-tion after mandibular vestibuloplasty. A5-year clinical and radiological follow-upstudy. Int J Oral Maxillofac Surg 1990:19: 212–5.

6. M YM, H JJ, W MCF.Buccal mucous membrane-fat graft in themanagement of the contracted socket.Ophthalmic Plast Reconstr Surg 1993: 9:267–72.

7. P RL. Management of the con-tracted eye socket. Int Ophthalmol 1981:5: 33–42.

8. P AM, K JW. A surgi-cal technique for the successful and stablereconstruction of the totally contractedocular socket. Ophthalmic Surg 1988: 19:193–201.

9. S V, T H, W K.Zur Exenteratio orbitae – Moglichkeitender liderhaltenden Chirurgie oder epi-thetische Versorgung. In: R R,B S, eds.: Orbitachirurgie. Rein-bek: Einhorn-Presse Verlag, 1997: 136–44.

10. S CL, S JA, P P.Hydroxyapatite orbital implants afterenucleation. Experience with initial 100consecutive cases. Arch Ophthalmol1992: 110: 333–8.

11. S B, B S, N F, L R.Dermis fat orbital implantation: 118cases. Ophthalmic Surg 1983: 14: 941–3.

12. T H. A technique of vestibularplasty using a free mucosal graft from thecheek. Int J Oral Surg 1972: 1: 76–80.

13. T AG, C JRO. Colour atlas ofophthalmic plastic surgery. Other prob-lems with the anopthalmic socket. Ox-ford: Butterworth-Heinemann, 1998:251–8.

14. G J, L CR. Correction ofa deep superior sulcus with dermis fatimplantation. Arch Ophthalmol 1986:104: 604–7.

Address:Dr. Dr. M. KleinBerlin Center of Facial ProsthesesMaxillofacial SurgeryCharite, Campus Virchow ClinicMedical Faculty of the Humboldt UniversityAugustenburger Platz 113353 BerlinGermany