Mucous Membrane Graft for Lower Fornix Reconstruction
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This is Richard Allen at the University of Iowa. This video demonstrates placement of a mucous membrane graft for recreation of the lower fornix in an anophthalmic patient. 4-0 silk sutures are placed through the lid margin at the level of the meibomian gland orifices. A lateral canthotomy is performed followed by an inferior cantholysis. A monopolar cautery is then used to make an incision inferior to the inferior border of the tarsus, extending from the punctum medially to the lateral canthotomy incision laterally. Dissection is then carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. A buccal mucous membrane graft has been harvested. This is demonstrated in another video. The mucous membrane graft is placed into the space between the conjunctiva and inferior border of the tarsus. A double-armed 5-0 Vicryl suture is then placed through the conjunctiva followed by the inferior border of the mucous membrane graft. Each arm of the suture is placed in the exact same manner. The needle is then placed full thickness through the eyelid at the desired depth of the fornix. The other arm is placed in the exact same manner. I do not feel the need to engage periosteum with these sutures. I believe that it may result in potential lower lid retraction. An additional double arm 5-0 vicryl suture is placed in the exact same manner centrally, followed by another suture placed laterally. These suture are left untied at this point. The mucous membrane graft is then sutured to the inferior border of the tarsus. This is performed with a 7-0 vicryl suture placed in a running fashion. The inferior border of the mucous membrane graft is then sutured to the edge of the conjunctiva. Again, this is performed with a 7-0 vicryl suture in running fashion. A lateral tarsal strip is then fashioned by dissecting between the anterior and posterior lamella for approximately 5 mm. The strip is then engaged with a double armed 4-0 mersilene suture. The suture then engages the periosteum of the lateral orbital rim at the level of Whitnalls tubercle. The suture is left untied. The fornix sutures are then tied over cotton bolsters. The conformer is then placed and the lateral tarsal strip suture is tied. The canthotomy incision is closed with the 7-0 vicryl suture. The eyelid is placed on stretch with the Frost sutures and the eye is patch for approximately one week.