Posterior auricular complex graft can be used as spacer in upper eyelid repair
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Use of the posterior auricular muscle complex graft as a spacer in upper eyelid retraction was first presented at the 20th annual scientific symposium of the American Society of Ophthalmic Plastic and Reconstructive Surgery in 1989.
The results were promising, with an obvious decrease in lid adjustment operations. In developing this technique, it was broached that utilization of an auricular cartilage graft, which was being widely used by ophthalmic plastic surgeons in lower eyelid retraction repair, had inherent problems in upper eyelid retraction repair. Often, the cartilage graft was thicker than desired and was replete with ridges and a concave shape that did not conform to the shape of the globe. Further, there was occasional difficulty with tissue purchase, where the needle did not grasp the graft as desired.
Repair of the upper lid in particular is challenging due to the specialized function, dynamic movement and increased globe coverage of the upper lid. Numerous grafts and surgical techniques are used for upper lid retraction repair, but all possess various limitations. Levator marginal myotomy was described by Grove in 1980; however, more than desirable postoperative adjustments were required.
There are different autologous grafts, including posterior auricular muscle complex graft (PAMCG) but also hard palate mucosa, free tarsal grafts, dermis fat and auricular cartilage, commonly used in the eyelid. However, hard palate mucosal grafts have been associated with contracture, ocular irritation from graft keratinization, corneal abrasions, donor site hemorrhage, persistent lid retraction, graft buckling, oronasal palatal fistula, trichiasis and pyogenic granuloma. Donor sclera can have higher rates of reoperations, mild keratopathy, pyogenic granuloma, wound dehiscence, ectropion and superficial punctate keratitis. Dermis fat graft complications involve persistent lid retraction with reoperation, ocular irritation and atrophy. Additionally, dermis fat grafts may grow in children after implantation and may require surgical debulking.
Although posterior auricular skin and cartilage had been used for many purposes in facial plastic surgery, the tissue in between these two layers was the posterior auricular muscle complex, which was approximately the same thickness of the eyelid. The complex includes muscle, fascia and vascular tissue. It was believed that this layer of tissue might serve as a reasonable graft for upper eyelid retraction instead of thicker auricular cartilage.
The pliable nature of the PAMCG conforms to the shape of the globe, especially during upper eyelid movements. Its relatively smooth surface minimizes the risk for corneal damage. Additionally, as an autologous graft, it has a lower probability of causing infection, rejection or adverse tissue reactions. Harvesting the graft behind the ear can provide a reasonable, inconspicuous scar that is concealed nicely.
The posterior auricular muscle is a vestigial muscle that is present in the majority of patients. It originates from the mastoid process and inserts into the posterior concha of the ear. It is directly superior to the ear cartilage and just inferior to the skin of the pinna. The main contributors to the PAMCG are the occipitalis muscle, trapezius muscle, temporalis fascia and sternocleidomastoid muscular fascia. The thick fascial layer adds strength to the graft and can pull the auricle backward. Accordingly, it is important to leave the posterior layer of the muscle intact to prevent outward rotation of the pinna and to maintain ear movement.
Harvesting of the PAMCG starts with a dermal incision from the posteromedial edge of the helix. This incision can continue onto the mastoid process if a larger, thicker graft is needed. Such a graft may be necessary for wrapping a hydroxyapatite orbital implant or as a patch graft for exposed hydroxyapatite implants. For repairing upper eyelid retraction, generally a graft harvested from the pinna is sufficient. Sharp dissection is used to reflect the dermis over the posterior auricular muscle at the level of the rete pegs. The deeper portion of the cord-like condensations of the posterior auricular muscle are left intact to prevent forward rotation of the pinna and preserve movement of the ear. The initial incision is deepened to the level of the posterior auricular cartilage through the perichondrium. The posterior auricular muscle is then reflected with sharp dissection and harvested. The auricular skin edges are coapted with interrupted 6-0 nylon sutures.
After instillation of a topical anesthetic, a lid plate is placed underneath the upper eyelid to protect the cornea and globe. Lidocaine 1% with epinephrine 1:100,000 is injected into the upper eyelid. A full eyelid thickness incision is made with a Bard-Parker blade No. 15 just superior to the tarsal plate. The PAMCG is placed in the space created by the previous incision. It is then trimmed to place the upper eyelid in the desired position. Ideally, the patient is placed in an upright position during this time. Then, 6-0 Vicryl sutures are used to secure the upper portion of the PAMCG to the outer portion of the levator aponeurosis and orbicularis muscle. The lower portion of the graft is sutured with interrupted 6-0 Vicryl sutures to the outer portion of the orbicularis and tarsus. Good tissue purchase should be obtained but not so deep as to damage the globe and cornea. The skin is then coapted with 6-0 interrupted nylon sutures.
To the best of our knowledge, the PAMCG had not been used before our presentation at ASOPRS in 1989. Overall, the well-concealed surgery site, flexibility, durability and autogenous nature of the PAMCG combined with excellent postoperative results attest to its value in upper eyelid retraction repair. The PAMCG can also work well when combined with lateral tarsorrhaphy and decompression for certain patients with thyroid eye disease.
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- For more information:
- Athena Cohen, MD, candidate class of 2026 at Tulane University School of Medicine, can be reached at acohen29@tulane.edu.
- Nikhil Dhall, MD, resident physician in the department of ophthalmology, class of 2025 at Tulane University School of Medicine, can be reached at ndhall@tulane.edu.
- Thomas C. Naugle Jr., MD, adjunct professor of ophthalmology at Tulane Medical School’s department of ophthalmology, oculofacial section, can be reached at thomasc.naugle@gmail.com.
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