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We want to congratulate Drs. S.L. Liao, et al., on their excellent
paper entitled "Surgical coverage of exposed hydroxyapatite implant with
retroauricular myoperiosteal graft". 1 In the paper they described "a
newly developed technique with an autogenous retroauricular
graft" to repair defects with exposed hydroxyapatite implants.
However, they did not mention our retrospect...
However, they did not mention our retrospective, multicentered work
published in 1999 in The American Journal of Ophthalmology. 2 In this
paper we discussed a technique very similar to that of Dr. Liao and
coworkers in which we covered exposed hydroxyapatite implants with a
retroauricular muscle complex graft (complex refers to muscle, fascia,
vascular tissues). As with Dr. Liao's, et al., technique, we placed our
retroauricular graft between the implant and the overlying Tenon's
and conjunctiva and the latter tissues migrated over the graft within
We also used the thicker, stronger, retroauricular tissues
combined with the thinner tissues overlying the pinna for additional
volume post-enucleation. This also facilitated the insertion of the
spicular hydroxyapatite into the orbit post-enucleation. Additionally,
used only the thicker tissue between the mastoid and the overlying
flap anteriorly as a "cap graft" post-enucleation. Our techniques
involved 83 patients with a mean follow-up of 36 months.
One difference in our technique and that of Dr. Liao and associates
was that they used periosteum in their retroauricular complex graft for
added strength and vascularity. We were reluctant to use periosteum in
our grafts for fear of unduly compromising the vascularity of the
underlying mastoid bone and the overlying dermal flap. The authors do
state that this occurred in their series of 9 patients in the duration
over one year. Accordingly, this may be a non-problem and it would
that both techniques are efficacious. However, incorporation of the
periosteum in the retroauricular myoperiosteal graft may not be
because of the strong, thick complex of muscle and fascia and vascular
tissues between the underlying periosteum and overlying dermal flap.
Another difference in our technique is that we did not have to
encounter active infections at the time of surgery and did not find it
necessary to burr down the implant anteriorly. By undermining
and Tenon's capsule the approximate distance of the equator of the
we have found that there is sufficient space for the graft to fit "flush
tight" in the recipient bed.
The authors and readers might read with interest an article
"Variability of the postauricular muscle complex - analysis of 40 hemi-cadaver dissections" by Guerra, et al., including myself. 3 This
identifies and analyzes variations in the patterns of the posterior
auricular muscle complex and the relations of the fascial contributions.
In our opinion, a signature thought would be to wrap a
orbital implant with a strong autogenous graft of the surgeon's choice
anteriorly to create a barrier between the implant and the overlying
conjunctiva and Tenon's capsule to significantly decrease the chance of
Our technique has been discussed in a presentation of the 9th
meeting of the European Society of Ophthalmic Plastic and Reconstructive
Surgery in Dublin, Ireland, 1991, a presentation at the 23rd annual
Scientific Symposium of the American Society of Ophthalmic, Plastic, and
Reconstructive Surgery in Dallas, Texas, 1992, and discussed as a
scientific video presentation at the annual meeting of the American
Academy of Ophthalmology, 1994.
1. Liao S.L., Kao S.C.S, Tseng J.H.S., et al. Surgical coverage of
exposed hydroxyapatite orbital implants with retroauricular
graft. Br J Ophthalmol 2005;89:92-95.
2. Naugle T.C., Lee A.M., Haik B.G., et al. Wrapping
orbital implants with posterior auricular muscle complex grafts. Am J
3. Guerra A.B., Metzinger S.E., Metzinger R.C., et al. Variability
postauricular muscle complex - analysis of 40 hemicadaver dissections.
Arch Facial Plast 2004;6:324-344.
Thomas C. Naugle Jr, M.D.
Department of Ophthalmology,
Tulane University School of Medicine,
New Orleans, LA, USA.