Tavşan alt göz kapağı posterior lamella defektlerin onarımında; ven-arter duvar greftleri, palatal-bukkal mukozal greftler ile onarımı ve sonuçlarının kıyaslanması /
Yazar: AYDIN AYDEMİR
Danışman: DR. ÖĞR. ÜYESİ SERKAN ERBATUR
Dicle Üniversitesi / Tıp Fakültesi / Plastik Rekonstrüktif ve Estetik Cerrahi Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2021
Konu: Plastik ve Rekonstrüktif Cerrahi = Plastic and Reconstructive Surgery
Dizin: Cerrahi-plastik = Surgery-plastic ; Göz kapakları = Eyelids ; Göz kapağı hastalıkları = Eyelid diseases ; Rekonstrüktif cerrahi prosedürleri = Reconstructive surgical procedures ; Tavşanlar = Rabbits ; Transplantlar = Transplants

Özet:
Amaç:
Çalışmamızın hipotezi literatürde eksik gördüğünüz şu ana maddeleri test etmek, literature yeni bir otojen greft seçimi kazandırmak amacıyla oluşturuldu 

1)Literatürde en sık kullanılan mukozal membran greftlerin 2 üyesi  sert damak mukozal greft ve bukkal mukoza greftlerin spontan epitelizasyona ya da konjonktival metaplazik diferansiasyon uğrayıp uğramadı uğruyorsa kantitatif objektif olarak histopatolojik olarak göstermek(9).
 
2) Bulbo-korneal hasar miktarını ve şiddetini  hasta semptomları gibi  subjektif  kriterlerle bildirilmiş literatürün aksinine  Kantitatif-objektif korneal boyama yöntemi ve biyomikroskobik inceleme,fotoğraflamak ve korneal opositenin patolojik doğasını ve şiddetini oposite gredlemesi ile evrelemek 

3)Ven duvar grefti  ve Arter duvar greftinin ile ilgili literatürde yapılan çalışmalarda yazarlar tarafından bildirilmemiş ve çalışılmamış vaküler greflerin  endotel yapısının   post-op  histolojik  değişimleri  saptamak ve kantitatif objektif olarak göstermek 

4) Ven duvar  grefti  ile ilgili literatürde yapılan tüm  çalışmalarda bu yapının tarso konjonktival yapı replasmanı amacıyla  kullanıldığı belirtilmiş ,fakat tarso konjuktival yapı posterior  lamellanın sadece bir komponenti dir . Rekonstrüksiyon da mutlaka göz önünde bulundurması gereken kapsülo palpebral fasiya, inferior tarsal kas  ve orbital septum dan  bahsedilmemiştir  biz bu çalışmada bu yapıları da  içerecek şekilde Total posterior lamellar defekt onarımında kullanarak  sonuçların  öncekilerle verilerle  kıyasla, aynı olup olmadığı  saptanmaya çalışılacaktır(43-44).

5) İdeal sonuçları bildirilen    ven duvar greftine  histoanatomik olarak avantajlı olabileceği düşündüğümüz arter duvar greftinin ideal greft  özelliklerini test ederek sonuçları objektif olarak ortaya koymak

Abstract:
Aim and hypothesis

The hypothesis of our study was created in order to test the following main a new autogenous graft selection to the literature

1) To demonstrate objectively whether the hard palate mucosal graft and buccal mucosal grafts undergo spontaneous epithelization or conjunctival metaplasic differentiation in two members of the most frequently used mucosal membrane grafts in the literature (9).
 
2) Contrary to the literature reported with subjective criteria such as the amount and severity of bulbo-corneal injury, quantitative-objective corneal staining method and biomicroscopic examination, photographing and staging the pathological nature and severity of the corneal opocyte by opocytosis

3) To determine post-op histological changes in the endothelial structure of vacular grafts that were not reported and studied by the authors in studies conducted in the literature on vein wall graft and arterial wall graft, and quantitatively demonstrating objectively.

4) In all the studies in the literature about vein wall graft, it was stated that this structure was used for tarso conjunctival structure replacement, but the tarso conjunctival structure is only one component of the posterior lamellae. Capsulo palpebral fascia, inferior tarsal muscle and orbital septum, which must be taken into consideration in reconstruction, are not mentioned.

5) To objectively reveal the results by testing the ideal graft properties of the arterial wall graft, which we think may be advantageous histoanatomically to the vein wall graft, whose ideal results are reported

Method


The study group was formed from a total of 16 lower eyelids, 16 non-operated contralateral eyelids were formed. The rabbits were divided into 4 groups with 4 paws. Hard palate mucosal graft was inserted in 4 lower eyelids, Buccal mucosal graft in 4 lower eyelids, Vein wall grafts in 4 lower eyelids, Arterial wall grafts were inserted in 4 lower eyelids Our study was carried out in 2 steps chronologically. 
1-To create a posterior lamella defect in the lower eyelid and to reconstruct it with the obtained graft materials     2- 6 weeks from graft insertion (29). then examining the corneal staining result with a biomicroscope of the eyes and eyelids, photographing the results and staging them according to the amount of corneal opacity. Taking the subject group eyelids and the contralateral eyelids of the control group, which we grafted in the same session, with the excisional biopsy principle and examine them histopathologically.
Findings
Mucous membrane grafts (buccal-hard palate mucosal graft) cause diffuse neovascularization in the whole eye and more severe fibrosis in the graft trace, resulting in increased corneal opacity: 37.5% (n = 3) stage4 37.5% (n = 3) Stage 3, 25% (n = 2) was evaluated as stage 2. In 75% of the subjects, stage 3-4 was evaluated as severe and very severe.
In all grafts, 100% (n = 8) no conjunctival epithelium and goblet cells were found and were completely covered with fibrosis and gronulation tissue: scored as NONE (0)
It was found that endothelial-cell Covered Membrane Grafts did not cause neovaculatory, fibrosis and corneal opacity increase in the eye. This finding was observed in 100% (n = 8) in all subjects. In opacity grading, Stage 0: Cornea was evaluated as completely transparent.
All grafts were covered with 100% (n = 8) total conjunctival epithelium including goblet cells: scored as PRESENT (1)

Result 

Endothelial-cell Lined Membrane Grafts, compared to Mucous Membrane Grafts, as a result of our findings in both literature and our study with objective quantitative parameters.
1- Surgical technique is easy and can be taken repeatedly in the desired amount
2- Almost no morbidity and no complications in the donor area
3-Due to its soft, thin, transparent, flexible features, it does not prevent ocular mobility, has a high rate of viability as a graft, cosmetic and functional leveling on the eyelid both internally and externally, asymmetry, mass effect does not cause deformity and frost suture, no need for eyelid closure.
4- No corneal damage during the period until spontaneous conjunctival epithelization occurs with its smooth, non-keratinized endothelial cover.
5-Can be used simultaneously and with sufficient amount of autogenous grafts in all indications in bulbar conjunctiva reconstruction, posterior lamella total reconstruction in Fornix reconstruction.
6- Because of their sterile floral they do not cause infections and do not induce chronic inflammation 
Endothelial-cell Lined Membrane Grafts have been evaluated as ideal due to their full histoanatomical analogical relationship with the vital posterior lamella and their excellent cosmetic and functional results. 
Keywords: Eyelid reconstruction, Posterior lamella reconstruction, Arterial wall graft, Vein wall graft