THE USE OF AUTOGENOUS FASCIA LATA

TO CORRECT LID AND ORBITAL

DEFORMITIES

BY Joseph C. Flanagan, MD, AND (BY INVITATION)

Charles B. Campbell, MD

FASCIA LATA IS A TRILAMINAR FIBROUS TISSUE SHEATH THAT ENVELOPS THE MUSCLE
groups -of the thigh. The iliotibial band is the conjoint aponeurosis of the
tensor fascia lata and the gluteus maximus with vertically oriented fibers
extending from the anterior superior iliac spine to the lateral condyle of
the tibia. Histologically, fascia lata is composed of a collagen matrix with
fibroblasts and elastic tissue. The relative acellularity and low nutritional
requirements make it suitable for grafting. Its fibrous sheetlike nature
permits it to be cut and shaped as required in reconstructive procedures.
Fascia lata is readily available to the experienced ophthalmic surgeon and
is, therefore, used as a structural element in a variety of ophthalmic
procedures.

HISTORICAL CONSIDERATIONS
Payr' is credited with pioneering the use of autogenous fascia in the
correction of congenital ptosis by suspending the tarsus from the frontalis
muscle. The follow-up period was only 1Y2 years and Payr made no com-
ment on the characteristics of fascia. In 1922 Wright2 described a similar
technique for the correction of congenital ptosis using autogenous fascia.
Follow-up was slightly over one year and he commented that his method
was at least as good as any other available procedure. In 1928 Derby3
described an autogenous fascia lata hammock for ptosis of unspecified
etiology. He credited Machek4 and Reese5 with the concept of frontalis
suspension of the ptotic upper lid. Follow-up was four years and the
results were reported as excellent. Crawford6 in 1956 presented the first
large series of patients where autogenous fascia lata was utilized to sus-
pend the upper lid from the frontalis muscle in the correction of ptosis.
TR. AM. OPHTH. Soc. vol. LXXIX, 1981
228 Flanagan
Crawford7 later compared tissue reaction to autogenous and homologous
fascia in New Zealand white rabbits and found it to be equal. He also
compared tissue reaction to fresh homologous and radiated homologous
fascia and found no difference. He performed an ingenious three week
study on fresh fascial homografts taken from male rabbits and implanted
into female rabbits and vice versa. At the end of three weeks he harvested
the grafts and studied the fibroblasts in tissue culture. Based on the
presence or absence of sex chromatin he was able to demonstrate that the
transplanted connective tissue cells had survived in -the host. His clinical
impression was that fresh autogenous, homologous and irradiated fascia
are equally useful in the frontalis suspension procedure. He observed that
fresh fascia is a desirable material because there is no tissue reaction or
rejection and it maintains tensile strength.
Preserved homologous fascia lata may be used in patients when autoge-
nous fascia is not available. Yasuna8 observed in 1962 that there was no
clinical difference in the frontalis suspension procedure when either au-
togenous or homologous fascia was utilized.
Crawford9 presented a 20 year review of 316 cases of ptosis, 189 of
which were corrected with autogenous fascia and 127 of which were
corrected with preserved homologous fascia. He reported that the fresh
autogenous tissue was preferable, caused less tissue reaction and was less
likely to be absorbed.
Blair10 utilized a strip of fascia lata to support the lower lid in ectropion
caused by seventh nerve palsy. Brenizer"l reported on the use of fascia
lata as a sling for an ectropic lower lid in 1940. Vistnes, Iverson and
Laub12 presented a series of patients with laxity of the lower lid after
enucleation, corrected with autogenous fascia lata suspension of the lower
lid from medial and lateral orbital rims. A similar procedure was reported
by Elliott'3 for correction of involutional entropion of the lower lid. Rizk
and Mishra14 presented a series of 62 cases of involutional entropion
successfully treated with bovine fascial suspension of the lower lid. The
cosmetic result in all of these cases was reported to be satisfactory.
Crawford7 reported the use of fascia for volume replacement in an
enucleated orbit after implant extrusion. Cutler15 in 1946 presented a
series of 134 patients with superior sulcus deformity after enucleation in
whom he had placed autogenous fascial grafts to the preseptal space of the
upper lid. He observed good cosmetic results and in one patient obtained
autopsy material from the grafted lid. The pathologist observed that there
was viable fascia without necrosis but with granulomatous inflammation
and foreign body giant cells.
Progressive sclerectatic myopia treated with autogenous fascia lata re-
 Autogenous Fascia Lata 229.
inforcement of the posterior globe was reported by Shevelev'6 in 1930.
Curtin17" 8 described the use of both autogenous and homologous fascia
grafts to construct a posterior periscleral ring and to reinforce ectatic
sclera in progressive myopia in 1961. He performed animal experiments
which demonstrated that both autogenous and homologous grafts were
tolerated by the globe, incited little tissue reaction and were equally
successful in supporting the posterior sclera. Nesterov and Libenson19
presented a large series of patients where progressive myopia was halted
by using fresh autogenous fascia. It was their clinical observation that
autogenous fascia was well tolerated by the globe.
Armstrong and McGovern20 successfully used fascia lata as a patch graft
in scleromalacia perforans in 1955. Bick,22 Taffet and Carter"2 Blum and
Salamoun,23 Bowers and Arnold,24 and Torchia, Dunn and Pease25 later
reported the same procedure with good clinical results.
Havener and Olson26 in 1962 described the use of fascia lata in retinal
detachment surgery. They found that preserved homologous fascia elimi-
nated the occurrence of infection and erosion encountered with synthetic
encircling bands. They made the clinical observations that the fascia is
incorporated into the wall of the eye, is invaded by connective tissue and
does not incite significant immunologic response.
Bertelsen and Syversen27 used fascia lata as an autogenous collar to
support a keratoprosthesis. The prosthesis is implanted into fascia lata and
harvested two to three months later, at which time the prosthesis and its
fascial collar are sutured into the host cornea.
In addition to the above, the authors have used autogenous fascia lata
for the correction of thyroid lid retraction, cicatricial entropion and as a
patch graft in orbital implant extrusion.

HARVESTING OF FASCIA LATA GRAFT

Fascia lata can be harvested under local or general anesthesia. With the
leg flexed at the knee and intorted at the hip, the iliotibial band is easily
palpated along the line extending from the anterior superior iliac spine to
the lateral condyle of the tibia (Fig 1A). A 3 cm incision is made approxi-
mately 10 cm superior to the lateral condyle (Fig 1B). The dissection is
carried down through skin and subcutaneous fat to the fascia (Fig 1C). If a
thin sheet of fascia is needed, the harvest is anterior to the iliotibial band
and if a thick fibrous strip is required a segment of iliotibial band is
harvested. In either event the required amount of fascia is sharply incised
(Fig 1D) and undermined with scissors (Fig 1E). In this manner a rela-
tively avascular plane is maintained and bleeding is prevented. The des-
 230 Flanagan

FIGURE 1
A: Leg flexed at the knee and intorted at the hip. B: Three centimeter incision 10 cm
superior to the lateral condyle. C: Skin and subcutaneous fat retracted exposing fascia. D:
Incising fascia with a No 15 Bard-Parker blade. E: Undermining fascia with scissors. F:
Excision of fascial strip with scissors.

ignated fascia is harvested (Fig 1F) and after hemostasis is obtained, the
wound is closed with deep vertical mattress and simple interrupted skin
sutures.
LID RETRACTION SECONDARY TO THYROID OPHTHALMOPATHY

Eyelid retraction is one of the signs of thyroid ophthalmopathy. It can

involve the upper and/or the lower eyelids and can be unilateral or
 Autogenous Fascia Lata 231

..... ......

FIGURE 2
A: Upper lid everted on a Desmarres lid retractor and superior tarsal border is identified
(black arrow). B: Small buttonhole incision through conjunctiva and Muiller's muscle at
upper tarsal border. C: Passage of an inis spatula in the natural plane between Muiller's
muscle and the levator aponeurosis. D: Conjunctiva and Muiller's muscle (black arrow)
dissected fr-om the levator aponeurosis (black arrow head).

bilateral. Henderson28 advised recession of conjunctiva and Miller's

muscle of the upper eyelid in cases of upper lid retraction and we have
modffied his technique by interposing a fascia lata graft between the
superior tarsal border and the recessed tissues. This stabilizes the reces-
sion and prevents recurrence of upper lid retraction in most cases. We
have used sclera for our interposed graft in the past but now prefer the
use of fascia.
The upper lid is everted on a Desmarres lid retractor and the superior
tarsal border is identffied (Fig 2A). A small buttonhole incision is made
through the conjunctiva and Muiller's muscle and an iris spatula is in-
serted and passed nasally and temporally in the plane between Muiller's
muscle and the levator aponeurosis (Fig 2B). One blade of the scissors is
placed in this plane and the conjunctiva and Muiller's muscle are dissected
232 Flanagan

FIGURE 3
A: Lower lid everted on a Desmarres lid retractor and a buttonhole incision is made through
the conjunctiva and the capsulopalpebral head of the inferior rectus muscle. B: Conjunctiva
and retractors are dissected from the lower tarsal border. C: Conjunctiva and retractors
(black arrow) dissected from orbital septum (black arrow head).
 Autogenous Fascia Lata 233
from the superior tarsal border (Fig 2C). The incision is extended for the
full extent of the tarsal plate. Conjunctiva and Muller's muscle are then
bluntly dissected from the levator aponeurosis for a distance of 8 mm
using cotton-tipped applicators (Fig 2D). The defect is filled with an
ellipse of fascia. We utilize 2 mm of fascia vertically for every 1 mm of
desired correction. The graft is sutured,with a running 7-0 vicryl suture
and the knot is placed at the temporal aspect of the wound. The lid is then
returned to its anatomic position and a light dressing is applied. Ice
compresses are started immediately to minimize swelling.
A similar procedure is performed for lower lid retraction. The lower lid
is secured on a Desmarres lid retractor and a buttonhole incision is made
through the conjunctiva and capsulopalpebral head of the inferior rectus
muscle adjacent to the inferior tarsal border (Fig 3A). A spatula is inserted
in the plane between the capsulopalpebral head of the inferior rectus and
the orbital septum. The conjunctiva and retractors are then dissected
from the tarsus and reflected inferiorly (Fig 3B). The remainder of the
dissection is performed with cotton-tipped applicators (Fig 3C). After
hemostasis is achieved the previously harvested fascia is trimmed to the
proper horizontal dimension and width to insure 2 mm of fascia for every
1 mm of lid retraction for which correction is sought (Fig 4). The graft is
sutured with a running 7-0 vicryl suture and the knot is tied at the
temporal aspect of the graft. The lid is returned to its anatomic position
and a light patch applied. Ice compresses are started immediately.

CASE REPORT

A 37-year-old female with an 11 year history of bilateral thyroid ophthalmopathy

presented with 5 mm of upper lid retraction and 2 mm of lower lid retraction (Fig
5A). Her complaints included bilateral foreign body sensation and cosmetically
unacceptable stare. Objective findings included bilateral lid retraction, lag-
ophthalmos and punctate keratopathy. She had a recession of the retractors of the
right upper lid with a 10 mm fascia graft, combined with a recession of the right
lower lid retractors with a 5 mm fascia graft. Her appearance one week post-
operatively is seen in Fig 5B. Traction sutures are occasionally left in place for one
week if the lid retraction is severe. Figure 5C shows her appearance four months
after the right side and one month after the left side was corrected. Her eyes now
close during sleep and the punctate keratopathy has cleared.

CICATRICIAL ENTROPION
Entropion caused by fibrosis and vertical shortening of the posterior lid
lamella of either the upper or lower lid is a vexing problem for both
234 Flanagan

FIGURE 4
Trimming fascial strip to proper length and height.

patient and surgeon. This condition can be a consequence of chemical

bums, ocular Stevens-Johnson syndrome, trachoma, pemphigoid and a
variety of ptosis and lid sharing procedures. The surgical technique to
restore the vertical dimension of the posterior lid lamella is similar to the
technique employed for the correction of lid retraction secondary to
thyroid ophthalmopathy.
CASE REPORT

A 64-year-old man sustained a moderate acid bum to the eye with contracture of
the posterior lamella of the lower lid (Fig 6A) with consequent persistent ocular
irritation as seen in Figure 6B. He underwent vertical lengthening of the poste-
rior lamella (Fig 6C) with an interposed fascia lata graft. Figure 6D shows the
appearance of the lid and eye one year postoperatively.

EXTRUDING ORBITAL IMPLANTS

Faulty wound closure and postoperative hemorrhage or infection are the

most common causes of acute orbital implant extrusion. Tissue intol-
erance to the alloplastic implant is the main cause of intermediate orbital
 Autogenous Fascia Lata 235r

. ........ ... .- 1- ..

FiGURE 5
A: Patient with thyroid ophthalmopathy showing 5 mm of upper lid retraction and 2 mm of
lower lid retraction. B: Appearance of patient one week postoperatively with traction suture
in place. C: Postoperative appearance, four months on the right side and one month on the
left side.
236 Flanagan

FIGURE 6
A: Contracture of the posterior lamella of the lower lid secondary to a chemical burn. B:
Ocular irritation from trichiasis secondary to chemical burn. C: Recession of conjunctiva and
retractors of lower lid. D: Appearance of lid and eye one year postoperatively.

implant extrusion. A poorly fitted prosthesis that does not adequately

vault the conjunctiva overlying the orbital implant will cause erosion of
the conjunctiva and late implant extrusion. Appropriate implant selection
and meticulous wound closure combined with a properly fitted prosthesis
are the best ways to avoid orbital implant extrusion. We have treated
patients with implant extrusion by unroofing the fibrous capsule that
generally forms around the implant, inserting a smaller sphere without
integrated components and suturing a circular shaped piece of fascia to
the fibrous capsule. We suture the incised conjunctival border to the
anterior surface of the fascial graft and allow the rest of the conjunctival
defect to epithelialize over the fascial graft. A high vaulted conformer is
placed at the time of surgery and a new prosthesis can be fitted one month
post-operatively.
CASE REPORT

The 60-year-old man seen in Figure 7A lost his left eye in an industrial accident
and had worn the same prosthesis for 20 years. He presented with chronic
discharge, contracture of the upper and lower cul de sacs and inability to retain
 Autogenous Fascia Lata 237

FIGURE 7
A: Contracted socket with a heavy mucoid discharge. B: Thin conjunctival covering with a
small dehiscence (black arrow). C: Postoperative appearance of socket after insertion of a
smaller implant and an autogenous fascia lata graft.
238 Flanagan
his prosthesis. A defect in the very thin conjunctival suiface over the implant was
observed (Fig 7B). He was treated as described above and his socket with good cul
de sacs superiorly and inferiorly is seen in Fig 7C. He now wears his prosthesis
with comfort.

DISCUSSION

Fascia lata has been used by ophthalmic surgeons in all of the subspecialty
surgical fields of ophthalmology with good results for many years. It
serves as an excellent material for grafting when performing oculoplastic
procedures. Many ophthalmic surgeons prefer to use homologous stored
fascia lata because a surgical procedure is not necessary on the recipient's
leg. This necessitates less operating time and gives some ease of mind to
the surgeon who is not familiar with the anatomy and physiology of the
leg. Crawford7 and Yasuna8 have pointed out that there is no clinical
difference in performing a frontalis suspension procedure to correct ptosis
with autogenous or homologous fascia. Crawford7 has pointed out, how-
ever, that fresh autogenous fascia lata is a more desirable material because
there is minimal to no tissue reaction or rejection and it maintains its
original tensile strength. Both types of fascia are excellent, however,
because of the relative acellular nature and the low nutritional require-
ments of fascia. The fibrous sheetlike nature of fascia permits it to be cut
and shaped as required in any type of reconstructive procedure. When
autogenous fascia lata is utilized it can be harvested under local or general
anesthesia.
Autogenous fascia lata was utilized in all of the cases discussed in this
paper. All but one case was performed under general anesthesia and the
average increase in operating time was approximately one half hour.
When surgery is necessary on both eyes it is performed at one sitting, so
as to require only one leg incision. A nonadhesive dressing is placed over
the leg wound and is left in place for one week. The leg sutures are
removed on the 14th postoperative day. The only leg complication in 39
consecutive cases was a hematoma, which responded to conservative
measures. The patients are allowed full weight bearing on the first post-
operative day; however, we caution them against strenuous exercise for at
least two weeks.
We have had no complications attributable to the use of fascia as a graft
material. The follow-up period ranged from three years to two months.
The fact that there is minimal host reaction to and absorption of autoge-
nous fascia minimizes the possibility of over and under correction, espe-
cially when correcting thyroid lid retraction. The surgeon can determine
preoperatively the amount of fascia to be used by measuring the distance
between the limbus and the lid border. The use of 2 mm of fascia for each
millimeter of desired correction has worked well and has proven to be a
reliable guide. When sutured to the inside of an eyelid the fascia does not
 Autogenous Fascia Lata 239
have to be covered by conjunctiva because spontaneous epithelialization
occurs within a short period of time and irritation of the cornea does not
occur. This is a significant consideration in the correction of lid retraction
secondary to thyroid ophthalmopathy and cicatricial entropion of the
upper or lower lid. Antibiotic ointment is generally instilled in the oper-
ated eye four times a day for one week as a prophylactic measure.

SUMMARY

Autogenous and homologous fascia lata have been used to correct many
problems in ophthalmic surgery. This paper has described the use of
autogenous fascia lata to correct lid retraction secondary to thyroid oph-
thalmopathy, cicatricial entropion and extruding orbital implants. The
surgical procedures have been briefly discussed, as well as the presenta-
tion of one clinical example of each procedure. The pathologic and immu-
nologic aspects of fascia lata grafts will be reported at a later date.

REFERENCES
1. Payr E: Plastick mittels freies faszientransplantation bei ptosis. Med Verein Greipwald
Deuthsche Med Wchnschi 35:822, 1908.
2. Wright WW: The use of living sutures in the treatment of ptosis. Arch Ophthalmol
51:99, 1922.
3. Derby GS: Correction of ptosis by fascia lata hammock. Am J Ophthalmol 11:352-354,
1928.
4. Machek P: An operation for ptosis. Arch Ophthalmol 44:539-544, 1915.
5. Reese RG: An operation for blepharoptosis. Trans Am Ophthalmol Soc 21:71-78, 1923.
6. Crawford JS: Repair of ptosis using frontalis muscle and fascia lata. Trans Am Acad
Ophthalmol Otolaryngol 60:672-678, 1956.
7. Crawford JS: Fascia lata: its nature and fate after implantation and its use in ophthalmic
surgery. Trans Am Ophthalmol Soc 66:673-745, 1968.
8. Yasuna E: Use of prepared fascia lata in correction of ptosis. Am J Ophthalmol
54:1097-1103, 1962.
9. Crawford JS: Repair of ptosis using frontalis muscle and fascia lata: A 20 year review.
Ophthalmic Surg 8:31-40, 1977.
10. Blair VP: Operative correction of facial palsy. South Med J 19:116, 1926.
11. Brenizer AG: Skin and fascia grafting. Am J Surg 47:265-279, 1940.
12. Vistnes LM, Iverson RE, Laub DR: The anophthalmic orbit. Surgical correction of
lower eyelid ptosis. Plast Reconstr Surg 52:346-351, 1973.
13. Elliott RA: Correction of senile entropion with fascia lata graft. Plast Reconstr Surg
29:698-701, 1962.
14. Rizk SNM, Mishra AK: Surgical correction of senile entropion of the lower lid with
fascia lata sling. Brit J Ophthalmol 63:117-119, 1979.
15. Cutler NL: Fascia lata transplant for retrotarsal atrophy of upper lid following enuclea-
tion. Am J Ophthalmol 29:176-179, 1946.
16. Shevelev MM: Russ Ophthal 11:107, 1930.
17. Curtin BJ: Surgical support of posterior sclera Part I. Experimental results. Am J
Ophthalmol 49:1341, 1960.
18. Curtin BJ: Scleral support of posterior sclera Part II. Clinical results. Am J Ophthalmol
52:833-862, 1961.
240 Flanagan
19. Nesterov AP, Libenson NB, Svirin AV: Early and late results of fascia lata transplan-
tation in high myopia. Brit J Ophthalmol 60:271-272, 1976.
20. Armstrong K, McGovern VJ: Scleromalacia perforans with repair grafting. Trans Oph-
thalmol Soc Australia 15:110, 1955.
21. Bick MW: Surgical treatment of scleromalacia perforans. Arch Ophthalmol 61:907,
1959.
22. Taffett S, Carter GZ: The use of fascia lata graft in the treatment of scleromalacia
perforans. Am J Ophthalmol 52:693, 1961.
23. Blum FG, Salamoun SG: Scleromalacia perforans. Arch Ophthalmol 69:287-289, 1963.
24. Bowers J, Arnold IL: Necrotizing scleral degeneration treated with graft of autogenous
fascia lata. J Tenn Med Assoc 63:846-848, 1970.
25. Torchia RT, Dunn RE, Pease PJ: Fascia lata grafting in scleromalacia perforans with
lamellar corneal-scleral dissection. Am J Ophthalmol 66:705-709, 1966.
26. Havener WH, Olson RS: Encircling fascia lata strips for retinal detachment. Arch
Ophthalmol 67:721-726, 1962.
27. Bertelsen TI, Syversen K: Experience with keratoprosthesis. Acta Ophthalmol (Suppl)
120:45-51, 1973.
28. Henderson JW: Relief of eyelid retraction: a surgical procedure. Arch Ophthalmol
74:205-210, 1965.

DISCUSSION
DR BYRON SMITH. The society is grateful to Doctors Flanagan and Campbell for
their diligent review of the literature and summarization of the use of fascia in
restoration of orbital lid deformities. Their good results confirm reports by pre-
vious investigators.
The authors have described the implantations of fascia as a conjunctival sub-
stitute and means of maintaining recession of the eye lid retractors. It is interest-
ing to note that they make no effort to cover the fascial implant with conjunctiva.
My experience differs in that I have always made an effort to place implants deep
in the conjunctiva whenever possible. Unfortunately, other colleagues as well as
myself have encountered corneal irritation, particularly in upper lid implants.
The use of fascia as well as other tissues to cover the surface of extruding of
migrated implants is a good temporizing measure. The health and longevity of
fascia and other tissues over an implant is dependent upon good circulation and
the absence of pressure from the overlying prosthetic device. Erosion through
fascia and other tissues covering an extruding implant caused me to resort to
autogenous dermal fat implantation rather than temporized with fascia and other
substitutes in most instances.
For frontalis suspension I have continued to use materials other than fascia.
Although the knots in fascia are bulky and cause local edema and irritation, time
usually corrects this disadvantage. It should be emphasized that the knots in the
fascia should be well secured and covered with a good layer of recipient
integument.
My observations of buried fascia used in ptosis surgery substantiates its lasting
results and low incidence of late complications. Not within the realm of this paper
is the fact that any type of frontalis fixation in ptosis surgery is an undesirable
solution if levator surgery is feasible.
 Autogenous Fascia Lata 241
We look forward to the future report by Doctor Flanagan on the pathologic and
immunologic aspects of fascia lata grafts.
DR JOHN S. CRAWFORD. I have enjoyed Doctor Flanagan's paper and I am pleased to
hear that he is advocating the use of fresh autogenous fascia as being preferable to
stored human or bovine fascia.
I have found that autogenous fascia is 100% successful in ptosis repair with no
rejection. Poor surgical results with autogenous fascia are the fault of the surgeon
and not because of rejection of the tissue. Bovine fascia has a high failure rate and
is unsatisfactory for use in humans. Stored human fascia sterilized with Cobalt 60
does save time but I have found a 10% failure rate. In these cases the stored fascia
placed in the ptotic lid is absorbed in from two to three months postoperatively.
Other uses for fascia lata include: (1) a sling to hold up ptotic lower lids. Here
the fascia is attached to the medial canthal region, passed under the skin of the
lower lid and secured to a hole in the orbital rim above and lateral to the outer
canthus. (2) Another important use for autogenous fascia is in the repair of ex-
truding implants. Three strips of fascia are placed under the conjunctiva 'covering
the extruding implant. One strip is placed from the 9 to 3 o'clock position, the
second from 7:30 to 1:30, and the third from 4:30 to 10:30 positions. The con-
junctiva is dissected free and brought over the fascia centrally. Autogenous fascia
is preferred in these cases.
I appreciate the opportunity of discussing this excellent paper.
DR D. DOUGHMAN. I appreciate hearing this discussion. As a corneal surgeon, I get
involved in this problem of trying to best advise patients on lid retraction prob-
lems and what to do. I would like Doctor Flanagan to tell us about his long-time
follow-up. A second question is, why not use sclera rather than fascia lata?
DR JOSEPH C. FLANAGAN. I would like to thank Doctor Byron Smith for his excellent
discussion. In answer to one question that Doctor Smith brought up, should you
make an incision through the skin and use the external approach or should you go
through the conjunctiva in an internal approach? The external approach does have
the advantage of leaving the conjunctiva intact and it does, therefore, possibly
give you a more comfortable patient in the early postoperative period.
I have used both sclera and fascia for approximately eight to ten years now and
by just recessing the conjunctiva and Muiller's muscle of the upper lid and sutur-
ing it in place generally we have a comfortable patient with no corneal staining.
However, we have had times where we kept a patient in the hospital for an extra
day or two because of an uncomfortable corneal abrasion. Whether you use sclera
or fascia spontaneous epithelialization does occur over the graft surface in approx-
imately one week.
I felt very timid giving a talk on fascia in front of Doctor Crawford. My bibliog-
raphy looks like his curriculum vitae and if anybody knows anything about fascia
Doctor Crawford is certainly the one and I thank him for his comments.
242 Flanagan
Doctor Doughman, we have used sclera on many occasions over the past 12
years. I used sclera initially because I was timid about harvesting the fascia
myself. I had a fellow who had taken a year of general plastic surgery before going
into ophthalmology and after working with him for a year I felt very comfortable
obtaining the fascia. The fellow or resident harvests the fascia and, therefore, the
operating time really is not increased. With direct reference to sclera, it is an
excellent graft material and for very young individuals where you wouldn't want
to make a leg incision sclera works well. The one fear that I have with sclera that
no one mentioned is that in sclera there is uveal pigment and I was always
concerned about the possibility of some type of sympathetic uveitis. We have
used sclera for years and have not experienced any serious complications. Autoge-
nous fascia lata produces less reaction and swelling and recently I have preferred
its use over sclera.