Table 3.

Intra-operative complications of lid-margin mucous membrane grafts

Site	Complication	Mechanism	Prevention	Management
Donor site	Excessive bleeding	Occurs secondary to deeper dissection, injuring muscle. Could increase further after patient is out of anesthesia as patient is not in a hypotensive state anymore	Precautions during general anesthesia	Pressure with gauze; Use of light cautery Clear the oral cavity of the blood clots, Admit the patient, because gag reflex is absent for the first view hours and aspiration of blood could occur; suture the wound with 6-0 polyglactin
Graft related	Button-holing of the graft	During the step to thin the graft, excessive thinning could lead to inadvertent button-holing	While thinning the graft, keep the hinge of the scissors flat over the graft instead of the sharp blades	Suture the gap in the tissue with 8-0 polyglactin; if the button-hole is towards the central portion of the graft, can ensure that division of the graft into parts is through the button-hole
	Under-sized graft horizontally (undersized graft vertically is not a problem unless the graft is <4 mm wide) [Fig. 7]	When the measurement of the raw bed is not done accurately; or miscalculation of the tissue required, ideal tissue size is 20 mm by 4-5 mm for each lid	Measure the raw de-epithelized bed on the lid margin, the oral mucosa should be marked and then excised accordingly	More tissue should be harvested from the oral mucosa and should be sutured to areas which need addressing of keratinization. Repeat MMG may be required in some eyes [Fig. 7]
Operated eye	Inappropriate positioning of the graft with postoperative posterior MMG [Fig. 7]	Initial cut too posterior to the gray line	Initial cut should be at the gray line, and if gray line is not discernable, should be just posterior to the lash line	If recognized intra-operatively, can address this at the same sitting by incising the lid margin at the right position. If recognized later, may cause early recurrence of LMK, which may need early repeat MMG [Fig. 7]

MMG=Mucous membrane graft; LMK=Lid margin keratinization