Comparative Analysis of the Nail Xenografts With Cartilage Autografts in Eyelid Reconstruction O ¨ zay O ¨ zkaya, MD,* Semra Kars ¸idag ˘, MD,Þ Onur Egemen, MD,* Arzu O ¨ zcan Akc ¸al, MD,þ Selami S ¸irvan, MD,Þ and Fevziye Kabukc ¸uog ˘lu, MD§ Objective: The tarsal plate is the skeleton support system of the eyelids; therefore, repair during eyelid reconstruction is crucial. Many autogenous graft materials have been proposed for the tarsal recon- struction, such as nasal cartilage, palatal mucosa, upper eyelid tarsus, and auricular cartilage. Nail thickness and shape are similar to the tarsal plate with enough support for the eyelid. It also easily integrates with host tissues. The aim of this experimental study was to macro- scopically and histopathologically compare nail xenografts with car- tilage autografts when used in eyelid reconstruction in rabbits. Methods: In total, 12 New Zealand rabbits were used in the ex- periment. Full-thickness defect with a 1-cm diameter was created in both upper eyelids. The right upper eyelids were used for carti- lage autograft reconstruction, and the left upper eyelids were used for nail xenograft reconstruction. All animals were killed on week 12 after eyelid reconstruction. After the animals were killed, the upper eyelids of the rabbits were resected for macroscopic and histologic analysis. Results: In histologic evaluation, moderate foreign body giant cell formation and moderate histiocytic, neutrophilic, basophilic, and lymphocytic infiltration were observed in both experimental group and control group. In addition, this marked fibrous capsule forma- tion was observed around the nail xenograft, which was absent in the cartilage autograft group. Conclusions: Nail has some advantages such as being cost-effective, being easy to obtain, and having less rejection risk for being com- posed of dead cells. Nail xenografts can be taken into account instead of cartilage grafts in eyelid reconstruction. Key Words: Nail, xenograft, eyelid reconstruction, cartilage graft, experimental study (J Craniofac Surg 2012;23: 1028Y1031) E yelid defects and malpositions can result from congenital or traumatic causes, or much more frequently, they can be caused by tumors. The goals of eyelid reconstruction are to provide struc- tural and functional restoration with an acceptable aesthetic result. The eyelid is divided into 2 main layers. The anterior lamella consists of skin and muscle, and the posterior lamella is formed by the tarsal plate and conjunctiva. 1,2 Reconstruction of the full- thickness eyelid defect requires 3 elements: an outer layer of the skin, inner layer of the mucosa, and a semirigid supporting struc- ture (acting as the tarsal plate) interposed between them. 3 Otherwise, correction of severe eyelid malpositions (such as anophthalmic socket syndrome) requires only posterior lamellar support with or without a tarsal plate spacer. 4 The tarsal plate is the skeleton support system of the eyelids; therefore, repair during eyelid reconstruction is crucial. The tarsal plates are approximately 25 mm long, 1 mm thick, and 10 and 4 mm in vertical height in the upper and lower eyelids, respectively. 4 Natural tarsus is specialized tissue that is neither purely fibrous nor cartilag- inous in composition. The tissue functions as the skeletal structure for the delicate mechanical properties of the lid. The tarsal plate is es- pecially important for vertical support and rigidity of the eyelid. If one were to eliminate it, an eyelid would conceivably flop. This vertical supportive task is important and fundamental in maintaining the upper eyelid 2 mm below the superior limbus on forward gaze, and the lower eyelid at or 1 mm above the inferior limbus. 5 Substitute materials necessary to correct lid function are limited because of the hybrid composition of this unique tissue type. Nail thickness and shape are similar to the tarsal plate with enough support for the eyelid. It also easily integrates with host tis- sues. Features such as semihard structure, having saving shape mem- ory such as cartilage, containing no live cells, being easily available, causing no donor-site morbidity because of regenerating after re- moval of nail even if used as autogen without being obtained from a cadaver, and not prolonging operation time made us to think of the nail for use as a xenograft. Preliminary study on the durability of nail as a xenograft was investigated in this laboratory with successful re- sults. 6 From the result of literature research we have conducted, no study is available in the literature in which nail xenografts were used in tarsal reconstruction. The objective of this study was to carry out a comparative analysis of macroscopic and histologic changes of cartilage auto- grafts with nail xenografts in reconstructed upper eyelids from the same rabbit when these grafts were used as a spacer for tarsal plate in posterior lamella reconstruction. ORIGINAL ARTICLE 1028 The Journal of Craniofacial Surgery & Volume 23, Number 4, July 2012 What Is This Box? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code links to the online version of the article. From the *Department of Plastic Reconstructive and Aesthetic Surgery, Okmeydanı Training and Research Hospital; †Department of Plastic Reconstructive and Aesthetic Surgery, S ¸is ¸li Etfal Training and Research Hospital, Istanbul; ‡Department of Plastic Reconstructive and Aesthetic Surgery, Kilis State Hospital, Kilis; and §Department of Pathology, S ¸is ¸li Etfal Training and Research Hospital, Istanbul, Turkey. Received October 11, 2011. Accepted for publication January 31, 2012. Address correspondence and reprint requests to O ¨ zay O ¨ zkaya, MD, Department of Plastic, Reconstructive and Aesthetic Surgery, Okmeydanı Training and Research Hospital, Istanbul, Turkey 34384; E-mail: oozozay@yahoo.com The authors report no conflict of interest. Copyright * 2012 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e31824dfa49 Copyright © 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.