Dermis Fat Graft to treat Contracted Socket
What is a Contracted Socket?
Fibrosis of the anopthalmic socket (bony socket, in which there is no eye, post eye loss / eye removal surgery) with subsequent volume loss, mucosal lining deficit and malposition of eyelids leading to varied degrees of disfigurement and difficulty to maintain an ocular prosthesis / artificial eye.
THE TECHNIQUES of eye socket reconstruction include methods to deepen both the superior and inferior fornices. The main aim of oculoplastic reconstructive surgery procedures is to allow the socket to maintain a prosthetic eye which has a satisfactory cosmetic appearance and, if possible, good motility.
The eye socket reconstruction is the recreation of the normal eye appearance in patients who have diseased eyes that require removal of the eye. Eye socket reconstructive surgery may also be needed post facial trauma, which disfigures or damages the eye. A contracted socket involves volume & surface replacement with a Dermis Fat Graft and the subsequent wear of a customized prosthesis that looks like the other eye.
Dermis Fat Graft:
The Autogenous dermis-fat graft (DFG), composed of dermis and appended subcutaneous fat (harvested from your own buttock fat), is one of the many alternatives available for orbital volume augmentation in an anophthalmic socket. In adults, unpredictable fat reabsorption poses a serious drawback to this technique; whereas in children, the composite DFG demonstrates continued growth along with the surrounding orbital tissue, thereby stimulating orbital development and maintenance of lost orbital volume after enucleation.
You may currently have just a hole in the place of where your eye was (no eye), but you can have an artificial eye, which looks and behaves just like your lost eye. No one needs to know you have lost an eye.
- First the scleral shell (remnant of the damaged eye, if present) is removed by transection of the optic nerve after imbricating the four recti muscles with 6-0 vicryl sutures, thus converting the evisceration into an enucleation.
- Hemostasis is obtained with pressure and mild wet-field cautery.
- Orbital soft-tissue reconstruction is then done with DFG obtained from the left gluteal (buttock) region.
- After raising the epidermis with a subcutaneous injection of xylocaine with epinephrine, an elliptical skin incision is made.
- The epidermis is dissected away from the underlying dermis by a combination of sharp and blunt dissection.
- Subsequently, a 20×20mm area of dermis with underlying fat is harvested.
- The gluteal wound is closed with interrupted 4-0 vicryl sutures.
- The dermis-fat graft is then inserted into the orbital socket cavity with the dermis layer anteriorly and the fatty side posteriorly oriented.
- The extraocular muscles and conjunctiva are sutured into the border of the dermis-fat graft using 6-0 vicryl sutures for the former and 5-0 interrupted vicryl sutures for the latter.
- A plastic conformer is inserted and after instillation of ointment, the eye is patched with a light pressure pad.
Possible post-surgical complications:
- Central ulceration due to failure of the conjunctiva to resurface the graft.
- Enopthalmos (posterior displacement of the prosthetic eye within the orbit)
- Keratinized sockets with chronic discharge and desquamation
- Conjunctival granuloma
- Infection as a result of graft
- Donor site hematoma
- Pyogenic Granuloma
- Fat atrophy and volume loss
- Graft wound dehiscence
- Conjunctival cysts
- Cilia retention at the recipient site
- Excessive dermis-fat growth
Advantages of a Dermis Fat Graft (DFG):
- DFG offers the advantages of replacing the lost orbital volume as well as preserving conjunctival surface area. This is achieved by partially covering the implanted dermis with conjunctiva and leaving an exposed area of dermis similar to the diameter of the cornea.
- Normal fornix depth is also maintained.
- There is no risk of infection transmission, implant extrusion or exposure.
- Additionally, this procedure carries no extra cost and offers excellent cosmetic and functional results.
Disadvantages are as follows:
- A certain lack of predictability such as underestimation of the adequate volume required of the harvested graft.
- Further, DFG also produces a scar at the donor site.
A Dermis Fat Graft is a relatively extensive surgery with minor complications. The excellent functional and cosmetic results and safety of this method make it an excellent alternative procedure for orbital volume augmentation in anophthalmic sockets.