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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 34  |  Issue : 2  |  Page : 130-136

The consequences of dermis fat graft in the reconstruction of anophthalmic socket with large orbital implant exposure


Department of Ophthalmology, Kartal Dr. Lutfi Kırdar Education and Research Hospital, Istanbul, Turkey

Date of Submission03-Feb-2021
Date of Decision22-Mar-2021
Date of Acceptance03-Aug-2021
Date of Web Publication30-Aug-2022

Correspondence Address:
Dr. Titap Yazicioglu
Department of Ophthalmology, Kartal Dr. Lutfi Kırdar Education and Research Hospital, Kartal, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_34_21

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  Abstract 


Purpose: To present our results of dermis-fat graft as a secondary procedure after implant extrusion. Materials and Methods: A retrospective chart review was performed to examine 34 anophthalmic socket carriers undergoing dermis-fat graft. All patients had a history of ocular trauma and underwent evisceration surgery. Small defects and Grade 5 contracted sockets were not included. The patients reported the complaints of pain and discharge. Data were collected on the characteristics of the exposed implant material and surgical technique used for implant insertion; complications related with dermis-fat graft, cosmesis; and functional results such as the ability to hold an external prosthesis. For socket reconstruction, the graft was taken from the lateral upper quadrant of the gluteal region, 30% larger than the orbital defect. The mean follow-up period was 12.26 ± 1.13 months. Results: Of the 34 patients, 26 had porous polyethylene implants and 8 had acrylic implants. The average diameter of the conjunctival defect with scleral melting was 11.6 mm. The findings encountered in the follow-up of patients who underwent socket reconstruction with dermis-fat graft were as follows: graft necrosis in one patient, reduction in graft size in two patients, insufficient vascularization of the graft in one patient, ptosis in two patients, deep superior sulcus in one patient, cysts over the dermis-fat graft in one patient, and necrosis at the donor site in two patients. Except for two patients with fornices shrinkage, all of them used their ocular prosthesis well. Conclusion: Dermis-fat graft with low complication rate is a good option for anophthalmic socket reconstruction, but care of the donor site should not be neglected.

Keywords: Anophthalmos, conjunctival defect, dermis-fat graft, implant exposure


How to cite this article:
Yazicioglu T. The consequences of dermis fat graft in the reconstruction of anophthalmic socket with large orbital implant exposure. Kerala J Ophthalmol 2022;34:130-6

How to cite this URL:
Yazicioglu T. The consequences of dermis fat graft in the reconstruction of anophthalmic socket with large orbital implant exposure. Kerala J Ophthalmol [serial online] 2022 [cited 2022 Sep 29];34:130-6. Available from: http://www.kjophthal.com/text.asp?2022/34/2/130/355035




  Introduction Top


Orbital implants are used to provide orbital integrity by compensating the reduced orbital volume in enucleation or evisceration surgery.[1],[2],[3],[4],[5]

However, it is a major problem that the implant causes a chronic inflammatory reaction, leading to necrosis in the conjunctiva and Tenon's capsule with an exposure rate, ranging from 2% to 10%.[1],[3],[6],[7] If the exposure area is small and the signs of inflammation are mild, observation, topical drops, or repair with a mucosal graft is recommended, but if the conjunctival defect is large with severe infection, autologous dermis-fat graft, which was first described in 1978, is advised to compensate the volume loss both cosmetically and functionally.[1],[8],[9],[10]

Dermis-fat graft has the advantages that it does not carry the risk of disease transmission and graft rejection and does not require special preparation or storage in the tissue bank.[1],[11]

The most preferred area for grafting is the lateral upper quadrant of the gluteal region. It is more easily accessible than other donor areas and causes mild postoperative pain and discomfort. In addition, grafts can also be taken from the abdomen or periumbilical region.[1],[12],[13]

In order to increase the success of dermis-fat graft, the rectus muscles should be meticulously sutured to the dermal margin of the graft, filleting Tenon's capsule and avoiding cauterization of the graft bed.[1],[14]

Here, we want to discuss our results of the dermis-fat graft, which we used to ensure socket integrity in our patients with implant exposure with excessive melting of the sclera.


  Materials and Methods Top


The medical records of 34 anophthalmic socket carriers who underwent secondary dermis-fat graft procedures, between March 2006 and December 2019, were reviewed retrospectively. The study protocol adhered to the tenets of Declaration of Helsinki and was approved by the ethics committee (decision number: 2020/514/181/6). Patient consent to publish identifiable photograph archival was taken from all patients.

A total of 34 patients, 14 males and 20 females, who had previously undergone evisceration surgery due to trauma and complaining about pain and irritation due to implant exposure, were included in the study. All patients had a large conjunctival defect, scleral melting with a diameter of 11.6 ± 1.4 mm (range, 10–14 mm), and discharge [Figure 1]. Small defects and Grade 5 contracted sockets were excluded.
Figure 1: Exposure of orbital implant with large conjunctival defect and scleral melting

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Data were collected on structure of the exposed implant; the technique used in evisceration surgery; complications related with dermis-fat graft used for socket reconstruction; and cosmetic and functional results, such as the ability to hold an external prosthesis. Patient demographics and ocular characteristics are presented in [Table 1].
Table 1: Demographic and ocular characteristics of patients who underwent dermis-fat graft procedure

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As the remaining sclera and volume were insufficient for the secondary implant insertion, we used dermis-fat graft for socket reconstruction.

Patients were operated under general anesthesia, and all procedures were done by the same surgeon. The lateral upper quadrant of the gluteal region was preferred for donor site. Intradermal injection of saline solution was applied to the marked donor area to facilitate de- epithelialization of the skin from the graft, and the graft consisting only of the dermis and fat was excised. Graft was taken 30% larger than the orbital defect (oversized of 30 mm in height and 35 mm in length with 20 mm of the fat thickness) [Figure 2].
Figure 2: The donor site of the dermis-fat graft

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The deep layers of the donor site and the skin were closed with 4.0 poliglecaprone (Monocryl, monofilament, Ethicon US, LLL, Cincinnati, OH) or 4.0 polyglactin (Coated Vicryl, Ethicon US, LLL, Cincinnati, OH) interrupted sutures [Figure 3].
Figure 3: Donor-site skin closure with 4/0 interrupted sutures

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Then, by making conjunctival incision horizontally, endo-orbital tissues, bundles, and septa were all separated with blunt dissection. After sufficient opening was achieved in the socket, the graft was placed centrally in the anophthalmic socket, and then sutured to the Tenon's capsule and conjunctiva, using and 7-0 polyglactin (Coated Vicryl, Ethicon US, LLL, Cincinnati, OH) interrupted sutures, respectively [Figure 4]. A conformer was inserted into the socket and by placing tarsorrhaphy sutures, the eye was closed.

On the 10th postoperative day, the surface of the central part of the dermis-fat graft was covered with an oral mucosal graft and epithelialization was completed within two weeks with artificial tears [Figure 5].
Figure 4: Insertion of the dermis-fat graft in the anophthalmic socket

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Figure 5: The surface of the dermis-fat graft was covered with an oral mucosa graft

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Although the graft surface was epithelialized spontaneously, we routinely prefer to cover the dermis-fat graft surface with an oral mucosal graft. This also helps to camouflage the white, porous appearance of the dermis-fat graft, which has an uncomfortable appearance for the patient. After the operation, steroid and antibiotic drops (dexamethasone and moxifloxacin) were given to the patients four times a day. Systemic antibiotics and anti-inflammatory drugs (clavulanic acid/amoxicillin and naproxen sodium) were given daily for 1 week. The donor site care was also taken with betadine solution.

Patients started using the ocular prostheses 4 weeks after surgery. The mean postoperative follow-up period was 12.26 ± 1.13 months. Patients were followed up at 1-day, 1-week, 1-month, and 3-month intervals until the end of the 1st year. The integrity of dermis-fat graft, fornices depth, the presence of eyelid malposition, complications, prostheses stability, and position in the socket were carefully evaluated at each visit.


  Results Top


Dermis-fat graft was used for socket reconstruction in 34 patients, with a mean age of 40.3 ± 15.0 years (minimum 20 years and maximum 65 years). The extruded implant produced melting in the conjunctiva and sclera with a mean diameter of 11.6 ± 1.4 mm (range, 10–14 mm). Twenty-six (78.5%) of the extruded implants were porous and eight (23.5%) were acrylic.

The outcomes in secondary reconstruction of the anophthalmic socket with dermis-fat graft are shown in [Table 2].
Table 2: The outcomes of dermis-fat graft in socket problems

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During the follow-up period, necrosis of the graft was developed in one (2.9%) patient. This is because of poor hygiene conditions of the patient and inappropriate use of medication following surgery. Purulent secretion and malodor in the socket were regressed with antibiotic treatment and recovered without surgical intervention. In 1(2.9%) of the patients, the graft was still not vascularized in the first month postoperatively [Figure 6].
Figure 6: Insufficient vascularization of the graft seen in the postoperative 1st month visit

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In addition to secondary repair with dermis-fat graft, secondary surgical intervention was also required for fornix reconstruction in two (5.8%) patients who had been previously operated as a result of a gunshot injury. Even though they were treated with mucous membrane graft and with copious lubrication, they did not wear prosthesis well.

In 2(5.8%) of our patients, due to their very thin structures, the thickness of the dermis-fat graft could not be obtained at the recommended thickness of minimum 2 cm, and graft shrinkage was observed at the postoperative 3rd month visit [Figure 7].
Figure 7: Atrophy of the dermis-fat graft in a patient at the postoperative 3rd month visit

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Only one (2.9%) patient was complaining of ptosis and deep superior sulcus [Figure 8]. Volume loss was compensated with dermis-fat graft by making standard upper blepharoplasty incision and tolerable improvement was achieved [Figure 9].
Figure 8: Patient with pseudoptosis and superior sulcus deformity, treated with dermis-fat graft following upper blepharoplasty incision

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Figure 9: The appearance of the same patient at the postoperative 3rd month control

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Cyst development was observed over the graft in one (2.9%) patient at the 1st year follow-up [Figure 10].
Figure 10: Cyst development seen over the graft at the 1st year control

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A donor-site necrosis was developed in two (5.8%) patients [Figure 11].
Figure 11: The necrosis of the donor site

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Except for two (5.8%) patients, all patients were satisfied with the result of dermis-fat graft and wore their prosthesis with 30° of horizontal and 15° of vertical mobility.


  Discussion Top


The dermis-fat graft is a safe and effective technique in the reconstruction of an exposed orbital implant with a large conjunctival defect, leading to severe signs of infection and scleral melting.[15]

The factors that are responsible for exposure can be listed as, the size of the implant, the rough surface, the depth of insertion, problems in closing the wound, or previously received radiotherapy and chemotherapy.[15] If the exposure area is small, it can be closed spontaneously, but if it is above 10 mm, autogenous or exogenous grafts are used. It is advised to use autogenous grafts, as exogenous grafts can cause immunological reactions and viral infection.[16],[17]

Dermis-fat graft can also be used in primary enucleation cases, superior sulcus defects due to fat atrophy, enophthalmos, and contracted sockets.[1],[18],[19],[20] The satisfaction rates of primary and secondary dermis-fat graft cases had been reported as 83% and 57%, respectively.[21],[22] The disadvantages of dermis-fat graft is the increased risk of morbidity due to the formation of a second surgical wound (donor area).[1] In our study, there were 34 patients with a history of phthisic eye associated with penetrating trauma, who underwent evisceration surgery and had an orbital sphere implanted. In cases where the implant was extruded with a large conjunctival defect (>10 mm) with scleral melting, we performed dermis-fat graft for anophthalmic socket reconstruction because of its advantage of no foreign-body reaction and disease transmission. The success rate in the present study was 94.11%. Except for two patients, there was no complaint at the donor site in the gluteal region. In all our cases in which the dermis-fat graft surface was covered with a lip mucosal graft, there was a complaint of pain in the mouth only on the first day after the operation.

Surgical technique has been found to have an important role on implant exposure. Recent studies have focused on evisceration surgery techniques that allow a larger orbital implant to be placed behind the sclera, rather than radial sclerotomies. Implant exposure may occur as late as 18 or 20 months after surgery. Previous studies have pointed out that longer follow-up may reveal more cases of implant exposure.[23] In our study, we encountered exposure of the implant as a late postoperative complication, where we placed large orbital implants with radial sclerotomy technique and tightly sutured scleral flaps. In addition to surgical technique, we think that some changes such as discoloration, dullness, and roughness on the prosthesis surface of our patients, who wear the same ocular prosthesis for more than 8 years, may cause implant exposure by mechanical trauma.

In studies investigating the effect of implants with different materials and designs used in evisceration surgery, it was stated that nonporous implants have a high migration rate and integrated porous implants have a high exposure rate, while in another study, the material does not play a role in the extrusion of the implant.[23] In our study, only 8 of the 34 patients had acrylic implants, whereas others had synthetic implants (porous polyethylene implant). We did not make a distinction regarding implant exposure, but implant extrusion was mostly due to the surgical technique performed.

Graft necrosis is a serious adverse effect reported as 17.7%.[1],[12],[18] It is more common after secondary dermis-fat graft and is related to the technique of obtaining dermis-fat graft or implantation of dermis-fat graft in the orbit.[1]

A history of poor vascularization or socket contracture, chronic orbital inflammation, fat atrophy, and a history of previous severe orbital trauma due to postoperative orbital volume loss or enucleation, multiple previous procedures, orbital radiotherapy, concomitant systemic vascular diseases (diabetes, hypertension, or others), immunosuppression, or coagulation problems are all predisposing factors for graft ulceration and necrosis.[1],[24] Central necrosis occurs as a result of insufficient vascularization between the graft and the recipient bed. To prevent this, the graft must be well sutured to the conjunctiva and tenon at the dermis level.[1],[14] In our study, we had one patient who had necrotic symptoms on the graft in the early postoperative period. This patient had a history of severely traumatized socket with late ocular surgery. We believe that the necrosis on the graft was due to poor hygienic conditions and inadequate use of medicine. She was successfully treated with appropriate antibiotics without the need for surgical intervention. In addition, one patient whose graft was not vascularized at the postoperative first month visit was diabetic and we think that this may be responsible for the insufficient vascularization between the graft and the recipient bed.

Atrophy or central necrosis may occur after a while as a result of large-tissue transplantation in patients with dermis-fat graft. Spontaneous graft atrophy is reported as 6–12.9% or even 40% of cases, so it is advised to take 30% larger than the defect measurement.[1],[9],[19],[20],[21],[25],[26] It has been stated that small grafts carry insufficient correction, and large grafts carry compression and ischemia-related central necrosis.[27] Graft thickness is also an important factor. In a study comparing grafts with 10- and 20-mm thickness, thicker ones were reported to be more successful.[26] In our study, graft shrinkage was observed only in two (5.8%) of our patients at the postoperative 3rd month visit. They had a very thin structure and the recommended minimum thickness of 2 cm dermis-fat graft could not be obtained. Another reported complication with dermis-fat graft is cyst formation on the graft, which are the epithelial islands remaining on the graft during preparation.[1],[18] In our study, we had only one patient with cysts over the dermis-fat graft, which was observed as a late sign.

Other reported postoperative complications of dermis-fat graft include hair growth on the graft, wound dehiscence in the donor area, hematoma, and keratinization of the socket.[1],[12],[28]

Epidermis dissection should be done carefully in order to prevent hair growth on the anterior surface of the graft, formation of conjunctival cysts, or granulomas.[29] In our study, necrosis at the donor site was developed in two (5.8%) patients. There was no hair growth on the graft in any of our patients.

The integrity of the conjunctiva is very important for a healthy socket. Previous multiple surgeries cause cicatrization of the conjunctiva, creating a risk factor for implant exposure.[23],[30] In our study, except two patients with inadequate fornix, who had a history of undergoing operation due to gunshot ocular injury, were gone to secondary repair with dermis-fat graft and also secondary surgical intervention for fornix reconstruction, all patients were able to wear their ocular prosthesis well.

Ptosis after anophthalmic socket reconstruction is not a true ptosis. This type of ptosis is usually caused by a lack of orbital volume, and microphthalmus, enophthalmos, phthisis bulbi, or improper use of prosthesis.[22] In our study, we had two patients with pseudoptosis, and one patient complained of deep superior sulcus. In this patient who was operated for the deep superior sulcus, a dermis-fat graft was placed in the sulcus with a blepharoplasty incision. Although there was a resorption in the size of the graft with time, the patient had tolerable cosmetic result.


  Conclusion Top


Dermis-fat graft is an effective way to overcome problems related to implant exposure, with low morbidity and a satisfactory cosmetic result. Complications such as graft necrosis or lid deformities are rare, and the cosmetic and functional results are favorable. However, it should be kept in mind that necrosis may develop at the donor site and care should be taken in its treatment.

Acknowledgment

I'm grateful to all with whom I have had work together.

Statement of ethics

The study protocol was approved by the Ethics Committee of Kartal, Lutfi Kirdar Education and Research Hospital, Istanbul, Turkey (decision number: 2020/514/181/6).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Hsu CR, Hsu CK, Tai MC, Chiang SY. Treatment of ıntractable orbital ımplant exposure with scleral melting by secondary ımplant of dermis fat graft-a case report. J Clin Exp Ophthalmol 2017;8:638.  Back to cited text no. 8
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]
 
 
    Tables

  [Table 1], [Table 2]



 

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