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| ORIGINAL ARTICLE |
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| Year : 1988 | Volume
: 36
| Issue : 3 | Page : 110-112 |
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Dermis fat grafting in contracted socket
SM Betharia, ND Patil
Dr. R.P. Centre for Ophthalmic Sciences, AIIMS, Ansari Nagar, New Delhi - 110 029, India
Correspondence Address:
S M Betharia
Dr. R.P. Centre for Ophthalmic Sciences, AIIMS, Ansari Nagar, New Delhi - 110 029
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 3255697 
5 cases of severely contracted sockets were reconstructed with the use of dermis-fat graft. This type of graft is extremely useful as it is more viable and is a suitable replacement for soft tissue deficiency as in case of contracted socket. Excellent results were obtained and this method seems to be the method of choice in the management of such cases.
How to cite this article:
Betharia S M, Patil N D. Dermis fat grafting in contracted socket. Indian J Ophthalmol 1988;36:110-2 |
| Introduction | |  |
Severely contracted sockets pose problem to all the oculoplastic surgeons. Earlier methods employed were use of mucous membrane and skin grafting. Various techniques of skin grafting gave variable results and the need for a newer technique in the management of this condition was always felt. Autogenous fat grafts [1] for the orbit were first used in 1901. In 1978 Smith & Petrelli [2] described the technique of dermis fat graft as a movable implant within the muscle cone. This technique supplied orbital volume, eliminated the risk of implant extrusion, preserved the existing conjunctiva and advanced it in, the fornices. It was hoped that the dermis would enhance vascularization [3], decrease the incidence of fat atrophy and act as a barrier against fatty augmentation. More recently people have successfully used lipodermal implants to reconstruct sockets following enucleation. [4],[5] The problems associated with the management of anophthalmic sockets such as implant extrusion, implant migration and conjuctival shrinkage were more commonly seen with the traditional methods of reconstruction. The volume loss leading to residual or recurrent enophthalmos persists. These problems are eliminated by dermis-fat grafting. [4],[5],[,6]
In this communication we are presenting the results of dermis-fat grafting in the management of severely contracted sockets.
| Material & Methods | | |
5 cases of severely contracted sockets ranging from 10 to 32 years of age were reconstructed by the use of dermis fat graft [Table - 1]. The donor site chosen was the upper outer qudrant of the buttock. The epidermis was carefully removed with the use of a razor blade. Care was taken not to damage the dermis and at the same time to exclude the epidermis. The eliptical area of the dermis was marked by gentian violet. The size of the graft taken was about 25% more than the defect. The fat along with dermis was removed without causing damage to the fascia underneath. After undermining the edges the wound was closed in two layers. The graft was transferred to the socket after excising the fibrous tissue and achieving complete haemostasis. The graft was sutured with 6'0 black silk to the remaining conjunctiva. The upper and lower fornices were formed by passing double arm sutures. A snugly fitting conformer with multiple holes was inserted into the reconstructed socket. Postoperatively the bandage was opened after 24 hrs and a gentle wash with saline was performed and antibiotic drops were instilled. The conformer was replaced with an artificial eye after 4 to 6 weeks.
| Results | | |
4 out of 5 cases gave satisfactory results without any significant complications during the follow up period of 6 to 9 months [Figure - 1][Figure - 2][Figure - 3]. In one case remarkable fat absorption occured resulting in a shallow lower fornix and extrusion of the artificial eye within period of 3 months. During the early post-operative period of two weeks there was minimum to moderate discharge found in almost all the cases and only one case developed central ulceration of the dermis exposing the fat leading to shallow fornices [Table - 2].
| Discussion | | |
The problems associated with the management of anophthalmic sockets such as implant extrusion, implant migration and conjuctival shrinkage resulting in contracted sockets are more commonly seen with the traditional methods of reconstruction. The reconstruction of mild to moderately contracted sockets was successfully done by the technique of mucous membrane grafting. Mustrade [7]sub and Stallard [8] have given the various techniques of reconstruction by means of split thickness skin grafts, the problems of skin grafting being, chances of infection, foul smelling discharge and inadequate take. The main problem of orbital volume loss is present in cases of severely contracted sockets. This technique of dermis-fat graft supplied the adequate orbital volume, eliminated the risk of implant extrusion, preserve the existing conjunctiva and advanced it into the fornices [9]. The dermis enhances the vascularization, decrease the incidence of fat atrophy and acts as a barrier against fatty augmentation. [10]
All the 5 cases taken in this study were of severely contracted sockets with inflammatory granulomas and fibrous bands and posed a surgical challenge. All the cases had unsuccessful reconstruction in the past with mucous membrane grafts.
The various early post-operative complications following dermis-fat grafting of ophthalmic sockets that were described in literature included central graft necrosis [11] central pitting [12], graft failure [4], central graft ulceration [6], graft shrinkage with orbital volume loss and socket infection [13]. In our series we found ulceration of the graft in one case and the cause was thought to be damage to the dermis while taking the graft. Central graft ulceration and enophthalmos accounted for 70% of the complications in the series reported by Shore et al [12]
The precaution to be taken during removal of the graft which we think was of extreme importance is to remove the epidermis without damaging the dermis. This very precaution prevents the graft ulceration, fat augmentation, early fat absorption and chances of hair growth, keratinization and possibility of infection. Though we have employed a simple technique of removal of epidermis with a razor blade the dermabrasers could be used as described in the past [11].
In a 9 month follow-up period we came across only one case of shallow fornices and enophthalmos due to marked absorption of the fat. In anophthalrnic sockets of children in whom there is an associated element of bony contraction and reduction in horizontal dimension of the socket, the results of this procedure were not encouraging. To be successful, the gratt must be designed to achieve precise fit in the socket and minimize fat atrophy [14]. The recent innovative baseball implant developed by Bullock [15], may reduce the incidence and severity of fat atrophy.
We feel that at present this method of dermis fat grafting is the best method and is therefore recommended for the management of severely contracted sockets.
| References | | |
| 1. | Barraquer, J. Arch. Offalmol Hisp-Am, 1:82, 1901.  |
| 2. | Smith B, Petrelli R., Am. J. Ophthalmol., 85:62, 1978. |
| 3. | Hynes, W., Br. J. Plast. Surg, 6:257, 1954. |
| 4. | Smith B, Bosniak S.L., Lisman R.D., Ophthalmology, 89:1067, 1982. |
| 5. | Przybyla VA Jr., La Piana F.G., Bergin, D.J., Ophthalmology, 88:904, 1981. |
| 6. | Shore, J.W., McCord, C.D., Bergin, D.J., Dittman, SJ Burks, W.R.,Ophthalmology, 92:1342, 1985. |
| 7. | Mustarde J.C., Repair and Reconstruction in the orbital region, Second Edition, pg. 218, Churchill Livingstone Edinburgh, London and New York, 1980. |
| 8. | Fox, S.A., Ophthalmic Plastic Surgery, Fifth Edition, pg. 515, Grune Stratton, New York, SanFrancisco, London, 1976. |
| 9. | Boering, G., Huffstadt, A., Br. J. Plast. Surg. 20:172, 1967. |
| 10. | Peer L.A. Plast Reconstr. Surg. 5:217, 1950. |
| 11. | Aguilar, G.L.. Shannon, G.M., Flanagan, J.C. Ophthalmology, 13:204, 1982. |
| 12. | Smith, B., Bosniak, S., Nesi, F., Lisman, R. Ophthalmic Surg., 14:941, 1983. |
| 13. | Soll, D.B. Ophthalmology; 89:407, 1982. |
| 14. | Bullock, J.D., Brickman, K.R., Ophthalmology, 91:204. 1984. |
| 15. | Bullock, J.D. Ophthalmic Surgery, 18:30, 1987. |
[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1], [Table - 2]
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