August 2007 Vol 7 copy.indd
ABSTRACT To our knowledge, there is no report of dermis-fat graft (DFG) implant for orbital reconstruction from Oman. We
hereby presented a case report of a 0-year-old boy with a blind and painful left eye secondary to penetrating eye injury presented
with implant extrusion following evisceration with a polymethyl methacrylate implant. The evisceration procedure was converted to
enucleation and a DFG orbital implant was then performed. Postoperatively, the graft was observed to be well integrated with the host
orbital tissues and had good cosmetic and functional outcomes.
Keywords: Anophthalmos; Eye enucleation; Orbital implants; Case report; Oman.
Autogenous Dermis-Fat Orbital Impant for
Anophthalmic Socket
*Abdullah Al-Mujaini, Anuradha Ganesh, Sana Al-Zuhaibi
Department of Ophthalmology, College of Medicine and Health Sciences, Sultan Qaboos University, P. O. Box 35, Al-Khod 123, Sultanate of Oman
*To whom correspondence should be addressed. Email: mujainisqu@hotmail.com
املقلة لعدمي احلجاج لشحمة ادمة الذاتية الزراعة
سناء الزهيبي جانيش، أنورادا ايني، عبد هللا
كفيف صبي حالة عن تقرير هنا ــتعرض نس ، احلجاج أدمة ــحمة ش ترقيع ــلطنة عن الس من تقرير أي هناك يوجد لدينا ال معلوم : كما هو امللخص
وبعد ميثيل بولي امليثاكريليك بغرس غاز العني فقء مت حيث بالعني نافذة إصابة نتيجة ــرى اليس بالعني ألم من ويعاني ــنوات س ــر عش العمر من يبلغ
نتيجة وهي ، احلجاج ــجة أنس مع جيدا الترقيع التئام العملية بعد لوحظ . العني حجاج ــة أدم ــحمة لش ذاتي ترقيع وعمل قلع العني مت ــراء اإلج ــذا ه
. واجلمالية العملية الناحية من جيدة
عمان تقرير حالة، العني، محجر استئصال العني، ترقيع العني، مقلة الكلمات: فقدان مفتاح
SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL
AUGUST 2007 VOL 7, NO. 2, P. 145-148
SULTAN QABOOS UNIVERSITY©
SUBMITTED - 23 DECEMBER 2006
C A S E R E P O R T
THE AUTOGENOUS DERMIS-FAT GRAFT (DFG) orbital implant, composed of dermis and ap-pended subcutaneous fat, is one of the many
alternatives available for orbital volume augmenta-
tion in an anophthalmic socket.1 In adults, unpredict-
able fat reabsorption poses a serious drawback to this
technique; however in children the composite DFG
demonstrates continued growth along with the sur-
rounding orbital tissue, thereby stimulating orbital de-
velopment and maintenance of lost orbital volume after
enucleation.2
To the best of our knowledge this is the first case of
a DFG implant for orbital reconstruction performed in
Oman.
C A S E R E P O R T
A 10-year-old boy presented with an exposed orbital
implant in an anophthalmic socket. He had under-
gone evisceration of the left eye three weeks prior to
presentation. The patient had sustained a penetrating
cornea-lens-retina injury with a knife at the age of 9
years and was left with a blind and painful left eye. Ex-
amination revealed an unaided Snellen visual acuity of
20/20 at distance and near in the right eye and no light
perception in the left eye. Anterior segment and fun-
dus examination of the right eye were unremarkable.
Additionally, visual field examination of the right eye
was within normal limits. Examination of the left eye
showed complete exposure of a spherical polymeth-
ylmethacrylate implant with conjunctival and scleral
wound dehiscence [Figure 1].
After obtaining informed consent, the child un-
derwent socket reconstruction with DFG. The scleral
shell was removed by transection of the optic nerve
after imbricating the four recti muscles with 6-0 vic-
ryl sutures, thus converting the evisceration into an
A B D U L L A H A L - M U J A I N I , A N U R A D H A G A N E S H , S A N A A L - Z U H A I B I
146
enucleation. Hemostasis was obtained with pressure
and mild wet-field cautery. Orbital soft-tissue recon-
struction was then done with DFG obtained from the
left gluteal region. After raising the epidermis with
a subcutaneous injection of xylocaine with epine-
phrine, an elliptical skin incision was made. The epi-
dermis was dissected away from the underlying der-
mis by a combination of sharp and blunt dissection
[Figure 2a]. Subsequently, a 20x20mm area of dermis
with underlying fat was harvested [Figure 2b]. The
gluteal wound was closed with interrupted 4-0 vicryl
sutures. The dermis-fat graft was then inserted into
the orbital socket cavity with the dermis layer anteri-
orly and the fatty side posteriorly oriented [Figure 3a].
The extraocular muscles and conjunctiva were sutured
into the border of the dermis-fat graft using 6-0 vic-
ryl sutures for the former and 5-0 interrupted vicryl
sutures for the latter [Figure 3b]. A plastic conformer
was inserted and after instillation of ointment, the eye
was patched with a light pressure pad.
On the first post-operative day, examination
showed the graft tissue well apposed with the host tis-
sue [Figure 4], thus the patient was discharged with
instructions to use antibiotic eye ointment. When
seen in the clinic a month later, the DFG was well inte-
grated with the orbital tissue. The graft-host junction
was healthy, with epithelialization of the surface of the
graft. There was no evidence of necrosis or infection
[Figure 5].
D I S C U S S I O N
Since their first use in orbital surgery by Smith and
Petrelli in 1978, 3 DFGs have been widely used in the
reconstruction of the anophthalmic socket, both pri-
marily after enucleation and secondarily after extru-
sion or migration of an existing alloplastic implant.
DFG orbital implant is an effective means of replac-
ing orbital volume and affording motility of the ocular
prosthesis. It is associated with low morbidity and a
satisfactory cosmetic result.1
The DFG is composed of dermis and appended
subcutaneous fat, after removal of the epidermis. The
dermis is believed to enhance vascularization and
decrease the incidence of fat atrophy. It also acts as a
barrier against fatty augmentation. The site most fre-
quently used to harvest the graft is the gluteal area, but
other areas such as the abdomen and the periumbilical
can also be used to harvest such a graft.4
Indications Contraindications
Primary implantation
post enucleation
post evisceration
Secondary implantation
post irradiation
Spherical (alloplastic
implant related
complications)
Severely contracted socket
Compromised orbital vascular supply
severe chemical injury
post irradiation
Multiple orbital surgery
Table 1: Dermis-Fat Graft - Indications and Con-
traindications
- Hematoma
- Infection
- Graft-wound dehiscence
- Conjunctival Cysts
- Granulomas
- Graft Ulcers
- Pyogenic granuloma
- Socket keratinization
- Cilia retention at the recipient site
- Fat atrophy and volume loss
- Excessive dermis-fat growth
- Graft failure
Table 2: Complications of Orbital Dermis-Fat
Graft
Figure 1: Complete exposure of the polymethyl-
methacrylate spherical orbital implant after the
first surgery
Figure 2a: An elliptical skin incision has been
marked. The epidermis is being dissected away
from the underlying dermis
A U T O G E N O U S D E R M I S - FAT O R B I TA L I M PA N T F O R A N O P H T H A L M I C S O C K E T
147
In the orbit, special attention should be given when
performing this procedure, the most important being
to respect the vascular supply of the recipient bed.
Thus, it should not be used in any orbit with compro-
mised vascular supply, such as after severe trauma (in
particular chemical burns), irradiation, or in patients
with systemic vascular disease because the risk of
graft atrophy and loss is significantly increased [Table
1]. The DFG should be in contact with orbital fat to
enhance graft viability. Thus, Tenon’s fascia, sclera, or
pseudocapsule left after implant extrusion should be
incised or excised to facilitate this. Other important
aspects to prevent or minimize the complications are
to avoid the following: excessive cautery of the graft
bed, use of oversized grafts, excessive handling of
the graft and excessive pressure on the graft follow-
ing implantation. A meticulous suturing technique is
mandatory. It has been seen that a fat pad thickness of
20mm significantly lowers the incidence of enophthal-
mos and superior sulcus deformity with no compro-
mise to implant motility.5
Although mainly performed following enucleation,
DFG orbital implants have been performed following
evisceration whereby the edge of the graft was sutured
to the anterior scleral ring.6 Conjunctival re-epitheli-
alization of the dermal surface and enhancement of
Figure 2b: The dermis fat graft (20x20mm)
Figure 3a: The DFG is being inserted into the
orbital socket cavity with the dermis layer ante-
riorly and the fatty side posteriorly oriented
Figure 3b: The extraocular muscles and con-
junctiva are being sutured into theborder of the
dermis fat graft using 6-0 vicryl sutures for the
former and 5-0 interrupted vicryl sutures for the
latter
Figure 4: First post-operative day: Graft tissue is
well- apposed with the host tissue
Figure 5: One month postoperative period: The
DFG is well integrated with the orbital tissue.
The surface of the graft has epithelialized. There
is no evidence of necrosis or infection
A B D U L L A H A L - M U J A I N I , A N U R A D H A G A N E S H , S A N A A L - Z U H A I B I
148
orbital volume after dermis-fat grafting in eviscerated
sockets have been reported.6 It is advisable to make re-
laxing incisions into the base of the existing scleral bed
to provide an adequate vascular bed for the composite
DFG.7
DFG offers the advantages of replacing the lost
orbital volume as well as preserving conjunctival sur-
face 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 extru-
sion or exposure. Additionally, this procedure carries
no extra cost and offers excellent cosmetic and func-
tional results. Disadvantages include a certain lack of
predictability such as underestimation of the adequate
volume required of the harvested graft. Further, DFGs
also produces a scar at the donor site.
Complications are usually minor [Table 2]. Most
complications can be avoided by employing the care-
ful surgical techniques mentioned earlier. Fat atrophy
and volume loss are variable and may require further
dermis-fat grafting. This complication is commonly
seen in cases of secondary implantation, particularly
following chemical injuries.1 Graft atrophy is usually
seen in older patients. In contrast, fatty augmentation
causing increase in the size of the graft is usually seen
in young children, representing the normal prolifera-
tion of fat cells seen in the young. This complication is
managed by surgical debulking of the graft.8 Graft fail-
ure is usually associated with a compromised orbital
vascular supply.
C O N C L U S I O N
In summary, a DFG orbital implant is a relatively ex-
tensive surgery with minor complications. The excel-
lent functional and cosmetic results and safety of this
method make it an excellent alternative procedure for
orbital volume augmentation in anophthalmic sock-
ets.
R E F E R E N C E S
1. Smith B, Bosniak S, Nesi F, Lisman R. Dermis-fat orbital
implantation: 118 cases. Ophthalmic Surg 1983; 14:941-
943.
2. The autogenous dermis-fat orbital implant in children.
Mitchell KT, Hollsten DA, White WL, O’Hara MA. J
AAPOS 2001; 5:367-369.
3. Smith B, Petrelli R. Dermis-fat graft as a movable im-
plant within the muscle cone. Am J Ophthalmol 1978;
85:62-66.
4. Bonavolonta G, Tranfa F, Salicone A, Strianese D. Or-
bital dermis-fat graft using periumbilical tissue. Plast
Reconstr Surg 200; 105:23-26.
5. Sihota R, Sujatha Y, Betharia SM. The fat pad in dermis
fat grafts. Ophthalmology 1994; 101:231-234.
6. Borodic GE, Townsend DJ, Beyer-Machule CK. Dermis
fat graft in eviscerated sockets. Ophthal Plast Reconstr
Surg 1989; 5:144-149.
7. Lasudry J, Jonckheere P, Robert P-V, Adenis J-P. Der-
mis-fat graft in orbital surgery. Oper Tech in Oculoplast
Orbit and Reconstr Surg 2001; 4:15-24.
8. Smith EM Jr, Dryden RM, Tabin GC, Thomas D, To KW,
Hofmann RJ. Comparison of the effects of enucleation
and orbital reconstruction using free-fat grafts, dermis
grafts, and porous polyethylene implants in infant rab-
bits. Ophthal Plast Reconstr Surg 1998; 14:415-424.