Surgical management of the severely contracted socket following reconstruction

A Sandwich-Like Oral Mucosa Graft–Conjunctiva In Situ–Dermis-Fat Graft for Reconstruction of the Anophthalmic Socket with Ocular Infection History

Introduction

A novel technique of using a sandwich-like structure, namely, an oral mucosa graft (OMG)–conjunctiva in situ–dermis-fat graft (DFG) (OMG-C-DFG), to reconstruct a contracted and low-capacity anophthalmic socket for a patient with ocular infection history was evaluated.

Methods

This was retrospective case study of four patients (cases) who underwent anophthalmic socket reconstruction surgery in which the OMG-C-DFG technique was applied. The procedures were performed in the Department of Ophthalmology at the Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine (Shanghai, China). Postoperative cosmetic appearance, graft outcome, the ability to wear an ocular prosthesis, and postoperative complications were evaluated.

Results

The median (± standard deviation) age of patients was 41.5 ± 22.1 (range 10–60) years. All patients suffered from contracted and low-capacity anophthalmic sockets. Three patients had a history of orbital implant infection and one patient had a history of enucleation due to exogenous endophthalmitis after globe rupture. The DFG and OMG were harvested from the abdominal region and lower lip, respectively. All four patients achieved a good postoperative appearance, with dermal surfaces appearing pink and smooth, the orbital areas showing good fullness, the ocular prosthesis showing good wearability, and no narrowing of the sockets. There was no lipid secretion, fat lysate outflow, or infection in the graft bed. There were only small amounts of scars and no infection of the donor site.

Conclusion

The sandwich-like structure can be effectively used to reconstruct the contracted and low-capacity anophthalmic socket with a history of orbital infection in one stage.

Recurrent contracted sockets treated with personalized, three-dimensionally printed conformers and buccal grafts

Purpose:

Recurrent contracted sockets are complex situations where previous surgeries have failed, disabling the wear of an ocular prosthesis. A combined method of surgery and long-term fixation using custom-made, three-dimensional (3D) printed conformers is evaluated.

Methods:

Retrospective case series of nine patients with recurrent excessive socket contraction and inability to wear a prosthesis, caused by chemical burns (n = 3), fireworks (n = 3), trauma (n = 2) and enucleation and radiotherapy at childhood due to optic nerve glioma (n = 1) with three average previous socket surgeries (range 2–6). Treatment consisted of a buccal mucosal graft and personalized 3D-printed conformer designed to be fixated to the periosteum and tarsal plates for minimal 2 months. Primary outcome was the retention of an ocular prosthesis. Secondary outcome was the need for additional surgeries.

Results:

Outcomes were measured at final follow-up between 7 and 36 months postoperatively (mean 20 months). Eight cases were able to wear an ocular prosthesis after 2 months. Three cases initially treated for only the upper or only the lower fornix needed subsequent surgery for the opposite fornix for functional reasons. Two cases had later surgery for cosmetic improvement of upper eyelid position. Despite pre-existing lid abnormalities (scar, entropion, lash deficiency), cosmetic outcome was judged highly acceptable in six cases because of symmetric contour and volume, and reasonably acceptable in the remaining two.

Conclusions:

Buccal mucosal transplant fixated with a personalized 3D-designed conformer enables retention of a well-fitted ocular prosthesis in previously failed socket surgeries. Initial treatment of both upper and lower fornices is recommended to avoid subsequent surgeries for functional reasons.

Autologous dermis - Fat grafts as primary and secondary orbital transplants before rehabilitation with artificial eyes

OBJECTIVE

The aim of this study was to examine the role of autologous dermis-fat grafts in the reconstruction of orbital soft-tissue defects.

PATIENTS

Thirty-six patients (3-84 years) were enrolled in this retrospective study from 2002 to 2014. The dermis-fat graft was primarily transplanted in seven cases, and secondarily in 29 patients. All the patients were evaluated for complications, adequate prosthetic cavity, possibility of artificial eye supply and movement, as well as cosmetic results. Follow-up periods ranged from 25 to 144 months.

RESULTS

All the patients could be supplied with an artificial eye in the long term after dermis-fat transplantation. The clinical evaluation revealed 17 complications allocated to 11 patients. A major complication occurred in three patients (8.3%) so that a surgical correction was necessary. Thirty-three patients (91.7%) showed an aesthetically stable long-term outcome.

CONCLUSION

Dermis-fat grafts for reconstruction of anophthalmic orbit represent a reliable method with a low complication rate and good cosmetic and functional results. The graft can be used as primary and secondary transplants. The stable long-term results and high aesthetic satisfaction lead us to recommend this method as a routine operation.

Comparative analysis of use of porous orbital implant with mucus membrane graft and dermis fat graft as a primary procedure in reconstruction of severely contracted socket

Purpose:

The purpose of our study is to present a surgical technique of primary porous orbital ball implantation with overlying mucus membrane graft (MMG) for reconstruction of severely contracted socket and to evaluate prosthesis retention and motility in comparison to dermis fat graft (DFG).

Study Design:

Prospective comparative study.

Materials and Methods:

A total of 24 patients of severe socket contracture (Grade 2-4 Krishna's classification) were subdivided into two groups, 12 patients in each group. In Group I, DFG have been used for reconstruction. In Group II, porous polyethylene implant with MMG has been used as a primary procedure for socket reconstruction. In Group I DFG was carried out in usual procedure. In case of Group II, vascularized scar tissues were separated 360° and were fashioned into four strips. A scleral capped porous polyethylene implant was placed in the intraconal space and four strips of scar tissue were secured to the scleral cap and extended part overlapped the implant to make a twofold barrier between the implant and MMG. Patients were followed-up as per prefixed proforma. Prosthesis motility and retention between the two groups were measured.

Results:

In Group I, four patients had recurrence of contracture with fall out of prosthesis. In Group II stable reconstruction was achieved in all the patients. In terms of prosthesis motility, maximum in Group I was 39.2% and Group II, was 59.3%. The difference in prosthesis retention (P = 0.001) and motility (P = 0.004) between the two groups was significant.

Conclusion:

Primary socket reconstruction with porous orbital implant and MMG for severe socket contracture is an effective method in terms of prosthesis motility and prosthesis retention.

Rigid nylon foil-anchored polytetrafluoroetyhlene (Gore-Tex) sheet stenting for conjunctival fornix reconstruction

PURPOSE

To describe an operative technique that deepens foreshortened conjunctival fornices by providing a scaffold for epithelialization that opposes contractile forces during wound healing.

DESIGN

Retrospective interventional case series.

PARTICIPANTS

Seventeen patients with anophthalmic sockets containing foreshortened conjunctival fornices.

METHODS

Conjunctival fornices was reconstructed with stents of expanded polytetrafluoroethylene (e-PTFE) sheet draped over rigid, 0.8-mm thick-nylon strips that were anchored to the orbital rim. Preoperative and postoperative symptoms, prosthesis retention, fornix depth, and lagophthalmos were assessed.

MAIN OUTCOME MEASURES

Prosthesis retention, fornix depth, and lagophthalmos.

RESULTS

All 17 patients had preoperative inability to retain their prosthesis. After postoperative follow-up of 47+/-43 months, retention was improved in all patients and was entirely satisfactory in 15 (88%) patients. After reconstruction, the repaired fornix was deep in 7 (41%) patients, adequate to retain a prosthesis in 9 (53%), and shallow in 1 (6%). Lagophthalmos improved in 15 (88%) patients and remained unchanged in 2 (12%). The superior fornix was reconstructed concurrently with the inferior fornix in 6 patients. In these patients, the superior fornix improved to deep (3 patients; 50%) or adequate (2; 33%). In 1 (17%) patient, it remained shallow.

CONCLUSIONS

Rigid, nylon foil-anchored e-PTFE stenting opposes postoperative contracture, improving prosthesis retention, and lagophthalmos. It does not require an additional surgical site for graft harvesting.