Autologous dermis graft at the time of evisceration or enucleation

Anophthalmic Socket Syndrome: Prevalence, Impact and Management Strategies

Anophthalmic socket syndrome determines functional deficits and facial deformities, and may lead to poor psychological outcomes. This review aims to comprehensively evaluate the features of the syndrome, based on literature review and authors’ clinical and surgical experience. An electronic database (PubMed,MEDLINE and Google Scholar) search of all articles written in English and non-English language with abstract translated to English on anophthalmic socket syndrome was performed. Data reviewed included demographics, presentations, investigations, management, complications and outcomes. Different types of orbital implants were evaluated; the management of implant exposure was examined; different orbital volume enhancement procedures such as secondary implantation, subperiosteal implants and the use of fillers in anophthalmic patients were described; the problems related to socket contraction were outlined; the treatment options for chronic anophthalmic socket pain and phantom eye syndrome were assessed; the most recent advances in the management of congenital anophthalmia were described. Current clinical evidence does not support a specific orbital implant; late exposure of porous implants may be due to pegging, which currently is seldom used; filler absorption in the orbit appears to be faster than in the dermis, and repeated treatments could be a potential source of inflammation; socket contraction results in significant functional and psychological disability, and management is challenging. Patients affected by anophthalmic socket pain and phantom eye syndrome need specific counseling. It is auspicable to use a standardized protocol to treat children affected by clinical congenital anophthalmia; dermis fat graft is a suitable option in these patients as it helps continued socket expansion. Dermis fat graft can also address the volume deficit in case of explantation of exposed implants and in contracted sockets in both children and adults. Appropriate clinical care is essential, as adequate prosthesis wearing improves the quality of life of anophthalmic patients.

Reconstruction of the Orbit and Anophthalmic Socket Using the Dermis Fat Graft: A Major Review

PURPOSE

To perform a comprehensive review of dermis fat graft (DFG) in socket reconstruction and illustrate the technical nuances and outcomes using a retrospective case review.

METHODS

A literature search of 143 texts was reviewed. A retrospective case series of 34 patients following primary or secondary DFG after enucleation at a single institution (2009-2019) was performed. Clinical outcomes were statistically analyzed. Variables investigated included age, sex, race, surgical indication, muscle reattachment, complications, motility, eyelid position, prosthesis fit, and need for additional surgery.

RESULTS

The history of DFG, use in socket reconstruction, primary and secondary indications, and surgical techniques are described. Thirty-two adults and 2 pediatric cases of DFG were reviewed; 18.75% indications were primary and 81.25% were secondary. Good eyelid position was observed in 83.3% of patients with primary DFG versus 37.5% with secondary DFG (p = 0.07). Postoperative complications occurred in 58.8% of patients, were typically mild, and resolved with minimal or no intervention. No statistically significant differences were found between occurrence of any particular complication in primary versus secondary DFG placement (p = 0.36) or between primary and secondary DFG placement and the need for additional surgery (p = 1.0). Among the 67.7% patients who had implant exposure or extrusion as an indication for DFG, 39.1% required additional surgery within 2 years. Advanced age was not associated with higher complication rates (p = 0.12).

CONCLUSIONS

DFG is an excellent option for socket reconstruction, particularly in cases involving pediatric patients, complicated orbits, history of multiple previous surgeries, and inflamed, contracted, or scarred sockets.

Outcomes of secondary autologus dermo-fat orbital implants in anophthalmic sockets

Objectives:

To evaluate the outcomes of secondary autologous dermis-fat graft as an orbital implant in anophthalmic sockets.

Methods:

In this prospective study, which was conducted at Jinnah Post Graduate Medical Centre, Karachi, between January 2015 and January 2020, we evaluated 12 patients between the ages of four and 60 years. Most of the adults were victims of trauma, whereas children were known cases of retinoblastoma or trauma and all underwent enucleation. All of them were primarily treated elsewhere and not offered primary orbital implants. We performed autologous dermis-fat graft as an orbital implant in these patients harvesting graft from gluteal region and followed them up to look for complications.

Results:

Out of 12 patients two went into failure, while rest of the patients showed successful outcome. All patients underwent successful surgery. Initially, a silicon conformer was placed, which was later on replaced with artificial prosthetic eye.

Conclusion:

Regardless of the small sample size, this procedure proved to be a safe and effective method for augmenting orbital volume in anophthalmic sockets in children and adults.

Primary Dermis Fat Grafting for Socket Reconstruction: Retrospective Comparison of Electrocoagulation versus Scalpel Dissection for Epidermis Removal

Purpose

To evaluate outcomes of the use of electrocoagulation for epidermis removal in dermis fat grafting (DFG) compared to the conventional scalpel dissection in patients who underwent primary anophthalmic socket reconstruction.

Design

Retrospective, observational, and comparative study.

Methods

A retrospective review was performed on patients who underwent primary DFG for socket reconstruction between 2017 and 2019 at tertiary teaching hospitals. Patients with previous orbital surgery, previous radiotherapy to the periocular region, any medical condition that affects healing, cicatrizing ocular surface disease or heavy smokers were excluded. Patients with complete documentation of preoperative and postoperative data only were included. Patients were divided into two groups; group A: epidermis removal by the traditional scalpel dissection and group B: epidermis removal using low power setting electrocoagulation. The main outcome was the timing of complete epithelialization of the dermis layer. Other outcomes included implant motility, prosthesis fitting, patient’s satisfaction, and any complications.

Results

A total of 27 patients met the study criteria, and the mean follow-up period was 24.81 months. There were no differences between both groups regarding preoperative characteristics. The mean duration of complete epithelialization of the DFG implant was 9.15 ± 2.94 weeks in group A compared to 22.29 ± 4.43 weeks in group B (p value <0.001). Dermal ulceration was noticed in 9 patients (64.3%) in group B compared to none in group A (p value =0.001). Dermal ulceration was significantly associated with long conjunctival healing period (p value <0.001). Volume loss was more common in group B while graft hirsutism and granuloma were more evident in group A. Final prosthesis fitting was possible in all included patients.

Conclusion

Epidermis removal using the electrocoagulation is related to much more delayed epithelialization of the dermis with a higher rate of dermal ulceration compared to the scalpel dissection technique. However, there was no significant difference between both groups regarding the final prosthesis fitting or the overall patient satisfaction.

Transcutaneous approach for orbital augmentation with alloplastic implants in acquired anophthalmia

Purpose: To report the outcomes of a transcutaneous surgical technique for orbital volume augmentation with secondary alloplastic implants in acquired anophthalmia.Methods: Retrospective case note review of patients who underwent secondary orbital implant insertion through a subciliary incision between January 2006 and December 2017. Collected data included age, gender, type and cause of primary surgery, time interval before secondary implantation, and details of secondary implantation surgery. The main outcome parameters included postoperative appearance, grade of superior sulcus deformity (SSD), implant centration, and prosthesis function.Results: Thirty-eight patients ranging from 2 to 54 years had undergone secondary alloplastic orbital implant placement through the subciliary approach. The mean follow-up was 5.3 years (range: 1-10 years). All the patients showed satisfactory orbital volume with the average SSD was grade 0.74. There were no cases with implant exposure or extrusion. Implant migration occurred in six cases (15.8%). Fitting a prosthesis was possible in all cases.Conclusion: Subciliary secondary orbital implantation is proved to be effective in correcting volume deficiency in acquired anophthalmia with rapid rehabilitation while avoiding anterior surface breakdown and implant exposure.

Postoperative Complications of Dermis-Fat Autografts in the Anophthalmic Socket

Reconstruction of the anophthalmic socket allows the use of an ocular prosthesis and rehabilitation of facial appearance. Dermis-fat grafting is one option in volume augmentation of the anophthalmic socket and presents unique benefits, including increased surface area within the socket and the ability to grow with pediatric patients. Postoperative complications of this procedure are relatively common. Minor complications, such as graft hirsutism, keratinization, and conjunctival cysts or granulomas, are managed easily by observation or simple intervention. Major complications, such as graft atrophy, infection, or ulceration, may prevent good prosthesis fit and may require return to the operating room.

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.

Long-term complications of different porous orbital implants: a 21-year review

AIMS

To analyse the long-term outcomes of different types of orbital implant and the results of dermis fat graft for the management of large-area implant exposure.

METHODS

Retrospective case series. From 1994 to 2015, 256 patients who received primary implantation after enucleation or evisceration and were followed up for an average of 108.9 months were recruited. Detailed characteristics of patients, including previous surgery or trauma, surgical indications and methods, pegging procedure, and implant types were collected. The long-term outcomes were recorded. For patients with extensive implant exposure (diameter of tissue defect >2 cm), implant removal and dermis fat graft were performed.

RESULTS

The risk factors for implant exposure included eviscerated globes and pegged implants. The exposure rates were higher (24.7% in hydroxyapatite (HA), 23.5% in bioceramic and 76.5% in Medpor) as compared with those in previous reports. The average times to exposure were 67.4 months in HA, 52.5 months in bioceramic and 73.4 months in Medpor implants. Among the cases with implant exposure, late exposure (>2 years after operation) accounted for 67% of cases. Thirty eyes with large-area exposure were managed with dermis fat grafts. Twenty-four cases were successfully treated with single surgery. The other six cases developed fornix loss and required additional reconstruction with full thickness skin graft.

CONCLUSIONS

Late exposures of porous orbital implants were noted during long-term follow-up. The causes of implant exposure may be associated with pegging procedures and evisceration. The implantation of dermis fat can be an effective procedure for the management of large-area implant exposure.

Indications and results in anophthalmic socket reconstruction using dermis-fat graft

Objectives

To present the indications for a dermis-fat graft in anophthalmic socket reconstruction and evaluate the results of this procedure.

Design

Retrospective review, interventional case series.

Methods

In our study, there were 41 patients who received either primary or secondary dermis-fat graft between August 1, 2007 and July 31, 2012 at Songklanagarind Hospital.

Results

The type of dermis-fat graft used in our study consisted of both primary dermis-fat grafts (6/41) and secondary dermis-fat grafts (35/41). The major indications for dermis-fat graft were exposure (13/41), extrusion (11/41), and volume insufficiency with a shallow fornix (10/41), which accounted for 82.9% of the total cases. A total of 30 patients were able to wear the eye prosthesis over a mean follow-up time of 32.3±19.0 months. The success rate of the dermis-fat graft alone was 73.3%, while that of the simultaneous dermis-fat graft and mucous-membrane graft was 25%.

Conclusion

The most common indications for a dermis-fat graft were extrusion and large exposure. Dermis-fat graft is an alternative implant type in complicated enucleation/evisceration patients, which has a good success rate.

Dermis-fat grafts and enucleation in Ghanaian children: 5 years' experience

BACKGROUND

Enucleation in young children often results in retarded orbital growth ipsilaterally. The need for an implant that will naturally grow with the child, like Dermis-fat Graft (DFG), for managing the anophthalmia has been of interest over the years.

OBJECTIVE

To evaluate the use of DFG as an implant for volume replacement post-enucleation.

STUDY DESIGN

A prospective non-comparative case series involving 18 consecutive children who had DFG either primarily or secondarily in conjunction with enucleation for intraocular pathologies, from December 2007 to September 2012, at the ophthalmology unit, Korle-Bu. Data from patients who had a minimum of three months follow up(FUP) were analysed.

OUTCOME MEASURES

Complete covering of DFG with healthy conjunctiva, increase in volume of DFG, and presence or absence of complications.

RESULTS

Fifteen patients were analysed, aged nine months to ten years (mean (SD), 3.7±2.7years). Eight (53.3%) were females. Thirteen (86.7%) DFGs were secondary and 2(13.3%) primary. Indications for enucleation were intraocular retinoblastoma (n=10, 66.7%), unexplained retinal detachment mimicking retinoblastoma (n=3,20.0%), anterior staphyloma (n=1,6.7%) and medulloepithelioma (n=1,6.7%). Fourteen (93.3%) patients showed increase in volume of DFG. Time for Conjunctival reepithelialisation of the dermal surface was four to fourteen weeks (mean/median=5.5/4.0). Complications encountered were infection (n=1,6.7%), infection with necrosis (n=1,6.7%), melanosis /keratinization (n=2, 13.3%) and cysts(n=2,13.3%). The patients were followed up for 3 to 54 months (mean/median 20.13 /16.00).

CONCLUSION

DFG for management of post-enucleation anophthalmia in Ghanaian children showed 93.3% success.

Periumbilical fat graft: a new resource to replace large volume in the orbit

GOAL

To describe the technique we use to obtain a fat graft from the periumbilical area to replace volume in our patients requiring total or partial orbital volume restoration or replacement.

MATERIALS AND METHODS

Under local anaesthesia a one-piece fat auto-graft is obtained from one of the quadrants of the periumbilical zone through a 10- to 15-mm incision at the umbilicus edge.

RESULTS

Excised adipose tissue contains connective tracts, with medium and small vascular vessels with discrete thickened wall and preserved endothelium, with more blood cells, and less dead cells.

CONCLUSIONS

Fat grafts are the ideal fillers for patients requiring orbital volume replacement. The periumbilical fat graft technique we describe is simple, safe and fast, the learning slope shallow and the results gratifying in both the replaced volume, and the donor area with an invisible scar. The amount of fat that can be obtained with this technique through a minimal incision can be large enough.

Current concepts of ocular adnexal surgery

Ophthalmic Plastic and Reconstructive Surgery is a specialized area of ophthalmology that deals with the management of deformities and abnormalities of the eyelids, lacrimal system and the orbit. An ophthalmoplastic surgeon is able to identify and correct abnormalities of the ocular adnexae such as ectropion, lid retraction, conjunctival scarring with severe entropion, that can cause secondary ocular surface disorders; manage patients with watering eye, and when needed intervene with a dacryocystorhinostomy by external or endonasal approach and moreover minimize disfigurement following enucleation or evisceration and prevent further corneal damage, alleviate complains of tearing and grittiness, but also cosmetic complaints in patients with Graves' orbitopathy. Aim of this manuscript was to review current established and recently evolving surgical procedures.

Dermis-fat graft for treatment of exposed porous polyethylene implants in pediatric postenucleation retinoblastoma patients

PURPOSE

To demonstrate the use of the autogenous dermis-fat graft for the treatment of porous polyethylene implant exposure and volume augmentation in postenucleation retinoblastoma children.

DESIGN

Retrospective, interventional case series.

METHODS

Ten children who received a dermis-fat graft at Seoul National University Hospital between July 1, 2005 and January 31, 2010 were included in this study. The patients had undergone unilateral enucleation for retinoblastoma, and received a subconjunctival dermis-fat graft to repair implant exposure and simultaneously correct enophthalmos. The clinical characteristics of the patients, rate of graft survival, and complications were analyzed. The cosmetic outcome was assessed using a grading system.

RESULTS

All patients had enucleation using porous polyethylene implant as a primary orbital implant. The average time to exposure was 89.1 ± 22.4 months and the median size of defect was 2 × 3 mm. With a mean follow-up of 28 months, 9 of 10 patients showed well-survived graft without re-exposure. One patient who experienced a graft failure managed with implant rotation and a scleral graft. Seven patients showed significant improvement of enophthalmos.

CONCLUSIONS

Implantation of an autogenous dermis-fat graft is a procedure that can be effectively used to treat porous polyethylene implant exposure and simultaneously correct enophthalmos. Use of this procedure can be particularly advantageous for pediatric postenucleation patients.

The use of autologous dermis grafts for the reconstruction of the anophthalmic socket

PURPOSE

The main objectives of enucleation, evisceration or secondary orbital implants are to replace orbital volume and obtain good motility and adaptation of the implant and the external prosthesis. We describe our experience using autologous dermis graft sutured to Tenon and conjunctiva following evisceration, enucleation and any reconstruction requiring either a primary or secondary orbital implant, even those with large tissue loss.

MATERIALS AND METHODS

A retrospective case series of patients who received an autologous dermis graft to assist in closure of a Tenon's capsule and conjunctiva at the time of placement of secondary orbital implants or evisceration or enucleation with fornices retraction or tension in tissues. We also describe how and from where to take the dermis graft.

RESULTS

72 patients were included and all received orbital porous polyethylene implants: 28 patients had secondary orbital implants, 36 patients had evisceration and 8 patients had enucleation. Implant size was 20 mm in most cases, but went to 22 mm. Follow-up ranged from 3 to 36 months. No intraoperative complications were observed in donor or receptor area. 8 cases had incipient ischemia of the dermis graft, but were treated and resolved with autologous serum.

CONCLUSIONS

Implant exposure is due to bad surgical technique, an inadequate implant size or excessive tension on the suture. Dermis autologous graft allows moving the orbital implant anteriorly because it replaces surface to suture Tenon and conjunctiva without tension, so a good adaptation of a thinner external prosthesis is possible, resulting in better motility.