Orbit, 2014; 33(1): 33–38 ! Informa Healthcare USA, Inc. ISSN: 0167-6830 print / 1744-5108 online DOI: 10.3109/01676830.2013.844172
ORIGINAL ARTICLE
Dermis Fat Grafts as Primary and Secondary Orbital Implants Martin M. Nentwich, Kirsten Schebitz-Walter, Christoph Hirneiss, and Christoph Hintschich Department of Ophthalmology, Ludwig-Maximilians-University, Munich, Germany
ABSTRACT Introduction: This study was performed to evaluate the outcome after autologous dermis-fat graft [DFG] orbital implants in a large sample. Materials and Methods: A retrospective chart review of all primary and secondary DFGs in a 16-year period was done. Aesthetic and functional results, patients’ satisfaction and postoperative complications were evaluated. Results: In total 468 DFGs were performed in the study period (315 primary [I ] and 153 secondary [II ] DGFs). In the analysis, 173 DFG I and 66 DFG II were included as sufficient follow-up was available. Median follow-up after DFG I was 21.5 months and 14 months after DFG II . After DFG I , in 76% of patients motility of the graft was possible in all directions; 81% had good fitting of the prosthesis and 83% were highly satisfied with the results. Mean width of palpebral apertures was 0.2 mm smaller and Hertel exophthalmometry revealed a mean enophthalmus of 1.6 mm on the operated side compared to the fellow-eye. After DFG II , motility was possible in all directions in 34% of patients. Fitting of the prosthesis was good/reasonable in 49%/ 41% and patients were highly satisfied in 57%. On average, on the operated side palpebral apertures were 0.6 mm smaller and Hertel measurements showed an enophthalmus of 2.6 mm. Major complications were uncommon. Complete necrosis of the implant was more often observed after II (6.1%) than after I DFG (3.5%). Discussion: In this large sample, DFG proved to be an effective and safe method for the reconstruction of anophthalmic sockets. Keywords: Anophthalmic socket, dermis fat graft, enucleation, orbital volume replacement
INTRODUCTION
19th century, marked atrophy of the implanted fat was observed and this technique was regarded not to be useful in the augmentation of volume deficit for many years.1 Later, composite grafts consisting of dermis and fat proved to be less prone to lose volume after implantation. The dermal portion of the composite graft serves as a scaffold for conjunctival growth over the superficial surface of the graft. For this, the conjunctiva is sutured to the implant to only partially coat it, leaving the central part of the implant surface uncovered. With this technique, the depth of the conjunctival fornices can be preserved. Additionally, the extraocular muscles are attached to the more rigid
20 14
Regardless of the reason for the removal of an eye (tumour, painful blind eye, etc.) a major change in functional and cosmetic appearance of the orbit occurs.1 To prevent postoperative orbital volume deficit, various alloplastic orbital implants have been developed for volume augmentation of the anophthalmic socket.2 These alloplastic implants are associated with several possible postoperative complications such as migration and exposure of the implant.3–5 Autologous free fat grafts can overcome some of the problems associated with alloplastic materials. However, in first attempts at the end of the
Received 14 May 2013; Revised 3 September 2013; Accepted 9 September 2013; Published online 4 November 2013 Correspondence: Dr. Martin Nentwich, Department of Ophthalmology, Ludwig-Maximilians University, Matildenstr. 8, 80336 Munich, Germany. E-mail: [email protected]
33
34 M. M. Nentwich et al. dermal portion of the implant allowing for postoperative motility of the implant.1 Smith et al. introduced the concept of dermis fat grafting for volume augmentation of volume-deficient anophthalmic orbits.6,7 In their first large series of 118 patients, they reported good postoperative results after implantation of dermis fat grafts [DFGs] either as primary or secondary orbital implants and concluded DFGs to be effective in maintaining orbital volume while preserving the fornices and conserving the conjunctiva.8 Since these reports, DFGs have been used for primary and secondary reconstructions of orbital volume deficits in adults and children.9–13 Even though DFGs are regarded to be a save alternative to alloplastic orbital implants, a review of the literature revealed a lack of data describing the results of large series of DFG apart from the initial publication by Smith et al.8 As such studies comprising a large number of patients have recently been published with regard to bioceramic and porous polyethylene orbital implants,3–5 all primary and secondary DFGs performed at the Department of Ophthalmology, Ludwig-Maximilians-University, Munich, within a 16-year period were reviewed and functional and cosmetic results were evaluated.
MATERIALS AND METHODS After approval by the Institutional Review Board had been obtained, a retrospective chart review of all primary and secondary DFGs at the Department of Ophthalmology, Ludwig-Maximilians University Munich performed between 1992 and 2007 was done.
Surgical Procedure During the study-period, the same surgery technique was used for all patients as described by Smith et al.6,7 All surgeries were performed under general anaesthesia. First, the autologous DFG was harvested from the donor site, which was located in the gluteal region of the patients. In adults, the standard size of the dermis fat graft was 25 mm in diameter and thickness, while its size varied in children according to the individual requirements from 12 to 25 mm. The epidermis was incised superficially with a No. 15 blade. Saline was injected intradermally at the donor site, then epidermis was dissected and separated from the dermis layer using a No. 20 scalpel. The fat layer was deeply transected, the dermis fat graft explanted and the donor site sutured in two layers with 2.0 absorbable sutures after control of obvious bleeding using a bipolar cautery. While the recipient site was being prepared, the harvested DFG was soaked in sterile saline solution. Before
implantation, the graft was trimmed to fit the recipient site, if necessary, with the goal to implant the maximum volume of dermis and fat that could easily fit into the socket avoiding excessive pressure. The graft was implanted with the dermal side showing up and the extraocular muscles were sutured to the dermal part of the graft. Finally, the conjunctiva was diligently sutured to the outer dermal part of the implant, a rigid conformer was inserted to support the fornices and ofloxacin eye drops were applied. At the end a pressure dressing was put on. Four to six weeks postoperatively a first prosthesis was fitted.
Postoperative Evaluation of Patients Aesthetic results were evaluated comparing symmetry of the palpebral fissures and Hertel exophthalmometry measurements of the operated side with prosthesis in place and the fellow-eye. Motility of the implant was assessed and graded as follows: good/excellent = full motility in 4 directions, reasonable = motility in 1 to 3 directions, bad = no motility. Fitting of the prosthesis was evaluated and graded: excellent = possibility to easily find a proper prosthesis þ good fit of the prosthesis þ high patient comfort with prosthesis þ good lid-function, reasonable = all but one of the above criteria are fulfilled, bad = more than one of the above mentioned criteria is not fulfilled. Patients and parents (in case of children) were interviewed about their satisfaction with the cosmetic result after surgery (graded as very good/excellent, satisfied/reasonable and not satisfied/bad). Finally, complications of this surgery were evaluated. Primary and secondary DFGs were analysed separately.
RESULTS In total, 468 DGFs were performed during the study period. Three-hundred and fifteen surgeries were primary DFG [DFG I ], while 153 patients underwent secondary DFG [DFG II ]. Figure 1 shows the number of surgeries performed per year during the study period. Sufficient follow-up was available for 173 patients after DFG I and 66 patients after DFG II . Only these were included in the analysis of the postoperative results. Median age of DFG I patients was 48 years (range 2–87 years) and 44 years (range 5–83) in DFG II . Median follow-up after DFG I was 21.5 months (range 2–123 months) and 14 months (range 2–82 months) after DFG II . The main indications for DFG are summarized in Tables 1 and 2. Orbit
Dermis Fat Graft as Orbital Implants
35
Number of surgeries per year 80 70 60 50 40 30 20 10 0
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
FIGURE 1 Total number of surgeries over the years. TABLE 1. Main indications for DFG (all DFGs performed in the study period). DFG I (n = 315) Painful blind eye Choroidal melanoma Others (buphthalmus, retinoblastoma, congenital anophthalmus) DFG II (n = 153) Contracted socket Extruded alloplastic implant Post enucleation socket syndrome [PES]
197 65 53
72 58 23
TABLE 2. Main indications for DFG included in the analysis of postoperative results. DFG I (n = 173) Painful blind eye Choroidal melanoma Others (buphthalmus, retinoblastoma, congenital anophthalmus) DFG II (n = 66) Contracted socket Extruded alloplastic implant Post enucleation socket syndrome [PES]
102 60 11
39 17 10
DFG I In DFG I , mean difference of palpebral aperture of the enucleated eye (with prosthesis) and the fellow eye was 0.2 mm (range 2 mm to þ2 mm), which means that the palpebral aperture of the enucleated side was slightly smaller. Mean difference in Hertel exophthalmometry measurements was 1.6 mm (range 8 mm to þ1 mm), which corresponds to a slight enophthalmus of the enucleated side. Seventy-six percent of patients were able to move the graft in all directions, 83% were very happy with the result and fitting of the prosthesis was excellent in 81%. Table 3 summarizes the results after DFG I . !
2014 Informa Healthcare USA, Inc.
TABLE 3. Results after DFG I (n = 173).
Motility Patient’s Satisfaction Fitting of the prosthesis
Excellent
Reasonable
Bad
132 (76%) 144 (83%) 140 (81%)
38 (22%) 28 (16%) 26 (15%)
3 (2%) 1 (1%) 7 (4%)
TABLE 4. Results after DFG II (n = 66).
Motility Patient’s Satisfaction Fitting of the prosthesis
Excellent
Reasonable
Bad
22 (34%) 38 (57%) 32 (49%)
29 (44%) 27 (41%) 27 (41%)
15 (22%) 1 (2%) 7 (10%)
DFG II After DFG II , mean difference of palpebral aperture of the enucleated eye (with prosthesis) and the fellow eye was 0.6 mm (range 4 mm to þ3 mm) (smaller on the enucleated side), while the difference in Hertel exophthalmometry measurements was 2.6 mm (range 4 mm to 0 mm) (enophthalmus of the enucleated side). Thirty-four percent of patients were able to move the graft in all directions. Patients were highly satisfied in 57% and fitting of the prosthesis was excellent or reasonable in 49% and 41%. Table 4 summarizes the results after DFG II . Two of the 39 patients who underwent DFG II due to contracted socked needed additional mucous membrane grafting during follow-up. Overall, major complications were not common after this surgery. However, necrosis or atrophy of the implant was more often seen after DFG II compared to DFG I . In DFG I , two of 173 patients received a secondary DFG during the follow-up period due to
36 M. M. Nentwich et al. TABLE 5. Complications after DFG. DFG I Major complications Complete necrosis Spontaneous atrophy Postoperative haemorrhage Subconjunctival cyst (deep) Minor complications Hair growth Subconjunctival cyst (superficial) Pyogenic granuloma Fat growth Donor site problems (wound dehiscence)
5/173 6/173 1/173 0/173
(2.9%) (3.5%) (0.6%) (0%)
DFG II 3/66 4/66 0/66 1/66
(4.5%) (6.1%) (0%) (1.5%)
12/173 (6.9%) 6/173 (3.5%)
5/66 (7.6%) 1/66 (1.5%)
8/173 (4.6%) 2/173 (1.2%) 1/173 (0.6%)
2/66 (3.0%) 0/66 (0%) 0/66 (0%)
loss of volume of the primary implant. Table 5 summarizes complications that were noted during the study period.
DISCUSSION DFGs have become accepted alternatives to allograft implants for the volume augmentation of anophthalmic sockets in adults since the description of the technique by Smith et al.6,7,14,15 More recently, results of DFG in paediatric patients either as primary or secondary orbital implants have been published.1,12,13 Surgery itself is more time-consuming in DFG compared to the use of alloplastic implants due to the second surgery site for harvesting the graft, but this technique overcomes some of the limitations of alloplastic orbital implants such as extrusion of the implanted material. Recent publications about alloplastic orbital implants comprising large groups of patients evaluated the strengths and limitations of these implants.3–5 Jordan et al. reported an implant exposure rate of bioceramic orbital implants of 9.6% and suggested long-term follow-up of patients after alloplastic orbital implants in order to detect this complication.3 In another series, the exposure rate of porous polyethylene implants was 4.5%, yet infections of the implant were rarely (1%) seen.5 Alloplastic implants may be different with regard to complications and exposure rates depending on the type of material used.4 Autologous DFGs, on the other hand, enable the surgeon to augment orbital volume without the implantation of any alloplastic material into the orbit and without the consequent risk of postoperative exposure of such an implant. Other advantages of DFG, as they are autologous transplants, are the absence of foreign-body-reactions and toxic effects after implantation into the orbit. In contrast to some alloplastic implants, no additional preserved scleral material is needed in DFG. Therefore the risk of transferring pathogens or prions is avoided.16
Suturing the extraocular muscles to the dermal part of the transplant in DFG I enables for good postoperative motility of the socket, which was superior to the results after implantation of synthetic spherical implants in a series by Bosniak et al.17 In particular, the preservation and augmentation of conjunctival surface is an advantage of DFGs in surgery for contracted sockets with unstable fitting of the prosthesis due to shrinkage of the fornices (16). DFGs can also be combined with autologous grafts of oral mucosa, if the conjunctiva does not allow forming proper fornices. In the present series, this was done in 2/39 patients, who had received DFG II because of contracted socket. Durability of the volume augmentation after surgery is an important parameter after autologous DFG as this technique is lacking a persistent alloplastic implant of defined volume. While implants consisting of fat only were absorbed to a great extent after surgery, the modification of the technique by including a dermal part into the transplant provided a more stable postoperative volume gain.1,16 In the literature an average loss of volume of 5–10% after primary dermis fat grafting is reported.8,18 In the present study sample, postoperative fitting of the prosthesis was excellent in 81% after DFG I and excellent or reasonable in DFG II in 49% and 41%, respectively. In comparison with the healthy fellow eye, Hertel exophthalmometry showed a slight enophthalmus of the treated side with prosthesis of 1.6 mm in DFG I and of 2.6 mm in DFG II . Nevertheless, after surgery, the implant lost more volume in DFG II compared to DFG I . This may be due to reduced vascularization or alterations of the orbital tissue at the time of revision surgery. In children even growth of the implant can be observed.16 Smith et al. reported atrophy of the transplant of more than 40% in 3 out of 9 patients after DFG II , while they only noted this amount of atrophy in 1 out of 109 patients after DFG I .8 On the other hand, postoperative loss of orbital volume is possible with alloplastic implants, too, and the so called post-enucleation syndrome can also occur in this group. In a survey conducted in Germany and the Netherlands on ocularists’ views on orbital implants primary implants were generally recommended by 94% of the responding ocularists. With regard to their favoured type of implant, ocularists especially named DFGs and ‘‘baseball’’ orbital implants. Even though this survey was published in 2001, a diligent literature review did not reveal any more recently published data on the ocularists’ opinion on orbital implants after enucleation.19 In the present study, necrosis of the transplant, which definitely is one of the most severe adverse events after this surgery, occurred in 2.9% in DFG I and 4.5% in the DFG II group. Marked spontaneous Orbit
Dermis Fat Graft as Orbital Implants atrophy was seen more frequently after DFG II (6.1%) than after DFG I (3.5%). This is in accordance with previously published literature which reports higher complication rates and more loss of volume after secondary dermis fat grafting (8, 10, 18, 20). Other complications such as subconjunctival cysts and pyogenic granulomas occurred infrequently and could be managed without any problems. In 1.2% (2/173) of patients after DFG I a growth of the transplant was seen, which was associated with marked weight gain of the patients. This can be managed either by encouraging the patient to lose weight again or by trimming of the excessive fat in revision surgery should adequate fitting of the prosthesis not be achieved. The gluteal region was chosen as the standard donor-site in our series due to functional and cosmetic reasons, as the dermis fat graft harvested from this location shows good functional characteristics and the scar is usually covered, even when the patients are wearing swim-wear. Data regarding the optimal volume of the implant vary in the literature. Sihota et al. compared their results after surgery using DFGs of 10 mm and 20 mm thickness and reported better outcomes with the thicker transplant.21 In the present series, transplants 25 mm in diameter and thickness were used. In revision surgery, DFG II is a good option for the treatment of orbital volume deficit after the removal of exposed alloplastic orbital implants and in case of contracted sockets. In complex cases DFGs can be combined with transplantation of oral mucosa in order to create sufficient conjunctival fornices. Due to the increased postoperative loss of volume in DFG II , a secondary alloplastic implant may be superior to DFG II in patients with orbital volume deficits in post-enucleation syndrome but sufficient conjunctival surface. As DFGs need to be positioned on soft tissue of sufficient volume to enable the vascularization of the transplant, we do not recommend putting a DFG over pre-existing alloplastic orbital implants or directly on orbital bone. As the functional and cosmetic results after DFG are satisfactory in the present series, DFG is routinely being used at the Department of Ophthalmology of LMU Munich as primary and secondary orbital implant. By avoiding the long-term risk of extrusion of alloplastic implants and due to the good preservation of conjunctival surface, primary DFG seems to be of special benefit in younger patients and patients with conjunctival scarring.
ACKNOWLEDGEMENTS Presented in part at the Annual Meeting of the European Society of Ophthalmic Plastic and !
2014 Informa Healthcare USA, Inc.
Reconstructive Surgery 2005, Crete, Greece.
(E.S.O.P.R.S.),
37
September
DECLARATION OF INTEREST No funding was received for this work. The authors have no proprietary interest in any of the material mentioned in this study. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES 1. Mitchell KT, Hollsten DA, White WL, O’Hara MA. The autogenous dermis-fat orbital implant in children. J AAPOS 2001;5(6):367–369. 2. Moshfeghi DM, Moshfeghi AA, Finger PT. Enucleation. Surv Ophthalmol 2000;44(4):277–301. 3. Jordan DR, Klapper SR, Gilberg SM, et al. The bioceramic implant: evaluation of implant exposures in 419 implants. Ophthalm Plast Reconst Surg 2010; 26(2):80–82. 4. Ramey N, Gupta D, Price K, et al. Comparison of complication rates of porous anophthalmic orbital implants. Ophthal Surg Lasers Imag 2011;42(5):434–440. 5. Jung SK, Cho WK, Paik JS, Yang SW. Long-term surgical outcomes of porous polyethylene orbital implants: a review of 314 cases. Br J Ophthalm 2012;96(4):494–498. 6. Smith B, Petrelli R. Dermis-fat graft as a movable implant within the muscle cone. Amer J Ophthalmol 1978; 85(1):62–66. 7. Smith B, Bosniak SL, Lisman RD. An autogenous kinetic dermis-fat orbital implant: an updated technique. Ophthalmology 1982;89(9):1067–1071. 8. Smith B, Bosniak S, Nesi F, Lisman R. Dermis-fat orbital implantation: 118 cases. Ophthalm Surg 1983; 14(11):941–943. 9. Aguilar GL, Shannon GM, Flanagan JC. Experience with dermis-fat grafting: an analysis of early postoperative complications and methods of prevention. Ophthalm Surg 1982;13(3):204–209. 10. Bosniak SL. Dermis-fat orbital implantation and complex socket deformities. Adv Ophthalm Plast Reconst Surg 1992;9: 131–141. 11. Hintschich CR, Beyer-Machule CK. Dermal fatty tissue transplant as primary and secondary orbital implant. Complications and results. Der Ophthalmologe 1996; 93(5):617–622. 12. Tarantini A, Hintschich C. Primary dermis-fat grafting in children. Orbit 2008;27(5):363–369. 13. Lee MJ, Khwarg SI, Choung HK, et al. Dermis-fat graft for treatment of exposed porous polyethylene implants in pediatric postenucleation retinoblastoma patients. Amer J Ophthalmol 2011;152(2):244–250 e2. 14. Nentwich MM, Mackert MJ, Hintschich C, Messmer EM. Large choroidal melanoma diagnosed after cataract surgery. Inter Ophthalmol 2012;32(5):481–483.14. 15. Mueller AJ, Schaller UC, Klingenstein A, Nentwich MM. Intraocular tumors in adults: uveal melanoma. Klinische Monatsblatter fur Augenheilkunde 2010;227(3):R29–R47. 16. Hintschich C. Dermis-fat graft. Possibilities and limitations. Der Ophthalmologe 2003;100(7):518–524.
38 M. M. Nentwich et al. 17. Bosniak SL, Nesi F, Smith BC, et al. A comparison of motility: autogenous dermis-fat vs synthetic spherical implants. Ophthalm Surg 1989;20(12): 889–891. 18. Martin PA, Rogers PA, Billson F. Dermis-fat graft: evolution of a living prosthesis. Austral New Zeal J Ophthalmol 1986;14(2):161–165.
19. Hintschich C, Baldeschi L. Rehabilitation of anophthalmic patients. Results of a survey. Der Ophthalmologe 2001; 98(1):74–80. 20. Bosniak SL. Complications of dermis-fat orbital implantation. Adv Ophthal Plast Reconst Surg 1990;8:170–181. 21. Sihota R, Sujatha Y, Betharia SM. The fat pad in dermis fat grafts. Ophthalmology 1994;101(2):231–234.
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ORIGINAL ARTICLE
Dermis Fat Grafts as Primary and Secondary Orbital Implants Martin M. Nentwich, Kirsten Schebitz-Walter, Christoph Hirneiss, and Christoph Hintschich Department of Ophthalmology, Ludwig-Maximilians-University, Munich, Germany
ABSTRACT Introduction: This study was performed to evaluate the outcome after autologous dermis-fat graft [DFG] orbital implants in a large sample. Materials and Methods: A retrospective chart review of all primary and secondary DFGs in a 16-year period was done. Aesthetic and functional results, patients’ satisfaction and postoperative complications were evaluated. Results: In total 468 DFGs were performed in the study period (315 primary [I ] and 153 secondary [II ] DGFs). In the analysis, 173 DFG I and 66 DFG II were included as sufficient follow-up was available. Median follow-up after DFG I was 21.5 months and 14 months after DFG II . After DFG I , in 76% of patients motility of the graft was possible in all directions; 81% had good fitting of the prosthesis and 83% were highly satisfied with the results. Mean width of palpebral apertures was 0.2 mm smaller and Hertel exophthalmometry revealed a mean enophthalmus of 1.6 mm on the operated side compared to the fellow-eye. After DFG II , motility was possible in all directions in 34% of patients. Fitting of the prosthesis was good/reasonable in 49%/ 41% and patients were highly satisfied in 57%. On average, on the operated side palpebral apertures were 0.6 mm smaller and Hertel measurements showed an enophthalmus of 2.6 mm. Major complications were uncommon. Complete necrosis of the implant was more often observed after II (6.1%) than after I DFG (3.5%). Discussion: In this large sample, DFG proved to be an effective and safe method for the reconstruction of anophthalmic sockets. Keywords: Anophthalmic socket, dermis fat graft, enucleation, orbital volume replacement
INTRODUCTION
19th century, marked atrophy of the implanted fat was observed and this technique was regarded not to be useful in the augmentation of volume deficit for many years.1 Later, composite grafts consisting of dermis and fat proved to be less prone to lose volume after implantation. The dermal portion of the composite graft serves as a scaffold for conjunctival growth over the superficial surface of the graft. For this, the conjunctiva is sutured to the implant to only partially coat it, leaving the central part of the implant surface uncovered. With this technique, the depth of the conjunctival fornices can be preserved. Additionally, the extraocular muscles are attached to the more rigid
20 14
Regardless of the reason for the removal of an eye (tumour, painful blind eye, etc.) a major change in functional and cosmetic appearance of the orbit occurs.1 To prevent postoperative orbital volume deficit, various alloplastic orbital implants have been developed for volume augmentation of the anophthalmic socket.2 These alloplastic implants are associated with several possible postoperative complications such as migration and exposure of the implant.3–5 Autologous free fat grafts can overcome some of the problems associated with alloplastic materials. However, in first attempts at the end of the
Received 14 May 2013; Revised 3 September 2013; Accepted 9 September 2013; Published online 4 November 2013 Correspondence: Dr. Martin Nentwich, Department of Ophthalmology, Ludwig-Maximilians University, Matildenstr. 8, 80336 Munich, Germany. E-mail: [email protected]
33
34 M. M. Nentwich et al. dermal portion of the implant allowing for postoperative motility of the implant.1 Smith et al. introduced the concept of dermis fat grafting for volume augmentation of volume-deficient anophthalmic orbits.6,7 In their first large series of 118 patients, they reported good postoperative results after implantation of dermis fat grafts [DFGs] either as primary or secondary orbital implants and concluded DFGs to be effective in maintaining orbital volume while preserving the fornices and conserving the conjunctiva.8 Since these reports, DFGs have been used for primary and secondary reconstructions of orbital volume deficits in adults and children.9–13 Even though DFGs are regarded to be a save alternative to alloplastic orbital implants, a review of the literature revealed a lack of data describing the results of large series of DFG apart from the initial publication by Smith et al.8 As such studies comprising a large number of patients have recently been published with regard to bioceramic and porous polyethylene orbital implants,3–5 all primary and secondary DFGs performed at the Department of Ophthalmology, Ludwig-Maximilians-University, Munich, within a 16-year period were reviewed and functional and cosmetic results were evaluated.
MATERIALS AND METHODS After approval by the Institutional Review Board had been obtained, a retrospective chart review of all primary and secondary DFGs at the Department of Ophthalmology, Ludwig-Maximilians University Munich performed between 1992 and 2007 was done.
Surgical Procedure During the study-period, the same surgery technique was used for all patients as described by Smith et al.6,7 All surgeries were performed under general anaesthesia. First, the autologous DFG was harvested from the donor site, which was located in the gluteal region of the patients. In adults, the standard size of the dermis fat graft was 25 mm in diameter and thickness, while its size varied in children according to the individual requirements from 12 to 25 mm. The epidermis was incised superficially with a No. 15 blade. Saline was injected intradermally at the donor site, then epidermis was dissected and separated from the dermis layer using a No. 20 scalpel. The fat layer was deeply transected, the dermis fat graft explanted and the donor site sutured in two layers with 2.0 absorbable sutures after control of obvious bleeding using a bipolar cautery. While the recipient site was being prepared, the harvested DFG was soaked in sterile saline solution. Before
implantation, the graft was trimmed to fit the recipient site, if necessary, with the goal to implant the maximum volume of dermis and fat that could easily fit into the socket avoiding excessive pressure. The graft was implanted with the dermal side showing up and the extraocular muscles were sutured to the dermal part of the graft. Finally, the conjunctiva was diligently sutured to the outer dermal part of the implant, a rigid conformer was inserted to support the fornices and ofloxacin eye drops were applied. At the end a pressure dressing was put on. Four to six weeks postoperatively a first prosthesis was fitted.
Postoperative Evaluation of Patients Aesthetic results were evaluated comparing symmetry of the palpebral fissures and Hertel exophthalmometry measurements of the operated side with prosthesis in place and the fellow-eye. Motility of the implant was assessed and graded as follows: good/excellent = full motility in 4 directions, reasonable = motility in 1 to 3 directions, bad = no motility. Fitting of the prosthesis was evaluated and graded: excellent = possibility to easily find a proper prosthesis þ good fit of the prosthesis þ high patient comfort with prosthesis þ good lid-function, reasonable = all but one of the above criteria are fulfilled, bad = more than one of the above mentioned criteria is not fulfilled. Patients and parents (in case of children) were interviewed about their satisfaction with the cosmetic result after surgery (graded as very good/excellent, satisfied/reasonable and not satisfied/bad). Finally, complications of this surgery were evaluated. Primary and secondary DFGs were analysed separately.
RESULTS In total, 468 DGFs were performed during the study period. Three-hundred and fifteen surgeries were primary DFG [DFG I ], while 153 patients underwent secondary DFG [DFG II ]. Figure 1 shows the number of surgeries performed per year during the study period. Sufficient follow-up was available for 173 patients after DFG I and 66 patients after DFG II . Only these were included in the analysis of the postoperative results. Median age of DFG I patients was 48 years (range 2–87 years) and 44 years (range 5–83) in DFG II . Median follow-up after DFG I was 21.5 months (range 2–123 months) and 14 months (range 2–82 months) after DFG II . The main indications for DFG are summarized in Tables 1 and 2. Orbit
Dermis Fat Graft as Orbital Implants
35
Number of surgeries per year 80 70 60 50 40 30 20 10 0
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
FIGURE 1 Total number of surgeries over the years. TABLE 1. Main indications for DFG (all DFGs performed in the study period). DFG I (n = 315) Painful blind eye Choroidal melanoma Others (buphthalmus, retinoblastoma, congenital anophthalmus) DFG II (n = 153) Contracted socket Extruded alloplastic implant Post enucleation socket syndrome [PES]
197 65 53
72 58 23
TABLE 2. Main indications for DFG included in the analysis of postoperative results. DFG I (n = 173) Painful blind eye Choroidal melanoma Others (buphthalmus, retinoblastoma, congenital anophthalmus) DFG II (n = 66) Contracted socket Extruded alloplastic implant Post enucleation socket syndrome [PES]
102 60 11
39 17 10
DFG I In DFG I , mean difference of palpebral aperture of the enucleated eye (with prosthesis) and the fellow eye was 0.2 mm (range 2 mm to þ2 mm), which means that the palpebral aperture of the enucleated side was slightly smaller. Mean difference in Hertel exophthalmometry measurements was 1.6 mm (range 8 mm to þ1 mm), which corresponds to a slight enophthalmus of the enucleated side. Seventy-six percent of patients were able to move the graft in all directions, 83% were very happy with the result and fitting of the prosthesis was excellent in 81%. Table 3 summarizes the results after DFG I . !
2014 Informa Healthcare USA, Inc.
TABLE 3. Results after DFG I (n = 173).
Motility Patient’s Satisfaction Fitting of the prosthesis
Excellent
Reasonable
Bad
132 (76%) 144 (83%) 140 (81%)
38 (22%) 28 (16%) 26 (15%)
3 (2%) 1 (1%) 7 (4%)
TABLE 4. Results after DFG II (n = 66).
Motility Patient’s Satisfaction Fitting of the prosthesis
Excellent
Reasonable
Bad
22 (34%) 38 (57%) 32 (49%)
29 (44%) 27 (41%) 27 (41%)
15 (22%) 1 (2%) 7 (10%)
DFG II After DFG II , mean difference of palpebral aperture of the enucleated eye (with prosthesis) and the fellow eye was 0.6 mm (range 4 mm to þ3 mm) (smaller on the enucleated side), while the difference in Hertel exophthalmometry measurements was 2.6 mm (range 4 mm to 0 mm) (enophthalmus of the enucleated side). Thirty-four percent of patients were able to move the graft in all directions. Patients were highly satisfied in 57% and fitting of the prosthesis was excellent or reasonable in 49% and 41%. Table 4 summarizes the results after DFG II . Two of the 39 patients who underwent DFG II due to contracted socked needed additional mucous membrane grafting during follow-up. Overall, major complications were not common after this surgery. However, necrosis or atrophy of the implant was more often seen after DFG II compared to DFG I . In DFG I , two of 173 patients received a secondary DFG during the follow-up period due to
36 M. M. Nentwich et al. TABLE 5. Complications after DFG. DFG I Major complications Complete necrosis Spontaneous atrophy Postoperative haemorrhage Subconjunctival cyst (deep) Minor complications Hair growth Subconjunctival cyst (superficial) Pyogenic granuloma Fat growth Donor site problems (wound dehiscence)
5/173 6/173 1/173 0/173
(2.9%) (3.5%) (0.6%) (0%)
DFG II 3/66 4/66 0/66 1/66
(4.5%) (6.1%) (0%) (1.5%)
12/173 (6.9%) 6/173 (3.5%)
5/66 (7.6%) 1/66 (1.5%)
8/173 (4.6%) 2/173 (1.2%) 1/173 (0.6%)
2/66 (3.0%) 0/66 (0%) 0/66 (0%)
loss of volume of the primary implant. Table 5 summarizes complications that were noted during the study period.
DISCUSSION DFGs have become accepted alternatives to allograft implants for the volume augmentation of anophthalmic sockets in adults since the description of the technique by Smith et al.6,7,14,15 More recently, results of DFG in paediatric patients either as primary or secondary orbital implants have been published.1,12,13 Surgery itself is more time-consuming in DFG compared to the use of alloplastic implants due to the second surgery site for harvesting the graft, but this technique overcomes some of the limitations of alloplastic orbital implants such as extrusion of the implanted material. Recent publications about alloplastic orbital implants comprising large groups of patients evaluated the strengths and limitations of these implants.3–5 Jordan et al. reported an implant exposure rate of bioceramic orbital implants of 9.6% and suggested long-term follow-up of patients after alloplastic orbital implants in order to detect this complication.3 In another series, the exposure rate of porous polyethylene implants was 4.5%, yet infections of the implant were rarely (1%) seen.5 Alloplastic implants may be different with regard to complications and exposure rates depending on the type of material used.4 Autologous DFGs, on the other hand, enable the surgeon to augment orbital volume without the implantation of any alloplastic material into the orbit and without the consequent risk of postoperative exposure of such an implant. Other advantages of DFG, as they are autologous transplants, are the absence of foreign-body-reactions and toxic effects after implantation into the orbit. In contrast to some alloplastic implants, no additional preserved scleral material is needed in DFG. Therefore the risk of transferring pathogens or prions is avoided.16
Suturing the extraocular muscles to the dermal part of the transplant in DFG I enables for good postoperative motility of the socket, which was superior to the results after implantation of synthetic spherical implants in a series by Bosniak et al.17 In particular, the preservation and augmentation of conjunctival surface is an advantage of DFGs in surgery for contracted sockets with unstable fitting of the prosthesis due to shrinkage of the fornices (16). DFGs can also be combined with autologous grafts of oral mucosa, if the conjunctiva does not allow forming proper fornices. In the present series, this was done in 2/39 patients, who had received DFG II because of contracted socket. Durability of the volume augmentation after surgery is an important parameter after autologous DFG as this technique is lacking a persistent alloplastic implant of defined volume. While implants consisting of fat only were absorbed to a great extent after surgery, the modification of the technique by including a dermal part into the transplant provided a more stable postoperative volume gain.1,16 In the literature an average loss of volume of 5–10% after primary dermis fat grafting is reported.8,18 In the present study sample, postoperative fitting of the prosthesis was excellent in 81% after DFG I and excellent or reasonable in DFG II in 49% and 41%, respectively. In comparison with the healthy fellow eye, Hertel exophthalmometry showed a slight enophthalmus of the treated side with prosthesis of 1.6 mm in DFG I and of 2.6 mm in DFG II . Nevertheless, after surgery, the implant lost more volume in DFG II compared to DFG I . This may be due to reduced vascularization or alterations of the orbital tissue at the time of revision surgery. In children even growth of the implant can be observed.16 Smith et al. reported atrophy of the transplant of more than 40% in 3 out of 9 patients after DFG II , while they only noted this amount of atrophy in 1 out of 109 patients after DFG I .8 On the other hand, postoperative loss of orbital volume is possible with alloplastic implants, too, and the so called post-enucleation syndrome can also occur in this group. In a survey conducted in Germany and the Netherlands on ocularists’ views on orbital implants primary implants were generally recommended by 94% of the responding ocularists. With regard to their favoured type of implant, ocularists especially named DFGs and ‘‘baseball’’ orbital implants. Even though this survey was published in 2001, a diligent literature review did not reveal any more recently published data on the ocularists’ opinion on orbital implants after enucleation.19 In the present study, necrosis of the transplant, which definitely is one of the most severe adverse events after this surgery, occurred in 2.9% in DFG I and 4.5% in the DFG II group. Marked spontaneous Orbit
Dermis Fat Graft as Orbital Implants atrophy was seen more frequently after DFG II (6.1%) than after DFG I (3.5%). This is in accordance with previously published literature which reports higher complication rates and more loss of volume after secondary dermis fat grafting (8, 10, 18, 20). Other complications such as subconjunctival cysts and pyogenic granulomas occurred infrequently and could be managed without any problems. In 1.2% (2/173) of patients after DFG I a growth of the transplant was seen, which was associated with marked weight gain of the patients. This can be managed either by encouraging the patient to lose weight again or by trimming of the excessive fat in revision surgery should adequate fitting of the prosthesis not be achieved. The gluteal region was chosen as the standard donor-site in our series due to functional and cosmetic reasons, as the dermis fat graft harvested from this location shows good functional characteristics and the scar is usually covered, even when the patients are wearing swim-wear. Data regarding the optimal volume of the implant vary in the literature. Sihota et al. compared their results after surgery using DFGs of 10 mm and 20 mm thickness and reported better outcomes with the thicker transplant.21 In the present series, transplants 25 mm in diameter and thickness were used. In revision surgery, DFG II is a good option for the treatment of orbital volume deficit after the removal of exposed alloplastic orbital implants and in case of contracted sockets. In complex cases DFGs can be combined with transplantation of oral mucosa in order to create sufficient conjunctival fornices. Due to the increased postoperative loss of volume in DFG II , a secondary alloplastic implant may be superior to DFG II in patients with orbital volume deficits in post-enucleation syndrome but sufficient conjunctival surface. As DFGs need to be positioned on soft tissue of sufficient volume to enable the vascularization of the transplant, we do not recommend putting a DFG over pre-existing alloplastic orbital implants or directly on orbital bone. As the functional and cosmetic results after DFG are satisfactory in the present series, DFG is routinely being used at the Department of Ophthalmology of LMU Munich as primary and secondary orbital implant. By avoiding the long-term risk of extrusion of alloplastic implants and due to the good preservation of conjunctival surface, primary DFG seems to be of special benefit in younger patients and patients with conjunctival scarring.
ACKNOWLEDGEMENTS Presented in part at the Annual Meeting of the European Society of Ophthalmic Plastic and !
2014 Informa Healthcare USA, Inc.
Reconstructive Surgery 2005, Crete, Greece.
(E.S.O.P.R.S.),
37
September
DECLARATION OF INTEREST No funding was received for this work. The authors have no proprietary interest in any of the material mentioned in this study. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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