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Dermis Fat Graft

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The dermis fat graft (DFG) for an anopthalmic socket reconstruction was first described by Smith and Petrelli in 1978. It has become widely employed as a technique by which to augment orbital volume in enucleated patients.[1] The technique is used both as a primary procedure following enucleation, and as a secondary procedure for extrusion or migration of an orbital implant.[1]Inadequate replacement of a volume deficit by an orbital implant and ocular prosthesis can lead to enophthalmos and depression of the upper eyelid.[2] In addition, changes in orbital vascularity and architecture have been cited as the basis for socket contracture, though the pathophysiology continues to be a topic of debate.[3]

Among conventional autografts, DFGs are preferred for their ability to augment both volume and surface area.[3] DFGs may be  harvested from the abdominal, gluteal, hip, groin, or thigh regions.[2][4] Not only do the fat and dermis provide a soft tissue and surface lining with vascular support respectively, but the graft can also act as a temporary biologic dressing.[2][4] DFGs are convenient and inexpensive, and do not cause local reactions or disease transmission.[1][4] Furthermore, chance of migration or extrusion is lower with the use of autologous tissue than with the use of artificial implants.[2]

The most commonly cited drawback of the procedure is an unpredictable rate of subsequent fat atrophy, more commonly in adults.[5] A prospective study by Bhattacharjee et al demonstrated recurrence of socket contracture with prosthesis extrusion in 4 out of 12 cases undergoing DFG, of which 11 of 12 patients were adults.[3] In comparison, Essuman et al reported a graft failure rate of only 7% in a study of 15 children.[6]

Patient Selection

Preoperative Evaluation

Surgical management is guided by patient age and history, orbital implant type, degree and duration of implant exposure, and defect size.[1][2] Larger defects are typically repaired with DFGs, but the procedure may not be appropriate for severely contracted sockets.[1][7] If available, axial length measurement of the healthy eye prior to enucleation or evisceration is obtained.[2] Preoperative inspection of the socket, superior sulcus, palpebral aperture, and lid is performed, and the level of socket contracture is graded.[3] Scar tissue in the conjunctiva, lid, and socket should be noted, and the graft site is examined for damage and poor vascular support, which can exacerbate fat atrophy.[2][3] Both recipient and donor sites should be free of infection prior to surgery.[2][3] Donor tissue must contain sufficient underlying fat to cover the area of the defect, and is ideally harvested from a region that is hairless, not subject to pressure, and easily hidden under swimwear.[2]

Vascular Support

Though DFGs are traditionally not recommended for atrophy and fibrosis secondary to ocular radiotherapy due to concerns of poor anastomosis between irradiated tissues and the graft, good results may still be achieved with hypercorrection of the donor tissue, and good intraoperative hemostasis.[5] Similarly, orbits that have suffered significant trauma, especially from chemical burns, and patients with systemic vascular disease, should receive careful consideration due to increased risk of graft failure secondary to a nonviable recipient bed.[7]

Children

DFGs may be particularly suitable for children since the graft grows with the surrounding orbital tissue. Herer and Katowitz described in 1998 that young children under age 4 were noted to have hypertrophy of the DFG that required debulking in some patients. .[5] In a prospective case series analyzing Ghanaian children between the ages of 9 months and 10 years with follow-up ranging from 3-54 months, volume augmentation of the graft and good facial symmetry were achieved in 14 out of 15 children.[6]  

Indications

One of the main indication for a Dermis fat grafts is congenital anophthalmia.[1][2][3] The procedure is also indicated for complications of secondary anophthalmia following occurrence of trauma, corneal ulcer, malignancy or intraocular tumor with or without radiotherapy, glaucoma, endopthalmitis, painful blind eye, and others.[1] In a retrospective review of 41 patients by Aryasit and Preechawai, the 3 major indications for secondary DFG included: 

  • Exposure of orbital implant (32%)

  • Extrusion of orbital implant (27%)

  • Volume insufficiency with shallow fornix (24%).[1]


Others have also indicated good success using DFG for:

  • Primary implantation

  • Severely contracted socket

Relative Contraindications

DFG may be used in these circumstances but may have limited success:

  • Compromised orbital vascular supply

  • Severe chemical injury

  • Secondary implantation post irradiation

  • Multiple orbital surgeries [7]

Surgical technique

  • An ellipsoid approximately 20 mm in diameter is placed in the lower abdominal quadrant or flank, This areas are less prone to be tender, and are non-weight bearing. Some surgeons prefer harvesting the DFG from the buttocks or lateral portion of the thigh. The ultimate diameter of the harvested graft most not exceed 25mm.

  • The surgical site is locally anesthetized with lidocaine 2% with epinephrine 1:100,000.

  • A #15 blade is then used to make an incision along the marking through the epidermis.

  • The #15 blade is then used to excise the epidermis from the underlying dermis. The epidermis is best removed with the dermal tissue in situ. The epidermis is excised so that keratin is not produced in the socket.

  • Holding the #15 blade perpendicular to the dermal face, an incision is made along the dermis to the underlying fat following the ellipse. Holding the blade perpendicularly is important in harvesting an adequate size composite-graft that is slightly wider at the base away from the dermal side. Beveling the blade will yield a conical-shaped graft with inadequate fatty tissue.

  • Steven scissors or Metzembaum scissors are then used to bevel out to excise as much fat as possible.

  • It is important to harvest more fat that what you think you will need since you will lose approximately 50% of your fat volume as things heal.

  • The graft can then be placed in moist saline gauze or in physiologic saline solution until needed.

  • The incision is then closed with deep interrupted 4-0 monocryl sutures. Vicryl sutures could also be used if preferred.

  • The skin can then be closed with a 5-0 or 4-0 prolene suture.

  • The edges of the skin should be everted. In this case a running horizontal mattress suture is placed.

  • Antibiotic ointment is then be placed over the incision, a Telfa dressing and a pressure bandage are applied for a week.

  • The graft is then transferred to the anophthalmic socket, and each of the muscles that have been tagged with the double armed 5-0 vicryl sutures are sutured to the edge of the dermis.  It should be very difficult to get all of the fat into the socket. 

  • The conjunctival edges are then sutured to the edge of the dermis with 6-0 vicryl suture, in a running or interrupted fashion. It is important to make sure that the edges of the conjunctiva are not buried or an inclusion cyst may later develop.  In the following 4 weeks approximately, the dermis should become epithelialized by migration of cells across the graft from the conjunctival edges. 

  • At the conclusion of the case a large conformer is placed.  A temporary suture tarsorrhaphy can often be placed.  The eye is then patched for a week. . [8] [9]

Postoperative care

Regarding the post-operative care for the surgical site from where the graft was obtained, tends to heal in the same fashion as other wounds approximated by primary  intention. Some surgeons place patient who undergo autogenous tissue grafts in oral cephalosporins for 5-7 days. Graft site hematomas have been reported, and should be dealt in a conservative manner. If the surgical site is under tension, it would be advisable to release the sutures, and apply a compression bandage to the site. Closure can be reattempted after the swelling has diminished. [9]

After appropriate layered closure has been achieved at the socket, after implantation of the DFG, a conformer should to placed, as well as antibiotic ointment. The conformer will  prevent extrusion of the graft , as well as proper maintenance of the fornices for a future ocular prosthesis to be fitted, usually by 6 weeks.

Complications

At the site from which the graft if harvested:

  • Hematoma

  • Infection

  • Graft-wound dehiscence


In the socket where the DFG is implanted:

  • Conjunctival cysts

  • Granulomas

  • Graft ulcers

  • Pyogenic granuloma

  • Socket keratinization

  • Cilia retention at the recipient site

  • Fat atrophy and volume loss --this occurs more commonly than fat hypertrophy, and may have many factors

  • Excessive dermis-fat growth-- this has been reported in dermis fat grafts placed in young children

  • Graft failure [7]


Shore et al. discuss their experience following sixty consecutive cases of dermis fat graft in an enophthalmic socket. Shore et al. report conjunctival ulceration in seven patients. Ten cases resulted in enophthalmos, given the reabsorption and atrophy y of the fat graft. Two patients developed keratinized sockets with chronic discharge and desquamation. Three patients required excision of conjunctival granulomas. One patient developed a primary graft infection. A donor site hematoma occurred in one patient. Secondary surgical intervention was required in ten patients. [10]

Nine complications in eight patients were managed in the office; five complications in four patients were observed and subsequently resolved without surgical intervention. Most complications occurred in patients with severely traumatized sockets who had undergone extensive earlier ocular surgery, or who had a systemic disease contributing to defective wound healing. [11]

In another report by Quaranta-Leoni et al. describing their experience with DFG in 22 patients, they describe only one complication in a child with exuberant fat growth of the implant. The reported differences in complication rates between Shore et al. and Quaranta-Leoni et. al might be due to differences in technique.  [12


Welcome International Prosthetic Eye Center

Your life-like Customized Artificial Eyes

We offered very natural looking artificial eyes!

In certain cases where normal eye is bulging forward, or have pain in the eyes with out Vision, these patient may under go for evisceration or enucleation with or with out use of orbital implant. The surgical procedure to remove the entire natural eye is referred to as an enucleation where as the surgical procedure to remove the contents of of a natural eye is referred to as evisceration.Both procedures will need prosthetic restoration with the fitting of an artificial eye. This process can usually begin approximately six weeks following the initial surgery.

Fitting the artificial eye begins with a board certified ocularist taking an impression mold of the surgically repaired eye socket or residual eye. This procedure ensures each patient attains the maximum amount of comfort and movement possible.

Our team of board certified ocularists have developed advanced art and sculpting techniques to recreate artificial eyes with life-like and natural appearance. These techniques are focus on carefully matching eyelid contours, eyelid folds, and other features involved in achieving facial symmetry. We make every effort to maximize the amount of movement and to recreate an exact color match to your natural eye.

At International Prosthetic Eye Center, we utilize a combination of digital photography and hand painted technques to replicate the color and details of your eye. Only natural earth pigments are used in the painting of our artificial eyes. These pigments provide exquisite detail, depth of color, and vibrancy for the life of your artificial eye.  

TOP EXPERT IN INDIA 

EXPERT IN DEALING POST Dermis Fat Graft TREATMENT 

Team is highly qualified and very passionated to care for you at every step of providing care. 

Kuldeep Raizada, Ph D BCO, BADO, FAAO

Kuldeep Raizada is a Licensed Ocularist in Hyderabad, a Board Certified Ocularist (BCO)  from National examination Board of ocularist’s, USA and a Board Approved Diplomate Ocularist (BADO) from American Society of ocularist’s, specializing in ocular prosthetics since 2001, Kuldeep places his emphasis on the satisfaction and well-being of every patient. His clinical  skill and expertise are equally matched by his personalized care for patients and attention to detail.

Kuldeep Raizada completed his basic optometry education at Gandhi Eye Hospital, Aligarh, and has his training at L V Prasad Eye Institute, Hyderabad. where he was also Founder and Head of the Department of Ocular Prosthesis services till 2009. He completed a second fellowship, in Anaplastolgy, at MD Anderson Cancer Centre, Houston. He has also been trained by the top most ocularist and anaplastologist in United States of America.

His clinical interests include ocular and facial prosthesis, particularly in pediatric patients. His research interests lie in newer advancement in development of new types of prosthesis, newer solution for ptosis corrective glasses. 

Kuldeep Raizada, is Founder & Director of the International Prosthetic Eye Center since 2010, where he is practicing since 2010.

Kuldeep Raizada has been recognized by the American Society of Ocularist, USA and American Anaplastology Association,USA and by several other professional organizations, for his excellence in research and clinical practice.

Kuldeep Raizada, have completed all requirements by American Society of Ocularist, which is hard work of 14000 working hours as well extensive study for prosthetics, Hence awarded the Diplomate Ocularist from American Society of Ocularist, USA, 2012, Chicago, USA, which is the First ever received all over Asia Pacific & throughout Middle East so ever. 

 At present he is reviewer of several journals like Contact Lens & Anterior Eye, International Journal of Anaplastology, Oculoplasty & Reconstructive  Surgery (OPRS) and Many others. He has published and presented world widely.

Fact About Kuldeep

  • CEO & Chairman of Akriti

  • Founder & Director International Prosthetic Eye Center, India

  • Founder of Healthcare India Magazine

  • Receipt of Abdul Kalam Award.

  • First ever Indian to received  Board Certifications, from National Board of examination of ocularist, USA, He was the first One all over Asia Pacific & throughout Middle East.

  • Developed First Digital Dynamic Facial Eye Prosthesis

  • Developed physiological Near Stereo test 

  • Developed physiological Distance Stereo test 

  • Developed ETDRS Log Mar Vision Charts in Hindi for 4 Meters

  • Developed ETDRS Log Mar Vision Charts in Telegu for 4 Meters 

  • Developed ETDRS Log Mar Vision Charts in Assamese  for 4 Meters 

  • Developed ETDRS Log Mar Vision Charts in Arabic for 4 Meters 

  • Developed ETDRS Log Mar Vision Charts in Bangla for 4 Meters 

  • Developed ETDRS Log Mar Vision Charts in Tamil for 4 Meters 

  • Developed ETDRS Log Mar Vision Charts in Oriya  for 4 Meters 

  • Developed ETDRS Log Mar Vision Charts in Kannada for 4 Meters

  • Developed ETDRS Log Mar Vision Charts in Malayalam for 4 Meters 


Deepa D Raizada, MS, BCA, BCO, BCCA 

Deepa completed her diploma and clinical fellowship in optometry at L V Prasad Eye Institute, India, in 2003, pursued her graduation from Madhurai Kamraj University, 2006.

She had completed her Master of Science (M Sc)  in “Maxillofacial and Craniofacial Technology” (2010-2012), King’s Collage London, UK where she was trained to work exclusively  in the field of Maxillofacial Prosthetics.

Deepa is also an associate Member of The Institute of Maxillofacial Prosthetist & Technologist, UK  (AIMPT) since 2014. & Active Member of International Anaplastology Association, (IAA) USA  since 2009.

Deepa Have make a remarkable success in becoming "Asia's First Board Certified Clinical Anaplastologist ( BCCA") and Bring glory for India as to Make India Fifth Nation to have a Board Certified  Clinical Anaplastologist.

She Did complete her Board Certification for Ocularist (BCO), By National Examination Board of ocularist, USA in March 2018 

She persued her basic training in Ocularistry from L V Prasad Eye Institute, Hyderabad and advanced training in Ocular Prosthetics (May – July, 2005) at Moorefield’s Eye Hospital, London, UK under Mr Nigel Saap. 

She worked as an Ocularist at Ocular Prosthesis Department, L V Prasad Eye Institute from 2003 – 2010. She worked with different type of techniques, developed new techniques in the fabrication and fitting of ocular & facial Prostheses. Her  work was well recognized and appreciated.

Her clinical interest include make her career in the art and science of facial prosthetics and ocular prosthetics, particularly in pediatric patients. Her research interests lie in developing new techniques in the field of facial prosthetics, and undertake research on materials used in this field.

Deepa Raizada has been recognized by the Oculoplasty Society of India, Indian Optometric Association and by several other professional organizations in India as well as Internationally, for her excellence in research and clinical practice.

Email ID: deepadraizada@gmail.com, deepaocularist@gmail.com

Fact about Deepa Raizada:

  1. She is the  First Indian Lady to be American Board Certified Ocularist  (BCO) as well as Board Certified Clinical Anaplastogist (CCA).

  2. Her credentials are unmatched with any one from Asia, Middle East, Africa &  Europe. First Ever Indian Lady to be American Board Certified Ocularist  (BCO) 2018 

  3. First Ever Indian Lady to received Her Board Certification in Clinical Anaplastology (CCA) 3rd Individual in the World to have CCA and BCO, (Other 2 in USA) 

  4. She bring the glory  to India for bringing the First Ever CCA &  made a land mark for India to 5th country in the world.