Dermis Fat Graft in Anophthalmos #1
If video fails to load, use this link: http://vimeo.com/138015171
This is Richard Allen at the University of Iowa. This video demonstrates placement of a dermis fat graft in an anophthalmic socket. This patient has a history of a chronically exposed orbital implant that has failed previous attempts at repair. Therefore, the orbital implant will be removed followed by placement of a dermis fat graft. Each of the rectus muscles is identified and tagged with a double armed 5-0 Vicryl suture. The implant is made from Medpor and has predrilled holes. The implant can be difficult to fixate; therefore, a towel clip is useful to engage the implant. Steven's scissors can then be used to transect the tissue adherent to the posterior surface of the implant. The implant is sent for culture.
Attention is then placed on harvesting the dermis fat graft. The graft will be obtained from the patient's buttocks. An incision is made with a 15 blade along a circle which is approximately 20 mm in diameter. Additional markings have been made to make an ellipse around the area of the harvest to aid in subsequent closure. The incision is made between the dermis and epidermis. The blade is used to excise the epidermis of the skin. This is performed so that keratin is not produced in the anophthalmic socket. This incision will dull your blade, so you will need to switch out for a new blade during the procedure. A new blade is now used to make an incision through the dermis along the edge of the incision. This incision is made down to the underlying fat. Metzenbaum scissors are used to bevel out the incision so that as much fat as possible is harvested. The most common mistake made is not taking enough fat, since you will likely lose about 50% of the fat after the placement of the graft. Looking at this harvest, this does not look like enough fat is being taken. The donor site is then closed after turning the site into an ellipse. The donor site can then be closed with deep interrupted 4-0 monocryl suture followed by interrupted 5-0 prolene suture placed in a mattress fashion.
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. In this case, I do not believe that the fat graft is large enough because it is too easy to get the fat in the socket. The conjunctival edges are then sutured to the edge of the dermis with 7-0 vicryl suture. This can be placed in a running fashion. It is important to make sure that the edges of the conjunctiva are not buried or you can get an inclusion cyst later. As this heals, 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.