Dermis Fat Graft in Anophthalmos #2
If video fails to load, use this link: http://vimeo.com/138016635
This is Richard Allen at the University of Iowa. This video demonstrates placement of a dermis fat graft. This patient has a history of a previous evisceration and now has an exposed orbital implant. The patient has elected to undergo removal of the implant with placement of dermis fat, rather than placement of a secondary implant. The evisceration scleral shell is removed similar to the way one would perform an enucleation. Each of the rectus muscles is identified and tagged with a 5-0 Vicryl suture placed in a locking fashion. The muscle is then disinserted from the surface of the globe. This is performed for the medial rectus, followed by the inferior rectus, followed by the lateral rectus. Finally, the superior rectus is tagged and disinserted, followed by transecting the superior oblique tendon and inferior oblique muscle. Enucleation scissors are then used to remove the shell from the socket.
The dermis fat graft has been harvested and in this case, a nice large volume of fat has been obtained. I think it is important to realize that when you place these grafts in the area of the socket, your first impression should be that the graft is too large. If that is the case, then it is probably enough. Each of the vicryl sutures is then sutured to the edge of the dermis. It is usually useful to tie two of the sutures 180 degrees away from each other. The fat can then be coaxed into the socket, followed by tying the remaining sutures. There is usually quite a bit of fat prolapsing around the area. Try to resist the urge to cut away any of this fat. The conjunctival edges are then sutured to the edge of the dermis with interrupted and running 7-0 vicryl sutures. The fact that it is difficult to place all of the fat is a positive predictor of good subsequent volume. The dermis will epithelialize with time from the edges of the conjunctiva. At the conclusion of the case, a large conformer is placed. A suture tarsorrhaphy is then placed with 5-0 chromic sutures to keep the eyelids closed and the conformer in place. The eye is patched for a week. The patient follows up in one week. Usually I let the sutures dissolve on their own.