DERMIS FAT GRAFT AS

PRIMARY AND SECONDARY

ORBITAL IMPLANTS
Martin M.Nentwich, Kirsten Schebitz-Walter, Christoph Hirneiss, Christoph Hintscich

Department of Ophthalmology, Ludwig-Maximilians-University, Munich, Germany

Presented by:
Teguh Setiawan

Supervised by:
Dr. Sri Inakawati, Msi.Med., Sp.M (K)
 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.
 INTRODUCTION

• major change in functional and cosmetic

Removal of an eye appearance of the orbit

• postoperative complications
Alloplastic orbital implants • migration and exposure of the implant

• atrophy of the implanted

Autologous free fat grafts • not to be useful in the augmentation of volume deficit
for many years

Composite grafts (dermis • less prone to lose volume after implantation

and fat)
 conjunctiva is sutured to the extraocular muscles
Dermal portion the implant to only are attached to the more
partially coat it rigid dermal portion

• scaffold for • leaving the central • allowing for post-

conjunctival growth part of the implant operative motility of
over the superficial surface uncovered the implant
surface of the graft • depth of the
conjunctival fornices
can be preserved
• Smith et al. first large series of 118 patients good postoperative results
after implantation of dermis fat grafts (DFGs) either as primary or
secondary
• DFGs to be effective in maintaining orbital volume while preserving
the fornices and conserving the conjunctiva
• DFGs have been used for primary and secondary reconstructions of
orbital volume deficits in adults and children
• 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
 MATHERIALS AND METHODS
• Surgical Procedure

donor site sutured in two

surgery technique by fat layer was deeply
layers with 2.0
Smith et al transected
absorbable.

autologous DFG was

harvested from the epidermis was dissected
control of obvious
donor site and separated from the
bleeding using a bipolar
Adult 25 mm dermis layer using a No.
cautery
20 scalpel
Children 12 to 25 mm

epidermis was incised harvested DFG was

Saline was injected
superficially with a No. soaked in sterile saline
intradermally.
15 blade solution
 the graft was ofloxacin eye drops
were applied pressure dressing
trimmed to fit the
was put on
recipient site

conjunctiva was Four to six weeks

rigid conformer was
diligently sutured to postoperatively a
inserted to support
the outer dermal first prosthesis was
the fornices
part of the implant fitted

the extraocular
The graft was
muscles were
implanted with the
sutured to the
dermal side showing
dermal part of the
up
graft
• 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
Fitting of the prosthesis was evaluated
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)
Complications of this surgery were evaluated
Motility of Fitting of
the the
implant prosthesis Excellent
Good/excellent possibility to easily find
full motility in 4 a proper prosthesis
directions good fit of the
prosthesis
high patient comfort
with prosthesis
good lid-function
Reasonable
motility in 1 to 3
directions Reasonable
all but one of the above
criteria are fulfilled

Bad Bad
no motility more than one of the
above mentioned
criteria is not fulfilled
 RESULTS
ANALYSIS OF THE
POSTOPERATIVE
RESULTS

315 DFG 173 DFG

I ○ I ○
468 DGFs
153 DFG 66 DFG
II○ II○
 • DFG I 48
○ years (range
Median 2–87 years)
age • DFG II○ 44 years (range 5–
83 years)
• DFG was 21.5 months
I ○
Median (range 2–123 months)
follow-
up • DFG II○ was 14 months
(range 2–82 months)
• 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 +2 mm)
Mean difference in Hertel exophthalmometry measurements was -1.6
mm (range -8 mm to +1 mm)
• 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 +3 mm)
Mean difference in Hertel exophthalmometry measurements was -2.6
mm (range -4 mm to ±0 mm)
 DISCUSSION

• DFGs have become accepted alternatives to allograft implants for the

volume augmentation of anophthalmic sockets in adults
• Alloplastic implants can give persistent defined volume
• The limitations of alloplastic orbital implants:
o extrusion of the implanted material
o risk of postoperative implant exposure (bioceramic, porous
polyethylene)
o foreign-body-reactions
o risk of transferring pathogens or prions
• Advantages of DFG:
o without any alloplastic material
o absence of foreign-body-reactions and toxic effects
o no additional preserved scleral material
o good post-operative motility of the socket
o preservation and augmentation of conjunctival surface for contracted sockets
o can be combined with autologous grafts of oral mucosa
o special benefit in younger patients and patients with conjunctival scarring

• The limitations of DFG:

o more time-consuming
o the implant lost more volume
o necrosis of the transplant
o transplant growth
• The gluteal region was chosen as the standard donor-site because
functional and cosmetic reasons
• 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
• DFGs need to be positioned on soft tissue to enable the vascularization,
we do not recommend putting a DFG over pre-existing alloplastic
orbital implants or directly on orbital bone
• 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.
 CRITICAL APPRAISAL
No. Internal Validity Criterion
1.1 The study addresses an appropriate and clearly focused Well covered
question.

No. Selection of Subjects Criterion

1.2 The two groups being studied are selected from source Well covered
populations that are comparable in all respects other than
the factor under investigation.

1.3 The study indicates how many of the people asked to take Well covered
part did so, in each of the groups being studied.

1.4 The likelihood that some eligible subjects might have the Well covered
outcome at the time of enrolment is assessed and taken
into account in the analysis.
No. Selection of Subjects Criterion
1.5 What percentage of individuals or clusters recruited into DFG I : 142 over 315 = 45%
each arm of the study dropped out before the study was DFG II : 87 over 153 = 56%
completed.

1.6 Comparison is made between full participants and those Not reported
lost to follow up, by exposure status.

No. Assesment Criterion

1.7 The outcomes are clearly defined. Well covered

1.8 The assessment of outcome is made blind to exposure Not applicable

status.

1.9 Where blinding was not possible, there is some Not applicable
recognition that knowledge of exposure status could have
influenced the assessment of outcome.

1.10 The measure of assessment of exposure is reliable. Not applicable

No. Assesment Criterion
1.11 Evidence from other sources is used to demonstrate that Well covered
the method of outcome assessment is valid and reliable.

1.12 Exposure level or prognostic factor is assessed. Not applicable

No. Confounding Criterion

1.13 The main potential confounders are identified and taken Not reported
into account in the design and analysis.

No. Statistical Analysis Criterion

1.14 Have confidence intervals been provided? No

No. Overall Assesment of The Study Criterion

2.1 How well was the study done to minimise the risk of bias +
or confounding, and to establish a causal relationship
between exposure and effect?

2.2 Taking into account clinical considerations, your Yes

evaluation of the methodology used, and the statistical
power of the study, are you certain that the overall effect
No. Overall Assesment of The Study Criterion
2.3 Are the results of this study directly applicable to the Yes
patient group targeted in this guideline?
No. Description of The Study Criterion
3.1 Do we know who the study was funded by? Academic Institution
3.2 How many centres are patients recruited from? One
3.3 What is the social setting (ie type of environment in Urban
which they live) of patients in the study?

3.4 What criteria are used to decide who should be Patients who undergo primary
INCLUDED in the study? DFG and secondary DFG in 16
year period
3.5 What criteria are used to decide who should be Patients who undergo primary
EXCLUDED from the study? DFG and secondary DFG in 16
year period that not have
sufficient follow up
3.6 What risk factor is investigated in the study? No
No. Description of The Study Criterion
3.7 Was the inception cohort applied? Not reported

3.8 How long were patients followed-up for, during the Median follow up after DFG I
study? was 21,5 months
Median follow up after DFG II
was 14 months
THANK YOU