Composite dermis-fat graft and mucous membrane graft in severe contracted socket reconstruction

Abstract

The management of a severely contracted socket necessitates the restoration of fornix depth, the meticulous release of fibrotic components without compromising the already limited conjunctival tissue, and the replacement of lost volume. In this case series of four patients, the authors employed mucous membrane placement using the lid-splitting approach to address the deficit in fornix conjunctiva. This approach involved releasing posterior lamellar tension and repositioning the retractors at the fornix, followed by augmentation with a dermis-fat graft to restore volume.

The contracted socket is characterized by the shrinkage and shortening of orbital tissues, resulting in decreased depth of the fornixes and orbital volume, which impairs the ability to retain an ocular prosthesis,[1] significantly impacting the quality of life for affected individuals. Contracted sockets are frequently associated with additional pathologies such as symblepharon, fibrous bands, lid retraction over the orbital rim, and cicatricial obliteration of the fornix.[2] Moreover, there is a notable risk that the inferior rectus muscle may become elevated within the socket, subsequently elevating the lower lid retractors and their attachments, including the fornix conjunctiva, specifically in an anophthalmic sockets.[3] Among all four fornixes, the inferior fornix is particularly significant due to its critical role in maintaining socket anatomy and function, as well as bearing the substantial weight of the prosthesis.[3]

Management of the severe contracted sockets is guided by two pivotal clinical findings severity, location of the symblepharon attributing to the fornix shortening, and the amount of residual orbital volume. Effective management aims to reconstruct the scarred fornix both vertically and posteriorly, closely mimicking the form and function of a normal fornix[4] and replacement of socket volume. This involves the surgical excision of all symblepharon, followed by the placement of a graft or flap to promote re-epithelialization and increase conjunctival surface area.[5]

In the literature, various autogenic grafts such as buccal mucous membrane grafts, amniotic membrane grafts, hard palate grafts, full-thickness skin grafts, vascularized pedicle flaps, fascia Lata, dermal fillers, and dermis-fat grafts have been described[6] to address both surface and volume loss. However, the management of severe contracted sockets is arduous and susceptible to recurrence. The approach to reconstruction should address the deficiency of the posterior lamella caused by associated symblepharon and fibrous bands without sacrificing the precious conjunctival surface, while also providing volume augmentation. Therefore, a composite dermis-fat graft (DFG) and mucous membrane graft (MMG) to amplify posterior lamella without incising the already sacrificed conjunctiva were attempted as a new technique to provide an additional armory in the management of severely contracted sockets.

Surgical Technique

We described the use of composite dermis-fat grafting and mucous membrane grafting in a total of four eyes with severe contracted sockets. The study followed the principles outlined in the Declaration of Helsinki and obtained patient consent for publication. The average age of the patients was 29.25 ± 1.47 years, and the mean duration of the contracted socket condition was 21.25 ± 3.34 years.

Fornix lengthening

Fig. 1 provides a visual representation of the MMG palcement technique used in the study. The MMG was placed using a lid split technique to lengthen the posterior lamella without cutting into the fornix conjunctiva or disturbing the retractors. An incision was made at the gray line to separate the anterior lamella from the posterior lamella. The dissection continued until the retractors were identified, the medial and lateral horns of the tarsus were cut down, and a bed was created. The mucous membrane was harvested either from the lower or upper lip, depending on the availability of the graft. The harvested graft was secured to the lid margin edges using absorbable running interlocking sutures. The inferior edge of the graft was secured with double-armed sutures passing through the tarsus, assisted with fibrin glue, and exiting at the skin level of the fornix. The patient was started on oral antibiotics, oral anti-inflammatory agents, betadine gargle, and topical steroids in a tapering dose, along with topical antibiotics and lubricants, for three months.

Figure 1.

Illustrations describing the surgical steps of lid MMG placement. (a) The anterior and posterior lamella of the eyelid were divided at the gray line. (b) Surgical dissection continued until the retractors of the lid were reached. (c) The horns of the tarsus were sacrificed at the medial and lateral ends to lengthen the posterior lamella, and the MMG was secured to the lid margin using interrupted sutures. (d and e) The inferior edge of the graft was secured by passing double-armed sutures through the MMG and tarsus, respectively, and (f) the sutures were exteriorized at the level of the fornix

Volume augmentation using DFG

After a period of three months, a second-stage procedure involving DFG placement was performed as shown in Fig. 2. A horizontal incision was made from the caruncle to the lateral canthi. Subconjunctival dissection was carried out to release the cicatrix, using minimal cautery, and the extraocular muscles were identified. The dimensions of the created host cavity were measured. The upper outer gluteal region was chosen for harvesting the DFG. An ellipse was marked according to the cavity dimensions, with the graft being approximately 30% larger than the cavity size. The epidermis was removed to expose pinpoint bleeders. A perpendicular incision was made through the dermis into the subcutaneous fat, approximately 2.5 cm deep. The harvested graft was then placed into the recipient bed, with gentle pressure applied to fit it into the cavity. The isolated rectus muscles were sutured to the deep fat. Initially, four cardinal sutures were applied, followed by a 360-degree continuous suture to secure the graft to the conjunctival rim, and a snugly fitted conformer was placed.

Figure 2.

Surgical steps of DFG placement in the socket. (a) A healthy pink labial mucosal graft at the lid noted. (b) An incision is made at the centre of the socket, extending the entire horizontal length, and dissection continues to release sub-conjunctival scar tissue. (c) A cavity is formed, and the recti muscles are explored (black arrow). (d) The epidermis is shaved off as per the dimensions of the created cavity, leaving pinpoint bleeders in the dermis. (e) The fat is cut deep down around 2.5–3mm. (f and g) The harvested DFG is placed over the bed, and the identified recti muscles are sutured to the dermis. This is followed by securing the DFG using four cardinal sutures. (h) The graft is sutured 360 degrees to the rim of the conjunctiva. (i) The DFG is well apposed

Result

Four patients, with a mean age of 29.25 ± 1.47 years (range: 27–31 years), underwent composite DFG and MMG procedures. The duration since the patients had not wwornocular prostheses was 21.25 ± 3.34 years (range: 17 to 25 years). Among these patients, three had undergone enucleation surgery without an implant, and one patient experienced secondary implant extrusion at 5 years of age. MMG placement was performed due to fibrosis and symblepharon, with two patients having MMG placement on one eyelid and two patients having MMG placement on both the upper and lower eyelids. Residual enophthalmos noted was 2 ± 1 mm (range: 1–3 mm) and observed lagophthalmos was 0.75 ± 0.82 mm (range: 0–2 mm) at a mean follow-up period of 1.37 ± 0.41 years (range: 1 to 2 years). Figs. 3 and 4 are the representative cases showing a superior fornix fibrotic band and a lower lid ring-shaped symblepharon with ankyloblepharon, respectively. MMG placement was executed to lengthen the posterior lamella and ensure adequate fornix depth, followed by DFG.

Figure 3.

(a and b) Preoperative photographs of severe contracted showing lower lid shelving with a superior fornix semilunar fibrotic band (black arrow). (c and d) Postoperative photographs showed well uptake of DFG and adequately retained artificial eye at one year follow-up with good cosmoses

Figure 4.

(a and b) Preoperative photographs, depicting a ring-shaped symblepharon at the lower lid (white arrow) and an elevated inferior fornix (black arrow). The patient underwent both upper and lower lid split with MMG placement. (c) Postoperative photograph following a composite mucous membrane graft with a DFG, showing 2 mm of residual enophthalmos at the 2-year follow-up

Discussion

Various allogenic and autogenic grafts have been described for the management of severely contracted sockets. In our study, DFG was preferred to obviate the possible complications associated with allogenic implants such as implant migration and exposure.[7] The study conducted by M. M. Nentwich et al.[8] revealed that 81% of primary DFG cases showed excellent prosthesis fitting. In contrast, secondary DFG cases demonstrated excellent or reasonable fitting in 49% and 41% of cases, respectively, which could be attributed to decreased vascularization or changes in the orbital tissue during revision surgery.[9] Hence, combinations of grafts were attempted to overcome the deficiencies seen with autogenic DFGs alone.

An innovative intervention introduced by C. J. Choi et al.[6] involved using a combined hard palate-dermis-fat composite graft in four patients, aimed to supplement volume, extend the posterior lamella, reconstruct the fornix, and serve as a surgical aid for contracted anophthalmic sockets. However, three of the four patients required additional interventions, highlighting the difficulties posed by excessive scar tissue formation in severely contracted sockets. Bhattacharjee et al.[10] employed a porous orbital implant with MMG as a primary reconstructive technique for severely contracted sockets. This approach proved effective in reconstructing the ocular cul-de-sac and stabilizing orbital implant retention, resulting in good prosthesis motility.

For managing contracted sockets, it is crucial to avoid excessive manipulation or insult to the delicate conjunctiva and Tenon’s capsule to prevent cicatrization. Therefore, in our study, we placed the MMG through a lid split, which seems to be more physiological than the conjunctival route. This method maintains the desired pull-down tension on the abnormally elevated lower lid retractors without disturbing the retractors and the fornix conjunctiva. This procedure was followed by placing DFG in the contracted socket to augment the volume loss. Our study observed residual enophthalmos of 1–3mm at the two-year follow-up. The limitation of our study is a small number of patients. Furthermore, the long-term follow‐up period was suggested to rule out the possible later contracture.

In conclusion, it is difficult to surpass one technique over another; however, we believe that this approach is a valuable addition to the armamentarium of reconstructive surgeries for severe contracted anophthalmic sockets.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.