the anophthalmic socket has been associated with many complications such as discharge , entropion , ectropion , exposure or extrusion of the orbital implant , infection , migration of the orbital implant , contracted socket , and ptosis.2 the dermis - fat graft is a treatment option for anophthalmic socket reconstruction , especially in patients with exposure or extrusion of the orbital implant.3 the advantage of dermis - fat graft consists of its ability to replace the orbital volume and surface of the anophthalmic socket ; moreover , it has never been exposed and extruded .
the dermis - fat graft can be used in cases of volume insufficiency in retinoblastoma eyes by means of volume augmentation.4 some children with an anophthalmic socket have undergone autologous dermis - fat grafts with good results.5 however , this procedure s disadvantages are a second site of surgical wound and dermis - fat graft shrinkage
. the dermis - fat graft has been used as an orbital implant in primary enucleation , secondary implants , and tissue augmentation in a contracted socket.3,69 in developed countries , most surgeons prefer to use a porous polyethylene implant.10,11 on the other hand , in thailand , surgeons use both nonporous and porous orbital implants in enucleation and evisceration .
regarding implant exposure , surgical management depends on the defect size , type of orbital implant , and duration of orbital implant exposure.12 the exposure size should be less than 3 mm , and the observation may be adequate . in case of larger exposures ,
the use of a mller muscle flap and tarsal patch - flap is recommended.1315 however , when the defect size is very large , surgeons usually perform a dermis - fat graft for anophthalmic socket reconstruction.16,17
this is a retrospective interventional case series containing data collected between august 1 , 2007 and july 31 , 2012 .
institutional review board / ethics committee approval was obtained at songklanagarind hospital , and this study adhered to the tenets of the declaration of helsinki .
we included patients who underwent either primary or secondary dermis - fat grafts for the first time .
we reviewed the medical records of these patients to obtain the following data : demographics , duration of symptoms , indications for the dermis - fat graft , and postoperative conditions for eye prosthesis wear and cosmesis .
the patient satisfaction ( obtained via interviews ) with the cosmetic result was classified as good , fair , or poor .
after informed consents were obtained , all patients underwent the dermis - fat graft under general anesthesia . a 1:1 mixture of 1% lidocaine ( 1:100,000 epinephrine ) with
we prepared the raw surface for the dermis - fat graft and measured it in three dimensions ( width , length , and depth ) . adding 30% to the measurement of the defect , an incision was performed on the patient s buttock where dermis - fat tissue was dissected and skin for the dermis - fat graft removed .
the dermis - fat graft was then placed in the prepared socket ; a single interrupted 60 polyglactin suture was performed between the dermis - fat graft and the conjunctiva 
all of the four patients who underwent the combined procedure ( dermis - fat graft with mucous - membrane graft ) had an inadequate fornix , intraoperatively following the dermis - fat graft .
therefore , a mucous membrane was added to deepen the fornix , and the size of the defect was measured .
the mucosal surface of the lip was marked and injected by a 1:1 mixture of 1% lidocaine ( 1:100,000 epinephrine ) with 0.5% bupivacaine .
the lip was retracted with two towel clamps and incised with a number-15 blade . the mucosal graft was dissected and defatted as thin as possible using westcott scissors .
the graft was sutured into the defect of the fornix using interrupted and continuous - running 60 polyglactin sutures .
this was followed by the placement of the conformer and temporary tarsorrhaphy . for the patients who underwent a dermis - fat graft but could not wear the eye prosthesis well because of a contracted socket
the palpebral conjunctiva was injected by a 1:1 mixture of 1% lidocaine ( 1:100,000 epinephrine ) with 0.5% bupivacaine and incised using monopolar cautery .
then we dissected and lysed the scar to create space , especially in the inferior fornix .
the mucous - membrane graft was prepared and sutured with interrupted and continuous - running 60 polyglactin sutures .
forty - one patients underwent dermis - fat grafts ; it was a primary procedure in six patients and a secondary one in 35 others .
our study comprised 23 males and 18 females , with a mean age of 40.38 ( 25.64 ) years .
the median duration between the date of visit and the date of secondary dermis - fat graft surgery was 7.1 months ( range 1 day38.2 months ) .
the commonest ( 13 cases ) clinical presentation to indicate the dermis - fat graft was an exposed implant ( mean width of 7.6 mm ; range 5.010.0 mm ) ; 10 of these cases involved infection .
the results confirmed infection by coagulase - negative staphylococcus in two cases and pseudomonas aeruginosa in one case , and the culture for the other one resulted in no growth .
three of the 13 exposed implants underwent defect - closure intervention by means of an amniotic membrane graft ( two ) and tarsoconjunctival graft ( one ) before the secondary dermis - fat graft .
eleven patients received dermis - fat grafts due to enucleation / evisceration related to trauma ( data shown in table 1 ) , which consisted of four blast injuries ( one primary dermis - fat graft , three severe globe distortions ) , four severe penetrating injuries ( one primary enucleation with nonporous implant , three posttraumatic endophthalmitis cases ) , and three unknown type of injuries .
six of the seven patients with an intraocular tumor received radiation , and in only three of those cases , the prosthesis could be successfully worn .
enucleation with a primary dermis - fat graft was performed in six patients  one suffered a blast injury , one a chemical burn , one a severe corneal ulcer with scleral melting , one advanced glaucoma with multiple surgeries , one necrotizing scleritis , and the last one had an unknown cause .
there were various types of orbital implants employed in this study : 24 nonporous and eight porous , and three patients received no orbital implant . before the secondary dermis - fat graft ,
thirty patients received a dermis - fat graft alone , and 22 of them were able to wear their eye prosthesis .
four patients underwent a combined procedure ( dermis - fat graft and fornix reconstruction using a mucous membrane or hard - palate graft ) .
of those , only one patient could wear the eye prosthesis and two others underwent fornix reconstruction subsequently and were able to wear their eye prosthesis .
moreover , seven patients had a dermis - fat graft with adding fornix reconstruction ; five of them could wear their eye prosthesis and one patient could wear the conformer . with regard to the primary dermis - fat graft cases , 50% of them could wear the eye prosthesis . finally , 30 of our total patients were able to wear their eye prosthesis and 29 of those accepted it cosmetically ( figures 1 and 2 ) .
six patients were on a conformer because four of them experienced chronic discharge and the other two did not present to the hospital to have their eye prosthesis made , and the other five could wear neither the eye prosthesis nor the conformer because of severe socket contraction .
in 1978 , the dermis - fat graft for anophthalmic socket reconstruction was introduced by smith et al.18 since then , it has been used both primarily , after enucleation , and secondarily , after the extrusion or migration of an existing implant.1821 smith et al have proposed that the advantage of the dermis - fat graft lies in its ability to replace the orbital volume , while , at the same time , maintaining the fornix and conjunctiva.19 therefore , it has been accepted as a technique to reconstruct the anophthalmic socket because this procedure is more preferable in the case of implant extrusion , large exposure , as well as volume insufficiency with a shallow fornix .
our study showed three major indications for a secondary dermis - fat graft  exposure ( 13/41 ) , extrusion ( 11/41 ) , and volume insufficiency with a shallow fornix ( 10/41 )  which accounted for 82.9% of our total cases .
a 4.5%9.6% implant - exposure rate for porous orbital implants has been reported , depending on the type of material.2022 autogenous dermis - fat grafts implanted within the orbit survive the best , with little loss of volume , when they are placed within tenon s capsule immediately following the removal of the globe and when the rectus muscles ( and anterior ciliary arteries ) are anastomosed to the dermal edge of the graft.23 the primary dermis - fat graft in young children s orbits appears to grow after implantation , which lends for a superior result for the primary procedure compared to the secondary one.7 we preferred to perform the dermis - fat graft in cases of implant exposure because many of our patients had concurrent infection .
this procedure has been successful in overcoming some limitations of implant extrusion or exposure in procedures involving other materials .
the autogenous dermis - fat graft is safe because it is characterized by no foreign - body reaction and disease transmission.24 out of the six adult patients who underwent primary dermis - fat grafts , only 50% were successful .
the success rate of a primary dermis - fat graft in our study was low because six patients had a severe conjunctival defect initially and a high risk for further socket retraction .
we preferred to perform a dermis - fat graft for implant extrusion because the average length of time before the secondary dermis - fat graft could be performed was 7.1 months , ie , it was a long enough period of time to introduce conjunctival shrinkage because our center is the only one in southern thailand to offer this procedure , and we experience long queues .
the enucleation / evisceration was most of the time performed by nonoculoplastic surgeons ( 91.4% ) , so the muscles and conjunctiva might not be preserved .
five patients could not wear their eye prosthesis , with an inadequate fornix being the main factor . although the dermis - fat graft can augment a volume - deficient socket and an insufficient fornix , nine of our patients underwent fornix reconstruction by a mucous membrane or a hard - palate graft .
initially , the surgeon performed the combined procedure , which was successful in 25% of cases , so the surgeon opted for a dermis - fat graft with an extended dermis to replace the superior and inferior fornix .
the possible reason for the low success rate in the combined procedure may be insufficient blood supply from the base , which is a cause of mucous - membrane graft shrinkage .
the size of the dermis - fat graft harvested in our study was 30% larger than the defect measurement size because some fat has the potential for shrinkage and also because smith et al reported a dermis - fat graft volume atrophy of more than 40% in three out of nine patients after the secondary procedure.19 on the other hand , a 5%10% dermis - fat volume loss in the primary procedure has been reported.19,25 however , according to sihota et al who compared the results between a 10-mm and a 20-mm thickness , the thicker the dermis - fat graft , the better the outcome.26 in conclusion , the dermis - fat graft has been used for anophthalmic socket reconstruction because it can replace the orbital volume , fornix , and conjunctiva .
it is suitable as both a primary and secondary procedure , and is able to overcome the problems related to implant exposure and extrusion .
 objectivesto present the indications for a dermis - fat graft in anophthalmic socket reconstruction and evaluate the results of this procedure.designretrospective review , interventional case series.methodsin our study , there were 41 patients who received either primary or secondary dermis - fat graft between august 1 , 2007 and july 31 , 2012 at songklanagarind hospital.resultsthe type of dermis - fat graft used in our study consisted of both primary dermis - fat grafts ( 6/41 ) and secondary dermis - fat grafts ( 35/41 ) . 
 the major indications for dermis - fat graft were exposure ( 13/41 ) , extrusion ( 11/41 ) , and volume insufficiency with a shallow fornix ( 10/41 ) , which accounted for 82.9% of the total cases . 
 a total of 30 patients were able to wear the eye prosthesis over a mean follow - up time of 32.319.0 months . 
 the success rate of the dermis - fat graft alone was 73.3% , while that of the simultaneous dermis - fat graft and mucous - membrane graft was 25%.conclusionthe most common indications for a dermis - fat graft were extrusion and large exposure . 
 dermis - fat graft is an alternative implant type in complicated enucleation / evisceration patients , which has a good success rate . 
Introduction
Materials and methods
Results
Discussion