Treatment of intractable orbital implant exposure with a large conjunctival defect by secondary insertion of the implant after preceding dermis fat graft

Abstract

Aim: To report a procedure and results of a two-stage operation to manage intractable extensive orbital implant exposure with a large conjunctival defect which was difficult to treat with dermis fat grafts due to repeated graft necrosis.

Methods: A retrospective chart review of four patients who had extensive orbital implant exposures with large conjunctival defects and had past histories of repeated autologous or preserved dermis graft failures was done. As a first-stage operation, the problematic pre-existing orbital implants were removed and autologous dermis fat grafts alone were performed on the defect area. Four months later, new orbital implants were secondarily inserted after confirmation of graft survival. The size of the conjunctival defects and state of the extraocular muscles were checked preoperatively. Success of the operations and complications were investigated.

Results: The mean size of the conjuctival defects was 17.3mm×16.0mm, and the mean time from the initial diagnosis of orbital implant exposure to implant removal and autologous dermis fat graft was 20.8 months. After implant removal and autologous dermis fat graft, no graft necrosis was observed in any patients. Also, implant exposure or fornix shortening was not observed in any patients after new orbital implant insertion.

Conclusion: The secondary insertion of a new orbital implant after pre-existing implant removal and preceding dermis fat graft is thought to be an another selective management of intractable orbital implant exposure in which dermis fat grafts persistently fail.

Keywords: conjunctival defect; dermis fat graft; orbital implant exposure.

Figure 1. Photographs show exposed orbital implants with wide conjunctival defects before failed dermis fat grafts

A: Hydroxyapatite implant; B: Medpor^® implant.

Figure 2. Photographs show melted and failed dermis fat graft on the exposed Medpor^® orbital implant.

Figure 3. Photographs show a well-grafted and surviving dermis fat graft performed after exposed orbital implant removal and before new orbital implant insertion

A: Immediately after graft; B: 2 weeks after graft; C: 2 months after graft.

Figure 4. Procedures of new orbital implant insertion after preceding dermis fat graft success

A: Horizontal incision line from the medial canthus to the lateral canthus was drawn on the well-grafted and conjunctivalized dermis, and an incision was performed along the line on the dermis; B: The intraorbital space was secured by meticulous dissection of orbital fat and surrounding tissue; C: A new Medpor^® orbital implant was inserted into the intraorbital space; D: After insertion of the new orbital implant, the incised dermis was sutured with 6-0 Vicryl.

Figure 5. Photographs show well healed and conjunctivalized dermis at 4 months after operation.