Debulking of Dermis-Fat Graft

I prefer placement of a dermis fat graft in children under the age of 2 after enucleation.  This is especially applicable for patients with microphthalmos.  The dermis fat graft is a “living implant” and grows with the child, stimulating orbital growth.  Sometimes, as in this case, the fat grows too much and there is a volume excess.  In my opinion, I would rather have a volume excess than volume deficiency.  If the prosthesis cannot be thinned to give an acceptable result, then the fat graft should be debulked.

This is Richard Allen at oculosurg.com.  This video demonstrates debulking of a dermis fat graft in a child with a history of microphthalmos, s/p enucleation with placement of a dermis fat graft.  The graft has grown, resulting in volume excess.  The socket is demonstated, showing adequate surface area and fornices.  A lid speculum is placed.  The incision for debulking is made with a 15 blade in the middle of the conjunctiva.  The incision is made centrally as you want to avoid any peripheral scarring in the fornices.  Westcott scissors are used to dissect under the dermis and the conjunctiva.  The fat is identified and dissection is carried out on the anterior surface of the fat.  This is performed inferiorly, then superiorly.  The extraocular muscles were sutured to the edge of the dermis during the original surgery.  The fat is not connected to the muscles and is in the intraconal space.  Additional dissection is carried out medially to mobilize the fat.  Portions of the fat are then excised with the Westcott scissors.  The volume is inspected without the speculum in.  Additional fat is resected inferior laterally.  The volume is again inspected.  Additional inferior lateral fat is resected.  The volume of the resected fat is noted.  The central incision is then closed with interrupted buried 7-0 Vicryl sutures.  There is no reason to place deep sutures as there is no foreign body to cover, and the wound is not on tension.  At the conclusion of the case, the prothesis is placed to ensure adequate volume was resected.  The patient will likely need to have the prosthesis refit.  Antibiotic ointment is placed over the sutures, and the patient will follow up in approximately one week.