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Reconstruction of the Orbit and Anophthalmic Socket Using the Dermis Fat Graft: A Major Review

Jovanovic, Nina M.D., M.Sc., M.P.H.*; Carniciu, Anaïs L. M.D.; Russell, William W. B.S.; Jarocki, Adrienne B.A.; Kahana, Alon M.D., Ph.D.†,‡

Author Information
Ophthalmic Plastic and Reconstructive Surgery: November/December 2020 - Volume 36 - Issue 6 - p 529-539
doi: 10.1097/IOP.0000000000001610
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Volume restoration and augmentation is often needed in orbital and periocular reconstructive surgery. A variety of options are available for orbital volume enhancement, including dermis fat grafting (DFG). The 2 critical components of a DFG—dermis and fat—have different responsibilities: the fat provides volume, while the dermis provides rigidity for suturing and a matrix for mucosal epithelialization. Additionally, the dermis integrates into the recipient environment to facilitate vascularization.1 The most common use of DFG in oculoplastic surgery is in socket reconstruction following enucleation or to treat congenital anophthalmia, as well as in management of socket contraction. DFG is also used for superior sulcus reconstruction, fornix reconstruction, and eyelid malposition, although these indications will not be covered here. As part of the manuscript, we also present a retrospective case series of DFG usage in socket reconstruction to describe the technical nuances of this procedure and assess outcomes.


A literature search was performed using the key words “dermis fat graft AND anophthalmic socket” with Boolean Operator “AND”. One hundred forty-six online full texts were generated and reviewed. The results of the most pertinent publications are discussed in this review.

Next, a retrospective surgical case series of patients at a single institution generated results of 34 patients who underwent primary or secondary DFG placement after enucleation. The study was approved by the University of Michigan Institutional Review Board (HUM00040783) and is compliant with the Health Insurance Portability and Accountability Act and the Helsinki Declaration. Written consent to publish images was obtained from the patients or their legal guardians. The charts of all patients who presented to Kellogg Eye Center from 2009 to 2019 who received a socket dermis-fat-fascia graft were reviewed. Of these patients, only those who had at least 1 follow-up visit were included in the study. The data were obtained from the University of Michigan Data Direct database using specific billing codes (Derma-fat-fascia Graft [15770] or Remove Tissue for Graft [20926]) to identify patients. Fellowship trained oculoplastic surgeons performed all surgeries.

The goal of this study was to examine the association of primary versus secondary DFG indications with observed clinical outcomes. Observed variables were age, sex, race, surgical indication, number of muscles attached to the dermis button, post-surgical complications, socket and prosthesis motility, upper and lower eyelid position, prosthesis fit, and need for additional surgery within the 2 years after initial DFG implantation. All variables were either categorical containing 2 levels, or ordinal containing 3 levels. Contingency tables and Fisher exact tests were used to examine the dependence between variables with 2-tailed p-values of <0.05. Fisher exact test was used to test the association between primary and secondary indication or number of muscles tagged and clinical outcomes. For the statistical analysis, R v 3.5.1 (R Foundation for Statistical Computing, Vienna, Austria) was used.

History of DFG.

DFG has been used in a multitude of ways intermittently since the 19th century. In 1893, the first fat transplantation was reported by Neuber. Although it was frequently used by Lexer for face contouring, fat lost its popularity and was replaced by other materials.2 Loewe is credited with being the first to use a fat graft with the addition of de-epithelialized skin in 1913.3 Figi may have been the first to describe the use of dermis-fat graft in frontal sinus fractures in 1931. DFG was reintroduced later in the 20th century by Smith and Petrelli in 1978. The use of DFG in primary enucleation and evisceration was described by Guberina et al.4 in 1983 with DFG placement into the Tenon’s sac and muscle cone. Hardy et al.5 later proposed the use of a micro-fat graft to mitigate infections caused by alloplastic materials, advocating that the graft caused minimal donor site morbidity. Subsequently, the use of DFG gained popularity for socket repair in cases of exposed orbital implants.

Socket Reconstruction.

A common use of DFG is in socket reconstruction in the context of anophthalmia, acquired or congenital. Congenital anophthalmia is a complete absence of the eye or ocular tissue, while the more common microphthalmia may at times be mistaken for true anophthalmia because the ocular remnants are so small; both are caused by maldevelopment of the optic vesicle.6,7 In contrast, acquired anophthalmia follows surgical enucleation of a damaged or diseased globe. In both congenital and acquired anophthalmia, socket reconstruction is desirable whenever possible8—in congenital cases, to facilitate facial bony development, and in both cases, to facilitate use of an ocular prosthesis and prevent occurrence of post-enucleation socket syndrome, characterized by redistribution of the orbital fat, ptosis, lagophthalmos, a deep superior eyelid sulcus, and a displaced lower eyelid position.9–15

Multiple options are available for orbital volume restoration, including alloplastic implants, allografts, and autologous grafts.16 DFG is an autologous graft usually obtained from a patient’s abdomen, buttocks, or inner thigh, preferably from a relatively hairless donor site. It is harvested at the time of orbital reconstructive surgery and immediately used in the recipient site. While alloplastic implants carry a small but significant risk of exposure, extrusion, and infection,17–19 DFG integrates extremely well into the socket, with favorable socket stability and motility.20 It is the preferred choice when (1) alloplastic material is not available, (2) there is a relative contraindication to alloplastic implant usage, or (3) the patient prefers this option.

Orbital Volume Considerations.

Dermis fat replacement for orbital volume deficit must take into account the volume of the orbit. The total volume of the bony orbit is classically described to be 30 ml.21 However, a more recent measurement based on high resolution CT scans calculated an orbital volume of 24 ml.22 The volume of a 24 mm globe (modeled as a sphere) is 7.2 ml (4/3*pi*r3). However, studies of post-enucleation volume loss reveal a somewhat larger volume, ranging between 7.0 and 9.0 ml 1,23 or 5.5 and 9.0 ml,24 with a mean volume of 7.9 ml.23 Reconstruction of a post-enucleation or post-evisceration socket requires volume replacement, which is achieved by a combination of an intraorbital graft/implant and an ocular prosthesis. Several calculations exist for estimating the optimal sizes of the implant/graft, assuming that the ideal size of an ocular prosthesis to be ~2.5 to 3.5 ml with a maximum of 4.2 mm25,26; excessively large prostheses can reduce motility, place pressure on the eyelids, and be a poor fit.

DFG Characteristics.

The DFG is composed of a dermis button, obtained by removing the overlying epidermis, with attached subcutaneous fat. The dermis provides stiffness, additional surface area, and a scaffold for suturing. Additionally, dermis helps with vascularization and decreases fat tissue atrophy. The dermal surface can either be flat or domed, as described by Migliori and Putterman.27

The anterior dermal surface of the graft usually ranges from 20 to 25 mm, although larger dermal buttons can be useful when additional surface area is required, such as with contracted sockets. The diameter of the fat graft should be ~20 to 35 mm, with the goal of preventing enophthalmos and a deep upper sulcus and achieving good socket motility.28 A large study by Guberina et al.4 and colleagues reported the use of a graft ranging from 20 × 30 mm2 to 30 × 30 mm2 for primary indications, and 20 × 25 to 25 × 30 for secondary indications.4 The graft sizing varies by surgeons, who oversize the graft anywhere from 10%29 to 30%15 compared with the original globe size. Post-surgical volume loss can be estimated after enucleation by measuring the diameter of the globe,30 and the appropriate DFG size can then be selected while considering the size of the prosthesis, the expected postoperative fat atrophy, and the final volume restoration goal. An excessively oversized graft may induce a compressive effect, causing congestion and ischemia that may lead to central necrosis31 and poor mucosal coverage. In contrast, an undersized graft may result in socket retraction due to atrophy.28 In cases of secondary DFG implantation, where the socket has already begun to contract, it is challenging to predict the appropriately-sized DFG to use. In these challenging cases, graft survival is directly associated with the existing level of inflammation, vascularization at the recipient bed, and connection of the muscles to the graft tissue. It is believed that the graft and the recipient vessels anastomose on the fourth day after implantation, provided there is good adipocyte survival.2 Importantly, persistent socket inflammation needs to be addressed prior to, or at the time of graft reconstruction, and the authors follow a protocol of 5-fluorouracil injections loosely based on the study by Priel et al.32

The ultimate goal of DFG is to fill the socket to avoid contracture, provide an adequate fornix, support a prosthesis with good motility, achieve symmetry to the contralateral globe, and prevent ptosis. Dermis fat has the necessary features of an excellent orbital volume replacement: it is inexpensive, inert, has a smooth contour, carries a low risk of exposure and no risk of extrusion, and can stimulate conjunctival growth to achieve an adequate fornix. It also lacks any potential foreign body risk and carries a low risk of infection. Additionally, DFG use can preserve conjunctiva for use in socket reformation. The average conjunctival sparing area is 100 to 150 mm,2 which approximates the size of the average corneal area.12 A modification of the DFG reported by Migliori and Putterman shows that a dome-shaped dermis allows for deeper fornices, closer DFG to prosthesis contact, and better prosthesis motility.27 After implantation, graft viability is evaluated by the presence of small blood stains on the dermis surface. The full epithelization of the dermis is usually achieved after 4 weeks, at which point it may be fitted with a prosthesis,12 although the authors prefer to wait 6 to 8 weeks after surgery in order to optimize the fit of a custom ocular prosthesis.

Considerations in Use of DFG.

The main advantages of DFG are good integration with no possibility of “extrusion,” deeper fornices, improved motility, and reduced cost when compared with alloplastic implants.8 The potential for a deeper fornix and attachment of extraocular muscles33 improves socket stability and prosthesis motility.34 Orbital volume replacement with DFG has also been shown to be effective in alleviating anophthalmic socket pain.35

Some disadvantages of this procedure include increased surgical time, an additional surgical site, unpredictability of fat tissue atrophy (or hypertrophy, particularly in young children), and subjectivity in measuring the correct graft volume. Anteriorization of the graft can lead to ballooning of the fat, thinning of the conjunctiva, and poor prosthesis fit. This is addressed by suturing the extraocular muscles to the dermal button, which generates a posterior force and pulls back on the graft to stabilize the socket, in addition to providing another source of rapid vascularization. In cases where the extraocular muscles are otherwise difficulty to find, the tunnel technique described by David Jordan can be useful.36 Variable and undesirable graft volume loss is mostly seen in cases of secondary implantation in older patients, while graft failure is seen when orbital vascular supply is compromised, leading to fat necrosis. Atrophy typically occurs within the first 6 months of surgery, and the atrophy rate and size increases if the graft or socket are traumatized, irradiated, or infected.1 For ideal outcomes, Nentwich advises avoiding placing dermis fat onto a preexisting alloplastic implant or directly onto bone.37

Indications in Adults


DFG may be used for socket reconstruction following enucleation as a primary or secondary implant. There are many indications for enucleation. The conditions in which DFG is indicated as a primary option for reconstruction include situations in which the orbit is particularly diseased or vulnerable, and an alloplastic implant is expected to have a higher rate of complications. These include sockets that had been treated with alcohol or irradiated, sockets that had significant infections prior to enucleation, or eyes that underwent multiple surgeries prior to enucleation, with significant periocular scarring and thinning/loss of conjunctiva. DFG with a larger dermal button is particularly useful for expanding socket surface area and deepening the fornices; sockets that are identified at time of enucleation for being at high risk of contracture should probably be reconstructed with DFG.12


Secondary placement of DFG is more common and, by the very nature of “secondary” reconstructions, carries a higher complication rate.38 The most common indications for secondary DFG include alloplastic implant exposure, extrusion, volume insufficiency with a shallow fornix,15 socket infection, and socket contraction.15,31,37,39 Other indications include traumatic laceration of Tenon’s fascia, delay following initial enucleation, and multiple prior surgeries. Reported exposure rates for porous polyethylene and hydroxyapatite implants range from 1.5% to 21.6% after enucleation and 0% to 3.3% after evisceration,40–43 and is higher in patients with radiation history. Implant migration within the orbit, generally speaking as a result of poor execution of the muscle attachments, can interfere with prosthesis fitting and may require removal and replacement with DFG, with muscles attached to the dermis button.

In cases of implant exposure, dermis graft can be used to replace surface area loss. To avoid posterior displacement of the implant and promote adequate forniceal depth, a circular shaped dermis graft can be placed onto the anterior surface of the implant and sutured to Tenon’s capsule.34 Alternatively, the avascular portion of an extruded integrated implant can be excised or burred down and replaced with a DFG. If the implant is avascular and the socket has adequate anterior tissue, the implant may be secondarily replaced with DFG to enhance the orbital volume,44 which addresses both implant exposure and conjunctival insufficiency. There are many options for using DFG for secondary socket reconstruction, but the approach favored by the authors is to remove the migrated/exposed/infected implant and replace it with a DFG that fully replaces the lost volume, with suturing of the extraocular muscles to the dermis button, and with suturing of the conjunctiva to the edges of the dermis button in order to increase socket surface area. DFG placement simultaneously with amniotic membrane has been reported, which can facilitate conjunctival growth over the grafted dermis button.45 On the other hand, placing a mucous membrane graft on top of a DFG is not recommended due to risk of mucous membrane graft contracture in the setting of DFG avascularity at time of implantation. In evisceration cases, placement of a porous orbital implant posterior to posterior sclera is an alternate technique associated with reduced implant exposure risk.46

DFG can also be used for reconstructing a deep superior sulcus by grafting the DFG superiorly in the socket between levator muscle and orbital roof and anchoring it to the periorbita; although the fat may not offer a smooth contour, it is an attempt worth of trying in cases when other options are not available.47

Lastly, DFG has an application in managing painful anophthalmic socket. A multicenter study by Shams et al35 successfully used DFG to alleviate chronic anophthalmic socket pain.

Indications in Children.

Pediatric anophthalmia can be congenital or acquired, and its management requires the surgeon to be aware of the relationship between orbital growth and the child’s facial and socket development. A study by Bentley et al.48 reported that by the age of 5, orbital volume reaches 80% of that of a fifteen-year-old adolescent. Others report that the orbital volume enlarges until the age of 14 to 15 years old, at which point it reaches the adult volume,49 while the globe triples in volume between birth and adolescence.50

Animal models and clinical studies alike have demonstrated that orbital bone mechanical stimulation is essential for orbital growth. One method of stimulating bony growth is through orbital implant insertion.51 However, serial placement of progressively larger implants may be necessary as the child grows.52 Among other options (e.g., expandable hydrogel),53 DFG can be an advantageous solution, especially in children under the age of 5, due to dermis fat growth as the child’s face develops.12,54–59 In these cases, it is not uncommon to debulk the expanding fat graft as the child grows.

Additionally, DFG may be beneficial for orbits that cannot accommodate an adequately sized sphere (at least 18 mm).60 In children, socket expansion should be encouraged using custom-made conformers, self-inflating conformers,7 serial acrylic conformers, or hydrophilic expanders (HEMA).61

Overall, primary DFG indications in children include congenital anophthalmia, ocular trauma, retinoblastoma, medulloepithelioma, scleromalacia, phthisis bulbi, buphthalmos, secondary glaucoma, and blind painful eye. As in adults, secondary pediatric indications include prior implant exposure and socket contraction.

Surgical Techniques.

DFG surgery involves dermis fat harvesting followed by implantation into the socket.

DFG Harvesting

Potential donor tissue can be acquired from any hairless area that offers sufficient fat tissue. Commonly used sites for DFG harvesting include the buttocks (inferomedial quadrant of the buttock,27 upper outer quadrant of the buttock),39,62 inner thigh, inner arm, groin, abdomen, flank, umbilicus,63 sacrum, ilium, radial forearm, or hip area (e.g., 5 cm below the middle point of a line between the anterior iliac crest and the sciatic tuberosity).48 Areas that are weight bearing, have hair, are under pressure, inflamed, or are involved in an infection should be avoided. In the pediatric population, gluteal DFG is used most often.

Graft harvesting may be done under local or general anesthesia, though general anesthesia is typically utilized if enucleation or orbital surgery is planned. The harvest site is marked, injected with local anesthesia, and prepped with disinfectant. A circular (25 mm diameter) or elliptical (~40 × 25 mm2) skin incision is made with a No. 15 blade (Figs. 1A, 1B, 1C). Next, the epidermis is removed with a blade, scissors, air-driven dermabrader, or a power drill with a 4-mm diamond burr27,62 (Figs. 1D, 1E, and 1F).

FIG. 1.
FIG. 1.:
Harvesting of the DFG. The ideal donor site will have little to no hair, and care should be taken to eliminate hair follicles along with the epidermis during the harvesting process. The donor tissue is marked and incised from (A) lower outer buttock quadrant, (B) inner thigh, and (C) upper outer buttock region. Debridement and excision of the graft epidermis using (D) a drill and a 4-mm diamond burr or (E) #15 Bard-Parker blade and Wescott scissors. Process of (F) harvesting tissue from the buttock region by excision of dermis and fat tissue with an #11 blade. G, Donor site defect ready for closure. DFG, dermis fat graft.
FIG. 2.
FIG. 2.:
Grafting the harvested dermis-fat. The size of the dermis button should correlate with the desired enhancement of the socket mucosal surface area, while fat volume should correlate with the desired volume replacement. Dermis button (A), donor tissue from the inner thigh (B), and upper outer buttock region (C) of 2 different patients. Suturing the tagged extraocular muscles to the edges of the dermis button to provide posterior force, improve stability, and enhance motility (D, E). Empty socket following enucleation (globe rupture), with rectus muscles tagged (F). DFG size in relation to the socket (G). Anchoring the muscles and Tenon fascia to the dermis button, providing posterior pull on the fat graft to facilitate reconstruction (H). A pediatric patient with a conformer in place 3 weeks status post dermis-fat graft implantation (I). The upper eyelid is being manually pulled to expose the conformer and socket. DFG, dermis fat graft.

Next, Metzenbaum scissors or a blade are used to sharply and bluntly dissect a fat graft around the dermis, thereby harvesting a dermis fat pedicle with an appropriate volume (Figs. 1G and 2A, 2B, 2C). The target DFG size is at least 10% larger than the recipient bed size. The graft is preserved in a gauze soaked with sterile saline solution. Hemostasis of the donor site is achieved with cautery, followed by layered closure of the incision. The donor site is covered with an antibiotic ointment and dressed in the usual fashion. The dermis is then trimmed to the appropriate size (~30 × 20 mm2).

Table 1. - Demographic Data vs Primary and Secondary Indication for the Surgery
Indication Age Sex Race
0-18 19-65 65+ Total (N), column %a p-value
female male Total (N),
column %a
White African-American Total (N), column %a p-value
primary 0 4 2 6 (17.6%) 0 5 5 (14.7%) 5 1 6 (17.6%)
secondary 2 24 2 28 (82.3%) 12 16 28 (82.3%) 25 1 26 (76.4%)
Total 2 28 4 34 (100%)b 12 21 33 (97.0%)b 30 2 32 (94.1%)b
amissing data not included in the tables
bpercentages are calculated in total number of 34 patients

Table 2. - The Surgical Techniques and Complications vs. Primary and Secondary Indications for Surgery
Indication Muscles attached Additional surgeries Complications Graft Harvest Location
0 4 5 Total (N), column %a p-value
yes no Total (N),
column %a
Yes No Total (N), column %a p-value
abdomen thigh flank Total (N), column %a
primary 1 0 5 6 (17.6%) 2 4 6 (17.6%) 5 1 6 (17.6%) 1 5 0 6 (17.6%)
secondary 19 6 1 26 (76.4%) 12 16 28 (82.3%) 15 13 28 (82.3%) 10 9 8 27 (79.4%)
Total 20 6 6 32 (94.1%)b 14 20 34 (100%)b 20 14 34 (100%)b 11 14 8 33 (97%)b
amissing data not included in the tables
bpercentages are calculated in total number of 34 patients

DFG Placement
Table 3. - Clinical Outcomes and Primary vs. Secondary Indications
Indication Prosthesis fit (ability to wear prosthesis ) Lid position Motility
no yes Total (N), column %a p-value
poor good Total (N),
column %a
poor moderate and good Total (N), column %a p-value
primary 2 4 6 (17.6%) 1 5 6 (17.6%) 1 5 6 (17.6%)
secondary 4 21 25 (73.5%) 15 9 24 (70.6%) 0 19 19 (55.8%)
Total 6 25 31 (91.2%)b 16 14 30 (88.2%)b 1 24 25 (73.5%)b
amissing data not included in the tables
bpercentages are calculated in total number of 34 patients

With the patient positioned supine, the socket is exposed, either following primary enucleation or after a prior implant had extruded or been removed. Any previous implant or scleral remnants64 can be excised, and a pseudocapsule54 can be excised or left in place. Blunt dissection of the orbital space is performed, taking care to avoid traumatizing the extraocular muscles.47 Openings on the posterior Tenon’s fascia can be made to improve graft survival.62 In an enucleation, the muscles are usually tagged. For secondary implantation, the muscles can be identified at ~12, 3, 6, and 9 o’clock position and tagged with sutures.63 The DFG is placed into the socket within Tenon’s fascia, using malleable ribbon or Desmarres retractors for exposure.65 The rectus muscles are attached to the dermis button using a horizontal mattress technique (Figs. 2D, 2E, 2F, 2G, 2H). The conjunctiva is draped over the edges of the graft to encourage epithelial migration across the dermis, with the underside of the conjunctiva sutured to the anterior surface of the dermis. The center of the dermis graft should be left uncovered (~15 × 10 mm2), to allow deepening of the fornices. A conformer or symblepharon ring63 and temporary tarsorrhaphy are placed for ~3 to 4 weeks (Fig. 2I). The surgical site is patched for 2 to 4 days with gentle pressure.

Overly large grafts and oversized post-surgical site packing may lead to excess pressure, tension, and ischemia. Postsurgical treatment should include rest, cold compresses, and pain control. Typically, the conjunctival epithelium will grow over the dermis in ~4 to 6 weeks.47 Once the dermis is fully epithelialized and edema resolved, a custom ocular prosthesis can be fitted.64

In cases of evisceration and primary graft implantation, the DFG and anterior scleral ring should be sutured together.66 In order to provide good vascular supply for the graft, an incision to the posterior scleral tissue should be performed67 so that the graft can be in contact with orbital fat in the recipient bed. As with any graft, excessive cautery55 and handling of the graft and graft bed should be avoided.

Case Series Results.

In our case series of 32 adult and 2 pediatric patients (34 subjects total), the median patient age was 49.75 years and average age was 47.74 years. Of those who underwent DFG surgery, 18.75% had a primary indication, and 81.25% had a secondary indication. Only 1 patient included in the study had a follow-up period <16 months. The reported indications for the primary DFG were: 2 painful blind eyes secondary to corneal ulcers, 1 phthisical eye, 2 severe open globe injuries, and 1 painful blind eye secondary to retinoschisis and multiple surgeries for attempted retinal re-detachment (Table 6). The most common secondary indications were orbital implant migration or extrusion (Table 6).

Table 4. - Clinical Outcomes Associated with Number of Attached Muscles
Muscles sutured Prosthesis fit (ability to wear prosthesis ) Lid position Motility
no yes Total (N), column %a p-value
poor good Total (N),
column %a
poor moderate and good Total (N), column %a p-value
zero 4 15 19 (55.8%) 11 6 17 (50.0%) 0 14 14 (41.2%)
4 muscles 0 5 5 (14.7%) 3 2 5 (14.7%) 0 5 5 (14.7%)
5 muscles 2 3 5 (14.7%) 1 5 6 (17.6%) 1 4 5 (14.7%)
Total 6 23 29 (85.3%)b 15 13 28 (82.3%)b 1 23 24 (70.5%)b
amissing data not included in the tables
bpercentages are calculated in total number of 34 patients

Percentage of patients who had 4 muscles tagged (rectus muscles) was 17.6%, 17.6% patients had 5 muscles tagged (rectus muscles plus inferior oblique), and 58.8% patients had 0 muscles attached. No data regarding muscle attachment were available for 2 patients (5.8%). Of the patients who had a primary DFG, 83.3% had all 5 muscles tagged, while 73.1% of patients who had secondary DFG had no muscles tagged (Table 2). This may reflect individual surgeon preferences, since the data include results from multiple surgeons.

Several factors analyzed in our study trended toward, but did not reach, statistical significance. Primary versus secondary DFG showed moderate-to-good graft motility in 83.3% and 100% of cases, respectively (p = 0.24). Prosthesis fit and wearability throughout the day was rated positive in 66.6% of cases for primary indications and 84% in secondary indications (p = 0.56). The closest association was observed in our analysis of eyelid position and indication (p = 0.07); a good eyelid position (defined as MRD1 and MRD2 values between 4 and 5mm) was observed in 83.3% of patients with primary DFG versus 37.5% with secondary DFG (Table 3).

Postoperative complications were noted in 58.8% of patients. However, the majority of reported complications were minor and resolved with minimal or no intervention. Some of the complications required additional interventions such as closure of the conjunctiva over the graft, eyelid tightening, or repeat DFG surgery (n = 2) (Table 8). The most common complications in primary DFG were minor infection, poor conjunctival growth over the graft, implantation cysts, and inferior fornix shortening. In secondary DFG, common complications included eyelid retraction and laxity, hair growth, hematoma, pyogenic granuloma, giant papillary conjunctivitis, socket infection, and socket contraction (Tables 7 and 8). However, there were no statistically significant differences between the occurrence of any particular complication in patients who underwent primary versus secondary DFG placement (p = 0.36). Among the 23 patients who had implant exposure or extrusion as their indication for DFG, 52.1% experienced a complication. In 41.17% patients, there was a need for an additional surgery within 2 years following grafting. However, there was no significant difference between primary and secondary DFG placement and the need for additional surgery (p = 1.0) (Table 2). Similarly, there was no association between specific indication for DFG placement and the need for additional surgery (p = 0.5). Among the 67.7% patients who had implant exposure or extrusion as an indication for DFG, 39.1% required additional surgery within 2 years. In our study, advanced age was not associated with higher complication rates (p = 0.12).


Outcomes of Primary Versus Secondary DFG Implantation in Adults.

One of the main concerns following DFG surgery is graft atrophy and under-correction. Multiple studies have reported less volume atrophy in primary versus secondary indications: 5% to 10% and 40%, respectively37; 0% and 13.4% respectively4; and 5% to 10% and 20% to 30%, respectively.62 This may be due to reduced vascularization of the orbital tissue at the time of revision surgery. In our study, only 1 patient had fat atrophy in the primary indication group. Graft atrophy was likely associated with previous socket infection that was successfully treated. In comparison to the pediatric population, adults have higher and more unpredictable fat absorption rates. In children, DFG grows together with the orbit and periorbital tissue.60 Our study had only 2 pediatric patients and results in both are congruent with the literature findings.

Table 5. - Additional Surgeries and Complications Associated with Number of Attached Muscles
Muscles sutured Additional surgeries Complications
yes no Total (N), column %a p-value
yes no Total (N),
column %a
zero 8 12 20 (58.8%) 11 9 20 (58.8%)
4 muscles 3 3 6 (17.6%) 3 3 6 (17.6%)
5 muscles 2 4 6 (17.6%) 4 2 6 (17.6%)
Total 13 19 32 (94.1%)b 18 14 32 (94.1%)b
amissing data not included in the tables
bpercentages are calculated in total number of 34 patients

Table 6. - Specific Indication for Dermis-Fat Graft
Indication for dermis-fat graft
Primary Secondary
blind, painful eye secondary to corneal ulcer socket deformity
glaucoma poor prosthesis retention
phthisical eye migration of orbital implant
open globe trauma multiple pyogenic granulomas with inferiorly displaced titanium implant
perforated globe no implant with orbital irritation
blind, painful eye following retinoschisis and retinal detachments contracted socket due to implant extrusion
MEDPOR implant exposure
extrusion of implant
no implant with shallow fornix
exposed and infected implant
deep superior sulcus and laxity of lower eyelid
exposed implant
severe superior papillary conjunctivitis
loss of silicone implant from socket
infected silicone orbital implant with exposure
extrusion of implant with recurrent MRSA infection
severe entropion of upper eyelid

In a study by Nentwich et al.,37 motility of the graft was better in primary indications. When motility scores were rated, the same study showed 76% of patients with excellent motility in primary indications, as opposed to 34% in secondary. Guberina et al.4 reported excellent and good motility in 92.8% in primary versus 60% in secondary indications, respectively. Although the difference was not statistically significant, our study trended towards superior results in the secondary indication group for the motility outcomes. In comparison to synthetic spherical implants, DFGs are reported to have superior motility.37 Acceptable movement of the ocular prosthesis was reported in every patient with a primary indication when extraocular muscles were sutured to the edge of the dermis-fat graft.64

In a study by Aryasit and Preechawai,15 a total of 30 patients were able to successfully wear a prosthesis for a mean follow-up time of 2.5 years. Specifically, Aryasit and Preechawai15 reported better outcomes for patients with secondary implantation, possibility due to the severely damaged conjunctiva in patients with primary indications. Similarly, our study showed better wearability of the prosthesis in the secondary indication group. In another study with a mean follow up of 21.5 months, 81% of patients with prior primary DFG experience excellent prosthesis fit.37

Table 7. - Specific Complications after Dermis-Fat Graft Surgery
orbit related donor site related
socket contraction wound dehiscence
central bulkiness causing extrusion blisters
shortening of inferior fornix bleeding
giant papillary conjunctivitis
socket pyogenic granuloma
infection and exposed DFG and limited conjunctival coverage
MRSA socket infection
fat atrophy with lower lid laxity
repeated infection status post debridement
lower lid laxity
lateral canthal retraction causing issues with prosthesis retention
re-exposure of the graft
copious mucous discharge
socket fistula
medial canthal ligament laxity
orbital cellulitis
poor prosthesis fit

Cosmetic Results.

In a study of oculoplastic surgeon-rated surgical results, 65.1% of 43 cases were reported to have “very good,” or “good” cosmetic results following DFG.64 In another cosmetic evaluation, 83% of patients receiving a primary DFG were satisfied with the results, as opposed to 57% undergoing a secondary DFG.37 In a third study of 30 patients with DFG, all had successful prosthetic fittings and satisfactory cosmetic outcomes.43 Our results suggest that the DFG may be a superior technique for primary indications compared with secondary when eyelid position was evaluated. Other possible reasons for worse eyelid position with secondary implants include scarring in the socket, preexisting lax socket syndrome, and secondary to prior socket surgery. Preoperative eyelid position was not evaluated in our study, which is a potentially limiting factor. Interestingly, the number of sutured muscles showed no significant association with the eyelid position. This finding contrasts with prior studies regarding the effect of the inferior oblique on the palpebral fissure,68–70 since most primary DFGs in our study were performed by a surgeon who attached the inferior oblique, while most secondary DFGs were performed by a surgeon who did not attach the inferior oblique. Karataş et al.38 found that all 7 patients (100%) undergoing primary DFG were satisfied with the outcome and could wear their prosthesis without any discomfort, while only 6 patients (60%) undergoing secondary DFG were satisfied with the outcome. In a series of 30 patients by Lin and Liao,43 the largest cosmetic problem following DFG was superior sulcus deformity due to fat volume loss in 14% of cases, and fornix loss in 20% of cases due to retraction of the superior muscle complex and forniceal foreshortening. In these cases, grafts were used to reconstruct the shortened fornices. A study by Sihota et al.28 showed superiority of 20 mm fat pad thickness compared with 10 mm in terms of superior sulcus aesthetics and enophthalmos.

The conclusion of these studies is that, given the superior results from primary versus secondary DFG, efforts should be made to identify patients who are good candidates for DFG and poor candidates for alloplastic implants and offer them primary DFG reconstruction.

DFG Complications in Adults.

The list of known complications from DFG is extensive and includes granulomas,23,29,64 graft-wound dehiscence and fat prolapse,62 graft ulceration,39 graft necrosis,31,38 graft atrophy, excessive graft growth, retro-implant hemorrhage, deep cysts,29,64 hypertrophic scarring,29,64 seroma,64 liquefaction of the transplant,64 socket keratinization,71 superficial central slough in oversized graft use,4 hair retention, and infection.4,64 These potential complications may involve both the donor and recipient sites. Previous studies have shown a 47% overall incidence of complications, with 58% of them minor in nature,72 which matches our results. Necrosis of the graft is one of the more severe adverse events and has been reported in 2.9% of patients with primary indications and 4.5% of patients with secondary indications.37 The risk factors for graft necrosis include inappropriate medication use following surgery and poor patient compliance.38 In our case series, there were no cases of graft necrosis.

Table 8. - Specific Indication and Complications following DFG surgery
Patient Indication Specific indication # AM Complications
1. S poor prosthesis retention, socket deformity, loss of inferior fornix, migration of orbital implant 5 none
2. P blind painful eye sec to corneal ulcer 5 infection
3. S multiple pyogenic granulomas, inferiorly displaced titanium implant 0 none
4. S exposed implant 2/2 chromic infection 4 lower lid retraction and laxity, large prosthesis
5. S contracted socket due to implant extrusion 0 poor prosthesis fit
6. S implant MEDPOR exposure 4 hairs growing, edema
7. S extrusion of implant 0 orbital hematoma, exposed silicone implant
8 S no implant, shallow fornix 0 none
9 S exposed, infected implant 0 lower lid laxity, lagophthalmos
10. S implant MEDPOR exposure 0 none
11. S exposed implant 0 none
12. S bilateral anophthalmia, implant exposure 0 none
13. S loss of silicone implant from socket 0 none
14. S infected exposed implant 0 none
15. S extrusion of implant with recurrent MRSA infection 0 pyogenic granuloma, GPC, lower lid hordeolum
16. P blind, painful eye sec to corneal ulcer 5 repeated infection, exposed DFG
17. S exposed implant 0 fat atrophy and lower lid laxity, second DFG placement, lid laxity
18. S implant extrusion 4 socket infection (MRSA), medial canthal ligament laxity
19. S exposed implant 4 none
20. S anophthalmos after left enucleation with no implant placement 0 none
21. S severe entropion of upper eyelid 0 none
22. S exposed implant 0 lateral canthal retraction causing issues with prosthesis retention, orbital cellulitis
23. S glaucoma 0 re-exposure
24. S exposed implant 0 copious mucous discharge
25. P phthisical eye 0 fistula in socket cyst
26. S exposed implant 0 none
27. S exposed implant NA blisters and bleeding from graft harvesting site
28. P trauma causing open globe 5 wound dehiscence of DFG harvest site
29. S infected silicone orbital implant with exposure NA pyogenic granuloma, lid lag requiring re-operation, poor prosthesis fit, canthopexy,
30. P blind, painful eye following retinoschisis with retinal detachment 5 none
31. P perforated globe 5 inferior fornix shortening, re-operation
32. S exposed implant 4 none
33. S deep superior sulcus and laxity of lower eyelid 0 central bulkiness causing extrusion
34. S implant extrusion 4 socket contraction

Cyst formation has been reported to occur in 3% to 11% of cases.34,37,64 Deep subconjunctival cysts may occur particularly in the context of secondary implantation, and with growth may push fat tissue forward, causing “proptosis” of the prosthesis.47 In our case series, cyst formation was a rare complication that occurred in only 1 patient (Table 7) with primary DFG for phthisis. The donor site in this case was the left abdominal region. In general, this complication can be avoided by selecting a hairless donor site and performing meticulous epidermis removal.64

Although DFG is can be used to treat forniceal shortening, the latter can also arise as a potential complication of DFG itself. In a study by Lin and Liao,43 fornix loss was reported in 20% of patients and superior sulcus deformity was reported in 13% of patients. Additionally, a study by Bhattacharjee et al.73 reported prosthesis extrusion and socket contracture recurrence in one-third of the patients who received DFG compared with porous implant and mucous membrane graft. Our study included 2 patients with inferior fornix foreshortening and 1 patient with socket contraction as indications for the DFG. Both patients with inferior forniceal shortening had no adverse events following DFG surgery, and the patient with socket contraction showed moderate prosthesis fit following surgery. Among our 34 patients, 2 had socket contraction or fornix shortening following DFG placement, requiring additional surgery. It is unclear whether the fornix shortening had been present preoperatively and not identified or whether it developed following surgery. No significant association was found when assessing primary versus secondary DFG indications (Table 8).

Graft failure and complications can occur in cases with excessive cautery and in older patients with comorbidities that contribute to defective wound healing, including diabetes mellitus, poor vascularization, vasculitis, and smoking.12,72,74 In our study, advanced age was not associated with increased complication rates (p = 0.12).

Widespread graft failure or loss can occur in chemical injury57 and post-radiation cases where orbital vasculature has been compromised. Risk of graft loss also increases if placed onto a preexisting alloplastic implant.47 Active orbital infection is an absolute contraindication to graft placement and must be successfully treated before socket reconstructive surgery of any type is performed. Additionally, previous history of orbital trauma or surgical resection of posterior orbital fat during enucleation can predispose to graft necrosis and ulceration, and dermis damage has been reported to be a risk factor for graft ulceration.39,72 In our study, 4 patients had socket infection following DFG placement. Two of these patients, including 1 who developed orbital cellulitis, required a second DFG placement. The underlying infection was successfully treated with conservative measures in the other 2 patients (Table 8). In cases where previous alloplastic implant infection was the indication for DFG surgery, lower eyelid laxity and pyogenic granuloma were rare complications (Table 8).

Outcomes and Complications in the Pediatric Population.

As in adults, the pediatric population appears to do better with primary DFG than secondary. This technique is safe with excellent functional and cosmetic results due in part to the graft growth after implantation. The graft maintains an adequate orbital volume, enables proper prosthesis fitting, and promotes orbital symmetry.75 Some of the primary outcome concerns are excessive graft growth, graft atrophy, and central ulceration.

In patients who are 4 years or younger, graft growth may lead to “proptosis” that requires surgical debunking, while patients over the age of 9 years may experience the opposite, graft atrophy similar to the adult population.76 Hence, DFG is a good option for children of all ages as long as expectations of future surgeries are properly explained and managed. Often, excessive DFG growth in younger patients can be due to systemic weight gain. However, a debulking procedure is an easy way to manage graft overgrowth complications. In a study of primary DFG in patients with unilateral enucleation due to retinoblastoma, 5 out of 14 patients required a debulking procedure due to excess fat growth.77

The size of the implant is essential, as an implant over 22 mm may lead to early volume loss due to initial tension and pressure. Surgeons should also be careful to not excessively manipulate the graft as this can lead to late atrophy. In a study by Quaranta-Leoni et al., no graft atrophy or necrosis occurred, and only 1 patient with primary DFG required debulking. The surgical outcome was rated as fair, satisfactory, or very satisfactory by 84.2% of patients.78 Additionally, Karataş et al.38 reported additional fat atrophy in a patient who already experienced prior orbital fat atrophy post-radiation therapy following enucleation for retinoblastoma. Intraorbital fat reduction may be a risk factor for secondary DFG atrophy.

In secondary outcomes, removing the exposed implant and replacing it with a DFG may be more successful than implanting the DFG on top of the exposed implant.78 The complications are similar to primary DFG and include hair growth, pyogenic granulomas, and graft ulcers. Our study included 2 orbits with secondary indications for DFG due to silicone implant exposure in a single patient; no DFG-related complications occurred in this case.

Managing DFG Complications.

Overall, major complications are uncommon and can typically be addressed with excellent outcomes. Adipose hyperplasia or hypertrophy can be managed with surgical debulking. Occasionally, lack of vascular supply may lead to localized fat necrosis, which may require surgical debridement. Fat necrosis may be associated with infection, which requires packing with iodoform gauze after debridement and a course of antibiotics. Finally, fat atrophy may require additional fat grafting. Minor complications, including pyogenic granulomas, cysts, and fistulas can be addressed with surgical excision. Eyelid laxity may require additional canthopexy or eyelid tightening. Hair growth can be managed by argon laser, while graft ulceration may require debridement or may spontaneously heal without any intervention. Large cyst formation, usually associated with the prolonged irritation due to implant exposure and invasion of the conjunctival epithelium, may be an indication for surgical removal. Lost volume may be addressed either by another DFG or alloplastic orbital implant.47


DFG is an excellent option for socket reconstruction and may be particularly useful in cases involving pediatric patients, complicated orbits, history of multiple previous orbital surgeries, inflamed sockets, and contracted or scarred sockets.38,47,79,80 Muscle suturing to the graft edge stabilizes the socket, reduces “ballooning” of the graft, and may improve prosthesis movement. The time-consuming nature of the procedure is its largest drawback, and the results may be variable and highly surgeon dependent.

Failure of the graft and associated complications usually occur in patients of advanced age with comorbidities of diabetes mellitus, poor vascularization, vasculitis, and/or smoking.12,74 In order to avoid potential major complications, it is necessary to thoroughly evaluate the socket, DFG indication, and any patient comorbidities. Possible outcomes and complications should be excessively discussed with the patient or legal guardian prior to surgery. Taking all recognized risk factors into consideration, patient selection plays an important role in surgical success, and complications that do arise are usually easily manageable.


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