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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 246-248

Use of volumetric analysis in the management of recurrent dermis fat graft hypertrophy


1 Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India
2 Consultant Radiologist, VRR Scan Center, Chennai, Tamil Nadu, India

Date of Submission13-Mar-2021
Date of Acceptance09-Jul-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Bipasha Mukherjee
Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_585_21

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  Abstract 


Autologous dermis fat graft is an option commonly used for volume replacement in congenital anophthalmic sockets. Hypertrophy of the graft is a very rare complication that can be managed by debulking the graft. Volumetric analysis by computed tomography or magnetic resonance imaging helps in calculating the amount of fat to be excised while debulking. We report a case of recurrent dermis fat graft hypertrophy managed by debulking with the aid of volumetric analysis. The patient underwent dermis fat grafting at the age of 1, followed by graft hypertrophy at the age of 2 years and recurrent hypertrophy at the age of 6 years. Debulking was done with the aid of volumetric analysis when hypertrophy recurred. The patient is doing well with a stable cosmesis at the last follow-up after 1 year.

Keywords: Dermis fat graft hypertrophy, socket reconstruction, volumetric analysis


How to cite this article:
Salim S, Noronha OV, Mukherjee B. Use of volumetric analysis in the management of recurrent dermis fat graft hypertrophy. Indian J Ophthalmol Case Rep 2022;2:246-8

How to cite this URL:
Salim S, Noronha OV, Mukherjee B. Use of volumetric analysis in the management of recurrent dermis fat graft hypertrophy. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Jan 16];2:246-8. Available from: https://www.ijoreports.in/text.asp?2022/2/1/246/334962



DERMIS fat grafting (DFG) is an established mode of volume replacement in an anophthalmic socket especially in children to stimulate orbital growth and thereby to maintain periorbital symmetry. Hypertrophy of the DFG, though rare, is most often seen in the pediatric age group. This is usually managed by the debulking of the fat graft. However, there is no objective way to determine the amount of debulking required. Recurrent DFG hypertrophy has also been described.[1],[2] We report a case with recurrent DFG hypertrophy and outline the management of this rare complication.


  Case Report Top


A 7-month-old female child presented to us with a history of absence of right eye since birth [Figure 1]a. On examination and ultrasonography, there was no evidence of an eyeball in the right socket, confirming the diagnosis of congenital anophthalmia. The right orbit was hypoplastic. We proceeded to enlarge her socket with serially enlarging conformers. She underwent a DFG at the age of 1 year. The graft was taken from the upper outer quadrant of the right buttock and the dimensions were 20 × 10 mm. The post-operative period was uneventful. Prosthesis fitting was done after 6 weeks with fair cosmesis. However, exuberant growth of the DFG with resultant proptosis was noted on review at the age of 2 years [Figure 1]b. Despite the modification of the prosthesis, the cosmesis remained unsatisfactory. The child underwent a debulking of the DFG. Intraoperatively, a linear incision was made along the central part of the conjunctiva overlying the DFG. Underlying tissues were dissected, and excess fat was removed till both eyes were at the same level on bird's eye view after placing a shell over the right socket. The conjunctiva was sutured with continuous 6-0 polyglactin sutures, and a conformer was placed in the socket. The post-operative period was uneventful.
Figure 1: (a) External color photograph showing right congenital anophthalmia; (b) External color photograph showing DFG hypertrophy with resultant proptosis at the age of 2 years

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The patient again presented to the clinic at the age of 6 years with complaints of the right eye appearing bigger. On examination, there was a regrowth of 2.80 cc of hypertrophied DFG on 3D magnetic resonance imaging (MRI)-assisted volumetric analysis using the Advantage Window (ADW 4.7) software.[3] 3D-MRI was performed using a clinical 1.5T whole-body superconducting imaging system (GE SIGNA HDxt 16 channel MRI) using eight-channel neurovascular coil. The MR imaging protocol consisted of a 3D FSPGR sequence and a 3D (T2/T1) WI sequence [(3D-FIESTA) in the axial plane. The DICOM images were exported to the image-processing software, Advantage Window (ADW 4.7). The orbital volumes were calculated in the axial slice for both orbits and fat graft. For orbital volume calculations, the region of interest was manually traced slice by slice. The orbit boundaries were manually delineated in axial slices. The posterior border was defined at the orbital margin of the optic foramen, and the anterior border was defined as a straight connecting line between the medial and lateral orbital rims. Fat graft volume was calculated by tracing the margins of the graft slice by slice, and computation was automatically done by the post-processing software.

However, the patient did not undergo surgery at this visit but reported a year later at 7 years of age with pseudoproptosis of the right eye [Figure 2]a, [Figure 2]b. 3D MRI-assisted volumetric analysis showed the right orbital volume to be 22.76 cc, left orbital volume 18.63 cc, and the hypertrophied DFG volume was 4.13 cc [Figure 2]c, [Figure 2]d, [Figure 2]e. We removed 4 cc of excess fat. The patient was fitted with a custom-made prosthesis after 6 weeks, and the cosmesis was satisfactory [Figure 2]f.
Figure 2: (a) External clinical photograph showing DFG hypertrophy with resultant proptosis at the age of 7 years without prosthesis; (b) with prosthesis; MRI volumetric analysis of the orbit showing (c) right orbital volume 22.76 cc, (d) left orbital volume 18.63 cc, and (e) the hypertrophied dermis fat graft volume of 4.13 cc; (f) External color photograph at final follow-up showing fair cosmesis with prosthesis

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  Discussion Top


Successful socket reconstruction involves fitting a stable prosthesis with acceptable cosmesis and adequate motility. The management of an anophthalmic socket in children is challenging. The absence of a growing eyeball leads to the loss of stimulation for orbital growth and ultimately to cosmetically unacceptable facial asymmetry. In cases of congenital anophthalmia, the treatment aims are the expansion of the eyelids, socket, and bony orbit. DFG is a composite autograft that caters to the needs of the pediatric age group as it has the potential to grow as the child grows. DFG has the advantage of providing both volume and surface for socket expansion with less fat resorption as compared to a free fat graft.

The possible complications of DFG include central graft necrosis, ulceration, graft failure, granuloma formation, graft hirsutism, keratinization of the socket, graft shrinkage with orbital volume loss, and rarely, excessive growth of the DFG, especially in infants.[1],[2] Unlike DFG in adults (which tends to undergo partial atrophy over time), the DFG in children appears to grow.[1] Rarely this can lead to an overgrowth of the DFG.[1] Excessive growth of DFG was reported in 75% of patients under 4 years of age by Heher et al.[1] Systemic weight gain has been noted to be associated with DFG hypertrophy.[4] Slowly progressive proptosis and poor prosthetic fit are the signs of exuberant growth of the DFG.[2],[5],[6] In the early stages, this can be managed by a prosthesis modification. Progressive hypertrophy is managed by debulking of the graft.[2],[6] Despite fat removal, recurrence has been reported in two previous studies and may require repeat debulking.[1],[2] [Table 1] shows a review of published literature on DFG hypertrophy. Till date, none of the published reports on DFG hypertrophy have discussed any method to calculate the volume of the fat to be removed. In our patient, the primary DFG was done at the age of 1 year. The hypertrophy was first noted at the age of 2 years, with recurrence at the age of 6 years. In this case, the volumetric analysis was done preoperatively to compare the volume of the anophthalmic socket with that of the normal eye, which revealed graft hypertrophy of 4 cc of extra volume compared to the normal side.
Table 1: Review of published literature on dermis fat graft hypertrophy

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  Conclusion Top


We conclude that preoperative volumetric analysis, preferably by an MRI, helps in objectively estimating the amount of fat to be removed at the time of surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Heher KL, Katowitz JA, Low JE. Unilateral dermis-fat graft implantation in the pediatric orbit. Ophthalmic Plast Reconstr Surg 1998;14:81-8.  Back to cited text no. 1
    
2.
Mitchell KT, Hollsten DA, White WL, O'Hara MA. The autogenous dermis-fat orbital Implant in children. J AAPOS 2001;5:367-9.  Back to cited text no. 2
    
3.
Bontzos G, Papadaki E, Mazonakis M, Maris GT, Kapsala Z, Blazaki S, et al. Quantification of effective orbital volume and its association with axial length of the eye. A 3D-MRI study. Rom J Ophthalmol 2019;63:360-6.  Back to cited text no. 3
    
4.
Nunery W, Hetzler K. Dermis-fat as a primary enucleation technique. Ophthalmology 1985;92:1256-61.  Back to cited text no. 4
    
5.
Tarantini A, Hintschich C. Primary dermis-fat grafting in children. Orbit 2008;27:363-9.  Back to cited text no. 5
    
6.
Quaranta-Leoni FM, Sposato S, Raglione P, Mastromarino A. Dermis-fat graft in children as primary and secondary orbital implant. Ophthalmic Plast Reconstr Surg 2016;32:214-9.  Back to cited text no. 6
    


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