Tips guide preparation of contracted socket for grafting

Key Points

Las Vegas-Contracted socket reconstruction is one of the most challenging procedures that oculoplastic surgeons face. Individualized treatment involves careful assessment to ascertain where the deficiency lies and then application of staged surgical step reconstruction principles, said Don O. Kikkawa, MD, during the 2006 joint scientific session of the American Society of Ocularists and the American Academy of Ophthalmology.

Dr. Kikkawa is professor of clinical ophthalmology and chief, Division of Ophthalmic Plastic and Reconstructive Surgery, Shiley Eye Center, University of California, San Diego, in La Jolla. He covered five practical tips for managing these challenging cases with specific examples on preparing the socket for grafting.

"If I am going to place an orbital implant, I tend to place them in the eyelid crease through an eyebrow incision," he said. "An alternative is placement through an infraciliary incision through the lower eyelid."

Dr. Kikkawa advised surgeons who wanted to proceed with surface area grafting to wait 3 to 6 months for the contracted socket to stabilize following other reconstructive surgery.

Tip 2-Recognize the specific deficiency whether it involves the bony orbit, the soft tissue, the lids, anterior lamellae, or a combination of these factors, he said.

Dr. Kikkawa showed the case of a woman who was unable to retain an ocular prosthesis even though her eyelids were in good position and her bony orbit was intact. The deficiency was in the conjunctival surface area only. In another example, a patient who had been in an automobile accident had avulsion injuries, losing the lower eyelid and sustaining traumatic enucleation, representing a combined conjunctiva and skin shortage. These cases are among the more difficult to reconstruct.

Developmental defects also can be challenging for the oculoplastic surgeon. Amniotic banding can be problematic, as was the case of child whose entire face was affected. The child had a cleft that affected the eyelids and the left side of the bony orbit, involving multiple layers of complexity.

Congenital microphthalmos tends to involve all the categories, including eyelid, surface area, and bony orbit. "With three-dimensional CT scanning, one can see the marked bony hyperplasia," Dr. Kikkawa said.

Another example is hemifacial microsomia, another developmental defect that can involve both eyelids and socket, he noted.

Tip 3-Assess the blood supply to ensure that it is adequate. "Many of these patients develop repeated cicatrix, mainly from fibroblast activation but also from poor wound-healing and poor blood supply," Dr. Kikkawa said. "We consider ordering some sort of imaging study, particularly on traumatic and irradiated cases, to assess the blood supply." A contrast magnetic resonance (MR) imaging or an MR angiogram is useful, he continued.

To increase vascularization, surgeons can use pedicle flaps as well as temporalis fascia grafts. "In severe cases, we will resort to microvascular free flaps," Dr. Kikkawa said.

Tip 4-Develop an individualized approach for each patient. "However, staged surgical step reconstruction principles do apply," he said. The first step is to ensure that the bony skeleton is intact. Then the orbital soft tissues should be assessed for adequate volume. At this point, the surgeon should replace any volume deficiency with implants and then finally direct his or her efforts to surface area grafting. After that, any eyelid defect can be addressed.