FEMALE SPEAKER: So, this patient previously had enucleation of both eyes and had a reconstruction with orbital implants, but she developed some loss of orbital volume over the years and also contraction of the conjunctival lining of the socket and is now unable to wear prostheses. We're going to start on the right side here and just open up the conjunctiva and create some space for the fat graft that we will place later. We're trying to do the least amount of dissection necessary to avoid further scarring and contraction of the socket. So, now we're going to do that same dissection on the other side, and again measure the opening that we've made in the conjunctiva to see what size of dermis fat graft we will be able to fit.

So, we're going to turn our attention to the dermis fat graft harvest site on the right hip. So, we previously marked out an ellipse here that will be adequate size. Our grafts are each 20 millimeters long, so this needs to be at least 40 millimeters long. We're just going to confirm that this will be appropriate size. We'll make our incision along the outer mark to have an elliptical shape that will close better, and we can take our two smaller ellipse-shaped grafts from that larger one. We take the epidermis off while the tissue is still in place. It will help us to maintain adequate tension.

We just for graft harvesting try to use an area that will provide appropriate tissue, and the second priority is to choose an area where the defect or the scar will not cause either functional deficits or be of much cosmetic concern. We don't need very much depth, probably about 1 centimeter, to give appropriate volume to the orbit, so we're going to incise straight down, not angle our blade, so that the graph does not become tapered towards its deep surface, and then excise it. Now we can just cut across the deep surface of the graft in a plane perpendicular to the skin surface.

Here is the graft that we're going to split up between the two sides, and we're just going to keep that on wet gauze while we obtain hemostasis here. So, since we measured the same size on both sides, we can just cut the graph in half and then just reshape it a little bit so each half is more of an ellipse that tapers towards the end. You can have some overlap between the conjunctiva and dermis edge, and it does not have to precisely fit in your opening, as long as it's not too small.

Now we can put our graft in place, tuck the adipose tissue into the pockets we've created. And then we're going to place some deep sutures to attach the adipose tissue there from our graft to the tenons and orbital fat. You can already see that we have improvement there of the enophthalmus, and the lids should be held open now if there is a prosthesis fitted on top of this.

When we place these deep sutures, we want to be careful that we don't incorporate tissues that are deep in the fornix so that we don't shorten our fornices by pulling them up to the site of the graft. Now that we have the two corners anchored nasally and temporally, we can just add a running suture along each edge. You can see that we have increased the surface area of the socket and added depth to the fornices, as well as volume.

We'll now repeat the same procedure on the other side. This conformer has fenestration, so that any fluid that builds up behind it can come out to the surface, and ointment or drops that we will put on the front of the conformer will get back to the tissue.

Now that we have the conformers in place, we get a little bit better idea of what it would look like with a prosthesis. The standard temporary tarsorraphy. I instruct patients to just keep the area clean, wash it normally with soap and water, and apply antibiotic ointment to these sutures twice a day for two weeks until we take it out. Now, we are going to finish closing our donor site.