Fig. 21.9 Type IV defects (orbitomaxillectomy). There is resection of the five upper walls of the maxilla, including the orbital contents, but sparing the palate (left). The resected specimen consists of the orbital contents, eyelid, cheek skin, and bone creating a large surface area/large volume defect (center, left). Note design (inset) of single skin island rectus abdominis myocutaneous free flap. This flap provides a large surface area with significant volume to reconstruct the defect (center, right). Rectus abdominis free flap in place, demonstrating the skin island used to resurface the external skin defect and subcutaneous fat with muscle used to fill in the soft tissue defect (right). From Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 2000;80:2331–46. Reprinted with permission

21.3.3 Reconstruction After Orbital Exenteration

Orbital exenteration involves removal of the contents of the orbit, including the globe, the extraocular muscles, and the periorbital soft tissues. It is most commonly performed for orbital and periorbital malignancies, including squamous cell carcinoma, basal cell carcinoma, sebaceous gland carcinoma, conjunctival and uveal melanoma, sarcoma, and adenoid cystic carcinoma of the lacrimal gland [18]. Invasive cancers may necessitate extended resections, resulting in communication of the orbit with the cranial vault, nasal cavity, and paranasal sinuses.

The primary goal of reconstruction after orbital exenteration is to either line or fill the orbit with durable tissue that excludes the nasal cavity and paranasal sinuses and, when there is a cranial defect, protects the brain. The tissues used for the reconstruction may need to be able to tolerate radiation therapy, and when the patient desires, the orbit should be able to accommodate a prosthesis. Numerous reconstructive methods that attempt to fulfill these goals have been described in case reports and small case series [19–23].

Recently, Hanasono et al. [24] at M.D. Anderson suggested an algorithm (Fig. 21.10) for surgical reconstruction and prosthetic rehabilitation after orbital exenteration. Based on their experience, numerous reconstructive options are available to successfully line the socket. The determining factor in the choice of reconstructive method is whether the patient underwent preoperative irradiation or is anticipated to undergo postoperative irradiation [24].

Fig. 21.10 Algorithm for reconstruction after orbital exenteration. From Hanasono MM, Lee JC, Yang JS, et al. Plast Reconstr Surg 2009;123:98. Reprinted with permission

Split-thickness or full-thickness skin grafts are used for reconstruction when an open cavity is desired; when there is no need to isolate the orbital cavity from the sinonasal, oral, or intracranial cavities; and when radiation therapy is not given preoperatively or postoperatively. Preoperative or postoperative radiation therapy is a contraindication to skin grafting because of the risk of poor graft take or subsequent graft loss [24].

Regional flaps and microvascular free flaps are used for reconstruction when orbital exenteration is combined with removal of orbital walls or if a patient received preoperative radiation therapy or is expected to receive postoperative radiation therapy. These flaps are used to provide soft tissue coverage of the bony walls of the orbit, isolate the orbit from the paranasal sinuses, or protect the intracranial contents in cases of exposure.

Aside from radiation therapy, the other major factor influencing the choice of reconstructive option is whether the cavity will be left open or closed. An opencavity reconstruction of the orbital socket is preferred when use of an orbital prosthesis is planned postoperatively. The open cavity allows for a more secure fit of the prosthesis and usually requires less extensive reconstructive surgery. The free flaps of choice to allow for an open cavity are radial forearm fasciocutaneous flaps, temporoparietal muscle flaps, and any myocutaneous flaps in which flap design can keep soft tissue bulk to a minimum.