A potential drawback of using skin grafts to line the orbital cavity is that they may result in downward displacement of the brow and cheek due to soft tissue contracture [21]. This may be less of a concern with full-thickness skin grafts as they contract less than split-thickness grafts.

Closed-cavity reconstructions tend to contract less and do not undergo the same amount of atrophy as skin grafts [21] but tend to be less amenable to a prosthesis. Prostheses over closed cavities may protrude excessively such that the affected side is not symmetric with the contralateral face. According to Hanasono et al. [24], closed cavities required surgical revisions before being able to accommodate a prosthesis successfully. These revisions consisted of flap debulking by direct tissue excision, usually combined with suction-assisted lipectomy.

21.4 Conclusion

Orbital reconstruction in cancer patients can be approached by many different avenues. The most important factors determining the reconstructive approach are the size of the defect, the periorbital structures exposed, and whether the area was irradiated preoperatively or will be irradiated postoperatively. There are several different new algorithms that provide a strong foundation for surgical planning. These, in addition to free-flap techniques, will continue to expand the options available to the orbital reconstructive surgeon.

References

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2.Ali A, Fardy MJ, Patton DW. To reconstruct or to obturate? Results of a UK survey of oral and maxillofacial surgeons. Br J Oral Maxillofac Surg 1995;33:207–10.

3.Shestak KC. Soft tissue reconstruction of craniofacial defects. Clin Plast Surg 1994;21: 107–11.

4.Wells MD, Luce EA. Reconstruction of mid-facial defects after surgical resection of malignancies. Clin Plast Surg 1995;22:79–89.

5.Coleman JJ III. Osseous reconstruction of the midface and orbits. Clin Plast Surg 1994;21:113–24.

6.Nakayama B, Matsuura H, Hasegawa Y, et al. New reconstruction for total maxillectomy defect with a fibula osteocutaneous free flap. Br J Plast Surg 1994;47:247–9.

7.McLoughlin PM, Gilhooly M, Phillips JG. Reconstruction of the infraorbital margin with a composite microvascular free flap. Br J Oral Maxillofac Surg 1993;31:227–9.

8.Schusterman MA, Reece GP, Miller MJ. Osseous free flaps for orbit and midface reconstruction. Am J Surg 1993;166:341–5.

9.Swartz WM, Banis JC, Newton ED, et al. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 1986;77:530–45.

10.Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 2000;80:2331–46.

11.Spiro RH, Strong EW, Shah JP. Maxillectomy and its classification. Head Neck 1997;19: 309–14.

12.Larson DL, Christ JE, Jesse RH. Preservation of the orbital contents in cancer of the maxillary sinus. Arch Otolaryngol 1982;108:370–2.

13.Stern S, Goepfert H, Clayman G, et al. Orbital preservation in maxillectomy. Otolaryngol Head Neck Surg 1993;109:111–5.

14.Schusterman MA. Discussion of reconstruction of total maxillectomy defects with preservation of the orbital contents (discussion). Plast Reconstr Surg 1998;102:1885.

15.Yamamoto Y, Minakawa H, Kawashima K, et al. Role of buttress reconstruction in zygomaticomaxillary skeletal defects. Plast Reconstr Surg 1998;101:943–50.

16.Cordeiro PG, Bacilious N, Schantz S, et al. The radial forearm osteocutaneous “sandwich” free flap for reconstruction of the bilateral subtotal maxillectomy defect. Ann Plast Surg 1998;40:397–402.

17.Kyutoku S, Tsuji H, Inoue T, et al. Experience with the rectus abdominis myocutaneous flap with vascularized hard tissue for immediate orbitofacial reconstruction. Plast Reconstr Surg 1999;103:395–402.

18.Rapidis AD, Liarikos S. Malignant orbital and orbitomaxillary tumors: surgical considerations. Orbit 1998;17:77–88.

19.Reese A. Exenteration of the orbit with transplantation of the temporalis muscle. Am J Ophthalmol 1958;45:386–90.

20.Goldberg RA, Kim JW, Shorr N. Orbital exenteration: results of an individualized approach. Ophthal Plast Reconstr Surg 2003;19:229–36.

21.Chepeha DB, Wang SJ, Marentette LJ, et al. Restoration of the orbital aesthetic subunit in complex midface defects. Laryngoscope 2004;114:1706–13.

22.Pryor SG, Moore EJ, Kasperbauer JL. Orbital exenteration reconstruction with rectus abdominis microvascular free flap. Laryngoscope 2005;115:1912–6.

23.Taylan G, Yildirim S, Aköz T. Reconstruction of large orbital exenteration defects after resection of periorbital tumors of advanced stage. J Reconstr Microsurg 2006;22:583–9.

24.Hanasono MM, Lee JC, Yang JS, et al. An algorithmic approach to reconstructive surgery and prosthetic rehabilitation after orbital exenteration. Plast Reconstr Surg 2009;123:98–105.

Chapter 22

Enucleation, Evisceration, Orbital Implants,

and Management of the Irradiated Socket

Miguel Gonzalez-Candial and Aaron Savar

Abstract Removal of an eye is sometimes necessary in the management of ocular malignancies. The most common intraocular malignancies necessitating enucleation are uveal melanoma in adults and retinoblastoma in children. In patients with retinoblastoma, the segment of optic nerve removed during enucleation must be long enough to ensure that the entire tumor has been removed. A number of different types of orbital implants are available, each with advantages and disadvantages. Radiation can cause atrophy and contraction of orbital tissues; thus, management of the socket in patients who have undergone radiation therapy is challenging. There is considerable debate over the benefits of enucleation versus evisceration. Evisceration is not appropriate in patients with intraocular tumors as it may leave tumor behind. Before evisceration is performed for an indication not related to cancer, the eye should be carefully examined to rule out the presence of intraocular tumor.

22.1 Introduction

The management of ocular malignancies sometimes necessitates the removal of an eye. The most common intraocular malignancies leading to enucleation are uveal melanoma in adults and retinoblastoma in children. Enucleation is also occasionally required in the management of ophthalmic complications resulting from the treatment of other cancers. Management of anophthalmic sockets in cancer patients presents unique challenges, especially in patients who have previously undergone radiation treatment. Evisceration may be appropriate in some cancer patients without intraocular malignancy.

M. Gonzalez-Candial (B)

Department of Orbital and Ophthalmic Plastic Surgery, Universitat Autonoma de Barcelona, I.M.O. Barcelona, Barcelona, Spain

e-mail: mgcandial@mac.com

Oncology Series 6, DOI 10.1007/978-1-4419-0374-7_22,

C Springer Science+Business Media, LLC 2011