Fig. 23.4 (a) Photograph of the large surgical defect following an orbital exenteration. (b) Postoperative appearance after reconstruction with an anterolateral thigh free flap

detection of arterial or venous insufficiency and a rapid return to the operating room may allow salvage of the free flap. Whether free flap reconstruction masks local recurrence and leads to a delayed diagnosis is a subject of controversy. Patients with free flap reconstruction are usually followed with periodic imaging studies, such as computed tomography or magnetic resonance imaging, at intervals appropriate for their specific disease.

23.6 Surgical Complications

Postoperative complications of orbital exenteration include bleeding, infection, skin graft or flap failure, sino-orbital fistula, morbidity associated with the skin graft or tissue flap donor site, and unsatisfactory rehabilitation with an orbitofacial prosthesis. Prevention of hematoma and infection increases the skin engraftment rate. Sino-orbital fistula can be avoided by employing a careful surgical approach that does not violate the orbital walls. In extended orbital exenterations after which the orbit is reconstructed with flaps, sino-orbital fistula may be prevented by placing a nasal trumpet into the ipsilateral nostril during the healing period, preventing air escape through the suture line. Small fistulae are usually asymptomatic and may heal spontaneously. Larger ones may necessitate further surgery. In the case of bulky flaps, revision by suction-assisted lipectomy or direct excision of tissue may improve the cosmetic appearance of the patient.

23.7 Rehabilitation After Orbital Exenteration

Custom-made orbitofacial prostheses are widely used for rehabilitation after orbital exenteration. For complex defects, high-resolution computed tomography modeling systems can further improve fitting of the prosthesis. Polymethylmethacrylate prostheses are biocompatible and well tolerated, and the aesthetic result is pleasing, especially when the prosthesis is camouflaged by use of eyeglasses. Options for retention include the use of adhesive or osseointegrated titanium implants, which are placed into the bony orbital margins. Bone must be at least 4 mm thick to accommodate the implants, which are then covered with skin and soft tissue. After allowing several months for osseointegration to occur, the implants are exposed, and abutments, which protrude above the level of the skin, are attached to the implants. Finally, the prosthesis is coupled to the abutments via magnetic attachments.

Multistaged prosthetic rehabilitation demands significant motivation from the patient. Using an eye patch or dark glasses may be satisfactory for some patients. As mentioned, a bulky flap may limit accommodation of an orbital prosthesis or may cause the prosthesis to protrude excessively compared to the contralateral side. In some cases, the fit and appearance of an orbital prosthesis can be improved by debulking or recontouring of the reconstructive flap. Limitations of prostheses include the inability of the eye to move and the lids to close. Also, several fittings may be needed, and prostheses, which can be costly, need to be replaced periodically because of normal wear and tear. Regardless of the degree of aesthetic rehabilitation, monocular precautions, including constant eye protection and regular ophthalmologic exams, are emphasized to all patients to better protect the remaining functional eye.

Suggested Readings

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

3.Groth MJ, Bhatnagar A, Clearihue WJ, et al. Long-term efficacy of biomodeled polymethyl methacrylate implants for orbitofacial defects. Arch Facial Plast Surg 2006;8:381–9.

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5.Limawararut V, Leibovitch I, Davis G, et al. Sino-orbital fistula: a complication of exenteration. Ophthalmology 2007;114:355–61.

6.Looi A, Kazim M, Cortes M, et al. Orbital reconstruction after eyelidand conjunctiva-sparing orbital exenteration. Ophthal Plast Recontr Surg 2006;22:1–6.

7.Menon NG, Girotto JA, Goldberg NH, et al. Orbital reconstruction after exenteration: use of a transorbital temporal muscle flap. Ann Plast Surg 2003;50:38–42.

8.Mohr C, Esser J. Orbital exenteration: surgical and reconstructive strategies. Graefes Arch Clin Exp Ophthalmol 1997;235:288–95.

9.Nassab RS, Thomas SS, Murray D. Orbital exenteration for advanced periorbital skin cancers: 20 years experience. J Plast Reconstr Aesthet Surg 2007;60:1103–9.

10.Nerad JA, Carter KD, LaVelle WE, et al. The osseointegration techniques for the rehabilitation of the exenterated orbit. Arch Ophthalmol 1991;109:1032–8.

11.Rahman I, Cook AE, Leatherbarrow B. Orbital exenteration: a 13 year Manchester experience. Br J Ophthalmol 2005;89:1335–40.

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

13.Shields JA, Shields CL, Demirci H, et al. Experience with eyelid-sparing orbital exenteration: the 2001 Tullos L. Coston lecture. Ophthal Plast Reconstr Surg 2001;17:355–61.

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

15.Hanasono MM, Lee JC, Yang JS, Skoracki RJ, Reece GP, Esmaeli B. An algorithmic approach to reconstructive surgery and prosthetic rehabilitation after orbital exenteration. Plast Reconstr Surg 2009;123:98–105.

Chapter 24

Periorbital Surgical Rehabilitation After Facial

Nerve Paralysis

Heather Chang, Mehryar Taban, and Tanuj Nakra

Abstract Facial nerve paralysis can result from a number of causes, including neoplasms, Bell’s palsy, infections, trauma, congenital conditions, and idiopathic processes. Both the medical and social consequences of facial nerve paralysis can be distressing for patients. The most significant ophthalmic consequence of facial nerve paralysis is loss of function of the orbicularis oculi muscle. The complete assessment of a patient with facial nerve paralysis includes clinical evaluation of the resting tone and active function of the facial muscles, as well as determination of the extent of dry eye and the function of the lacrimal gland and lacrimal drainage system. The goal of medical therapy is symptomatic relief of dry eye and exposure keratopathy. Botulinum toxin can also be employed to treat other symptoms, such as synkinesis, hypertonicity, and spasms. The goal of surgical therapy is improved protection of the cornea, as well as a more symmetric static and dynamic appearance. Lagophthalmos and exposure keratopathy can be addressed with procedures such as surgical closure of the eyelids, known as tarsorrhaphy, or other alternatives, such as placement of an alloplastic gold weight in the upper eyelid, injection of hyaluronic acid gel into the upper eyelid, or palpebral springs. Ectropion also commonly results from facial nerve paralysis and can be improved with lateral or medial canthal procedures. Reanimation of the midface can be accomplished by any of several surgical techniques; some provide static support for the midface, while others attempt to restore dynamic movement to the paralyzed face.

24.1 Introduction

Facial nerve paralysis can result from a number of causes, including neoplastic processes, Bell’s palsy, infections, trauma, congenital conditions, and idiopathic processes. Tumors can lead to facial nerve paralysis directly by mass effect or

H. Chang (B)

Jules Stein Eye Institute, UCLA Medical Center, Los Angeles, CA, USA e-mail: hkwon88@yahoo.com

Oncology Series 6, DOI 10.1007/978-1-4419-0374-7_24,

C Springer Science+Business Media, LLC 2011