Orbital exenteration reconstruction using a superficial temporalis muscle flap: The "Carpaccio flap", an innovative approach

INTRODUCTION

Malignant orbital diseases may lead surgeons to practice an orbital exenteration associated with chemotherapy and/or radiotherapy to ensure curative treatment. That radical procedure makes physicians consider reconstructive filling in order to allow prothesis wearing and reduce esthetic and social after-effects. We first describe the clinical case of a 6-year-old patient who presented an orbital rhabdomyosarcoma and underwent an orbital exenteration with immediate reconstruction by a superficial temporal pedicled on the middle temporalis muscle flap.

TECHNICAL NOTE

Through that case-report, we propose an original temporal flap to repair ipsilateral midface defects which may reduce donor site side effects and allow furthers corrections.

DISCUSSION

In pediatrics cases, our Carpaccio flap was an available regional tool to rehabilitate an irradiated orbital socket with an appropriate bulking and vascularization effect after subtotal exenteration. Furthermore, we prescribe that flap as a posterior orbital filling, when eyelid and conjunctiva are spared, to prepare orbital prosthesis implementation. A mild sunken temporal fossa appears with our procedure but by preserving the deep layer of the temporalis muscle, autologous reconstruction such as lipofilling are permitted in post-radiotherapy condition to enhance esthetic sequelae.

Modified procedure of anterior orbital exenteration enables eye socket reconstruction: A retrospective cohort study

The conventional procedure of anterior orbital exenteration is unfavorable for eye socket reconstruction, whereas a modified procedure enables socket reconstruction and prosthesis fitting. Our study aims to compare the cosmetic outcomes between these 2 surgical techniques.We retrospectively recruited patients treated with modified or conventional exenteration during January 2015 to May 2021 in our hospital. The conventional approach was performed along with dermis-fat graft transplantation. The modified approach was conducted followed by eye socket reconstruction and eyelid blepharoplasty. The clinical data were collected and analyzed, including demographics, tumor characteristics, postoperative complications, tumor-related events, and cosmetic outcomes.Forty-nine patients were consecutively recruited in this study, including 22 cases of modified exenteration and 27 cases of conventional exenteration. Forty-four subjects (89.8%) were diagnosed with ocular surface malignancies (conjunctival melanoma and squamous cell carcinoma) and 5 subjects (10.2%) were diagnosed with extraocular stage of uveal melanoma. After follow-up for 31.8 ± 17.1 months, the 1-, 2-, 5-year overall survival rate was calculated as 100%, 79.2%, and 59.2% in the Modified group, and 94.2%, 73.8%, and 51.5% in the Conventional group. Comparison of the survival curves showed no significant differences. In the Modified group, all patients received orbital implant placement and eye socket reconstruction. The implant motility was satisfactory in 12 cases (54.5%) with movements in 3 to 4 directions. The eyelid function was acceptable in 17 cases (77.3%) with no entropion, ectropion or lower lid laxity. Ocular prosthesis was delivered in 17 cases (77.3%) with successful fitting in 11 cases (64.7%). The self-rated cosmetic score was statistically (t test, P < .0001) higher in the Modified group (6.7 ± 0.9) than the Conventional group (2.2 ± 0.4).The modified approach to anterior orbital exenteration enables eye socket reconstruction and cosmetic rehabilitation while still preserves the curable chance for the treatment of advanced periocular/intraocular malignancies.

Mixed (nodular and morpheic) upper eyelid basal cell carcinoma with orbital invasion - histological and clinical features

Basal cell carcinoma (BCC) is the most common type of cancer located in the periocular area. We will present the clinical case of a 63-year-old male patient who was admitted to the 2nd Clinic of Neurosurgery, "Prof. Dr. Nicolae Oblu" Emergency Clinical Hospital, Iaşi, Romania, for an ulcerated tumor of about 0.8×0.7 cm in diameter with rolled edges and central necrosis in the upper eyelid with orbital invasion. According to the patient's personal history, he also underwent Cortisone treatment for dermatomyositis. The magnetic resonance imaging (MRI) scan revealed behind the cutaneous flap, a lesion with 15∕38∕19 mm anteroposterior (AP)∕transverse (T)∕craniocaudal (CC) diameters. The surgeons made the excision of the tumor together with the eyelid remnants, and the left orbit exenteration defect. The histopathological exam of the surgical samples revealed an ulcerated epithelial tumor having its origin in the eyelid epidermis and invading all the thickness of the eyelid toward the palpebral conjunctiva, but also the orbital tissue. Immunohistochemical studies showed positive staining for cytokeratin (CK) AE1∕AE3, CK5∕6, and CK17, but not for CK7. The Ki-67 labeling index was 12%, suggesting a moderate proliferative activity. The final pathological diagnosis was mixed (nodular and morpheic) eyelid BCC infiltrative into the orbital tissue. Although BCC of the upper eyelid is a rare cancer and generally has a low recurrence risk, in the case of a patient undergoing Cortisone treatment for an autoimmune disease, the tumor may grow more rapidly by invading the neighboring tissues including orbit.

Treatment of Metastatic Eyelid Carcinoma

PURPOSE

The aim of this study was to report management and outcomes in patients affected by eyelids carcinomas involving regional lymph nodes.

METHODS

We have retrospectively analyzed the data of patients affected by eyelids carcinoma with nodal involvement. The clinical records of 10 patients with malignant eyelid carcinoma and regional nodal metastasis treated between September 2011 and March 2015 have been analyzed.

RESULTS

The study included 5 women and 5 men (median age 54,5 years; range 37-80 years). The most common tumor was the squamous cell carcinoma (4 cases) followed by sebaceous carcinoma (2 cases): 1 case of epidermoid carcinoma, 1 case of malignant melanoma, 1 case of Merkel carcinoma, and 1 case of basal cell carcinoma. All patients were treated by surgical resection; in 2 cases, orbital exenteration was required. The treatment of regional nodal metastasis consisted of parotidectomy and radical neck dissection followed by radiation therapy. None of the patients developed local recurrence. Three patients died: one, affected by Merkel cell carcinoma, died after 2 months because of metastatic dissemination to the lung; another one, affected by epidermoid carcinoma involving the orbit, died because of liver metastasis; the third one, affected by malignant melanoma, died because of other causes. The follow-up time ranged from 9 to 36 months (median 19.3 months).

CONCLUSIONS

Patients affected by advanced malignant eyelid carcinoma need to be strictly controlled because metastasis can develop at least 5 years after surgical treatment. Therapy may include a combination of local surgery, neck dissection, and radiation.

Nitroglycerin hypotensive effect and application in a combined surgery for reconstruction after ipsilateral maxillectomy and orbit evisceration

The oral and maxillofacial region is rich in blood, and it is often difficult to stop bleeding during the operation of maxilla. Nitroglycerin is one of the most commonly used antihypertensive drugs in our hospital. We observed the effect of controlled hypotension in patients with maxillary resection. In group N, the patients had different degrees of tachycardia after using nitroglycerin only. In addition, nitroglycerin has the characteristics of rapid drug resistance. A combined reversed temporal muscle flap and random forehead flap technique was performed successfully to reconstruct the large defect after ipsilateral maxillectomy and orbit evisceration. There were 43 cases used this method during 2014-2016 without large side effects.

[Exenteration of the Orbit for Basal Cell Carcinoma]

AIM

Primary treatment of basal cell carcinoma of the lower eyelid and the inner corner is essentially surgical, but advanced lesions require extensive surgical interventions. In some cases it is necessary to continue with the mutilating surgery--exenteration of the orbit. In this work we evaluate the indications of radical solutions in patients with basal cell carcinoma invading the orbit and the subsequent possibility for individually made prosthesis to cover the defect of the cavity.

MATERIALS AND METHODS

Indications to exenteration of the orbit in patients with basal cell carcinoma findings in 2008-2013. Case report of 2 patients.

RESULTS

In period 2008-20013 at the Dept. of Ophthalmology, Comenius University in Bratislava totally 221 patients with histologically confirmed basal cell carcinoma of the eyelids and the inner corner were treated. In 5 cases (2.7 %) with infiltration of the orbit the radical surgical procedure, exenteration was necessary. In 3 patients exenteration was indicated as the first surgical procedure in the treatment of basal cell carcinoma, since they had never visited ophthalmologist before only at in the stage of infiltration of the orbit (stage T4). In one case was indicated exenteration after previous surgical interventions and relapses. After healing the cavity patients got individually prepared epithesis.

CONCLUSION

Surgical treatment of basal cell carcinoma involves the radical removal of the neoplasm entire eyelid and stage T1 or T2 can effectively cure virtually all tumors with satisfactory cosmetic and functional results. In advanced stages (T4 stage) by infiltrating the orbit by basal cell carcinoma exenteration of the orbit is necessary. This surgery is a serious situation for the patient and also for his relatives. Individually made prosthesis helps the patient to be enrolled to the social environment.

Orbital exenteration - a salvage procedure?

Orbital exenteration is a procedure performed usually for malignancies. The subsequent reconstructive efforts are directed towards rapid and stable healing but allowing detection of recurrent disease, obliteration of any communication between the orbit and surrounding cavities and above all a good quality of life. The surgical options must be tailored to each patient; we have to achieve first disease control and to compensate a 3D defect as best as we can. In the following, we present a series of three patients with aggressive tumors of the midface, admitted in our clinic in the last four years. For each case, orbital exenteration was performed in order to achieve tumor clearance. The results were good excepting one case (a relapse at three years interval) with a squamous cell carcinoma and perineural invasion.

Supratrochlear artery island paramedian forehead flap for reconstructing the exenterated patient

Orbital exenteration may be needed for surgical extirpation of advanced squamous or basal carcinoma of the eye or ocular adnexa. Many surgeons prefer to allow the exenterated socket granulate by secondary intention. This leads to morbidity and can be very disturbing for the patient. Moreover, it delays the delivery of adjunctive radiation often required in these individuals. We suggest a 1-stage operation that can be undertaken at the time of exenteration or as a delayed procedure to reconstruct the orbit and ensure rapid wound healing and patient rehabilitation. There is minimal donor site morbidity. A total of 5 exenterated orbits have been reconstructed by a new technique utilizing islanded median forehead flap based upon ipsilateral supratrochlear vessels. The donor site could be closed primarily in all patients. The healing was uneventful; the median hospital stay was 3 days. Although there is inevitable scarring of the forehead, this improves considerably over a period of time and does not appear to cause undue aesthetic concerns among our patients. Thus an islandised ipsilateral paramedian forehead flap based upon supratrochlear vessels is another option to close an exenteration defect.

Orbital exenteration: a 10-year experience of a general oncology hospital

BACKGROUND

The aim of this study is to review the 10-year experience with orbital exenteration, determining the indications, clinical features of patients and the factors that cause the need for exenteration.

METHODS

The records of patients that underwent exenteration between 1997 and 2007 were reviewed retrospectively. The age, sex, the location of tumour, the duration of symptoms, histopathological diagnosis, and previous recurrences were noted.

RESULTS

Orbital exenteration was performed on 68 patients. Bone resection in 6 and sinusectomy in 13 patients was combined with exenteration. The major indication was secondary orbital tumours accounting for 95.6% of the series and the eyelid and conjunctival tumours were the most frequent. Seven different types of histopathology were encountered: squamous cell carcinoma (31 cases), basal cell carcinoma (26 cases), malignant melanoma (5 cases), sebaceous cell carcinoma (2 cases), rhabdomyosarcoma (2 cases), mucoepidermoid carcinoma (1 case) and adenoid cystic carcinoma (1 case). The rate of previous recurrence was 85.7% in eyelid tumours and 42.1% in the conjunctival tumours.

CONCLUSIONS

Large proportion of the patients that underwent exenteration had a history of previous unsuccessful treatment and a long duration of disease. Because exenteration of the orbit is a disfiguring procedure, the incidence must be reduced by early presentation, prompt treatment, and adequate observation to preserve the eye.

Orbital exenteration for invasive skin tumours

Orbital exenteration aims at local control of disease invading the orbit that is potentially fatal or relentlessly progressive. Of all exenterations presenting to ophthalmologists, 40-50% are required for tumours in the eyelid or periocular skin. 99% of these are basal cell carcinomas and 4-6% each are squamous cell carcinomas or sebaceous gland carcinomas. Orbital invasion results in progressive fixation of the tumour to bone and reduced ocular motility. Perineural invasion of branches of the trigeminal nerve leads to numbness or pain, and that the facial nerve, to weakness. Biopsy identifies the cell type and the presence of perineural invasion. CT and MRI scanning help in the assessment of tumour spread within the orbit. Management should be in collaboration with an oncologist. Exenteration may be total-the removal of all orbital contents-or lid-sparing if the tumour is placed posteriorly. The socket may be allowed to heal by granulation or lined with a split skin graft or local flap. Complications may be seen following 20-25% of exenterations and include fistulae, tissue necrosis, exposed bone, and infection. Incomplete clearance of tumours occurs in about 38% of total exenterations and 17% of subtotal. The overall 5-year survival is 55-65%, but significantly worse if there was perineural spread. Facial prostheses may be mounted on glasses or secured with tissue glue or osseointegrated implants. Excellent cosmetic results can be achieved but many patients prefer to wear a patch.

Surgical Management of Locally Advanced Adenoid Cystic Carcinoma of the Lacrimal Gland

PURPOSE

To review our experience with multidisciplinary surgical management of locally advanced adenoid cystic carcinoma of the lacrimal gland.

METHODS

We present a case series of 7 patients with lacrimal gland adenoid cystic carcinoma treated at our institution between June 2001 and October 2003. Clinical records, histologic sections, and radiographic images were reviewed.

RESULTS

The study included 3 men and 4 women (mean age at diagnosis, 44 years). All 7 patients underwent an orbital exenteration with bone removal. Five patients had an orbitectomy through a craniotomy approach and 2 patients had an exenteration through a fronto-orbito-zygomatic approach, all with removal of the bone of the superior and lateral wall. Six patients underwent reconstruction of the socket through the use of a vascularized flap. The surgical approach involved a neurosurgeon, an oculoplastic or head and neck surgeon, and a plastic surgeon. Six patients received postoperative radiation therapy. One patient with a recurrent tumor had already received radiation therapy, which precluded additional radiation therapy after surgical resection. The radiation field included the orbit and the skull base because all patients had evidence of perineural invasion. As of this writing, there have been no local recurrences. Five patients had development of distant metastases and died of disease, at follow-up times from 12 to 32 months after surgery. Two patients are alive without evidence of disease, both at 24 months' follow-up.

CONCLUSIONS

Orbitectomy with bone removal may be indicated for achieving local and regional control in advanced cases of adenoid cystic carcinoma of the lacrimal gland. This surgery does not decrease the risk of distant metastasis. The cases in our series highlight the locally invasive and metastatic behavior of this cancer.

Postmortem orbital findings in shaken baby syndrome

PURPOSE

To compare postmortem orbital findings in pediatric accidental head injury to Shaken Baby Syndrome (SBS).

DESIGN

Retrospective study.

METHODS

SETTING

Institutional.

STUDY POPULATION

Thirty-six patients underwent postmortem modified exenteration with sectioning of the orbital contents; 18 victims of SBS and 18 cases of fatal accidental head trauma.

OBSERVATION PROCEDURE

In all cases of children who died from accidental head trauma, the orbital tissues were separated to expose the optic nerve sheath. Patients with gross evidence of hemorrhage within the sheath were included. All cases of SBS were included. After accidental head injury, exenteration was performed only if optic nerve sheath hemorrhage was suspected on gross examination. All children younger than 18 years old with head injury as primary cause of death were included. SBS is defined as having at least two of the following: (1) typical abnormal findings on neuroimaging, (2) typical skeletal injury, (3) retinal hemorrhages, (4) history of abusive shaking with or without blunt head trauma, or (5) an inadequate history to explain the observed injuries.

MAIN OUTCOME MEASURE

Presence or absence of orbital hemorrhage.

RESULTS

Orbital tissue injury is more common in SBS than accidental head trauma without orbital fracture. In addition, optic nerve sheath and optic nerve intradural hemorrhage are also significantly more common in SBS (P < .0001).

CONCLUSIONS

Our study reports new evidence of injury to orbital tissues in SBS and supports the concept that these finding are due to unique acceleration-deceleration forces of this type of abusive head injury.

[Primary benign orbital tumors in experience of the Department of Otolaryngology Jagiellonian University]

BACKGROUND

The important question in primary eye socket tumors surgery is total surgery and saving the patient's sight.

THE AIM OF THE STUDY

It was assessment of the data of primary non malignant tumor therapy in Cracovian Department of Otolaryngology.

MATERIAL AND METHODS

145 patients (79 male and 66 female), aged 7 months-84 years, were treated in Otolaryngological Department Jagiellonian University in years 1991-2001. In 118 cases primary benign orbital tumors were removed, in remaining patients tumors were malignant. In 89 patients lateral orbitotomy by Kronlein was performed and in other cases different types of orbitotomy were used. 5 years otolaryngological and ophtalmological catamnnesis wascomplete.

RESULTS

In all patients eyeball was preserved, even in 6 with optic nerve glioma. Reccurent tumors were observed in 2 cases, diplopia in 15 patients and sight's lost in 8 (in 6 with optic nerve glioma).

CONCLUSIONS

In the majority of patients with radical oncological surgery it is possible to preserve eyesight.

Massive Congenital Orbital Teratoma

Orbital teratomas are rare embryonic tumors composed of a wide diversity of tissues derived from the three germinal layers. The presenting features include, a healthy newborn with extreme unilateral proptosis; marked stretching of the eyelids over a tense, fluctuating mass, with elongation of the palpebral fissure; enlargement of the bony orbit (two to three times normal size) with subsequent nasal and malar deformities; and transillumination of all or part of the orbital mass. Commonly the eye is normally developed but often vision is not preserved either due to exposure or secondary optic atrophy. The objective in the management of orbital teratoma is to save the eye to encourage orbitofacial development, maintain cosmesis and retain some vision. We report a case of massive congenital orbital teratoma successfully removed by an eyelid-sparing exenteration technique.

Complete Mobilization of the Cheek Zone for Orbit Exenteration

Patients with malignant orbital tumors often undergo eyeball excision, orbital tissues and lids, which results in severe deformities. Our experience concerns the use of a skin fascial flap of the cheek zone, the V-Y design, in 10 patients after ocular malignant tumor resection. Seven patients had basal cell carcinomas of the lower lids with invasion of the ocular tissues. The complete tumor resection was controlled by frozen-section biopsy in all patients. The results were evaluated from an oncologic, functional, and aesthetic point of view. We noticed 2 recurrences in a minimum follow up of 2 years. The functional and aesthetic results were quite satisfactory and no serious complications were noticed in our series. The primary advantage of this interesting flap is the dominant vasculature derived from arteria transversa faciei, arteria facialis, and arteria infraorbitalis that secure good vascular contribution. It should be regarded as very useful for surface coverage problems at the orbit because it performs in a one-stage procedure with minimum morbility and good functional result.

Endoscopic power-assisted orbital exenteration

BACKGROUND

Orbital exenteration can be accomplished by either an external eyelid-sparing or eyelid-sacrificing approach. The purpose of this study was to describe an alternative technique for orbital exenteration and its specific advantages over traditional methods.

METHODS

A retrospective analysis at a tertiary care referral center was performed. Three patients with sinonasal malignancy (two cases) and fulminant invasive fungal sinusitis (one case) are reported. Intraconal involvement was evident in all patients by imaging and surgical pathology. Advanced endoscopic techniques in conjunction with image guidance and soft-tissue shaver technology were used for resection in all cases.

RESULTS

The orbit was successfully exenterated via an eyelid-sparing endoscopic approach with minimal blood loss in all three patients. Exenteration was completed within 30-45 minutes. Uninvolved superior and lateral orbital periosteum was preserved in all patients, which permitted cavity "mucosalization" within 8 weeks. Two patients are alive without disease at 15-month follow-up. One patient with persistent cavernous sinus malignant peripheral nerve sheath tumor died 4 months after resection despite proton beam therapy.

CONCLUSION

This preliminary experience showed endoscopic power-assisted orbital exenteration to be an effective technique for exenteration of the orbit. Endoscopic power-assisted orbital exenteration offers two critical advantages: (1) direct transnasal control of the ophthalmic artery as it emerges from the optic foramen and (2) the ability to preserve the uninvolved superior and lateral periorbita. This can facilitate mucosal coverage of the exenterated space and obviate the need for tissue grafts and/or packing. Additionally, intraorbital pathology can be better visualized and blood loss and operative time are minimized. This technique may serve as an important adjunct for management of the orbit in patients with sinonasal malignancy or invasive fungal rhinosinusitis.

Éviscération modifiée pour implant orbitaire biocolonisable : la technique des « quatre carrés »

INTRODUCTION

The introduction of a porous, biocolonizable, orbital implant is difficult after a classic evisceration. We have developed a modification of the method that provides better results.

MATERIAL AND METHODS

Four scleral squares pediculized on the right oculomotor muscles were cut. They were sutured two-by-two over the anterior part of the implant.

RESULTS

Fifteen patients were operated. There were no complications during a mean follow-up of 12.4 months.

DISCUSSION

The soft anterior tissues were protected by the two vascularized scleral layers. The diameter of the implant was 18 mm for three patients, 20 mm for eight patients, and 22 mm for four patients. Operating time was much shorter than with enucleation and covering of the implant with autologous sclera.

CONCLUSION

Evisceration with the four-square technique is a safe and quick method, which can be used for most patients, except those with an intraocular neoplasia.

Use of a caudal auricular axial pattern flap in three cats and one dog following orbital exenteration

Orbital exenteration accompanied by wide eyelid excision in the cat and dog may leave a defect that cannot be closed in a primary fashion. This report describes the use of a caudal auricular axial pattern flap to effect closure following orbital exenteration in three cats and one dog. The most common complication was distal flap necrosis, which necessitated a second surgery in two patients.

Orbital exenteration: results of an individualized approach

PURPOSE

The authors report and evaluate their experience with an individualized approach to orbital exenteration.

METHODS

Retrospective chart review was performed on a consecutive series of 25 orbital exenteration patients at a tertiary care center. The cases were classified into two groups for the retrospective analysis: Total exenteration procedures involved the removal of the entire orbital contents including the periorbita (13 cases), and subtotal procedures preserved at least a quadrant of the orbit or the orbital tissues posterior to the globe (12 cases).

RESULTS

The total exenteration group had a lower rate of clear surgical margins and a higher rate of systemic metastasis, whereas patients in the subtotal exenteration group had fewer surgical complications and better functional and aesthetic results.

CONCLUSIONS

The surgical planning for orbital exenteration should take into account the location, extent, and biological behavior of the orbital disease process and the reconstructive and prosthetic options for the exenterated socket. When an individualized approach to orbital exenteration is used, subtotal procedures can offer improved functional and aesthetic results while still maximizing the chances for a surgical cure.

Invasive sino-orbital aspergillosis: surgical decisions and dilemmas

Invasive aspergillosis, one of the common paranasal sinus fungal infections, often secondarily involves the orbit. We report six such cases with orbital extension, all occurring in apparently immunocompetent hosts, to specifically address the difficult diagnostic and therapeutic issues involved. Limited biopsy procedures were often inconclusive, necessitating wide surgical excision to establish the histopathological diagnosis. Conservative orbital debridement proved adequate for cases with disease limited to the infero-medial compartment of the orbit, but resulted in residual progressive disease in the two of the four cases with retro-orbital and apical extension. Orbital exenteration in this latter group, however, proved successful in controlling disease. The present report emphasizes the importance of near-complete extirpation and adjuvant chemotherapy in ensuring a favourable outcome in invasive Aspergillus infections. Orbital exenteration appears justified for posterior orbital disease, regardless of the functional status of the eye, but is inappropriate for anterior orbital disease.

Orbital exenteration for secondary orbital tumors: a series of seven cases

BACKGROUND

Exenteration is indicated in patients with malignant neoplasms of orbital contents. It entails the removal of the eyeball together with its extraocular muscles and other soft tissues. Exenterations can be classified into (1) total, (2) subtotal, and (3) supertotal exenteration. Retrospectively study, we reviewed 7 patients that had received exenteration/subtotal exenteration with spontaneous granulation/myocutaneous flap implantation or eyelid-sparing exenteration with myocutaneous flap. Primary lesions, histopathological examination results, treatments, and recurrences are discussed.

METHODS

A retrospective study of the years 1987 through 2000 disclosed 7 patients that underwent exenteration/subtotal exenteration. The patients ranged in age from 41 to 68 years. Two patients underwent total exenteration without socket augmentation; 4 patients underwent exenteration/ subtotal exenteration with immediate facial reconstruction, and 1 with delayed facial reconstruction.

RESULTS

Classification of the 7 patients showed that 2 had basal cell carcinoma of the skin, 2 had squamous cell carcinoma of the conjunctiva, 1 had squamous cell carcinoma of the paranasal sinus, 1 had rhabdomyosarcoma of the paranasal sinus, and 1 had intracranial meningioma. Radiotherapy was performed in 6 of the patients and chemotherapy in 2. Central nerve system invasion was noted in 2 patients, and 1 died due to it.

CONCLUSION

Secondary orbital tumors involved the orbit from adjacent tissues: paranasal sinuses, nasopharynx, lacrimal sac, conjunctiva, eyelid, intraocular tissue, and intracranial tissues. Combined surgeries are necessary for complete tumor removal. And the imaging studies should include the field of the orbit, sinus, and brain to search for the primary lesions.

One-stage reconstruction of the eye socket with vascularized temporalis muscle flap in orbital exenteration

AIM

Two cases of one-stage reconstruction of exenterated orbit with vascularized temporalis muscle flap in oncological patients are presented. The anatomical characteristics of the temporalis muscle flap and the choice of one-stage or delayed reconstruction of the exenterated orbit are discussed.

METHODS

Two patients were operated for malignancy recurrence during the period May-November 2000. One patient suffered recurrent squamous cell carcinoma in the left nasolabial region that infiltrated the lower eyelid and periorbit. The other patient had recurrence of previously operated primary rhabdomyosarcoma of the orbit. Both patients underwent orbital exenteration. In the first patient it supplemented the tumor excision and partial maxillary excision resulting in large orbitomaxillary defect communicating with the nasal meatuses.

RESULTS

In both patients good filling effect and isolation of the orbit from the neighbouring nasal meatuses and cranial cavity were obtained using vascularized temporalis muscle flap.

CONCLUSION

The vascularized muscle flap appears a reliable technique and method of choice in one-stage as well as in delayed reconstruction in orbital exenteration.

Orbital reconstruction following sino-nasal mucormycosis

We discuss the reconstruction of an orbit destroyed by an invasive fungal infection. Sino-nasal mucormycosis is usually associated with a poor prognosis, and occurs almost exclusively in immunocompromised patients. Serial imaging leading to repeated radical debridement, along with intravenous amphotericin, helped the patient to recover from this serious disease. A well-vascularised galeal frontalis-pericranial flap from the mid-forehead region was used to reconstruct the orbital defect.

[Orbital exenteration]

Exenteration of the orbit is a disfiguring and destructive procedure that is usually reserved for treatment of life-threatening orbital malignancy when a less radical operation such as local surgery, chemotherapy, or irradiation are deemed inadequate or have failed. Many methods have been published for managing the socket, but of primary importance is the need to remove all diseased tissue prior to considering any reconstructive efforts. Options include spontaneous granulation, skin grafting, or muscle flaps. This article will describe the development and the indications for this procedure and will outline the surgical techniques and its complications, the various reconstructive efforts, and survival. The success of orbital exenteration depends on recurrence, histological type, tumor size, and tumor-free margins.

Globe sparing orbital exenteration

OBJECTIVE

Orbital exenteration has long been the oncologic standard for malignant craniofacial lesions that invade the periorbita/orbit from adjacent locations. Although oncologically sound, this radical surgical procedure is cosmetically disfiguring for all patients. Most of the reconstructive options available are complex, requiring further surgery and/or expense. We herein introduce an alternative surgical technique for radical orbital surgery that spares the globe, thereby allowing an early, aesthetic appearance at a nominal cost.

STUDY DESIGN AND SETTING

Twenty consecutive patients requiring an oncologic orbital exenteration and meeting the indications for the new procedure underwent surgery at a tertiary care medical center. Follow-up ranged from 1 to 6 years.

RESULTS

Only 1 patient recurred in the orbit due to an error in patient selection. There was no surgical morbidity resulting from the globe-sparing technique itself.

CONCLUSION

Globe-sparing orbital exenteration is a one-step, oncologically sound, aesthetically superior, low-cost alternative for those patients requiring radical orbital surgery and reconstruction.

Experience with eyelid-sparing orbital exenteration: the 2000 Tullos O. Coston Lecture

PURPOSE

To provide data on types of lesions that require orbital exenteration and discuss our experience with exenteration, emphasizing the eyelid-sparing technique.

METHODS

The records were reviewed on all patients who underwent orbital exenteration by the senior author and his colleagues. The underlying disease, method of exenteration, healing times, complications, cosmetic outcome, local tumor control, and patient survival were analyzed.

RESULTS

Of 56 orbital exenterations, 47 were done by eyelid-sparing technique and 9 by eyelid-sacrificing technique. The 9 tumors of eyelid origin that required exenteration included basal cell carcinoma (4), sebaceous gland carcinoma (3), squamous cell carcinoma (1), and melanoma (1). Four of the eyelid lesions were managed by the eyelid-sparing technique and 5 by the eyelid-sacrificing method. The 24 tumors of conjunctival origin included melanoma (20) and squamous cell carcinoma (4). The eyelid-sparing method was used in 22 of the 24 cases. The 10 primary orbital lesions included melanoma (3), malignant lacrimal gland tumor (3), a rhabdoid tumor, meningioma, Wegener's granulomatosis, and aspergillosis. The eyelid-sparing method was used in 8 of the 10 cases. Among intraocular tumors were uveal melanomas (10) and retinoblastoma (1). The eyelid sparing method was used in all 11. With the eyelid-sparing technique, the mean time from exenteration to wound healing and readiness for a prosthesis was 4 weeks (median, 2 weeks; range, 2 to 24 weeks). With the eyelid-sacrificing technique, the mean time was 68 weeks (median, 34 weeks; range, 2 to 340 weeks). Complications were few and cosmetic results were satisfactory. Local tumor control with exenteration was achieved in 53 of 56 cases, but metastasis occurred in 11 of 20 cases of conjunctival melanoma (55%) and in 6 of 10 patients with uveal melanoma (60%). Metastasis has developed in none of the 3 patients with malignant epithelial tumors of lacrimal gland origin.

CONCLUSIONS

Orbital exenteration is an appropriate procedure for orbital involvement by unresectable malignant tumors of the eyelids, conjunctiva, intraocular structures, and orbit. In most of these cases, including about half of tumors originating in the eyelids, an eyelid-sparing exenteration can be used to achieve more rapid healing.

Surgery for orbital tumors. Part II: transorbital approaches

Orbital tumors can be excised or biopsy samples obtained via transorbital approaches, especially those located in the anterior two thirds of the orbit. The indications and various surgical steps will be reviewed for the anterior, the anteromedial, and the lateral approaches. Some of these approaches can be combined or extended to accommodate large or deep-seated tumors.

Evisceration with scleral modification

PURPOSE

To describe an evisceration technique that combines scleral modification with optic nerve release for coverage of any sized orbital implant.

METHODS

The medical records of 70 patients who underwent the described evisceration procedure were reviewed.

RESULTS

The average implant was 20 mm in diameter, with 50 patients (71%) receiving a solid polymethylmethacrylate sphere. Fifty-eight patients (83%) had a history of at least one previous ocular surgery, and 12 patients (17%) had phthisical eyes preoperatively with moderate to severe scleral cicatrization. Postoperatively, there were two cases of new or worsened ptosis, no cases of worsened motility, and no cases of implant extrusion.

CONCLUSION

Evisceration with scleral modification is a simple and effective procedure that allows placement of any size orbital implant. Surgical results are excellent with few complications.

The temporalis muscle plus glabellar flap: handy local flaps for orbital repair after exenteration

Primary tissue coverage of the orbit is desirable after orbital exenteration. This apart from reducing morbidity, is cost effective. Two patients who had immediate local flap reconstruction with temporalis muscle and glabellar skin, after major orbital resection are presented. The advantages of flap reconstruction over skin grafting are discussed.

Orbital exenteration and placement of a prosthesis in fish

OBJECTIVE

To develop a procedure for orbital exenteration and prosthesis placement in fish.

DESIGN

Prospective study.

ANIMALS

5 cultured hybrid striped bass (Morone saxatilis x M chrysops) ranging from 30 to 50 cm in length.

PROCEDURE

Exenteration was performed, using a dorsal approach in which blunt dissection was performed in the circumorbital sulcus. The orbit was then dried, and simple interrupted sutures were placed, leaving 2 suture loops within the orbit. The orbit was filled with polyvinylsiloxane, and a prosthetic glass eye was seated in the polyvinylsiloxane.

RESULTS

All fish retained the prosthesis and had satisfactory cosmetic results at the end of the 8-week study period.

CLINICAL IMPLICATIONS

The increase in popularity of pet fish and abundance of valuable aquarium and show fish have led to heightened awareness of piscine ocular disease. Aquarium fish are often euthanatized because of disfiguring ocular problems. The technique described here for surgical exenteration and cosmetic orbital prosthesis placement in fish may extend the captive life of public display fish.

[Primary soft tissue coverage and specific after-care of endosseous implants in pre-irradiated orbits]

After orbital exenteration and high- dose irradiation (60 Gy on average), 17 endosseous implants were placed periorbitally in 5 patients. No hyperbaric oxygen therapy was performed. All implants were primarily covered with regional or free flaps. After second-stage surgery and aesthetic rehabilitation with an external maxillofacial prosthesis, the pocket depth and implant stability (periotest) were checked, an occipitonasomental radiograph was taken and the soft tissue assessed in short recall intervals. When the implant was uncovered, osseointegration was stable. Within a follow-up period of 35 months, no fixation had failed. In two patients, peri-implant inflammation (microbiologically confirmed Staphylococcus aureus) occurred, which was clinically only determined by soft tissue oedema and rubor. The results demonstrate primary soft tissue covering as essential for non-irritating implant osseointegration in the irradiated orbita. In extraoral implants the clinical estimation of the peri-implant soft tissue, including a microbiological examination, is required for early detection of peri-implant inflammation in order to avoid secondary implant failure. In contrast, periotest and pocket depth are not relevant in recognizing an ensuing peri-implant inflammation.

Orbital exenteration: surgical and reconstructive strategies

BACKGROUND

Radical exenteration procedures, which include the removal of orbital content and eyelids, result in serious functional limitations, especially with respect to eating and speaking. Therefore we have recently changed our surgical concept.

METHODS

Seventy-seven patients underwent orbital exenteration during the 20-year period from 1974 to 1995 at the Department of Maxillofacial Surgery, Essen University. The simultaneous removal of periorbital bone was performed in 45 of these cases.

RESULTS

The 1-year survival rate was 89%, the 5-year rate was 63% and the 10-year rate was 48%. The surgical approach, the amount of resected orbital tissue and the reconstructive procedure have been adapted to the individual needs, depending on the location and extent of the tumor. Subsequently, the surgical morbidity has decreased.

DISCUSSION

Detailed consideration of all clinical and histological findings is essential before surgery, in order to prevent a higher rate of recurrence following these modified operations.