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Reconstruction of the Orbit
PLASTIC SURGICAL RECONSTRUCTION: POSSIBILITIES IN SURGICAL ONCOLOGY I1
1055-3207/97 $0.00
+ .20
RECONSTRUCTION OF THE ORBIT Henry M. Spinelli, MD, FACS, and Pia Ali-Salaam, MD
There are various ways to approach repair in the orbital region. All ways, of course, depend on what the defect is and what tissue is available for the repair. The orbital region is generally divided into two broad areas when approaching repair: the orbit and the periorbital region. The periorbital region lies external to the septum and consists of soft-tissue structures. The orbital region lies posterior to the septum, is bounded by the bony orbital cone, and contains intraorbital soft-tissue structures, including the eyeball, extraocular muscles, orbital fat, and structures that transgress the orbital cone, such as the anterior and posterior ethmoidal neurovascular bundles (ethmoidal foramina) or the first and second divisions of the fifth cranial nerve (superior and inferior sphenoid fissures). The bony orbit directly abuts extraorbital structures in addition to multiple foramina, allowing transgression of nerves and blood vessels in and out of the orbit. Examples are the adjacent air sinuses (ethmoid) and intracranial cavities such as the middle cranial fossa posteriorly and the anterior cranial fossa superiorly. Therefore, oncologic processes involving the orbit and the periorbital regions as well as extraorbital tumors frequently require complete or partial resections within the orbital and periorbital region and appropriate bony and soft-tissue reconstructions.
From Cornell University Medical College (HMS); New York Hospital/Cornell Medical Center (HMS), New York, New York; Yale-New Haven Hospital (HMS); and the Department of Surgery, Yale University School of Medicine (PA-S), New Haven, Connecticut
SURGICAL ONCOLOGY CLINICS OF NORTH AMERICA
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VOLUME 6 . NUMBER 1 JANUARY 1997
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SPINELLI & ALI-SALAAM
Basal cell and squamous cell carcinomas and melanoma in situ frequently affect the eyelids, canthi, and periocular tissues. Surgical excision often produces large defects that can result in significant visual impairment if reconstruction is not carefully planned and precisely executed. Orbital pathologic conditions, like periorbital pathologic conditions, can be caused by various tumors: skin, gland, vascular, nerve, lymphoid, mesenchymal, and metastatic. The surgical approach to diverse malignancies has been described in the literature: lacrimal gland fossa tumor, adenoid cystic carcinoma, chondrosarcoma, malignant teratoma, basal and squamous cell cancer, unilateral and bilateral retinoblastomas, orbital rhabdomyosarcomas, osteogenic sarcoma of the lateral orbital region, malignant histiocytoma, frontal meningioma, optic nerve glioma, squamous cell of the oropharynx requiring total exenteration of the 48, 55 orbit, and hemimaxillectomy.23~ ANATOMY
Reconstruction of the periocular region requires special considerations and a complete understanding of the specialized anatomy of the region. The eyelids, especially the upper eyelids, are designed to protect the eyes from debris, excess light, and exposure. They also function during blinking to clear and redistribute the multipurpose tear film.56 The lacrimal production system consists of those structures involved with baseline and reflex tear production, such as the conjunctival goblet cells, subconjunctival glands of Krause and Wolfring, and the oil-producing glands of Zeis and Moll, along with the Meibomian glands. The lacrimal drainage system, assisted by a complex muscular pumping system, extends from the puncta on the lid margin to the inferior meatus 65, 68 of the nose (Fig. The medial canthus contains the bony attachments of the eyelids, lacrimal collecting and drainage structures, and neurovascular structures arising from the deep orbit. The lateral canthus or, more accurately, the lateral retinaculum consists of an extension of the levator superioris termed the lateral horn, the lateral canthal tendon, the inferior suspensory ligament of the globe (Lockwood's ligament), and the check ligament of the lateral rectus muscle. The lateral retinacular tissues attach to the lateral orbital wall at Whitnall's tubercle, a bony promontory just within the orbital rim (Fig. 2).56,64 The orbital septum is a fascia1 membrane that separates the eyelids and associated structures from the deeper orbital structures. It serves as an important barrier to hemorrhage, infection, inflammation, and neoplastic disease processes. The six extraocular muscles insert on the globe behind the septum and are responsible for complex binocular
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Lacrimal Gland
Figure 1. The lacrimal production system consists of basic and reflex secretors. Tears are multilaminated with an aqueous core and a hydrophobic coating. Distribution is made possible by eyelid action. The lacrimal drainage system is an active pump that depends on muscular action. Tears enter the proximal system, are sucked into the lacrimal sac, then forced into the nose below the inferior turbinate.
Figure 2. The medial and lateral canthal structures support the upper and lower eyelids and allow fixation points for muscular action (i.e., blinking and lacrimal pump). Both canthi are anchored posterior to the bony orbital rim.
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motion, including rotary movements. A fascia1 system within the orbit provides interconnected scaffolding and supports orbital contents, including the globe. The optic nerve and first and second divisions of the fifth cranial nerve enter the orbit at its apex through the foramina in the bony architecture of the sphenoid bone.32,56 The orbital margin, which has been described clearly, is formed by the frontal, maxillary, and zygomatic bones." The walls of the orbit are formed superiorly by the frontal bone and the lesser wing of the sphenoid, laterally by the zygomatic bone and the greater wing of the sphenoid, inferiorly by the maxillary, zygomatic, and palatine bones, and medially by the ethmoid bone, lacrimal bone, and body of the sphenoid bone. Many important structures communicate with the globe through the bony orbit's many openings: (1) superior orbital fissure, which carries oculomotor nerve, trochlear nerve, abducens nerve, ophthalmic nerves, and ophthalmic veins; (2) inferior orbital fissure, which carries maxillary nerve and infraorbital vessels; (3) optic canal, which carries optic nerve and ophthalmic artery; (4) supraorbital notch, which carries the supraorbital nerve and vessels; (5) infraorbital groove and foramen, which carry infraorbital nerve and vessels; and (6) nasolacrimal canal, which transmits the nasolacrimal duct from the lacrimal sac to the inferior nasal meatus." The aforementioned structures in addition to the ocular muscles (superior rectus, inferior rectus, medial rectus, lateral rectus, levator palpebrae superioris, superior oblique, and inferior oblique) attach to the globe. The globe itself is an extension of the brain: the sclera analogous to the dura, the choroid comparable to the arachnoid, and the retina homologous to the neuroparenchyma. THE PERIOCULAR REGION: RECONSTRUCTION
It is helpful to divide the periocular region into zones, based on special anatomic and functional demands.56In patients with basal cell, squamous cell, and melanoma of the periocular region, surgical defects can be classified into five zones: Zone I, or the upper eyelid; Zone 11, or the lower eyelid; Zone 111, or the medial canthal region; Zone IV, or the lateral canthal region; and Zone V, located primarily outside of Zones I to IV but contiguous with those zones (Fig. 3). Any good reconstructive plan should incorporate tissue that is innervated, well vascularized, thin, pliable, and composite (skin, muscle, tarsoligamentous, and mucous membrane). In general, this tissue should be transferred from adjacent and intact eyelid structures. More complex eyelid and adjacent canthal, cheek, and brow reconstructions require advancement, transposition, and rotation flaps designed and supported in such a fashion that three-dimensional distraction forces are minimized. Distraction forces, such as gravity, edema, and early or late
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Figure 3. The eyelids and periocular structures can be divided into five surgical zones. Zone I on the upper eyelid, Zone II on the lower eyelid, Zone Ill on the medial canthal region (note the deep medial canthal structures), Zone IV the lateral canthal region, and Zone V any area outside of Zone I-IV but contiguous with those zones. (From Spinelli HM, Jelks GW: Periocular reconstruction: A systematic approach. Plast Reconstr Surg 91 :1017-1024, 1993; with permission.)
wound contraction, can displace periocular tissue away from its intended position, causing lid malposition, an irregular tear film, abnormal lacrimal drainage, corneal exposure, and unsatisfactory cosmesis (Fig. 4).41 Partial-thickness defects in zone I and I1 exceeding 50% of the wound are best reconstructed with full-thickness skin grafts harvested from the opposite upper lid, retroauricular or supraclavicular area. Partial-thickness defects less than 50% can be closed by advancing regional lid tissue or a myocutaneous flap from upper to lower lid.14, 19,31, 35, 67 Full-thickness upper lid defects present a greater risk to the eyeball than lower lid defects. Zone I full-thickness defects of up to 25% of lid width can be closed primarily with the aid of a lateral canthotomy and cantholysis of the superior crus. For defects exceeding 25% of lid width that cannot be closed primarily, sliding tarsoconjunctival flaps are preferred whenever possible.27Larger upper lid defects may require lower lid switch flaps and lower lid bridge flaps.13,42, s2 Additionally, one should consider using tarsoconjunctival and the split-lamellae switch flap for reconstructing central upper lid defects with a remnant of intact 30
Zone I1 full-thickness defects are closed primarily with the aid of canthotomy and cantholysis when they are less than 50% of lid width. Semicircular flaps can be added to allow tissue advancement. Transposed or advanced orbicularis myocutaneous flaps over cartilage lid
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Figure 4. Forces acting on the lower lid. A, Intrinsic lid support in a superior and posterior direction is provided by the sum of vector forces provided by (1) the medial canthal tendon, (2) the lateral canthal tendon, and (3) the tarsus and orbicularis muscle. B, Distraction forces are the sum of vector forces working against intrinsic lid support. These forces can displace periocular tissue away from its intended position when intrinsic lid support is exceeded. (From Spinelli HM, Jelks GW: Periocular reconstruction: A systematic approach. Plast Reconstr Surg 91 :I017-1 024,1993;with permission.)
grafts also can be used for small marginal or lateral defects.38,39 To prevent corneal irritation, rigid free cartilage grafts should be avoided in favor of free or transposed tarsoconj~nctiva.~~ 33, 62 Defects exceeding 50% are best approached with bridge or transposition tarsoconjunctival flaps.2426, 53 Cervical facial advancement flaps are most useful in defects of the lower lid extending into the cheek (Zone V), especially in older patients with skin laxity (Fig. 5).'jz4O Zone I11 defects can be corrected with more latitude. Although upper lid medially based myocutaneous flaps supplied by branches of the infratrochlear vessels are first choice, the use of other local flaps or skin grafts, or in some cases healing by secondary intention, may be quite ac~eptable.~, 17,34 Lacrimal probing with silicone catheter intubation and medial canthal support should be performed routinely as part of all repairs. Zone IV lesions are best reconstructed with cheek advancement flaps or skin grafts, alone or in combination with other flaps.1° As with the Zone 111 lesions, the type of soft-tissue reconstruction used is of less importance than the indication for an ancillary procedure, namely, a lateral canthopexy. Lateral canthal support procedures should be performed routinely even when the lateral canthal tendinous system is not disrupted by the extirpative phase of treatment.44,55 Zone V lesions can be approached by any available reconstructive technique, with special care taken to address the needs of Zonks I to IV.
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This is especially true in lesions and defects inferior to the lower eyelid, where soft-tissue ptosis alone can produce ectropion and scleral show. The classification system summarized previously can be applied to defects as well as to benign and malignant tumors. These defects then can be approached with a reconstructive ladder based on the anatomic and functional requirements of the zones affected (Fig. 6).56
THE ORBIT: RECONSTRUCTION
Orbital exenteration with excision of the eye and the orbital contents is one of the most definitive and deforming cancer therapies. The type, the extent, and the natural history of the various malignancies define the type of resection needed. Six indications for orbital exenteration have been described, and most of these are applicable currently.18 A graded approach to orbital reconstruction after tumor resection has been reviewed.36If there is significant risk of recurrence and observance of the socket is important or if the patient is debilitated and cannot tolerate extensive surgery, then reconstruction should be limited to a local solution (e.g., healing by secondary intention, split-thickness skin graft, and full-thickness graft). If, on the other hand, the patient has undergone a definitive tumor resection and a recurrence-free postexenteration period, then a more extensive reconstruction using regional or distant flaps can be planned. Of course, not all orbital tumors require exenteration. When discussing orbital reconstruction, the range of repair required varies with the orbital deficiency. Several questions must be addressed. Is there any normal orbital or periorbital tissue? Is there adequate lining of the orbit? How much has orbital volume been reduced? Have the eyelids been sacrificed? Are there any fistulae between the orbit and the nasal and paranasal sinuses that must be sealed? Does the patient need skin, mucosa, muscle bulk, bone, cartilage, or prosthetic material? Is regional blood supply adequate to support a local reconstructive effort? There are also the usual preoperative considerations: timing of repair, choosing a donor site, appreciating the needs of the recipient site, and aesthetic considerations.
TIMING
Immediate repair offers several benefits. The patient undergoes only one operation with one hospitalization, and the patient has psychological In benefits rendered from having cosmesis addressed imrnediatel~.~~ addition, any extirpation that leaves the eyeball intact but compromises
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Figure 5. A, Patient status post morpheaform basal cell carcinoma with large resection of lower lid defect extending inferiorly beyond the limits of the orbital septum and rim (cheek) and medially into the canthal region involving the lacrimal drainage system (Zones 11, 111, V, from Spinelli classification). Patient's reconstruction consisted of a Hughes tarsoconjunctival flap, medial canthal tendon, and lacrimal system reconstruction (B), combined with a cervical facial flap for cheek reconstruction in a single aesthetic unit (C). illustration continued on opposite page
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Figure 5 (Continued). Patient approximately 3 months after division and insetting of tarsoconjunctival flap with comfortable well-protected globe and a functional lower lid and lacrimal drainage system in both opening (D) and closure (E).
PT<50% 1' Closue with local tissue advancement
,& PT
FT<25% advanced
r - 2
-xmv3
FT>75% Slidinghrsal conjunctival flap, levator recession; or composite graft
FT>75% Lower lid switch flap for very large detects
Zone IV
&-
ALL: Lateral cantha1 support procedure
OR
-
Other lacal flaps '
l'T<50%
Figure 6. A summary of reconstructive guidelines for the periocular eyelids and region. Zone V has been excluded from the drawing because Zone V reconstructions may be addressed with latitude as long as the needs of Zone I through IV have been met. PT = partial-thickness defects; FT = full-thickness defects. (From Spinelli HM, Jelks GW: Periocular reconstruction: A systematic approach. Plast Reconstr Surg 91:I017-1 024, 1993; with permission.)
l"~los;;;~;,"~;lti~~ue
+#
lnClosure with canthotomy and cantholyis, local tissue advanced
OR PT>50% FTSG from opPo"i~uPP"~d
OR Myocutaneous transposition flapf"msameu~~"lid
Slidmg tarsal-canj~ncti~a~ flap w ~ t hskin graft
FT>50% Sliding tarsal-conjunctival flap withskin graft
~~>75% Composite graft w ~ t hcheek advancement
FTSG
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the protective periocular structures usually creates more cogent reason for immediate reconstruction, namely maintenance of a functional, painfree eye. Immediate repair carries with it the risk of reconstruction with incomplete tumor excision. However, even if microscopic margins are negative, recurrences or second primary lesions may appear. Their clinical detection may be related not only to location but also to the type of reconstruction used. For example, a recurrence in an orbit treated by exenteration is more easily detected when the reconstruction is by skin graft rather than a myocutaneous flap. The need for immediate reconstructions with extensive flaps and possibly bone grafts becomes much more relevant when extraorbital structures (i.e., cranial base, orbital bone, and dura) are resected in extensive lesions that cannot be resected and reconstructed practically or safely at disparate surgical procedure^.^^ A single extirpation and repair is justified for several reasons.47 Resection of a tumor usually has been the most extensive resection compatible with life or acceptable to the patient. Leaving a tumor resection open to allow for tumor surveillance leaves the problems of large open wounds with associated osteitis, cerebrospinal fluid leaks, meningitis, and grotesque facial deformities. When appropriate, concomitant reconstruction allows adjuvant therapy (chemotherapy and radiotherapy) to be instituted earlier.
REPAIR: LOCAL FLAPS AND GRAFTS
Many factors must be considered in choosing the donor site for reconstruction of the orbit: ease in monitoring recurrent disease, aesthetic result, reliability, difficulty of surgery, operative time, donor defect, morbidity and mortality, and number of stages. Healing by secondary intention after orbital resection has several advantages in reconstruction of exenterated orbits. It is easy to monitor for recurrence, and it is easy to care for the orbit once healed. The problem is that healing takes several weeks to months, requires frequent dressing changes, and may lead to a contraction deformity of the surrounding tissues. In nonradiated sites, this approach may be quite practi48 cal and a~ceptable.~" Split-thickness skin grafts also allow for ease in monitoring for cancer recurrence. They are relatively quick and easy to perform and require no care once healed. Healing time is short. The donor defect is usually the upper thigh, which is cosmetically acceptable to most persons. These grafts are, however, inadequate for major sinus and dura resections. Split-thickness grafts can be used in combination with socket mold wired or sutured to the orbital rim.48The bones of the orbit provide
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enough blood supply so that a thin split-thickness skin graft properly immobilized can survive. The split-thickness skin graft may be satisfactory in older patients or in persons with lesions prone to recurrence even when air sinus fistulae are present (Fig. 7). Dermis fat grafts also can be used in reconstruction. The dermis is used to replace surface area and the fat is used to enhance orbital volume. It is useful when palliative subtotal exenteration or enucleation is performed, and proponents claim that it speeds wound healing, enhances cosmesis, gives comfort, and provides freedom from chronic socket problems such as fistula formation, skin desquamation, and continuous wound breakdown. The disadvantages are that one usually loses volume with time (approximately 50%). Additionally, there have been reports of hair growth and epidermidalization of the grafts. In cases of enucleation with preservation of the extraocular muscles, the dermis component can serve as an insertion for the extraocular muscles; hence, a "motorized" or movable autogenous implant can be provided. Translation of motion to an overlying prosthetic shell is generally less than satisfactory. The subgaleal fascial flap is based on either the supraorbital or superficial temporal vessels. Subgaleal fascia is readily dissected from superficial galea and deep periosteum, leaving behind a well-vascularized scalp and skin graftable calvarium. This flap takes skin graft well. Subgaleal fascial flaps have been reported to be used to patch dural defects and fill sinus dead space. One should consider using a subgaleal fascial flap when an ultrathin, vascularized coverage is needed. Advantages of these flaps, such as their delicate nature, versatil-
Figure 7. Split-thickness skin graft lining of orbit exenterated for a recurrent malignant orbital tumor in an elderly patient.
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ity, elasticity, gliding nature, supportability of skin grafts, and adaptability to spatial demands, have been delineated.9 The authors find these flaps much less applicable, and many of the supposed advantages have been found to be detracting qualities. For example, dural substitution and support in the cranial base requires much more durable autogenous reconstructions, and sinus obliteration requires significant volume, which is not provided by these flaps. The subgaleal fascia1 flaps can be used as "liners" in the anterior cranial base, ethmoid and frontal sinus exenterations to separate the nasal air cavity from the orbit or cranial compartment (Fig. 8). The retroauricular island flap uses cutaneous postauricular skin, deepithelialized scalp and fascia above the ear, and some of the superficial temporal fascia. It is based on both the superficial temporal artery and random pattern circulation from the fascia and dermal and subderma1 plexus and can be rotated 360" and used in a two-stage repair to reconstruct the contracted irradiated orbit.20Its main disadvantage is the problem of venous congestion. This flap also has been used in combination with the frontal flap in a one-stage procedure for eyelid and orbit recon~truction.~~ The scalp flap is a regional flap that is easy to harvest and is durable. Anterior scalp flaps based on superficial temporal system have been described to cover the orbit. One must weigh the deformity caused by the scalp defect against the benefits of repair of defect in the orbit. Scalp is thick and has a rich blood supply: occipital and superficial
Figure 8. Galeal-frontalis flap harvested from the undersurface of a scalp elevated by a coronal incision. Flap was used to line the anterior cranial base (orbital roofs) isolating the nasal air sinuses.
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temporal branches of external carotid as well as the supraorbital branch of internal carotid. Because the defect site is adjacent to donor site, this flap has the advantage of many regional flaps in that one need not reposition the patient in the operating room. Postoperatively, this thick vascular flap stands up well to irradiation. Additionally, with uncontoured defects from composite resections of the orbit, this flap can be depended on to reinforce and resurface the dura at an early date, thereby allowing early delivery of postoperative adjuvant therapy. The disadvantages of using the scalp flap are that color and texture may not match and that one is moving hair-bearing tissue into a nonhairy cosmetically important zone. Overall, this is an excellent flap. One can use a depilatory to remove the hair. This graft is easy to access and harvest and allows for transfer of large areas of durable tissue.51Donor sites can be skin grafted with little difficulty, even when large cranial base resections and reconstructions are undertaken (Fig. 9).58 The frontalis muscle also provides a vascular bed for cosmetic rehabilitation of the exenterated orbit. This muscular flap, which includes galea, obtains its blood supply from the superficial temporal artery. It is rotated anteriorly into the orbit while remaining attached to its insertion on the dermis under the eyebrow. Its posterior surface then faces anteriorly and is usually sutured to periosteum. This wellvascularized muscle is able to support a pro~thesis.~ The disadvantages of using this muscle are that it provides only limited tissue volume, may have its blood supply sacrificed at surgery, or, in many instances, is resected along with the primary tumor.47 The temporalis muscle receives its blood supply from the internal maxillary artery. It furnishes bulk for contour augmentation and innervated muscle for dynamic reconstruction, is reliably vascularized, and has minimal morbidity associated with its use.3The dense deep temporal fascia covering its surface attaches to the zygomatic arch and when disinserted and mobilized with this muscle serves as a rigid and durable barrier. It is a good reconstructive choice when posterior lateral orbital resections are combined with middle cranial fossa exposures and dural replacement or cranial base support is necessary. Some of its disadvantages are that it provides a vascular bed but obliges the surgeon to make a wide osteotomy in the lateral wall of the orbit in order to mobilize
Figure 9. Orbital-cranial resection for squamous cell carcinoma with bony reconstruction provided by split cranial bone and coverage by way of a scalp flap. Patient at surgery with split cranial bone rigidly fixed to reconstruct orbital roofs, anterior cranial base, supraorbital rim, and nasofrontal junction after resection of tumor (A). A scalping flap, based on the left superficial temporal vascular system is used for soft tissue coverage (6). Patient after division and insetting of scalping flap approximately 4 years after original extirpative surgery (C).
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muscle into the orbit, it produces a secondary significant depression in the temporalis fossa, and it does not have an axial vessel, but is a thick, short, muscle that is cumbersome to rotate. As with the frontalis muscle, the temporalis muscle or its blood supply may be sacrificed during the 16,22,54,60 cancer surgery resection, making plans to use it tenuous (Fig. 10).3,8, The temporoparietal fascial flap relies on the layer of fascia that is continuous with the superficial musculoaponeurotic system. The blood supply is through the superficial temporal artery of the external carotid system. During surgery, the flap is exposed by a preauricular incision extended into a hemicoronal incision, separated from scalp and pericranium, and subcutaneously tunneled into the orbit. There are several possible complications, including acute hair loss and facial nerve injury. Successful flap elevation requires careful dissection and experience. The distal tip of the temporoparietal fascial flap or its pericranial extension is sometimes unreliable as a vascularized bed for free or autogenous bone grafts.60This flap has a reliable blood supply with a predictable axial blood vessel, is contiguous with the orbit and so well suited for orbital or eyelid reconstruction because of its delicate quality and proximity, leaves inconspicuous donor site (the incision is hidden in hair-bearing scalp) with minimal donor site morbidity, and is thin and pliable, allowing for exact contouring to the underlying defect without bulk. This flap may be transferred as either a pedicled or free microvascular reconstruction.
Figure 10. Patient at orbital exenteration for malignant tumor with right temporalis muscle used to line posterior orbit. Lateral orbital wall is removed, leaving orbital rim intact for cosmesis.
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REPAIR: DISTANT FLAPS
Muscle or myocutaneous flaps are the standards by which definitive well-vascularized soft-tissue bulk can be provided in the orbital and periorbital region. These flaps fill in defects, are capable of sealing dural and cerebrospinal fluids leaks, and are appropriate in irradiated beds because of their high blood flow. They also provide a means for diffusion of systemic antibiotics locally and assist the body's local host immune defenses4This aspect is important when resection of the cancer extends beyond the orbit, especially into the contaminated (colonized) oronasal cavity and sinuses. These bacteria are some of the more common reasons for the postoperative complications of wound infection, flap necrosis, 47 Many of the muscle flaps cerebrospinal fluid leaks, and meningiti~.~, described later can be transposed with microvascular techniques as freetissue transfers. However, specific details of microvascular techniques are not covered in this article. The trapezius musculocutaneous flap, for example, is good for single-stage reconstruction of extensive defects centered about the orbit and extending beyond the supraorbital rim and across the midline or for intracranial reconstruction. Primary blood supply of the posterior muscle is from the descending branch of the transverse cervical artery. The muscle can be buried under the skin or rotated externally around to the orbit and later divided. The advantage of the former option is that it provides for one-stage reconstruction with a donor site scar in an inconspicuous position. The latter method, on the other hand, requires two operations but requires the surgeon to debulk the flap.47 The single, biggest advantage of this flap is its enormous arc of rotation. The major disadvantages are sacrifice of function of trapezius, sacrifice of eleventh nerve, poor color match for the face, and required intraoperative repositioning. A modified trapezius osteomyocutaneous flap using trapezius muscle with transverse cervical artery and vein that also contains a triangular piece of the medial border of the shoulder blade along with the innermost part of the scapular spine can be elevated. This flap can be used to reconstruct the lateral wall of the orbit, the malar bone, zygomatic arch, and the surrounding soft parts in a single procedure. The pectoralis major has been described extensively for use in the head and neck region, including the orbit.5 This is a flat, fan-shaped muscle with a large axial blood supply from the thoracoacromial artery. After an orbital exenteration, the pectoralis flap is elevated with skin over the entire length of the flap across the chest, as wide as the defect to be covered. The skin is removed over the distal 4 to 6 cm of the flap, and the underlying soft tissue and muscle are used to fill the orbital cavity. The edges of the skin flap are then sutured to the wound margin,
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and the donor site is closed primarily. The pedicle is left external to the face and neck. The undersurface is protected from desiccation by a topical antibiotic cream. After approximately 2 weeks, the flap is divided and inset, and the pedicle may be discarded (Fig. ll).4 The rectus abdominis may be transferred as a microvascular free flap to be used in orbital reconstruction with or without associated dural defects. It has a long pedicle that allows it to reach almost any defect, it has large-caliber vessels that are easy to work with, it has a good blood supply that facilitates thinning and shaping to mold the flap into whatever form is required, and it has a donor site that is remote from the ablative surgery. The rectus abdominis free flap as a pure muscle or myocutaneous unit can be harvested with the patient in the supine position so that, in most cases, the patient need not be turned during the course of the surgery. The latissimus dorsi may be used as an island flap or as a myocutaneous free flap. It is a large fan-shaped muscle with blood supply from the thoracodorsal artery and vein. As a pedicled flap, it may have an insufficient arc of rotation and be difficult to mobilize enough to reach the supraorbital area. As a free flap, it has the advantage of being mobile. The skin covering the latissimus provides a good texture match
Figure 11. A, Pectoralis major myocutaneous flap elevated on a skeletonized thoracoacromial vascular leash and used to line an orbit. B, Flap pedicle divided and flap inset approximately 2 weeks after original surgery.
Figure 12. A, Latissimus dorsi myocutaneous flap elevated on the thoracodorsal vascular system. The flap was transferred to the exenterated orbit and cranial base as a free flap using microvascular anastomoses. B, Patient with viable flap approximately 1 week after reconstruction.
for the face. This muscle provides enough bulk to obliterate orbital volume deficits, especially when folded upon itself. The main problem with the latissimus myocutaneous unit can be its bulk and poor color match. Thick tissue may prevent optimal examination for tumor recurrence. In addition, additional debulking procedures may be required for acceptable cosmesis (Fig. 12). Cross arm or forearm flaps provide a thin flap that can be used for both the inner layer of the eyelid and the socket lining. Tagliacozzi first used the cross arm flap in 1576 for reconstruction of the nose. It is a fairly thin flap that can be made slightly thicker than a full-thickness skin graft. A cross arm flap lines the socket with a good durable skin that can hold a prosthesis and has minimal tendency to shrink, keeping the socket supple rather than hard. It provides some volume, thereby decreasing the hollowness of the orbit. This is not an optimal choice given the wide variety of other pedicled or free-tissue flaps. It should be viewed as an historical option. The free radial forearm flap is a fasciocutaneous flap and is raised by using a free vascularized skin flap based on radial artery, which may then be anastomosed to the superficial temporal artery or facial artery; the cephalic vein or vena comitans may be anastomosed to the superficial temporal vein or external jugular vein. It provides bulk and augments the contents of the orbital space. However, it does leave a conspicuous scar on the forearm.59 In general, free-tissue transfer can be used when the appropriate conditions warrant. Many different free flaps have been used in the
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orbital region, including the revascularized tensor fascia lata myocutaneous flap, groin flap, dorsalis pedis flap, scapular flap, and latissimus dorsi flap. The selection and design of flaps are determined by the degree of orbital depression, the amount of remnant conjunctiva for the lining, and the amount of healthy palpebral skin. Most free-tissue transfers require additional surgery for debulking, dermal fat grafts, canthopexy, and fascia suspension. Composite flaps may be useful for concomitant reconstruction of bony and soft-tissue deformities. Multiple flaps have been described, including the temporal muscle with the coronoid process, the sixth rib with overlying serratus anterior muscle together with the latissimus dorsi muscle, all based on the thoracodorsal vessels, the iliac crestinternal oblique microsurgical free flap based on deep circumflex iliac vessels, and the osseofasciocutaneous radial forearm free flap.12,23, 50 Composite flaps concomitantly solve the problem of deficiency in both the soft-tissue and bony defects. However, free bone grafts with adequate well-vascularized soft-tissue coverage may serve equally well, with the possible exception of heavily irradiated fields.
Bone reconstruction in the orbit can be provided by autogenous bone or alloplastic material. Autogenous bone can be harvested in the form of a split calvarial bone graft or various osseous free flaps. The advantage of using calvarium is that there is less infection (as with all autogenous bone). One can contour the bone to fit the orbit and restore normal anatomy. Additionally, calvarium has a high resistance to resorption due to its high cortical content. The disadvantage may be the morbidity associated with the harvest; however, there have not been any associated complications in more than 100 such bone grafts in the senior author's experience. Reports of others corroborate our experien~e.~~ As a second choice, there are various osseous free flaps: rib, splitiliac crest, fibula, radial forearm, corticoperiosteal flap from the femur, free scapular flap, and lingual cortical bone of the mandible, which have been previously described. They are indicated when previous irradiation to the head prevents the use of calvarium. They have a higher rate of resorption and infection when used as nonvascularized grafts. Cartilage (nasal septal, conchal, preserved irradiated homologous, and lyophilized dura and cartilage) can be used in certain circumstances to provide support for the orbit. The cartilage substitutes become especially important in middle lamellae reconstructions of the eyelids and periorbital structures.
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A last choice for bone replacement is alloplastic materials. Polyethylene (Medpor [Porex, College Park, GA]) is the most widely used. It does not require harvesting or lead to donor site defects. It is easily cut and contoured to the desired size and shape, and it provides support. For small defects, hydroxyapatite, together with bone meal, antibiotic, and fibrin sealant, has been used. Supramid (Jackson, Inc., Alexandria, VA), Teflon, silicone, polyurethane, methyl methacrylate, and polydioxone are also good for small defects, and these materials are well tolerated. Some are eventually absorbed and replaced by bone. In general, however, these materials are difficult to contour. Metal plates such as titanium, vitallium, and stainless steel mesh have been advocated as good substitutes for bone. Questions of longterm safety and stability currently are being evaluated as well as interference with image quality on CT and MR image scanning.
DURA
Dura is generally not used as a flap, but it requires reconstruction to prevent cerebrospinal fluid leaks. Dural flaps have been described and can be useful in special circumstances, as in irradiated defects in the cranial base d ~ r aThis . ~ allows ~ a well-vascularized flap to be placed in a dependent and relatively inaccessible area to obviate cerebrospinal fluid leaks. The donor site can be reconstructed with more traditional methods. Fascia1 as well as muscular flaps can be used for its reconstructi~n.~~
PEDIATRIC PATIENTS
The goals for children with orbital and periorbital tumors are the same as described for adults: namely, to allow for detection of recurrent disease and restore boundaries between the orbit and the surrounding cavities while maximizing aesthetics and function.36Pediatric cancer resection and reconstruction, however, involve several special considerations. First, as expected, one must be aware of growth patterns and potential. By age 2, the orbit is almost adult size. By age 7, the orbit is full adult size. Second, young children do not have sinuses. Finally, the teeth in the maxillary sinus are under the periosteum, hugging the infraorbital rim. When possible, one must be careful not to damage these structures during resection or dissection. In general, growth disturbances secondary to surgery are related to age.ss The pediatric cranium is much thinner and more pliable than the adult. There is more cancellous than cortical bone. Split grafting is still the first choice, but it is important to consider the age of the child. At
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age 3, the two cortices are defined, and by age 9, in situ split-cranial grafting can be carried out readily. Iliac crest and rib grafts are alternatives. In children, one usually does not use alloplastic materials because long-term consequences of hardware with its affect on growth and any other long-term sequelae are, as yet, unanswered. As with the adult, it is important to be sure that all grafts (bone, rib, or iliac crest) are contoured to the normal orbital dimensions. Proper concavities and convexities obviate dystopia of the globe and subsequent diplopia, when the eyeball is left intact. Incorrect orbital rim contouring adversely affects eyelid function, causing ptosis, lid retraction, or corneal tear film problems. In the older population, cosmesis may not be a priority. Elderly persons are often spared and not offered the multiple-stage repairs that may be required for optimal aesthetic results. Children, on the other hand, with their ability to tolerate surgeries, are often subjected to extensive reconstructive efforts. However, multiple-stage procedures, even in children, may not necessarily result in improved cosmesis. In a study of 14 children who underwent orbital exenteration and radiation for rhabdomyosarcomas and retinoblastoma, it was found that filling the orbit alone produced marked improvement in appearance and occluded existing fistulae. However, further procedures, including a second operation in which orbital rims and eyelids were shaped and a third surgery for creation of a cavity for a static eye prosthesis, did not necessarily Children do not necessarily prefer a prosdecrease the di~figurement.~~ thesis, and so one must consider individual needs before performing multiple procedures to reach a cosmetic goal. CONCLUSION
Advances in the diagnosis of orbital and periorbital tumors are occurring as immunocytochemistry is used to aid in histopathologic studies. Treatment options also may improve as diagnostic modalities that allow better definition of orbitocranial bony and soft-tissue deformi.~~ treatment of these malignant tumors ties are d e ~ e l o p e d Meanwhile, continues to require the expertise of a treatment team composed of surgeons (plastic surgeons, ophthalmologists, neurosurgeons, and otolaryngologic surgeons), medical and radiation oncologists, and individual and family psychological and social supports. References 1. Anderson RL, Jordan DR, Beard C: Full-thickness unipedicle flap for lower eyelid reconstruction. Arch Ophthalmol 106:122-125, 1988
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2. Anderson RL, Edwards JJ: Reconstruction by myocutaneous eyelid flaps. Arch Ophthalmol 972358-2362, 1979 3. Antonyshyn 0 , Gruss JS, Birt BD: Versatility of temporal muscle and fascial flaps. Br J Plast Surg 41:118-131, 1988 4. Ariyan S: Pectoralis major, sternomastoid, and other musculocutaneous flaps for head and neck reconstruction. Clin Plast Surg 789-109, 1980 5. Ariyan S: The pectoralis major for single stage reconstruction of the difficult wounds of the orbit and pharynoesphagus. Plast Reconstr Surg 72:468-477, 1983 6. Beare R: Flap repair following exenteration of the orbit. Proceedings of the Royal Society of Medicine 62:1087-1090, 1969 7. Bonavolonta G: Frontalis muscle transfer in the reconstruction of the exenterated orbit. Adv Ophthalmic Plast Reconstr Surg 9:239-242, 1992 8. Bosniak S, Sachs M, Smith B: Temporalis muscle transfer: A vascular bed for autogenous dermis-fat orbital implantation. Ophthalmology 92:292-296, 1985 9. Carstens MH, Greco RJ, Hurwitz DJ, et al: Clinical application of subgaleal fascia. Plast Reconstr Surg 87:615-626, 1991 10. Chiarelli A, Baldelli A, DiVincenzo A, et al: Utilization of the superficial temporoparietal fascia in reconstructive plastic surgery: A clinical case. ophthal Plast ~ e c i n s tSurg i 5:274-276, 1989 11. Chung KW: Gross Anatomy. Baltimore, William and Wilkins, 1991, pp 297-307 12. Curioni C. Toscano P. Fioretti C. et al: Reconstruction of the orbital floor with the muscle-bone flap (temporal muscle with cornoid process). J Maxillofac Surg 11:263268, 1983 13. Cutler ML, Beard C: A method for partial and total upper lid reconstruction. Am J Ophthalmol 39:l-7, 1955 14. Destro MW, daSilva AL, Speranzini MB: Lower eyelid repair utilizing triangular skin flaps with subcutaneous pedicles. Br J Plast Surg 44363-367, 1991 15. Doermann A, Hauter D, Zook EG, et al: V-Y advancement flaps of tumor excision defects of the eyelids. Ann Plast Surg 22429435, 1989 16. Ellis DS, Toth BA, Stewart WB: Temporoparietal fascial flap for orbital and eyelid reconstruction. Plast Reconstr Surg 89:606-612, 1992 17. Fox SA, Beard C: Spontaneous lid repair. Am J Ophthalmol58:947-952,1964 18. Gaisford JC, Hanna DC: Orbital exenteration. Plast Reconstr Surg 31:363-369, 1963 19. Guerrissi J 0 , Cabouli JL: Upper lid musculocutaneous flap. AM Plast Surg 21:108115, 1988 20. Guyuron B: Retroauricular island flap for eye socket reconstruction. Plast Reconstr Surg 76:527-533, 1985 21. Guyuron B: The role of flaps in the management of the constricted eye sockets. Adv Ophthalmic Plast Reconstr Surg 9:143-157, 1992 22. Habal MB: Aesthetic considerations in the reconstruction of the anophthalmic orbit. Aesthetic Plast Surg 11:229-239, 1987 23. Habal MB, Murray JE: Orbital reconstruction after radical resection. Arch Surg 106:352355, 1973 24. Hargiss JL: Bipedicle tarsoconjunctival flap. Ophthal Plast Reconstr Surg 5:99-103,1989 25. Hewes EH, Sullivan JH, Beard C: Lower eyelid reconstruction by tarsal transposition. Am J Ophthalmol 81:512-514, 1976 26. Holmstrom H, Bartholdson L, Johanson B: Surgical treatment of eyelid cancer with special reference to tarsoconjunctival flaps. Scand J Plast Reconstr Surg Hand Surg 9:107-115, 1975 27. Hughes WH: Reconstruction of the lids. Am J Ophthalmol 28:1203-1211, 1945 28. Janeka IP: Orbital reconstruction. Plast Reconstr Surg 71:20-26, 1983 29. Jordan DR, Anderson RL, Nowinski TS: Tarsoconjunctival flap for upper eyelid reconstruction. Arch Ophthalmol 107:599-603, 1989 30. Kasai K, Ogawa Y, Kyutoko S: Split lamellae switch flap for upper eyelid reconstruction. Ophthal Plast Reconstr Surg 6:126-129, 1990 31. Khan JA: Subcilial lining skin-muscle-flap repair of anterior lamella lower eyelid defects. J Dermatol Surg Oncol 17:167-170, 1991 32. Koornneef L: Orbital septa: Anatomy and function. Ophthalmology 862376-880, 1979
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33. Leone CR, Van Gemert JV: Lower eyelid reconstruction using tarsoconjunctival grafts and bipedicled skin muscle flap. Arch Ophthalmol 107:758-760, 1989 34. Leone CR, Hand SI: Reconstruction of the medial eyelid. Am J Ophthalmol 87797801, 1979 35. Levin ML, Leone CR: Bipedicle myocutaneous flap repair of cicatricial ectropion. Ophthal Plast Reconstr Surg 6:119-121, 1990 36. Levin PS, Ellis DS, Stewart WB, et al: Orbital exenteration: The reconstructive ladder. Ophthal Plast Reconstr Surg 784-92, 1991 37. Marques A, Brenda E, Magrin J, et al: Critical analysis of methods of reconstruction of exenterated orbits. Br J Plast Surg 45:523-528, 1992 38. Matsuo K, Sakaguchi Y, Kiyono M, et al: Lid margin reconstruction with an orbicularis oculi musculocutaneous advancement flap and a conchal cartilage graft. Plast Reconstr Surg 87:142-145, 1991 39. Matsuo K, Kiyono M, Hirose T: Lower eyelid reconstruction with an orbicularis oculi musculocutaneous transposition flap and a conchal cartilage graft. Ophthal Plast Reconstr Surg 6:177-180, 1990 40. Mercer DM: The cervicofacial flap. Br J Plast Surg 41:470474, 1988 41. Montandon D: Extrinsic eyelid ectropion. Ann Plast Surg 26:353-357, 1991 42. Mustarde JC: Eyelid reconstruction. Orbit 1:3343, 1982 43. Ohtsuka H: Eye socket and eyelid reconstruction using the combined island frontal flap and retroauricular island flap: A preliminary report. Ann Plast Surg 20:244-248, 1988 44. Phillips JH, Gruss JS, Wells MD, et al: Periosteal suspension of the lower eyelid and cheek following subciliary exposure of facial fractures. Plast Reconstr Surg 88:145148, 1991 45. Raffaini M, Costa P: The temporoparietal fascial flap in reconstruction of the craniomaxillofacial area. J Craniomaxillofac Surg 22:261-267, 1994 46. Richards MA: Free composite reconstruction of a complex craniofacial defect. Aust N Z J Surg 57:129-132, 1987 47. Rosen HM: The extended trapezius musculocutaneous flap for cranio-orbital facial reconstruction. Plast Reconstr Surg 75:318-327, 1985 48. Savage RC: Orbital exenteration and reconstruction for massive basal cell and squamous cell carcinoma of cutaneous origin. Ann Plast Surg 10:458466, 1983 49. Shaffrey M, Persing JA: Duraplasty and cranial base tumor resection. J Craniofacial Surg 2:152-155, 1991 50. Shenaq SM: Reconstruction of complex cranial and craniofacial defects utilizing iliac crest-internal oblique microsurgical free flap. Microsurgery 9:154-158, 1988 51. Shenoy AM, Nanjundappa, Nayak UK, et al: Scalp flap: A utility. A reconstructive option for head and neck surgeons. J Laryngol Otol 107324-328, 1993 52. Smith B, Obear M: Bridge flap technique for large upper lid defects. Plast Reconstr Surg 38:45-88, 1966 53. Smith B: Eyelid surgery. Surg Clin North Am 39:367-378, 1959 54. Speculand B: The origin of the temporalis muscle flap. Br J Oral Maxillofac Surg 30:390-392, 1992 55. Spinelli HM, Criscuolo GR, Tripps M, et al: Massive congenital orbital teratoma in the newborn. Ann Plast Surg 31:453458, 1993 56. Spinelli HM, Jelks GW: Periocular reconstruction: A systematic approach. Plast Reconstr Surg 91:1017-1024,1993 57. Spinelli HM, Persing JA, Walser B: Reconstruction of the cranial base. Clin Plast Surg 22:555-561, 1995 58. Spinelli HM: Reconstruction of the upper cranial and cranial base defects utilizing the scalping flap. Presented at the 12th Annual Meeting of the Northeastern Society of Plastic Surgeons. Boston, November 3-5, 1995 59. Tahara S, Susuki T: Eye socket reconstruction with free radial forearm flap. Ann Plast Surg 23:112-116, 1989 60. Teichgraeber JF: Temporoparietal fascial flap in orbital reconstruction. Laryngoscope 103:931-935, 1993 61. Toth B, Di Loreto DA, Stewart WB: Multidisciplinary approach to the management of
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62. 63. 64. 65. 66. 67. 68.
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complex bony and soft tissue orbitocranial disorders. Ophthalmology 95:1013-1026, 1988 van der Meulen JC: Reconstruction of the medial half of the lower eyelid using a "switch" split lid procedure. Plast Reconstr Surg 88:718-722, 1991 Wexler MR, Peled I, Kaplan H: Socket reconstruction using cross arm flaps. Plast Reconstr Surg 68:18-22, 1981 Whitnall SE: Anatomy of the Human Orbit and the Accessory Organs of Vision. London, Oxford University Press, 1932 Wolfe E: Anatomy of the Eye and Orbit. Philadelphia, WB Saunders, 1968 Wolfe SA: Application of craniofacial surgical precepts in orbital reconstruction following trauma and tumour removal. Journal of Maxillofacial Surgery 10:212-223, 1982 Yoshimura Y, Nakajima T, Yoneda K: Reconstruction of the entire upper eyelid area with a subcutaneous pedicle flap based on the orbicularis oculi muscle. Plast Reconstr Surg 88:136-139, 1991 Zide BM, Jelks GW: Surgical Anatomy of the Orbit. New York, Raven Press, 1985
Address reprint requests to Henry M. Spinelli, MD 830 Park Avenue New York, NY 10021
1055-3207/97 $0.00
+ .20
RECONSTRUCTION OF THE ORBIT Henry M. Spinelli, MD, FACS, and Pia Ali-Salaam, MD
There are various ways to approach repair in the orbital region. All ways, of course, depend on what the defect is and what tissue is available for the repair. The orbital region is generally divided into two broad areas when approaching repair: the orbit and the periorbital region. The periorbital region lies external to the septum and consists of soft-tissue structures. The orbital region lies posterior to the septum, is bounded by the bony orbital cone, and contains intraorbital soft-tissue structures, including the eyeball, extraocular muscles, orbital fat, and structures that transgress the orbital cone, such as the anterior and posterior ethmoidal neurovascular bundles (ethmoidal foramina) or the first and second divisions of the fifth cranial nerve (superior and inferior sphenoid fissures). The bony orbit directly abuts extraorbital structures in addition to multiple foramina, allowing transgression of nerves and blood vessels in and out of the orbit. Examples are the adjacent air sinuses (ethmoid) and intracranial cavities such as the middle cranial fossa posteriorly and the anterior cranial fossa superiorly. Therefore, oncologic processes involving the orbit and the periorbital regions as well as extraorbital tumors frequently require complete or partial resections within the orbital and periorbital region and appropriate bony and soft-tissue reconstructions.
From Cornell University Medical College (HMS); New York Hospital/Cornell Medical Center (HMS), New York, New York; Yale-New Haven Hospital (HMS); and the Department of Surgery, Yale University School of Medicine (PA-S), New Haven, Connecticut
SURGICAL ONCOLOGY CLINICS OF NORTH AMERICA
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VOLUME 6 . NUMBER 1 JANUARY 1997
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SPINELLI & ALI-SALAAM
Basal cell and squamous cell carcinomas and melanoma in situ frequently affect the eyelids, canthi, and periocular tissues. Surgical excision often produces large defects that can result in significant visual impairment if reconstruction is not carefully planned and precisely executed. Orbital pathologic conditions, like periorbital pathologic conditions, can be caused by various tumors: skin, gland, vascular, nerve, lymphoid, mesenchymal, and metastatic. The surgical approach to diverse malignancies has been described in the literature: lacrimal gland fossa tumor, adenoid cystic carcinoma, chondrosarcoma, malignant teratoma, basal and squamous cell cancer, unilateral and bilateral retinoblastomas, orbital rhabdomyosarcomas, osteogenic sarcoma of the lateral orbital region, malignant histiocytoma, frontal meningioma, optic nerve glioma, squamous cell of the oropharynx requiring total exenteration of the 48, 55 orbit, and hemimaxillectomy.23~ ANATOMY
Reconstruction of the periocular region requires special considerations and a complete understanding of the specialized anatomy of the region. The eyelids, especially the upper eyelids, are designed to protect the eyes from debris, excess light, and exposure. They also function during blinking to clear and redistribute the multipurpose tear film.56 The lacrimal production system consists of those structures involved with baseline and reflex tear production, such as the conjunctival goblet cells, subconjunctival glands of Krause and Wolfring, and the oil-producing glands of Zeis and Moll, along with the Meibomian glands. The lacrimal drainage system, assisted by a complex muscular pumping system, extends from the puncta on the lid margin to the inferior meatus 65, 68 of the nose (Fig. The medial canthus contains the bony attachments of the eyelids, lacrimal collecting and drainage structures, and neurovascular structures arising from the deep orbit. The lateral canthus or, more accurately, the lateral retinaculum consists of an extension of the levator superioris termed the lateral horn, the lateral canthal tendon, the inferior suspensory ligament of the globe (Lockwood's ligament), and the check ligament of the lateral rectus muscle. The lateral retinacular tissues attach to the lateral orbital wall at Whitnall's tubercle, a bony promontory just within the orbital rim (Fig. 2).56,64 The orbital septum is a fascia1 membrane that separates the eyelids and associated structures from the deeper orbital structures. It serves as an important barrier to hemorrhage, infection, inflammation, and neoplastic disease processes. The six extraocular muscles insert on the globe behind the septum and are responsible for complex binocular
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Lacrimal Gland
Figure 1. The lacrimal production system consists of basic and reflex secretors. Tears are multilaminated with an aqueous core and a hydrophobic coating. Distribution is made possible by eyelid action. The lacrimal drainage system is an active pump that depends on muscular action. Tears enter the proximal system, are sucked into the lacrimal sac, then forced into the nose below the inferior turbinate.
Figure 2. The medial and lateral canthal structures support the upper and lower eyelids and allow fixation points for muscular action (i.e., blinking and lacrimal pump). Both canthi are anchored posterior to the bony orbital rim.
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motion, including rotary movements. A fascia1 system within the orbit provides interconnected scaffolding and supports orbital contents, including the globe. The optic nerve and first and second divisions of the fifth cranial nerve enter the orbit at its apex through the foramina in the bony architecture of the sphenoid bone.32,56 The orbital margin, which has been described clearly, is formed by the frontal, maxillary, and zygomatic bones." The walls of the orbit are formed superiorly by the frontal bone and the lesser wing of the sphenoid, laterally by the zygomatic bone and the greater wing of the sphenoid, inferiorly by the maxillary, zygomatic, and palatine bones, and medially by the ethmoid bone, lacrimal bone, and body of the sphenoid bone. Many important structures communicate with the globe through the bony orbit's many openings: (1) superior orbital fissure, which carries oculomotor nerve, trochlear nerve, abducens nerve, ophthalmic nerves, and ophthalmic veins; (2) inferior orbital fissure, which carries maxillary nerve and infraorbital vessels; (3) optic canal, which carries optic nerve and ophthalmic artery; (4) supraorbital notch, which carries the supraorbital nerve and vessels; (5) infraorbital groove and foramen, which carry infraorbital nerve and vessels; and (6) nasolacrimal canal, which transmits the nasolacrimal duct from the lacrimal sac to the inferior nasal meatus." The aforementioned structures in addition to the ocular muscles (superior rectus, inferior rectus, medial rectus, lateral rectus, levator palpebrae superioris, superior oblique, and inferior oblique) attach to the globe. The globe itself is an extension of the brain: the sclera analogous to the dura, the choroid comparable to the arachnoid, and the retina homologous to the neuroparenchyma. THE PERIOCULAR REGION: RECONSTRUCTION
It is helpful to divide the periocular region into zones, based on special anatomic and functional demands.56In patients with basal cell, squamous cell, and melanoma of the periocular region, surgical defects can be classified into five zones: Zone I, or the upper eyelid; Zone 11, or the lower eyelid; Zone 111, or the medial canthal region; Zone IV, or the lateral canthal region; and Zone V, located primarily outside of Zones I to IV but contiguous with those zones (Fig. 3). Any good reconstructive plan should incorporate tissue that is innervated, well vascularized, thin, pliable, and composite (skin, muscle, tarsoligamentous, and mucous membrane). In general, this tissue should be transferred from adjacent and intact eyelid structures. More complex eyelid and adjacent canthal, cheek, and brow reconstructions require advancement, transposition, and rotation flaps designed and supported in such a fashion that three-dimensional distraction forces are minimized. Distraction forces, such as gravity, edema, and early or late
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Figure 3. The eyelids and periocular structures can be divided into five surgical zones. Zone I on the upper eyelid, Zone II on the lower eyelid, Zone Ill on the medial canthal region (note the deep medial canthal structures), Zone IV the lateral canthal region, and Zone V any area outside of Zone I-IV but contiguous with those zones. (From Spinelli HM, Jelks GW: Periocular reconstruction: A systematic approach. Plast Reconstr Surg 91 :1017-1024, 1993; with permission.)
wound contraction, can displace periocular tissue away from its intended position, causing lid malposition, an irregular tear film, abnormal lacrimal drainage, corneal exposure, and unsatisfactory cosmesis (Fig. 4).41 Partial-thickness defects in zone I and I1 exceeding 50% of the wound are best reconstructed with full-thickness skin grafts harvested from the opposite upper lid, retroauricular or supraclavicular area. Partial-thickness defects less than 50% can be closed by advancing regional lid tissue or a myocutaneous flap from upper to lower lid.14, 19,31, 35, 67 Full-thickness upper lid defects present a greater risk to the eyeball than lower lid defects. Zone I full-thickness defects of up to 25% of lid width can be closed primarily with the aid of a lateral canthotomy and cantholysis of the superior crus. For defects exceeding 25% of lid width that cannot be closed primarily, sliding tarsoconjunctival flaps are preferred whenever possible.27Larger upper lid defects may require lower lid switch flaps and lower lid bridge flaps.13,42, s2 Additionally, one should consider using tarsoconjunctival and the split-lamellae switch flap for reconstructing central upper lid defects with a remnant of intact 30
Zone I1 full-thickness defects are closed primarily with the aid of canthotomy and cantholysis when they are less than 50% of lid width. Semicircular flaps can be added to allow tissue advancement. Transposed or advanced orbicularis myocutaneous flaps over cartilage lid
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Figure 4. Forces acting on the lower lid. A, Intrinsic lid support in a superior and posterior direction is provided by the sum of vector forces provided by (1) the medial canthal tendon, (2) the lateral canthal tendon, and (3) the tarsus and orbicularis muscle. B, Distraction forces are the sum of vector forces working against intrinsic lid support. These forces can displace periocular tissue away from its intended position when intrinsic lid support is exceeded. (From Spinelli HM, Jelks GW: Periocular reconstruction: A systematic approach. Plast Reconstr Surg 91 :I017-1 024,1993;with permission.)
grafts also can be used for small marginal or lateral defects.38,39 To prevent corneal irritation, rigid free cartilage grafts should be avoided in favor of free or transposed tarsoconj~nctiva.~~ 33, 62 Defects exceeding 50% are best approached with bridge or transposition tarsoconjunctival flaps.2426, 53 Cervical facial advancement flaps are most useful in defects of the lower lid extending into the cheek (Zone V), especially in older patients with skin laxity (Fig. 5).'jz4O Zone I11 defects can be corrected with more latitude. Although upper lid medially based myocutaneous flaps supplied by branches of the infratrochlear vessels are first choice, the use of other local flaps or skin grafts, or in some cases healing by secondary intention, may be quite ac~eptable.~, 17,34 Lacrimal probing with silicone catheter intubation and medial canthal support should be performed routinely as part of all repairs. Zone IV lesions are best reconstructed with cheek advancement flaps or skin grafts, alone or in combination with other flaps.1° As with the Zone 111 lesions, the type of soft-tissue reconstruction used is of less importance than the indication for an ancillary procedure, namely, a lateral canthopexy. Lateral canthal support procedures should be performed routinely even when the lateral canthal tendinous system is not disrupted by the extirpative phase of treatment.44,55 Zone V lesions can be approached by any available reconstructive technique, with special care taken to address the needs of Zonks I to IV.
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This is especially true in lesions and defects inferior to the lower eyelid, where soft-tissue ptosis alone can produce ectropion and scleral show. The classification system summarized previously can be applied to defects as well as to benign and malignant tumors. These defects then can be approached with a reconstructive ladder based on the anatomic and functional requirements of the zones affected (Fig. 6).56
THE ORBIT: RECONSTRUCTION
Orbital exenteration with excision of the eye and the orbital contents is one of the most definitive and deforming cancer therapies. The type, the extent, and the natural history of the various malignancies define the type of resection needed. Six indications for orbital exenteration have been described, and most of these are applicable currently.18 A graded approach to orbital reconstruction after tumor resection has been reviewed.36If there is significant risk of recurrence and observance of the socket is important or if the patient is debilitated and cannot tolerate extensive surgery, then reconstruction should be limited to a local solution (e.g., healing by secondary intention, split-thickness skin graft, and full-thickness graft). If, on the other hand, the patient has undergone a definitive tumor resection and a recurrence-free postexenteration period, then a more extensive reconstruction using regional or distant flaps can be planned. Of course, not all orbital tumors require exenteration. When discussing orbital reconstruction, the range of repair required varies with the orbital deficiency. Several questions must be addressed. Is there any normal orbital or periorbital tissue? Is there adequate lining of the orbit? How much has orbital volume been reduced? Have the eyelids been sacrificed? Are there any fistulae between the orbit and the nasal and paranasal sinuses that must be sealed? Does the patient need skin, mucosa, muscle bulk, bone, cartilage, or prosthetic material? Is regional blood supply adequate to support a local reconstructive effort? There are also the usual preoperative considerations: timing of repair, choosing a donor site, appreciating the needs of the recipient site, and aesthetic considerations.
TIMING
Immediate repair offers several benefits. The patient undergoes only one operation with one hospitalization, and the patient has psychological In benefits rendered from having cosmesis addressed imrnediatel~.~~ addition, any extirpation that leaves the eyeball intact but compromises
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SPINELLI & ALI-SALAAM
Figure 5. A, Patient status post morpheaform basal cell carcinoma with large resection of lower lid defect extending inferiorly beyond the limits of the orbital septum and rim (cheek) and medially into the canthal region involving the lacrimal drainage system (Zones 11, 111, V, from Spinelli classification). Patient's reconstruction consisted of a Hughes tarsoconjunctival flap, medial canthal tendon, and lacrimal system reconstruction (B), combined with a cervical facial flap for cheek reconstruction in a single aesthetic unit (C). illustration continued on opposite page
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Figure 5 (Continued). Patient approximately 3 months after division and insetting of tarsoconjunctival flap with comfortable well-protected globe and a functional lower lid and lacrimal drainage system in both opening (D) and closure (E).
PT<50% 1' Closue with local tissue advancement
,& PT
FT<25% advanced
r - 2
-xmv3
FT>75% Slidinghrsal conjunctival flap, levator recession; or composite graft
FT>75% Lower lid switch flap for very large detects
Zone IV
&-
ALL: Lateral cantha1 support procedure
OR
-
Other lacal flaps '
l'T<50%
Figure 6. A summary of reconstructive guidelines for the periocular eyelids and region. Zone V has been excluded from the drawing because Zone V reconstructions may be addressed with latitude as long as the needs of Zone I through IV have been met. PT = partial-thickness defects; FT = full-thickness defects. (From Spinelli HM, Jelks GW: Periocular reconstruction: A systematic approach. Plast Reconstr Surg 91:I017-1 024, 1993; with permission.)
l"~los;;;~;,"~;lti~~ue
+#
lnClosure with canthotomy and cantholyis, local tissue advanced
OR PT>50% FTSG from opPo"i~uPP"~d
OR Myocutaneous transposition flapf"msameu~~"lid
Slidmg tarsal-canj~ncti~a~ flap w ~ t hskin graft
FT>50% Sliding tarsal-conjunctival flap withskin graft
~~>75% Composite graft w ~ t hcheek advancement
FTSG
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the protective periocular structures usually creates more cogent reason for immediate reconstruction, namely maintenance of a functional, painfree eye. Immediate repair carries with it the risk of reconstruction with incomplete tumor excision. However, even if microscopic margins are negative, recurrences or second primary lesions may appear. Their clinical detection may be related not only to location but also to the type of reconstruction used. For example, a recurrence in an orbit treated by exenteration is more easily detected when the reconstruction is by skin graft rather than a myocutaneous flap. The need for immediate reconstructions with extensive flaps and possibly bone grafts becomes much more relevant when extraorbital structures (i.e., cranial base, orbital bone, and dura) are resected in extensive lesions that cannot be resected and reconstructed practically or safely at disparate surgical procedure^.^^ A single extirpation and repair is justified for several reasons.47 Resection of a tumor usually has been the most extensive resection compatible with life or acceptable to the patient. Leaving a tumor resection open to allow for tumor surveillance leaves the problems of large open wounds with associated osteitis, cerebrospinal fluid leaks, meningitis, and grotesque facial deformities. When appropriate, concomitant reconstruction allows adjuvant therapy (chemotherapy and radiotherapy) to be instituted earlier.
REPAIR: LOCAL FLAPS AND GRAFTS
Many factors must be considered in choosing the donor site for reconstruction of the orbit: ease in monitoring recurrent disease, aesthetic result, reliability, difficulty of surgery, operative time, donor defect, morbidity and mortality, and number of stages. Healing by secondary intention after orbital resection has several advantages in reconstruction of exenterated orbits. It is easy to monitor for recurrence, and it is easy to care for the orbit once healed. The problem is that healing takes several weeks to months, requires frequent dressing changes, and may lead to a contraction deformity of the surrounding tissues. In nonradiated sites, this approach may be quite practi48 cal and a~ceptable.~" Split-thickness skin grafts also allow for ease in monitoring for cancer recurrence. They are relatively quick and easy to perform and require no care once healed. Healing time is short. The donor defect is usually the upper thigh, which is cosmetically acceptable to most persons. These grafts are, however, inadequate for major sinus and dura resections. Split-thickness grafts can be used in combination with socket mold wired or sutured to the orbital rim.48The bones of the orbit provide
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enough blood supply so that a thin split-thickness skin graft properly immobilized can survive. The split-thickness skin graft may be satisfactory in older patients or in persons with lesions prone to recurrence even when air sinus fistulae are present (Fig. 7). Dermis fat grafts also can be used in reconstruction. The dermis is used to replace surface area and the fat is used to enhance orbital volume. It is useful when palliative subtotal exenteration or enucleation is performed, and proponents claim that it speeds wound healing, enhances cosmesis, gives comfort, and provides freedom from chronic socket problems such as fistula formation, skin desquamation, and continuous wound breakdown. The disadvantages are that one usually loses volume with time (approximately 50%). Additionally, there have been reports of hair growth and epidermidalization of the grafts. In cases of enucleation with preservation of the extraocular muscles, the dermis component can serve as an insertion for the extraocular muscles; hence, a "motorized" or movable autogenous implant can be provided. Translation of motion to an overlying prosthetic shell is generally less than satisfactory. The subgaleal fascial flap is based on either the supraorbital or superficial temporal vessels. Subgaleal fascia is readily dissected from superficial galea and deep periosteum, leaving behind a well-vascularized scalp and skin graftable calvarium. This flap takes skin graft well. Subgaleal fascial flaps have been reported to be used to patch dural defects and fill sinus dead space. One should consider using a subgaleal fascial flap when an ultrathin, vascularized coverage is needed. Advantages of these flaps, such as their delicate nature, versatil-
Figure 7. Split-thickness skin graft lining of orbit exenterated for a recurrent malignant orbital tumor in an elderly patient.
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ity, elasticity, gliding nature, supportability of skin grafts, and adaptability to spatial demands, have been delineated.9 The authors find these flaps much less applicable, and many of the supposed advantages have been found to be detracting qualities. For example, dural substitution and support in the cranial base requires much more durable autogenous reconstructions, and sinus obliteration requires significant volume, which is not provided by these flaps. The subgaleal fascia1 flaps can be used as "liners" in the anterior cranial base, ethmoid and frontal sinus exenterations to separate the nasal air cavity from the orbit or cranial compartment (Fig. 8). The retroauricular island flap uses cutaneous postauricular skin, deepithelialized scalp and fascia above the ear, and some of the superficial temporal fascia. It is based on both the superficial temporal artery and random pattern circulation from the fascia and dermal and subderma1 plexus and can be rotated 360" and used in a two-stage repair to reconstruct the contracted irradiated orbit.20Its main disadvantage is the problem of venous congestion. This flap also has been used in combination with the frontal flap in a one-stage procedure for eyelid and orbit recon~truction.~~ The scalp flap is a regional flap that is easy to harvest and is durable. Anterior scalp flaps based on superficial temporal system have been described to cover the orbit. One must weigh the deformity caused by the scalp defect against the benefits of repair of defect in the orbit. Scalp is thick and has a rich blood supply: occipital and superficial
Figure 8. Galeal-frontalis flap harvested from the undersurface of a scalp elevated by a coronal incision. Flap was used to line the anterior cranial base (orbital roofs) isolating the nasal air sinuses.
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59
temporal branches of external carotid as well as the supraorbital branch of internal carotid. Because the defect site is adjacent to donor site, this flap has the advantage of many regional flaps in that one need not reposition the patient in the operating room. Postoperatively, this thick vascular flap stands up well to irradiation. Additionally, with uncontoured defects from composite resections of the orbit, this flap can be depended on to reinforce and resurface the dura at an early date, thereby allowing early delivery of postoperative adjuvant therapy. The disadvantages of using the scalp flap are that color and texture may not match and that one is moving hair-bearing tissue into a nonhairy cosmetically important zone. Overall, this is an excellent flap. One can use a depilatory to remove the hair. This graft is easy to access and harvest and allows for transfer of large areas of durable tissue.51Donor sites can be skin grafted with little difficulty, even when large cranial base resections and reconstructions are undertaken (Fig. 9).58 The frontalis muscle also provides a vascular bed for cosmetic rehabilitation of the exenterated orbit. This muscular flap, which includes galea, obtains its blood supply from the superficial temporal artery. It is rotated anteriorly into the orbit while remaining attached to its insertion on the dermis under the eyebrow. Its posterior surface then faces anteriorly and is usually sutured to periosteum. This wellvascularized muscle is able to support a pro~thesis.~ The disadvantages of using this muscle are that it provides only limited tissue volume, may have its blood supply sacrificed at surgery, or, in many instances, is resected along with the primary tumor.47 The temporalis muscle receives its blood supply from the internal maxillary artery. It furnishes bulk for contour augmentation and innervated muscle for dynamic reconstruction, is reliably vascularized, and has minimal morbidity associated with its use.3The dense deep temporal fascia covering its surface attaches to the zygomatic arch and when disinserted and mobilized with this muscle serves as a rigid and durable barrier. It is a good reconstructive choice when posterior lateral orbital resections are combined with middle cranial fossa exposures and dural replacement or cranial base support is necessary. Some of its disadvantages are that it provides a vascular bed but obliges the surgeon to make a wide osteotomy in the lateral wall of the orbit in order to mobilize
Figure 9. Orbital-cranial resection for squamous cell carcinoma with bony reconstruction provided by split cranial bone and coverage by way of a scalp flap. Patient at surgery with split cranial bone rigidly fixed to reconstruct orbital roofs, anterior cranial base, supraorbital rim, and nasofrontal junction after resection of tumor (A). A scalping flap, based on the left superficial temporal vascular system is used for soft tissue coverage (6). Patient after division and insetting of scalping flap approximately 4 years after original extirpative surgery (C).
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muscle into the orbit, it produces a secondary significant depression in the temporalis fossa, and it does not have an axial vessel, but is a thick, short, muscle that is cumbersome to rotate. As with the frontalis muscle, the temporalis muscle or its blood supply may be sacrificed during the 16,22,54,60 cancer surgery resection, making plans to use it tenuous (Fig. 10).3,8, The temporoparietal fascial flap relies on the layer of fascia that is continuous with the superficial musculoaponeurotic system. The blood supply is through the superficial temporal artery of the external carotid system. During surgery, the flap is exposed by a preauricular incision extended into a hemicoronal incision, separated from scalp and pericranium, and subcutaneously tunneled into the orbit. There are several possible complications, including acute hair loss and facial nerve injury. Successful flap elevation requires careful dissection and experience. The distal tip of the temporoparietal fascial flap or its pericranial extension is sometimes unreliable as a vascularized bed for free or autogenous bone grafts.60This flap has a reliable blood supply with a predictable axial blood vessel, is contiguous with the orbit and so well suited for orbital or eyelid reconstruction because of its delicate quality and proximity, leaves inconspicuous donor site (the incision is hidden in hair-bearing scalp) with minimal donor site morbidity, and is thin and pliable, allowing for exact contouring to the underlying defect without bulk. This flap may be transferred as either a pedicled or free microvascular reconstruction.
Figure 10. Patient at orbital exenteration for malignant tumor with right temporalis muscle used to line posterior orbit. Lateral orbital wall is removed, leaving orbital rim intact for cosmesis.
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REPAIR: DISTANT FLAPS
Muscle or myocutaneous flaps are the standards by which definitive well-vascularized soft-tissue bulk can be provided in the orbital and periorbital region. These flaps fill in defects, are capable of sealing dural and cerebrospinal fluids leaks, and are appropriate in irradiated beds because of their high blood flow. They also provide a means for diffusion of systemic antibiotics locally and assist the body's local host immune defenses4This aspect is important when resection of the cancer extends beyond the orbit, especially into the contaminated (colonized) oronasal cavity and sinuses. These bacteria are some of the more common reasons for the postoperative complications of wound infection, flap necrosis, 47 Many of the muscle flaps cerebrospinal fluid leaks, and meningiti~.~, described later can be transposed with microvascular techniques as freetissue transfers. However, specific details of microvascular techniques are not covered in this article. The trapezius musculocutaneous flap, for example, is good for single-stage reconstruction of extensive defects centered about the orbit and extending beyond the supraorbital rim and across the midline or for intracranial reconstruction. Primary blood supply of the posterior muscle is from the descending branch of the transverse cervical artery. The muscle can be buried under the skin or rotated externally around to the orbit and later divided. The advantage of the former option is that it provides for one-stage reconstruction with a donor site scar in an inconspicuous position. The latter method, on the other hand, requires two operations but requires the surgeon to debulk the flap.47 The single, biggest advantage of this flap is its enormous arc of rotation. The major disadvantages are sacrifice of function of trapezius, sacrifice of eleventh nerve, poor color match for the face, and required intraoperative repositioning. A modified trapezius osteomyocutaneous flap using trapezius muscle with transverse cervical artery and vein that also contains a triangular piece of the medial border of the shoulder blade along with the innermost part of the scapular spine can be elevated. This flap can be used to reconstruct the lateral wall of the orbit, the malar bone, zygomatic arch, and the surrounding soft parts in a single procedure. The pectoralis major has been described extensively for use in the head and neck region, including the orbit.5 This is a flat, fan-shaped muscle with a large axial blood supply from the thoracoacromial artery. After an orbital exenteration, the pectoralis flap is elevated with skin over the entire length of the flap across the chest, as wide as the defect to be covered. The skin is removed over the distal 4 to 6 cm of the flap, and the underlying soft tissue and muscle are used to fill the orbital cavity. The edges of the skin flap are then sutured to the wound margin,
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and the donor site is closed primarily. The pedicle is left external to the face and neck. The undersurface is protected from desiccation by a topical antibiotic cream. After approximately 2 weeks, the flap is divided and inset, and the pedicle may be discarded (Fig. ll).4 The rectus abdominis may be transferred as a microvascular free flap to be used in orbital reconstruction with or without associated dural defects. It has a long pedicle that allows it to reach almost any defect, it has large-caliber vessels that are easy to work with, it has a good blood supply that facilitates thinning and shaping to mold the flap into whatever form is required, and it has a donor site that is remote from the ablative surgery. The rectus abdominis free flap as a pure muscle or myocutaneous unit can be harvested with the patient in the supine position so that, in most cases, the patient need not be turned during the course of the surgery. The latissimus dorsi may be used as an island flap or as a myocutaneous free flap. It is a large fan-shaped muscle with blood supply from the thoracodorsal artery and vein. As a pedicled flap, it may have an insufficient arc of rotation and be difficult to mobilize enough to reach the supraorbital area. As a free flap, it has the advantage of being mobile. The skin covering the latissimus provides a good texture match
Figure 11. A, Pectoralis major myocutaneous flap elevated on a skeletonized thoracoacromial vascular leash and used to line an orbit. B, Flap pedicle divided and flap inset approximately 2 weeks after original surgery.
Figure 12. A, Latissimus dorsi myocutaneous flap elevated on the thoracodorsal vascular system. The flap was transferred to the exenterated orbit and cranial base as a free flap using microvascular anastomoses. B, Patient with viable flap approximately 1 week after reconstruction.
for the face. This muscle provides enough bulk to obliterate orbital volume deficits, especially when folded upon itself. The main problem with the latissimus myocutaneous unit can be its bulk and poor color match. Thick tissue may prevent optimal examination for tumor recurrence. In addition, additional debulking procedures may be required for acceptable cosmesis (Fig. 12). Cross arm or forearm flaps provide a thin flap that can be used for both the inner layer of the eyelid and the socket lining. Tagliacozzi first used the cross arm flap in 1576 for reconstruction of the nose. It is a fairly thin flap that can be made slightly thicker than a full-thickness skin graft. A cross arm flap lines the socket with a good durable skin that can hold a prosthesis and has minimal tendency to shrink, keeping the socket supple rather than hard. It provides some volume, thereby decreasing the hollowness of the orbit. This is not an optimal choice given the wide variety of other pedicled or free-tissue flaps. It should be viewed as an historical option. The free radial forearm flap is a fasciocutaneous flap and is raised by using a free vascularized skin flap based on radial artery, which may then be anastomosed to the superficial temporal artery or facial artery; the cephalic vein or vena comitans may be anastomosed to the superficial temporal vein or external jugular vein. It provides bulk and augments the contents of the orbital space. However, it does leave a conspicuous scar on the forearm.59 In general, free-tissue transfer can be used when the appropriate conditions warrant. Many different free flaps have been used in the
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orbital region, including the revascularized tensor fascia lata myocutaneous flap, groin flap, dorsalis pedis flap, scapular flap, and latissimus dorsi flap. The selection and design of flaps are determined by the degree of orbital depression, the amount of remnant conjunctiva for the lining, and the amount of healthy palpebral skin. Most free-tissue transfers require additional surgery for debulking, dermal fat grafts, canthopexy, and fascia suspension. Composite flaps may be useful for concomitant reconstruction of bony and soft-tissue deformities. Multiple flaps have been described, including the temporal muscle with the coronoid process, the sixth rib with overlying serratus anterior muscle together with the latissimus dorsi muscle, all based on the thoracodorsal vessels, the iliac crestinternal oblique microsurgical free flap based on deep circumflex iliac vessels, and the osseofasciocutaneous radial forearm free flap.12,23, 50 Composite flaps concomitantly solve the problem of deficiency in both the soft-tissue and bony defects. However, free bone grafts with adequate well-vascularized soft-tissue coverage may serve equally well, with the possible exception of heavily irradiated fields.
Bone reconstruction in the orbit can be provided by autogenous bone or alloplastic material. Autogenous bone can be harvested in the form of a split calvarial bone graft or various osseous free flaps. The advantage of using calvarium is that there is less infection (as with all autogenous bone). One can contour the bone to fit the orbit and restore normal anatomy. Additionally, calvarium has a high resistance to resorption due to its high cortical content. The disadvantage may be the morbidity associated with the harvest; however, there have not been any associated complications in more than 100 such bone grafts in the senior author's experience. Reports of others corroborate our experien~e.~~ As a second choice, there are various osseous free flaps: rib, splitiliac crest, fibula, radial forearm, corticoperiosteal flap from the femur, free scapular flap, and lingual cortical bone of the mandible, which have been previously described. They are indicated when previous irradiation to the head prevents the use of calvarium. They have a higher rate of resorption and infection when used as nonvascularized grafts. Cartilage (nasal septal, conchal, preserved irradiated homologous, and lyophilized dura and cartilage) can be used in certain circumstances to provide support for the orbit. The cartilage substitutes become especially important in middle lamellae reconstructions of the eyelids and periorbital structures.
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A last choice for bone replacement is alloplastic materials. Polyethylene (Medpor [Porex, College Park, GA]) is the most widely used. It does not require harvesting or lead to donor site defects. It is easily cut and contoured to the desired size and shape, and it provides support. For small defects, hydroxyapatite, together with bone meal, antibiotic, and fibrin sealant, has been used. Supramid (Jackson, Inc., Alexandria, VA), Teflon, silicone, polyurethane, methyl methacrylate, and polydioxone are also good for small defects, and these materials are well tolerated. Some are eventually absorbed and replaced by bone. In general, however, these materials are difficult to contour. Metal plates such as titanium, vitallium, and stainless steel mesh have been advocated as good substitutes for bone. Questions of longterm safety and stability currently are being evaluated as well as interference with image quality on CT and MR image scanning.
DURA
Dura is generally not used as a flap, but it requires reconstruction to prevent cerebrospinal fluid leaks. Dural flaps have been described and can be useful in special circumstances, as in irradiated defects in the cranial base d ~ r aThis . ~ allows ~ a well-vascularized flap to be placed in a dependent and relatively inaccessible area to obviate cerebrospinal fluid leaks. The donor site can be reconstructed with more traditional methods. Fascia1 as well as muscular flaps can be used for its reconstructi~n.~~
PEDIATRIC PATIENTS
The goals for children with orbital and periorbital tumors are the same as described for adults: namely, to allow for detection of recurrent disease and restore boundaries between the orbit and the surrounding cavities while maximizing aesthetics and function.36Pediatric cancer resection and reconstruction, however, involve several special considerations. First, as expected, one must be aware of growth patterns and potential. By age 2, the orbit is almost adult size. By age 7, the orbit is full adult size. Second, young children do not have sinuses. Finally, the teeth in the maxillary sinus are under the periosteum, hugging the infraorbital rim. When possible, one must be careful not to damage these structures during resection or dissection. In general, growth disturbances secondary to surgery are related to age.ss The pediatric cranium is much thinner and more pliable than the adult. There is more cancellous than cortical bone. Split grafting is still the first choice, but it is important to consider the age of the child. At
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age 3, the two cortices are defined, and by age 9, in situ split-cranial grafting can be carried out readily. Iliac crest and rib grafts are alternatives. In children, one usually does not use alloplastic materials because long-term consequences of hardware with its affect on growth and any other long-term sequelae are, as yet, unanswered. As with the adult, it is important to be sure that all grafts (bone, rib, or iliac crest) are contoured to the normal orbital dimensions. Proper concavities and convexities obviate dystopia of the globe and subsequent diplopia, when the eyeball is left intact. Incorrect orbital rim contouring adversely affects eyelid function, causing ptosis, lid retraction, or corneal tear film problems. In the older population, cosmesis may not be a priority. Elderly persons are often spared and not offered the multiple-stage repairs that may be required for optimal aesthetic results. Children, on the other hand, with their ability to tolerate surgeries, are often subjected to extensive reconstructive efforts. However, multiple-stage procedures, even in children, may not necessarily result in improved cosmesis. In a study of 14 children who underwent orbital exenteration and radiation for rhabdomyosarcomas and retinoblastoma, it was found that filling the orbit alone produced marked improvement in appearance and occluded existing fistulae. However, further procedures, including a second operation in which orbital rims and eyelids were shaped and a third surgery for creation of a cavity for a static eye prosthesis, did not necessarily Children do not necessarily prefer a prosdecrease the di~figurement.~~ thesis, and so one must consider individual needs before performing multiple procedures to reach a cosmetic goal. CONCLUSION
Advances in the diagnosis of orbital and periorbital tumors are occurring as immunocytochemistry is used to aid in histopathologic studies. Treatment options also may improve as diagnostic modalities that allow better definition of orbitocranial bony and soft-tissue deformi.~~ treatment of these malignant tumors ties are d e ~ e l o p e d Meanwhile, continues to require the expertise of a treatment team composed of surgeons (plastic surgeons, ophthalmologists, neurosurgeons, and otolaryngologic surgeons), medical and radiation oncologists, and individual and family psychological and social supports. References 1. Anderson RL, Jordan DR, Beard C: Full-thickness unipedicle flap for lower eyelid reconstruction. Arch Ophthalmol 106:122-125, 1988
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2. Anderson RL, Edwards JJ: Reconstruction by myocutaneous eyelid flaps. Arch Ophthalmol 972358-2362, 1979 3. Antonyshyn 0 , Gruss JS, Birt BD: Versatility of temporal muscle and fascial flaps. Br J Plast Surg 41:118-131, 1988 4. Ariyan S: Pectoralis major, sternomastoid, and other musculocutaneous flaps for head and neck reconstruction. Clin Plast Surg 789-109, 1980 5. Ariyan S: The pectoralis major for single stage reconstruction of the difficult wounds of the orbit and pharynoesphagus. Plast Reconstr Surg 72:468-477, 1983 6. Beare R: Flap repair following exenteration of the orbit. Proceedings of the Royal Society of Medicine 62:1087-1090, 1969 7. Bonavolonta G: Frontalis muscle transfer in the reconstruction of the exenterated orbit. Adv Ophthalmic Plast Reconstr Surg 9:239-242, 1992 8. Bosniak S, Sachs M, Smith B: Temporalis muscle transfer: A vascular bed for autogenous dermis-fat orbital implantation. Ophthalmology 92:292-296, 1985 9. Carstens MH, Greco RJ, Hurwitz DJ, et al: Clinical application of subgaleal fascia. Plast Reconstr Surg 87:615-626, 1991 10. Chiarelli A, Baldelli A, DiVincenzo A, et al: Utilization of the superficial temporoparietal fascia in reconstructive plastic surgery: A clinical case. ophthal Plast ~ e c i n s tSurg i 5:274-276, 1989 11. Chung KW: Gross Anatomy. Baltimore, William and Wilkins, 1991, pp 297-307 12. Curioni C. Toscano P. Fioretti C. et al: Reconstruction of the orbital floor with the muscle-bone flap (temporal muscle with cornoid process). J Maxillofac Surg 11:263268, 1983 13. Cutler ML, Beard C: A method for partial and total upper lid reconstruction. Am J Ophthalmol 39:l-7, 1955 14. Destro MW, daSilva AL, Speranzini MB: Lower eyelid repair utilizing triangular skin flaps with subcutaneous pedicles. Br J Plast Surg 44363-367, 1991 15. Doermann A, Hauter D, Zook EG, et al: V-Y advancement flaps of tumor excision defects of the eyelids. Ann Plast Surg 22429435, 1989 16. Ellis DS, Toth BA, Stewart WB: Temporoparietal fascial flap for orbital and eyelid reconstruction. Plast Reconstr Surg 89:606-612, 1992 17. Fox SA, Beard C: Spontaneous lid repair. Am J Ophthalmol58:947-952,1964 18. Gaisford JC, Hanna DC: Orbital exenteration. Plast Reconstr Surg 31:363-369, 1963 19. Guerrissi J 0 , Cabouli JL: Upper lid musculocutaneous flap. AM Plast Surg 21:108115, 1988 20. Guyuron B: Retroauricular island flap for eye socket reconstruction. Plast Reconstr Surg 76:527-533, 1985 21. Guyuron B: The role of flaps in the management of the constricted eye sockets. Adv Ophthalmic Plast Reconstr Surg 9:143-157, 1992 22. Habal MB: Aesthetic considerations in the reconstruction of the anophthalmic orbit. Aesthetic Plast Surg 11:229-239, 1987 23. Habal MB, Murray JE: Orbital reconstruction after radical resection. Arch Surg 106:352355, 1973 24. Hargiss JL: Bipedicle tarsoconjunctival flap. Ophthal Plast Reconstr Surg 5:99-103,1989 25. Hewes EH, Sullivan JH, Beard C: Lower eyelid reconstruction by tarsal transposition. Am J Ophthalmol 81:512-514, 1976 26. Holmstrom H, Bartholdson L, Johanson B: Surgical treatment of eyelid cancer with special reference to tarsoconjunctival flaps. Scand J Plast Reconstr Surg Hand Surg 9:107-115, 1975 27. Hughes WH: Reconstruction of the lids. Am J Ophthalmol 28:1203-1211, 1945 28. Janeka IP: Orbital reconstruction. Plast Reconstr Surg 71:20-26, 1983 29. Jordan DR, Anderson RL, Nowinski TS: Tarsoconjunctival flap for upper eyelid reconstruction. Arch Ophthalmol 107:599-603, 1989 30. Kasai K, Ogawa Y, Kyutoko S: Split lamellae switch flap for upper eyelid reconstruction. Ophthal Plast Reconstr Surg 6:126-129, 1990 31. Khan JA: Subcilial lining skin-muscle-flap repair of anterior lamella lower eyelid defects. J Dermatol Surg Oncol 17:167-170, 1991 32. Koornneef L: Orbital septa: Anatomy and function. Ophthalmology 862376-880, 1979
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33. Leone CR, Van Gemert JV: Lower eyelid reconstruction using tarsoconjunctival grafts and bipedicled skin muscle flap. Arch Ophthalmol 107:758-760, 1989 34. Leone CR, Hand SI: Reconstruction of the medial eyelid. Am J Ophthalmol 87797801, 1979 35. Levin ML, Leone CR: Bipedicle myocutaneous flap repair of cicatricial ectropion. Ophthal Plast Reconstr Surg 6:119-121, 1990 36. Levin PS, Ellis DS, Stewart WB, et al: Orbital exenteration: The reconstructive ladder. Ophthal Plast Reconstr Surg 784-92, 1991 37. Marques A, Brenda E, Magrin J, et al: Critical analysis of methods of reconstruction of exenterated orbits. Br J Plast Surg 45:523-528, 1992 38. Matsuo K, Sakaguchi Y, Kiyono M, et al: Lid margin reconstruction with an orbicularis oculi musculocutaneous advancement flap and a conchal cartilage graft. Plast Reconstr Surg 87:142-145, 1991 39. Matsuo K, Kiyono M, Hirose T: Lower eyelid reconstruction with an orbicularis oculi musculocutaneous transposition flap and a conchal cartilage graft. Ophthal Plast Reconstr Surg 6:177-180, 1990 40. Mercer DM: The cervicofacial flap. Br J Plast Surg 41:470474, 1988 41. Montandon D: Extrinsic eyelid ectropion. Ann Plast Surg 26:353-357, 1991 42. Mustarde JC: Eyelid reconstruction. Orbit 1:3343, 1982 43. Ohtsuka H: Eye socket and eyelid reconstruction using the combined island frontal flap and retroauricular island flap: A preliminary report. Ann Plast Surg 20:244-248, 1988 44. Phillips JH, Gruss JS, Wells MD, et al: Periosteal suspension of the lower eyelid and cheek following subciliary exposure of facial fractures. Plast Reconstr Surg 88:145148, 1991 45. Raffaini M, Costa P: The temporoparietal fascial flap in reconstruction of the craniomaxillofacial area. J Craniomaxillofac Surg 22:261-267, 1994 46. Richards MA: Free composite reconstruction of a complex craniofacial defect. Aust N Z J Surg 57:129-132, 1987 47. Rosen HM: The extended trapezius musculocutaneous flap for cranio-orbital facial reconstruction. Plast Reconstr Surg 75:318-327, 1985 48. Savage RC: Orbital exenteration and reconstruction for massive basal cell and squamous cell carcinoma of cutaneous origin. Ann Plast Surg 10:458466, 1983 49. Shaffrey M, Persing JA: Duraplasty and cranial base tumor resection. J Craniofacial Surg 2:152-155, 1991 50. Shenaq SM: Reconstruction of complex cranial and craniofacial defects utilizing iliac crest-internal oblique microsurgical free flap. Microsurgery 9:154-158, 1988 51. Shenoy AM, Nanjundappa, Nayak UK, et al: Scalp flap: A utility. A reconstructive option for head and neck surgeons. J Laryngol Otol 107324-328, 1993 52. Smith B, Obear M: Bridge flap technique for large upper lid defects. Plast Reconstr Surg 38:45-88, 1966 53. Smith B: Eyelid surgery. Surg Clin North Am 39:367-378, 1959 54. Speculand B: The origin of the temporalis muscle flap. Br J Oral Maxillofac Surg 30:390-392, 1992 55. Spinelli HM, Criscuolo GR, Tripps M, et al: Massive congenital orbital teratoma in the newborn. Ann Plast Surg 31:453458, 1993 56. Spinelli HM, Jelks GW: Periocular reconstruction: A systematic approach. Plast Reconstr Surg 91:1017-1024,1993 57. Spinelli HM, Persing JA, Walser B: Reconstruction of the cranial base. Clin Plast Surg 22:555-561, 1995 58. Spinelli HM: Reconstruction of the upper cranial and cranial base defects utilizing the scalping flap. Presented at the 12th Annual Meeting of the Northeastern Society of Plastic Surgeons. Boston, November 3-5, 1995 59. Tahara S, Susuki T: Eye socket reconstruction with free radial forearm flap. Ann Plast Surg 23:112-116, 1989 60. Teichgraeber JF: Temporoparietal fascial flap in orbital reconstruction. Laryngoscope 103:931-935, 1993 61. Toth B, Di Loreto DA, Stewart WB: Multidisciplinary approach to the management of
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complex bony and soft tissue orbitocranial disorders. Ophthalmology 95:1013-1026, 1988 van der Meulen JC: Reconstruction of the medial half of the lower eyelid using a "switch" split lid procedure. Plast Reconstr Surg 88:718-722, 1991 Wexler MR, Peled I, Kaplan H: Socket reconstruction using cross arm flaps. Plast Reconstr Surg 68:18-22, 1981 Whitnall SE: Anatomy of the Human Orbit and the Accessory Organs of Vision. London, Oxford University Press, 1932 Wolfe E: Anatomy of the Eye and Orbit. Philadelphia, WB Saunders, 1968 Wolfe SA: Application of craniofacial surgical precepts in orbital reconstruction following trauma and tumour removal. Journal of Maxillofacial Surgery 10:212-223, 1982 Yoshimura Y, Nakajima T, Yoneda K: Reconstruction of the entire upper eyelid area with a subcutaneous pedicle flap based on the orbicularis oculi muscle. Plast Reconstr Surg 88:136-139, 1991 Zide BM, Jelks GW: Surgical Anatomy of the Orbit. New York, Raven Press, 1985
Address reprint requests to Henry M. Spinelli, MD 830 Park Avenue New York, NY 10021