Soft Tissue Microvascular Reconstruction of Orbital Exenteration Defects

Abstract

The main goal of head and neck reconstruction is the restoration of form and function. Oncologic surgery makes this process more complex, as the preplanned defect can be very different from its intraoperative counterpart. This emphasizes the role of preoperative planning and a diverse reconstructive “tool box” that can accommodate a variety of complicated defects. The other reconstructive goals are determined by the patient with the aid of an interdisciplinary team. While multiple local and regional reconstructive options are available, free tissue transfer provides a versatile and reliable option for reconstruction—especially for complex orbital defects. Here the authors discuss free soft tissue transfer options for orbital exenteration. This review will catalog the advantages and disadvantages of the radial forearm, rectus abdominis, latissimus, and anterolateral thigh.

Orbital Extenteration Defects: Ablative and Reconstructive Flowchart Proposal

“…Orbital exenteration type IIIt requires the closure of the palate; the medial wall of the maxilla often needs to be restored to maintain an adequate airway; and the extensive external defect, which can involve the eyelids, cheek, and occasionally the lip, needs to be reconstructed. Free transverse rectus abdominis myocutaneous (fTRAM) flap, if the external skin of the cheek is intact, could be used to close the palate with a second skin island to restore the lateral nasal wall 40,41. Even the latissimus dorsi free flap can be used to fill the orbital cavity, seal the palate, and recontour the soft tissue of the face and cheek length 42.…”

Anterior skull base reconstruction: a contemporary review

“…This approach is beneficial among patients with prior skull base surgery and/or radiation [15] , given the independent blood supply from a healthy donor site [2] . The vasculature of free tissue transfer can withstand adjuvant radiation therapy and improve healing [15,23] . It is also particularly useful for complex orbitofacial defects, as they may require restoration of the bony contour, soft tissue volume of the orbit, and an external skin paddle for facial restoration, in addition to a watertight coverage of the skull base [24][25][26] .…”

“…This vascular supply can also be beneficial in the setting of previously failed reconstructions or irradiation to the neck [66] . Other potential recipient vessels that have been described based on cadaveric studies include the superior trochlear system [23] . and the third segment of the maxillary artery [67] .…”

“…Reyes et al [23] reported an average diameter of 2.5 mm 2 for the superior trochlear artery in six cadavers, which was then anastomosed to a fascia lata free flap for ASB reconstruction. The superior trochlear vessels were isolated via a Lynch incision and the fascia lata pedicle was then tunneled through a radix osteotomy [23] . This novel technique could be a feasible option for complex skull base defects especially in salvage cases but further in vivo studies are warranted.…”

Reconstructive options following orbital exenteration

“…For larger resections involving significant surrounding soft tissue, especially in the setting of periorbital skin cancers, free tissue transfer is often necessary for adequate reconstruction. Fasciocutaneous free flaps, like radial forearm free flaps, offer thin, pliable, and reliable tissue for reconstruction [6] . Both regional and free flaps facilitate safe, vascularlized wounds, able to withstand postoperative radiation.…”