Tumi Flap: A Novel Modification to Frontal Flap for Orbital Exenteration Defects.

Orbital exenteration remains a significant disfigurement in the face. Many reconstructive options were reported for one stage covering the defects. Local flaps are used primarily in elderly patients who are not candidates for microvascular procedures. Local flaps generally close the gap without achieving 3-dimensional adjustment perioperatively. Secondary procedures or shrinking by time are needed for better orbital adaptation. In this case report, we describe a novel frontal flap design influenced by a Tumi knife, an ancient Peruvian trepanation instrument. The design helps us to create a conic shape that can resurface the orbital cavity at the time of the operation.

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

INTRODUCTION: Malignant orbital diseases may lead surgeons to practice an orbital exenteration associated with chemotherapy and/or radiotherapy to ensure curative treatment. That radical procedure makes physicians consider reconstructive filling in order to allow prothesis wearing and reduce esthetic and social after-effects. We first describe the clinical case of a 6-year-old patient who presented an orbital rhabdomyosarcoma and underwent an orbital exenteration with immediate reconstruction by a superficial temporal pedicled on the middle temporalis muscle flap. TECHNICAL NOTE: Through that case-report, we propose an original temporal flap to repair ipsilateral midface defects which may reduce donor site side effects and allow furthers corrections. DISCUSSION: In pediatrics cases, our Carpaccio flap was an available regional tool to rehabilitate an irradiated orbital socket with an appropriate bulking and vascularization effect after subtotal exenteration. Furthermore, we prescribe that flap as a posterior orbital filling, when eyelid and conjunctiva are spared, to prepare orbital prosthesis implementation. A mild sunken temporal fossa appears with our procedure but by preserving the deep layer of the temporalis muscle, autologous reconstruction such as lipofilling are permitted in post-radiotherapy condition to enhance esthetic sequelae.

Orbital Extenteration Defects: Ablative and Reconstructive Flowchart Proposal.

ABSTRACT: Orbital exenteration is a radical and disfiguring operation. It is still under debate the absence of correlation between the term describing the resulting orbital defect and the type of reconstruction. Authors' goal was to propose a consistent and uniform terminology for Orbital Exenteration surgery in anticipation of patients' tailored management. Twenty-five patients who underwent orbital exenteration between 2014 and 2020 were reviewed. A parallel comprehensive literature review was carried on. Five different types of orbital exenteration where outlined. Multiple reconstructive procedures were enclosed. An algorithm for orbital reconstruction was proposed based on anatomic boundaries restoration. Eyelid removal was first considered as an independent reconstructive factor, and both orbital roof and floor were indicated as independent reconstructive goals, which deserve different defect classification. In our opinion, this algorithm could be a useful tool for patient counseling and treatment selection, which might allow a more tailored patient care protocol. LEVEL OF EVIDENCE: Level III.

Orbital Exenteration for Advanced Periocular Adnexal Malignancies: Curative Versus Palliative Surgical Intent.

PURPOSE: To evaluate the survival benefit of orbital exenteration in periocular malignancy, taking account of preoperative intent. PATIENTS AND METHODS: Patients undergoing exenteration had retrospective chart review for demographics, clinical features, radiology, histology, and outcome. Based on systemic tumor status, the patient was either "Class I" (with absent or well-controlled systemic disease) or "Class II" (incurable active metastatic disease), and based on the extent of orbital disease and exenteration intent , was classed as either "Group A" (locally curative) or "Group B" (locally palliative). RESULTS: One hundred thirty-three patients (78 females; 59%) underwent exenteration at an average age of 61 years (median 64; range 5-91) for sebaceous, squamous and basal cell carcinomas, or for melanoma (22%, 19%, 11%, and 28%, respectively). There were 20% systemically incurable patients (26/133; Class II), and incurable local disease ("Group B") in 5% (5/107) of Class I and 15% (4/26) Class II patients. The overall survival (OS) was 88% at 12 months, 57% at 5 years, and 41% at 10 years, prognosis being worse with age more than 70 years ( p = 0.005), prior local radiotherapy ( p = 0.005) or positive resection margins ( p = 0.002). The mean OS for Type IA exenteration (145 months; 95% CI 122-168) was significantly different to 50 months for Type IB (95% CI 22-79; p = 0.02); likewise, OS for Type IIA procedures (31 months; 95% CI 11-51) was different to Type IIB (19 months; 95% CI 2-36) ( p = 0.001). CONCLUSION: Exenteration confers a significant survival with advanced periocular malignancies, even in patients with uncontrollable systemic disease, or where the local disease is deemed incurable.

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

ABSTRACT: The conventional procedure of anterior orbital exenteration is unfavorable for eye socket reconstruction, whereas a modified procedure enables socket reconstruction and prosthesis fitting. Our study aims to compare the cosmetic outcomes between these 2 surgical techniques.We retrospectively recruited patients treated with modified or conventional exenteration during January 2015 to May 2021 in our hospital. The conventional approach was performed along with dermis-fat graft transplantation. The modified approach was conducted followed by eye socket reconstruction and eyelid blepharoplasty. The clinical data were collected and analyzed, including demographics, tumor characteristics, postoperative complications, tumor-related events, and cosmetic outcomes.Forty-nine patients were consecutively recruited in this study, including 22 cases of modified exenteration and 27 cases of conventional exenteration. Forty-four subjects (89.8%) were diagnosed with ocular surface malignancies (conjunctival melanoma and squamous cell carcinoma) and 5 subjects (10.2%) were diagnosed with extraocular stage of uveal melanoma. After follow-up for 31.8 ±â€Š17.1 months, the 1-, 2-, 5-year overall survival rate was calculated as 100%, 79.2%, and 59.2% in the Modified group, and 94.2%, 73.8%, and 51.5% in the Conventional group. Comparison of the survival curves showed no significant differences. In the Modified group, all patients received orbital implant placement and eye socket reconstruction. The implant motility was satisfactory in 12 cases (54.5%) with movements in 3 to 4 directions. The eyelid function was acceptable in 17 cases (77.3%) with no entropion, ectropion or lower lid laxity. Ocular prosthesis was delivered in 17 cases (77.3%) with successful fitting in 11 cases (64.7%). The self-rated cosmetic score was statistically (t test, P < .0001) higher in the Modified group (6.7 ±â€Š0.9) than the Conventional group (2.2 ±â€Š0.4).The modified approach to anterior orbital exenteration enables eye socket reconstruction and cosmetic rehabilitation while still preserves the curable chance for the treatment of advanced periocular/intraocular malignancies.

The combined coronal-transconjunctival approach: an innovative surgical access for orbital exenteration in craniofacial resection.

Malignant tumours arising in the paranasal sinuses or maxilla usually spread to the surrounding regions. The skull base and the anterior cranial fossa are frequently affected as well. When the resection of a tumour involves an orbital exenteration, a transconjunctival-perilimbic incision can be added to a coronal approach in order to preserve the eyelids and the conjunctiva, avoiding cutaneous midfacial incisions. Patients with a diagnosis of malignant tumour affecting the orbit, upper jaw, paranasal sinuses, and/or anterior skull base were eligible for this technique. Tumoural invasion of the eyelids, conjunctiva, lacrimal system, or surrounding skin was considered a contraindication for this technique. A retrospective study of the clinical records was performed and age, type of tumour, location, and reconstructive technique were evaluated. Eight patients referred to the study department between 2015 and 2019 were selected. All patients underwent craniofacial surgery and orbital exenteration. The transconjunctival-perilimbic approach was combined with a coronal incision in all cases. In our experience, the transconjunctival-perilimbic approach to orbital exenteration proposed in this paper can be used successfully in skull base surgery. Combined with a coronal and transmandibular approach, it allows wide access to the facial skeleton/anterior skull base while avoiding skin incisions in the midface.

[Reconstruction of orbital exenteration defects: about 20 cases]. / Couverture des cavités d´exentération: à propos de 20 cas.

The face is social support. Eyes allow the individual to interact with the environment and others. Orbital exenteration defects are the results of extreme disfiguring surgery, leading to functional, aesthetic and psychological sequelae. Reconstruction is essential and must meet several objectives: filling the cavity and closing any communications with the adjacent structures, obtaining rapid healing, allowing for local monitoring and finally enabling patients to reintegrate into society and achieve a satisfactory quality of life. We here present our experience in filling and reconstructing these cavities. Our study involved 20 patients with orbital exenteration defects over a period of 5 years (February 2015-February 2020). We analyzed the epidemiological features, clinical profile, and methods of the reconstruction as well as patients´ outcomes in our hospital. The average age of patients was 58.5 years. Squamous cell carcinoma was the main histological type, followed by basal cell carcinoma. Filling techniques included directed wound healing (7 cases), temporalis fascia flap (2 cases), temporalis muscle flap (10 cases). Methods of reconstruction included directed wound healing (6 cases), full-thickness skin graft (1 case), mediofrontal flap (6 cases; alone or associated with the temporalis muscle), converse scalping flap in three cases. Free latissimus dorsi flap was used in two cases. Thirteen patients showed good outcomes, with good healing after an average follow-up period of 9 months. The most common complication was infection and suture release. Two patients were lost to follow-up. Orbital exenteration defects can be approached in many ways. Temporalis muscle flap has been shown to be a robust and safe choice as well as an excellent filling solution. Prostheses are an aesthetic but expensive solution that should be developed in our hospital.

Orbital exenteration for conjunctival melanoma: comparison of long-term outcome between individualised and conventional techniques.

BACKGROUND: Growing evidence supports an individualised approach rather than radical surgery for conjunctival melanoma (CM). This study aimed to compare the long-term outcome between individualised and conventional exenteration techniques. METHODS: Our study retrospectively recruited advanced CM (clinical T3 stage) patients treated with individualised (13 cases) or conventional (18 cases) exenteration from June 2014 to April 2019. The individualised approach preserved at least three quadrants of the orbit, and the conventional procedures removed at least one third of the orbital tissues. The medical records were collected and analyzed during April 2020, including demographics, tumour characteristics, surgical details, postoperative rehabilitation and tumour-related prognosis. RESULTS: The tumour basal diameter was statistically (P = 0.011) larger in the conventional group (23.3 ± 7.6 mm) than in the individualised group (15.4 ± 6.3 mm). More tissues were preserved in the individualised group, resulting in a shorter duration of wound healing (2.1 ± 0.6 vs. 3.6 ± 2.0 weeks, P = 0.018) and less incidence of hollow appearance (15% vs. 72%, P = 0.003) than the conventional group. After follow-up for 39.3 ± 17.3 months, a comparison of survival curves showed no significant differences (P = 0.638) between the two groups. The 1- and 2-year overall survival rates were estimated as 100% and 80.0% in the individualised group, and 93.8% and 72.5% in the conventional group, respectively. Low or mixed pigmentation was identified as the risk factor for tumour-related mortality based on multivariate regression analysis. CONCLUSIONS: The individualised approach to exenteration offers improved aesthetic results while still maximises the curable chance for advanced CM.

Orbital exenteration: an updated review with perspectives.

Orbital exenteration is a radical and disfiguring surgery mainly performed in specialized tertiary care centers. Orbital exenteration has long been considered the treatment of choice for managing periocular tumors invading the orbit or primary orbital malignancies. Over the past decades, attention has been directed toward reducing the perioperative morbidity by developing new surgical devices and new strategies and promoting cosmetic rehabilitation by providing adequate facial prostheses. Despite these advances, several studies have questioned the role of orbital exenteration in improving overall survival. The last decade has been marked by the emergence of a new paradigm: the "eye-sparing" strategies based on conservative surgery with or without adjuvant radiotherapy and/or targeted therapies and immunotherapies. We summarize the data on orbital exenteration, including epidemiology, etiologies, use of surgical ablative and reconstructive techniques, complications, outcomes, and the related controversies.

Combined retro-peribulbar and subconjunctival anesthesia for evisceration surgery.

PURPOSE: To evaluate the efficacy of retro-peribulbar and subconjunctival anesthesia associated with intravenous sedation in patients undergoing evisceration and orbital implant placement. METHODS: The charts of 217 patients who underwent evisceration with trans-scleral implant placement were reviewed. Midazolam and fentanyl were used for intravenous sedation. For local anesthesia, a combination of lidocaine with epinephrine and bupivacaine was injected into the retrobulbar, upper peribulbar, and subconjunctival areas. The intraoperative pain and need for supplemental anesthetic injection were recorded prospectively. RESULTS: The surgery was performed with local anesthesia in 116 patients (53%) and with general anesthesia in 101 patients (47%). Patients were significantly older in the local anesthesia group than in the general anesthesia group (mean age, 59.9 years vs 45.2 years; P < .05). Supplemental retrobulbar anesthesia was required in 5 patients (4.3%). Transition to general anesthesia was required in 1 patient (0.9%) due to severe anxiety. Orbital hemorrhage developed after retrobulbar injection in 1 patient (0.9%), but did not preclude performing evisceration. CONCLUSIONS: Combined retro-peribulbar and subconjunctival anesthesia with intravenous sedation can provide safe and effective intraoperative analgesia for evisceration surgery with trans-scleral implant placement.

Reconstruction of exenteration socket with Integra® dermal substitute and skin graft.

The authors report their experience with the use of Integra® dermal substitute, in combination with a thin skin graft, following an orbital exenteration. The clinical case described relates to a 42-year-old gentleman with an ulcerative retractile lesion of the right lower eyelid. Histopathological examination diagnosed a moderately differentiated epidermoid carcinoma infiltrating the orbit. Total exenteration was necessary as well as secondary radiation therapy and chemotherapy. Rehabilitation of the exenterated socket was performed by inserting an Integra® patch, followed by an additional thin skin graft one month later. The authors review the various available techniques for exenterations, their indications and the various possible secondary rehabilitations. Despite being less utilized, the dermal substitute technique, which is relatively new, seems to offer quicker and easier rehabilitation compared to traditional techniques. A comparative study would be necessary to define superiority among the different techniques of exenteration, with respect to the speed of rehabilitation and resistance to radiation therapy.

A surgical approach for extensive orbital exenteration in dogs; a description of technique and its application in 4 cases.

OBJECTIVE: To describe a surgical approach for preplanned orbital exenteration. ANIMALS STUDIED: Indications included intraconal orbital mass lesions. Four dogs were included, 3 with neoplasia and one with retro bulbar nodular fasciitis. PROCEDURE: To facilitate complete removal of lesions, exenteration was performed by a new procedure for wide access. The frontalis and temporalis muscles were elevated and retracted through a single U-shaped skin incision. Zygomatic arch osteotomy was performed, followed by a 360-degree peritomy and zygomatic process osteotomy. The eyelids were divided from each other through the lateral cantus and then folded forward to expose the globe. The orbit was exenterated by blunt and sharp dissection. Osteotomies were closed with cerclage wires, soft tissues closed and the skin wound sutured in a T-shape. RESULTS: The present exenteration procedure gave excellent access to remove orbital contents flush with the optic foramen and orbital fissure. Postoperative swelling and pain were limited and healing uneventful. Two of the 3 neoplasia cases experienced tumor recurrence involving the brain at 18 and 20 months postoperatively, respectively. Both of these had optic canal or intracranial tumor extension preoperatively. Long-term complications included mild concavity of the operated side of the face. CONCLUSIONS: The present approach for preplanned exenteration offers excellent access for complete removal of orbital contents to the level of the optic foramen. Complications due to the surgical method are few and limited.

Primary Orbital Leiomyosarcoma in an Adult Male.

A 71-year-old male presented with a history of noticing gradual painless progressive proptosis along with a pinkish mass seen on the outer aspect of his left eyeball. Orbital CT revealed a fairly defined homogenous lesion, abutting the left eyeball and involving the lateral orbit reaching almost till orbital apex. Histopathology analysis aided with immunohistochemistry after an incision biopsy was consistent with leiomyosarcoma. Positron emission tomography scan ruled out presence of any distant primary or metastatic tumor. He underwent eyelid sparing total orbital exenteration with confirmed tumor free soft-tissue margins. He is doing well at 5 months of follow-up with no sign of local recurrence or distant metastasis. Primary orbital leiomyosarcoma is a rare tumor. It is mainly found in older woman; it is even rarer in males. Complete surgical excision with tumor free margins is the recommended treatment. Histopathology and immunohistochemistry are valuable in diagnosis and management.

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

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

Socket Reconstruction With Bleomycin, Gentamicin, and Gelatin Sponges Following Eyelid-Sparing Orbital Exenteration for a Colobomatous Macrocyst in an Infant.

Microphthalmia is defined by a globe axial length greater than or equal to 2 standard deviations below the age-adjusted mean and can occur as part of a broader syndrome. The presence of a colobomatous cyst with microphthalmia signifies failure of the embryonic neuroectodermal fissure to close appropriately during development of the globe, creating a protuberant globular appendage that inhibits normal growth and development of the eye itself. Cystic reaccumulation of fluid is common after aspiration or surgical removal. Here, the authors describe a case of a young boy with a colobomatous cyst who underwent eyelid-sparing orbital exenteration followed by reconstruction with absorbable gelatin sponge (Gelfoam, Pfizer, Inc.) and the chemotherapeutic agent bleomycin to promote scarring, achieving the equivalent of a biointegrated implant and facilitating satisfactory placement of an ocular prosthesis. A 2-year follow-up MRI revealed adequate volume in the posterior orbit.

Orbital exenteration for sinonasal malignancies: indications, rehabilitation and oncologic outcomes.

PURPOSE OF REVIEW: Review the recent literature regarding the management of orbital invasion in sinonasal malignant tumors. RECENT FINDINGS: There is a recent trend in preserving the orbit in cases of minimal invasion of periosteum and limited periorbit involvement, as well as in presence of good response to neoadjuvant chemotherapy, mainly in squamous cell carcinoma and neuroendocrine histologies. SUMMARY: The decision about orbital exenteration in cases of sinonasal malignancies is facilitated if the patient already has clear clinical signs of intraconal invasion such as visual loss, restriction of ocular mobility or infiltration of the eyeglobe. However, in borderline situations, confirmation of orbital involvement should be performed intraoperatively. In selected cases with minimal orbital invasion without functional compromise, orbit sparing surgery can be done with acceptable oncological outcomes.