Acta Oto-Laryngologica. 2014; 134: 1205–1210
SHORT COMMUNICATION
Dynamic eye socket reconstruction after extensive resection of midfacial malignancies: preliminary results using temporalis transfer
HISASHI MOTOMURA1, HIROYOSHI IGUCHI2, TAKAHARU HATANO1, RIE KOBAYASHI1, DAISUKE SAKAHARA1, NAHO FUJII1 & MARI MINEO1 1
Department of Plastic and Reconstructive Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan and 2Department of Otolaryngology and Head & Neck Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
Abstract The functional and esthetic results of reconstructive surgery after extended total maxillectomy or extended orbital exenteration greatly depend on the quality of the orbital reconstruction. We developed dynamic eye socket reconstruction using temporalis transfer to achieve good orbital reconstruction, and examined the usefulness of our technique. Five patients (three men and two women, aged 44–72 years) who underwent extensive resection of midfacial malignancies were treated with dynamic eye socket reconstruction using temporalis transfer. In most cases, eye socket reconstruction was performed approximately 1 year after the initial surgery, and temporalis transfer was used after maturation of the eye socket. The follow-up period ranged from 16 to 120 months (average 63.8 months). Movement of the upper and lower eyelids was achieved in all cases, and definite creases at the lateral canthus were observed in two patients. A good shape in the reconstructed medial and lateral canthal areas was maintained in all patients. Our reconstruction technique is extremely effective in creating natural creases (‘crow’s feet’) at the lateral canthus during smiling, enabling movement of the upper and lower eyelids, and maintaining a sharp palpebral morphology.
Keywords: dynamic reconstruction, eyelid, maxillectomy, maxillary reconstruction, orbital exenteration
Introduction In reconstructive surgery following extended total maxillectomy or extended orbital exenteration, functional and esthetic results must be the most important concerns for both the surgeon and the patient, and the quality of orbital reconstruction greatly influences the results. We consider it extremely important for the reconstruction to enable movement of the upper and lower eyelids and provide a sharp palpebral morphology. We previously reported two cases in which successful results were obtained with our own technique of dynamic eye socket reconstruction using temporalis transfer [1]. In this study, we describe our technique of dynamic eye socket reconstruction using
temporalis transfer in more detail, and report the preliminary results of the method in a case series including five cases treated in our hospital. Material and methods We performed maxillary reconstruction after extended total maxillectomy in eight patients over the 11-year period from October 2002 to October 2013. Dynamic eye socket reconstruction using temporalis transfer was performed in four of these eight patients (50%; the remaining four died of the underlying disease), and in one more patient who underwent resection for orbital malignancy. The patients undergoing dynamic eye socket reconstruction consisted of three men and two women (age 44–72 years, average 62.2 years) (Table I).
Correspondence: Hisashi Motomura MD, Department of Plastic and Reconstructive Surgery, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan. Tel: +81 6 6645 3892. Fax: +81 6 6646 6059. E-mail: [email protected]
(Received 13 May 2014; accepted 25 June 2014) ISSN 0001-6489 print/ISSN 1651-2251 online 2014 Informa Healthcare DOI: 10.3109/00016489.2014.940555
Male
Male
Female
Female
2
3
4
5
44
63
70
62
72
Age (years)
Orbital cancer
Maxillary cancer
Maxillary cancer
Maxillary cancer
Maxillary cancer
Primary tumor
RAM
RAM
RAM
p-LD
RAM
Resonstruction
0.22
0.30
0.22
0.23
0.19
Lid closure rate
p-LD: pedicled latissimus dorsi flap; RAM: rectus abdominis myocutaneous flap.
Male
Sex
1
Case no.
Table I. Summary of the case series.
23
66
16
94
120
Follow-up period (months)
Fair
Excellent
Excellent
Good
Good
Patient satisfaction Preoperative finding
Post operative finding
1206 H. Motomura et al.
Results of dynamic eye socket reconstruction
1207
d
a
Flap
Reconstructed hard tissue
e
b Scaphoid fossa cartilage
Scapha composite graft
c
Figure 1. Schema of our strategy for eye socket reconstruction following extended total maxillectomy. (a) Our usual procedure is a single-stage reconstruction that uses a rectus abdominis myocutaneous free flap combined with vascularized costal cartilage. If it is difficult to perform a single-staged reconstruction using an osteocutaneous flap because of space problems or other considerations, we then perform a two-stage hard tissue reconstruction using an artificial bone implant [4]. (b) Eye socket reconstruction is carried out in the secondary operation, approximately 1 year after the initial operation. The posterior lobe of the eye socket is reconstructed with the scapha composite graft and a skin paddle of rectus abdominis myocutaneous free flap. (c) The anterior lobe is reconstructed with a malar flap and a remnant of upper eyelid. (d) No functioning muscle is present in the vicinity of a scapha composite graft, leading to sagging and loss of contact with the eye prosthesis postoperatively, and often deformity associated with repeated insertion and removal of the eye prosthesis. We then performed an innervated muscle transfer through a zigzag incision in the temporal region in the third operation. (e) We performed a temporalis transfer using the method reported by Andersen [2] as a dynamic reconstruction of the upper and lower eyelids.
In most cases, we performed eye socket reconstruction (Figure 1) approximately 1 year after the initial postmaxillectomy facial reconstruction. We then performed a temporalis transfer using the methods reported by Andersen [2] between 4 and 9 months (mean 6.5 months) later. We make a zigzag incision in the temporal region, and use a segment of the temporalis muscle slightly anterior to the midportion, including the anterior deep temporal nerve. At the lateral canthus, to produce wrinkles (so-called ‘crow’s feet’ [3,4]), we undermine a superficial layer, and where possible, place the body of the temporalis muscle. With the base at approximately 30
superolateral to the lateral canthus, we guide the reflected muscle fascia directly over the scaphoid fossa cartilage transplanted on the upper and lower eyelids, and pass it medially. For the medial canthus, we can use the fixed part from the orbital reconstruction, but in patients with preoperative looseness, we refix the temporalis muscle to the deep cranial region. As with procedures in patients with facial palsy, we adjust the tension so that the upper and lower eyelids overlap by approximately 2 mm, with the lower eyelid tension the stronger of the two. After the surgery, we train the patients to consciously bite down when they wish to smile.
1208
H. Motomura et al.
a
b
Figure 2. Definition of the lid closure rate. a = distance between the upper and lower eyelids when the eye is open; b = distance between the upper and lower eyelids when the eye is closed. a = distance between the upper and lower eyelids when the eye is open; b = distance between the upper and lower eyelids when the eye is closed. The lid closure rate is calculated by (a–b)/a.
On postoperative photographs, the distance between the upper and lower eyelids along the center line of the pupil of the artificial eye was measured when the eye was opened and closed. The lid closure rate was defined and calculated as follows: (distance between the upper and lower eyelids when the eye is opened – distance between the upper and lower eyelids when the eye is closed)/ (distance between the upper and lower eyelids when the eye is opened) (Figure 2). Accordingly, if the eye is completely opened, the value would be 1, whereas if there is no movement, the value would be 0. Moreover, the degree of patient satisfaction after our reconstruction method was evaluated according to the following four categories; (1) excellent: patients can go out without any covering, (2) good: patients can go out with a pair of sunglasses, (3) fair: patients can go out with some gauze covering, and (4) poor: patients cannot go out. Ethical approval We made an effort to preserve patients’ privacy in our figures, and obtained informed consent. The patients have seen and agreed to the submitted version of the paper. Results The follow-up periods ranged from 16 to 120 months (average 63.8 months). No acute complications occurred postoperatively in any patients, and healing was rapid in all cases. Although definite creases at the lateral canthus, so-called crow’s feet, could be seen in only two patients when they smiled, movement of both upper and lower eyelids was achieved in all cases. The lid closure rate was 0.19–0.30 (mean 0.232). Sharp morphology of the upper and lower eyelids was maintained in all patients. Four of five patients (80%) no longer needed any eye covering in their daily life. The degree of patient satisfaction was excellent in two patients, good in two, and fair in one patient.
Case presentations Case 5 (Figure 3). A 44-year-old woman with a T4N1M0 cancer of the right lower eyelid underwent an extended orbital exenteration with resection of both eyelids. She simultaneously underwent a singlestage reconstruction using a rectus abdominis myocutaneous free flap. One year postoperatively, atrophy of the transplanted rectus abdominis muscle was thought to have been completed, and we performed a secondary orbital reconstruction. However, the eye socket became deformed postoperatively, so we performed a temporalis transfer procedure 1 year after the orbital reconstruction. The lid closure rate was 0.22. Approximately 2 years after the final procedure, the patient was able to maintain a sharp morphology of eyelids, and movement of both upper and lower eyelids was achieved. Case 2. A 62-year-old man presented with squamous cell carcinoma arising from the right maxillary sinus. A pedicled latissimus dorsi myocutaneous flap was used for reconstruction after right extended total maxillectomy. After the transplanted tissue had stabilized 1 year after the first procedure, he underwent orbital reconstruction and zygomaticomaxillary buttress reconstruction using artificial bone [5]. Furthermore, 6 months after the orbital reconstruction and artificial bone transplantation, the patient underwent a temporalis transfer procedure as a dynamic reconstruction of the upper and lower eyelids. The lid closure rate was 0.23. Approximately 8 years after the final procedure, he is still able to produce creases (crow’s feet) at the outer canthus, and the orbit has also maintained its shape (Figure 4). Discussion The reconstruction of a midfacial defect following extended total maxillectomy or extended orbital exenteration can represent a formidable challenge for
Results of dynamic eye socket reconstruction a
b
c
d
1209
Figure 3. Treatment progress of case 5. (a) A 44-year-old woman underwent an extended orbital exenteration with resection of both eyelids for a T4N1M0 right lower eyelid cancer. She simultaneously underwent a single-stage reconstruction using a rectus abdominis myocutaneous free flap. (b) One year postoperatively, we performed a secondary eye socket reconstruction with bilateral scapha composite grafts. However, the eye socket became deformed postoperatively. (c) Sequential view of the dynamic eye socket reconstruction using temporalis transfer. (d) Postoperative findings. The patient was able to maintain a sharp palpebral morphology throughout the follow-up period.
a
b
Figure 4. Final results of case 2. (a) Sharp morphology of the upper and lower eyelids was achieved in neutral position. (b) When the patient smiles, definite creases (crow’s feet) at the lateral canthus can be seen (arrows).
reconstructive plastic surgeons. When performing reconstruction following resection of midfacial malignancies, surgeons have to consider not only functional but also esthetic results in order to avoid impairing the quality of life of the patients [6]. It has been difficult to achieve satisfactory results with previously described reconstruction methods after an extended total maxillectomy along with resection of the upper and lower eyelids, because of the lack of functioning muscles in the reconstructed eyelids. We previously introduced our dynamic eye socket reconstruction method using temporalis transfer. This method is characterized by reconstruction of an eye socket with functioning muscles. With this technique, the following four benefits can be achieved: (1) formation of natural creases at the lateral canthus (crow’s feet) during smiling, (2) movement of both upper and lower eyelids, (3) approximation of the eye prosthesis and eyelid posterior lamella, and (4) long-term maintenance of a sharp palpebral morphology [1,7]. Regarding surgical timing, temporalis transfer can be performed at the same time as the orbital reconstruction; however,
appropriate adjustments are required, so we consider it preferable to wait for maturation of the reconstructed eye socket. Although a mean eyelid closure rate of 0.232 in this case series might not be considered a satisfactory result, the aforementioned benefits were achieved at this value, and it is important to continue to maintain this level. Both functional and esthetic results tended to improve with time in all patients, probably because patients get used to intensive daily training, as with temporalis transfer following facial nerve palsy. In conclusion, the reconstruction method we describe here is an extremely useful technique for orbital reconstruction following extended total maxillectomy with resection of both eyelids, and we currently use this method for all patients who need orbital reconstruction following extended total maxillectomy. In the future, we plan to treat more cases with our dynamic reconstruction method, thus allowing opening and closing of the upper and lower eyelids. Further, we will seek optimal reconstruction procedures that can improve the quality of life of patients after extended surgery for maxillary cancers.
1210
H. Motomura et al.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References [1] Motomura H, Hatano T, Kobayashi R, Sakahara D, Fujii N, Mineo M. Dynamic eye socket reconstruction after extended total maxillectomy using temporalis transfer. J Plast Reconstr Aesthet Surg 2014;67:e78–80. [2] Andersen JG. Surgical treatment of lagophthalmos in leprosy by the Gillies temporalis transfer. Br J Plast Surg 1961;14: 339–45.
[3] Kligman AM, Zheng P, Lavker RM. The anatomy and pathogenesis of wrinkles. Br J Dermatol 1985;113:37–42. [4] Fogli A. Orbicularis oculi muscle and crow’s feet. Pathogenesis and surgical approach. Ann Chir Plast Esthet 1992;37:510–18. [5] Motomura H, Iguchi H. Simple maxillary reconstruction following total maxillectomy using artificial bone wrapped with vascularized tissue: five key points to ensure success. Acta Otolaryngol 2012;132:887–92. [6] Cordeiro PG, Chen CM. A 15-year review of midface reconstruction after total and subtotal maxillectomy: part II. Technical modifications to maximize aesthetic and functional outcomes. Plast Reconstr Surg 2012;129:139–47. [7] Hashikawa K, Terashi H, Tahara S. Therapeutic strategy for the triad of acquired anophthalmic orbit. Plast Reconstr Surg 2007;119:2182–8; discussion 2189–91.
Copyright of Acta Oto-Laryngologica is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
SHORT COMMUNICATION
Dynamic eye socket reconstruction after extensive resection of midfacial malignancies: preliminary results using temporalis transfer
HISASHI MOTOMURA1, HIROYOSHI IGUCHI2, TAKAHARU HATANO1, RIE KOBAYASHI1, DAISUKE SAKAHARA1, NAHO FUJII1 & MARI MINEO1 1
Department of Plastic and Reconstructive Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan and 2Department of Otolaryngology and Head & Neck Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
Abstract The functional and esthetic results of reconstructive surgery after extended total maxillectomy or extended orbital exenteration greatly depend on the quality of the orbital reconstruction. We developed dynamic eye socket reconstruction using temporalis transfer to achieve good orbital reconstruction, and examined the usefulness of our technique. Five patients (three men and two women, aged 44–72 years) who underwent extensive resection of midfacial malignancies were treated with dynamic eye socket reconstruction using temporalis transfer. In most cases, eye socket reconstruction was performed approximately 1 year after the initial surgery, and temporalis transfer was used after maturation of the eye socket. The follow-up period ranged from 16 to 120 months (average 63.8 months). Movement of the upper and lower eyelids was achieved in all cases, and definite creases at the lateral canthus were observed in two patients. A good shape in the reconstructed medial and lateral canthal areas was maintained in all patients. Our reconstruction technique is extremely effective in creating natural creases (‘crow’s feet’) at the lateral canthus during smiling, enabling movement of the upper and lower eyelids, and maintaining a sharp palpebral morphology.
Keywords: dynamic reconstruction, eyelid, maxillectomy, maxillary reconstruction, orbital exenteration
Introduction In reconstructive surgery following extended total maxillectomy or extended orbital exenteration, functional and esthetic results must be the most important concerns for both the surgeon and the patient, and the quality of orbital reconstruction greatly influences the results. We consider it extremely important for the reconstruction to enable movement of the upper and lower eyelids and provide a sharp palpebral morphology. We previously reported two cases in which successful results were obtained with our own technique of dynamic eye socket reconstruction using temporalis transfer [1]. In this study, we describe our technique of dynamic eye socket reconstruction using
temporalis transfer in more detail, and report the preliminary results of the method in a case series including five cases treated in our hospital. Material and methods We performed maxillary reconstruction after extended total maxillectomy in eight patients over the 11-year period from October 2002 to October 2013. Dynamic eye socket reconstruction using temporalis transfer was performed in four of these eight patients (50%; the remaining four died of the underlying disease), and in one more patient who underwent resection for orbital malignancy. The patients undergoing dynamic eye socket reconstruction consisted of three men and two women (age 44–72 years, average 62.2 years) (Table I).
Correspondence: Hisashi Motomura MD, Department of Plastic and Reconstructive Surgery, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan. Tel: +81 6 6645 3892. Fax: +81 6 6646 6059. E-mail: [email protected]
(Received 13 May 2014; accepted 25 June 2014) ISSN 0001-6489 print/ISSN 1651-2251 online 2014 Informa Healthcare DOI: 10.3109/00016489.2014.940555
Male
Male
Female
Female
2
3
4
5
44
63
70
62
72
Age (years)
Orbital cancer
Maxillary cancer
Maxillary cancer
Maxillary cancer
Maxillary cancer
Primary tumor
RAM
RAM
RAM
p-LD
RAM
Resonstruction
0.22
0.30
0.22
0.23
0.19
Lid closure rate
p-LD: pedicled latissimus dorsi flap; RAM: rectus abdominis myocutaneous flap.
Male
Sex
1
Case no.
Table I. Summary of the case series.
23
66
16
94
120
Follow-up period (months)
Fair
Excellent
Excellent
Good
Good
Patient satisfaction Preoperative finding
Post operative finding
1206 H. Motomura et al.
Results of dynamic eye socket reconstruction
1207
d
a
Flap
Reconstructed hard tissue
e
b Scaphoid fossa cartilage
Scapha composite graft
c
Figure 1. Schema of our strategy for eye socket reconstruction following extended total maxillectomy. (a) Our usual procedure is a single-stage reconstruction that uses a rectus abdominis myocutaneous free flap combined with vascularized costal cartilage. If it is difficult to perform a single-staged reconstruction using an osteocutaneous flap because of space problems or other considerations, we then perform a two-stage hard tissue reconstruction using an artificial bone implant [4]. (b) Eye socket reconstruction is carried out in the secondary operation, approximately 1 year after the initial operation. The posterior lobe of the eye socket is reconstructed with the scapha composite graft and a skin paddle of rectus abdominis myocutaneous free flap. (c) The anterior lobe is reconstructed with a malar flap and a remnant of upper eyelid. (d) No functioning muscle is present in the vicinity of a scapha composite graft, leading to sagging and loss of contact with the eye prosthesis postoperatively, and often deformity associated with repeated insertion and removal of the eye prosthesis. We then performed an innervated muscle transfer through a zigzag incision in the temporal region in the third operation. (e) We performed a temporalis transfer using the method reported by Andersen [2] as a dynamic reconstruction of the upper and lower eyelids.
In most cases, we performed eye socket reconstruction (Figure 1) approximately 1 year after the initial postmaxillectomy facial reconstruction. We then performed a temporalis transfer using the methods reported by Andersen [2] between 4 and 9 months (mean 6.5 months) later. We make a zigzag incision in the temporal region, and use a segment of the temporalis muscle slightly anterior to the midportion, including the anterior deep temporal nerve. At the lateral canthus, to produce wrinkles (so-called ‘crow’s feet’ [3,4]), we undermine a superficial layer, and where possible, place the body of the temporalis muscle. With the base at approximately 30
superolateral to the lateral canthus, we guide the reflected muscle fascia directly over the scaphoid fossa cartilage transplanted on the upper and lower eyelids, and pass it medially. For the medial canthus, we can use the fixed part from the orbital reconstruction, but in patients with preoperative looseness, we refix the temporalis muscle to the deep cranial region. As with procedures in patients with facial palsy, we adjust the tension so that the upper and lower eyelids overlap by approximately 2 mm, with the lower eyelid tension the stronger of the two. After the surgery, we train the patients to consciously bite down when they wish to smile.
1208
H. Motomura et al.
a
b
Figure 2. Definition of the lid closure rate. a = distance between the upper and lower eyelids when the eye is open; b = distance between the upper and lower eyelids when the eye is closed. a = distance between the upper and lower eyelids when the eye is open; b = distance between the upper and lower eyelids when the eye is closed. The lid closure rate is calculated by (a–b)/a.
On postoperative photographs, the distance between the upper and lower eyelids along the center line of the pupil of the artificial eye was measured when the eye was opened and closed. The lid closure rate was defined and calculated as follows: (distance between the upper and lower eyelids when the eye is opened – distance between the upper and lower eyelids when the eye is closed)/ (distance between the upper and lower eyelids when the eye is opened) (Figure 2). Accordingly, if the eye is completely opened, the value would be 1, whereas if there is no movement, the value would be 0. Moreover, the degree of patient satisfaction after our reconstruction method was evaluated according to the following four categories; (1) excellent: patients can go out without any covering, (2) good: patients can go out with a pair of sunglasses, (3) fair: patients can go out with some gauze covering, and (4) poor: patients cannot go out. Ethical approval We made an effort to preserve patients’ privacy in our figures, and obtained informed consent. The patients have seen and agreed to the submitted version of the paper. Results The follow-up periods ranged from 16 to 120 months (average 63.8 months). No acute complications occurred postoperatively in any patients, and healing was rapid in all cases. Although definite creases at the lateral canthus, so-called crow’s feet, could be seen in only two patients when they smiled, movement of both upper and lower eyelids was achieved in all cases. The lid closure rate was 0.19–0.30 (mean 0.232). Sharp morphology of the upper and lower eyelids was maintained in all patients. Four of five patients (80%) no longer needed any eye covering in their daily life. The degree of patient satisfaction was excellent in two patients, good in two, and fair in one patient.
Case presentations Case 5 (Figure 3). A 44-year-old woman with a T4N1M0 cancer of the right lower eyelid underwent an extended orbital exenteration with resection of both eyelids. She simultaneously underwent a singlestage reconstruction using a rectus abdominis myocutaneous free flap. One year postoperatively, atrophy of the transplanted rectus abdominis muscle was thought to have been completed, and we performed a secondary orbital reconstruction. However, the eye socket became deformed postoperatively, so we performed a temporalis transfer procedure 1 year after the orbital reconstruction. The lid closure rate was 0.22. Approximately 2 years after the final procedure, the patient was able to maintain a sharp morphology of eyelids, and movement of both upper and lower eyelids was achieved. Case 2. A 62-year-old man presented with squamous cell carcinoma arising from the right maxillary sinus. A pedicled latissimus dorsi myocutaneous flap was used for reconstruction after right extended total maxillectomy. After the transplanted tissue had stabilized 1 year after the first procedure, he underwent orbital reconstruction and zygomaticomaxillary buttress reconstruction using artificial bone [5]. Furthermore, 6 months after the orbital reconstruction and artificial bone transplantation, the patient underwent a temporalis transfer procedure as a dynamic reconstruction of the upper and lower eyelids. The lid closure rate was 0.23. Approximately 8 years after the final procedure, he is still able to produce creases (crow’s feet) at the outer canthus, and the orbit has also maintained its shape (Figure 4). Discussion The reconstruction of a midfacial defect following extended total maxillectomy or extended orbital exenteration can represent a formidable challenge for
Results of dynamic eye socket reconstruction a
b
c
d
1209
Figure 3. Treatment progress of case 5. (a) A 44-year-old woman underwent an extended orbital exenteration with resection of both eyelids for a T4N1M0 right lower eyelid cancer. She simultaneously underwent a single-stage reconstruction using a rectus abdominis myocutaneous free flap. (b) One year postoperatively, we performed a secondary eye socket reconstruction with bilateral scapha composite grafts. However, the eye socket became deformed postoperatively. (c) Sequential view of the dynamic eye socket reconstruction using temporalis transfer. (d) Postoperative findings. The patient was able to maintain a sharp palpebral morphology throughout the follow-up period.
a
b
Figure 4. Final results of case 2. (a) Sharp morphology of the upper and lower eyelids was achieved in neutral position. (b) When the patient smiles, definite creases (crow’s feet) at the lateral canthus can be seen (arrows).
reconstructive plastic surgeons. When performing reconstruction following resection of midfacial malignancies, surgeons have to consider not only functional but also esthetic results in order to avoid impairing the quality of life of the patients [6]. It has been difficult to achieve satisfactory results with previously described reconstruction methods after an extended total maxillectomy along with resection of the upper and lower eyelids, because of the lack of functioning muscles in the reconstructed eyelids. We previously introduced our dynamic eye socket reconstruction method using temporalis transfer. This method is characterized by reconstruction of an eye socket with functioning muscles. With this technique, the following four benefits can be achieved: (1) formation of natural creases at the lateral canthus (crow’s feet) during smiling, (2) movement of both upper and lower eyelids, (3) approximation of the eye prosthesis and eyelid posterior lamella, and (4) long-term maintenance of a sharp palpebral morphology [1,7]. Regarding surgical timing, temporalis transfer can be performed at the same time as the orbital reconstruction; however,
appropriate adjustments are required, so we consider it preferable to wait for maturation of the reconstructed eye socket. Although a mean eyelid closure rate of 0.232 in this case series might not be considered a satisfactory result, the aforementioned benefits were achieved at this value, and it is important to continue to maintain this level. Both functional and esthetic results tended to improve with time in all patients, probably because patients get used to intensive daily training, as with temporalis transfer following facial nerve palsy. In conclusion, the reconstruction method we describe here is an extremely useful technique for orbital reconstruction following extended total maxillectomy with resection of both eyelids, and we currently use this method for all patients who need orbital reconstruction following extended total maxillectomy. In the future, we plan to treat more cases with our dynamic reconstruction method, thus allowing opening and closing of the upper and lower eyelids. Further, we will seek optimal reconstruction procedures that can improve the quality of life of patients after extended surgery for maxillary cancers.
1210
H. Motomura et al.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References [1] Motomura H, Hatano T, Kobayashi R, Sakahara D, Fujii N, Mineo M. Dynamic eye socket reconstruction after extended total maxillectomy using temporalis transfer. J Plast Reconstr Aesthet Surg 2014;67:e78–80. [2] Andersen JG. Surgical treatment of lagophthalmos in leprosy by the Gillies temporalis transfer. Br J Plast Surg 1961;14: 339–45.
[3] Kligman AM, Zheng P, Lavker RM. The anatomy and pathogenesis of wrinkles. Br J Dermatol 1985;113:37–42. [4] Fogli A. Orbicularis oculi muscle and crow’s feet. Pathogenesis and surgical approach. Ann Chir Plast Esthet 1992;37:510–18. [5] Motomura H, Iguchi H. Simple maxillary reconstruction following total maxillectomy using artificial bone wrapped with vascularized tissue: five key points to ensure success. Acta Otolaryngol 2012;132:887–92. [6] Cordeiro PG, Chen CM. A 15-year review of midface reconstruction after total and subtotal maxillectomy: part II. Technical modifications to maximize aesthetic and functional outcomes. Plast Reconstr Surg 2012;129:139–47. [7] Hashikawa K, Terashi H, Tahara S. Therapeutic strategy for the triad of acquired anophthalmic orbit. Plast Reconstr Surg 2007;119:2182–8; discussion 2189–91.
Copyright of Acta Oto-Laryngologica is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
