SURGICAL ONCOLOGY AND RECONSTRUCTION
Orbital Exenteration and Periorbital Skin Cancers Ahmad Qassemyar, MD,* Nawaf Aljudaibi, MD,y Olivier Wavreille, MD,z Laurent Mortier, MD, PhD,x Veronique Martinot-Duquennoy, MD, PhD,k and Pierre Guerreschi, MD, PhD{ Purpose:
Orbital exenteration is a disfiguring surgical procedure that requires thoughtful reconstruction.
Patients and Methods:
We analyzed all cases of orbital exenteration done in our department since 1998.
Results:
A total of 26 patients had undergone surgery during our study period, and 27 exenterations have been conducted since 1998. The reconstruction was performed in 20 patients using an ipsilateral temporal muscle flap. One patient underwent reconstruction using a temporalis fascia flap and 6 using free flaps. A total of 11 patients received postoperative radiotherapy. Data collection revealed 6 patients with an ocular prosthesis. The prosthesis had either been glued or mounted onto glasses.
Conclusions: Analyzing our results and the published data, we found that the reconstruction mode influences prosthetic rehabilitation. Thus, we have identified 2 categories. In the first category, postoperative radiotherapy will be required and coverage with a flap will be needed. In the second category, postoperative radiotherapy is not indicated and thus the healing time might be extended in favor of more space for better retention of the prosthetic rehabilitation. Ó 2014 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 72:811-816, 2014
if radiotherapy has been planned or to fit an ocular prosthesis. In the present study, we report our series of orbital exenteration during the past 15 years. We evaluated our reconstruction choices and their influence on rehabilitation. We have also proposed a decision tree to help in patient management.
Orbital exenteration is a disfiguring surgical procedure, defined by the removal of the entire orbital contents, including the periosteum, and leaving the orbital cavity with bare bony walls. In most cases, exenteration is performed for the management of periorbital tumors with intraorbital extension. This procedure requires careful reconstruction, particularly in elderly patients. The reconstruction is mainly accomplished using spontaneous epithelialization, skin grafts, local flaps, or free flaps. The objectives of orbital reconstruction have included being able to detect local recurrence, restoring continuity between the orbit and neighboring cavities, and obtaining rapid healing
Patients and Methods We conducted a single-center retrospective analysis of all consecutive cases of orbital exenteration since 1998 using a computerized database from the University
*Doctor, Department of Plastic, Reconstructive and Aesthetic
{Doctor, Department of Plastic, Reconstructive and Aesthetic
Surgery, Roger Salengro Hospital, University Hospitals of Lille, Lille, France.
Surgery, Roger Salengro Hospital, University Hospitals of Lille, Lille, France.
yDoctor, Department of Plastic, Reconstructive and Aesthetic
Address correspondence and reprint requests to Dr Qassemyar:
Surgery, Roger Salengro Hospital, University Hospitals of Lille, Lille,
Department of Plastic, Reconstructive and Aesthetic Surgery, Univer-
France; and Department of Plastic, Reconstructive and Aesthetic
sity Hospitals of Lille, Roger Salengro Hospital, rue Emile Laine, Lille
Surgery, King Fahad Hospital (MOH), Jeddah, Saudi Arabia.
59037, France; e-mail:
[email protected] zDoctor, Department of Ophthalmology, Claude Huriez Hospital,
Received February 27 2013
University Hospitals of Lille, Lille, France.
Accepted September 10 2013
xProfessor, Department of Dermatology, Claude Huriez Hospital, University Hospitals of Lille, Lille, France.
Ó 2014 American Association of Oral and Maxillofacial Surgeons 0278-2391/13/01201-9$36.00/0
kProfessor, Department of Plastic, Reconstructive and Aesthetic
http://dx.doi.org/10.1016/j.joms.2013.09.014
Surgery, Roger Salengro Hospital, University Hospitals of Lille, Lille, France.
811
812 Hospital of Lille. Because of the retrospective nature of the present study, it was granted an exemption in writing by the University of Lille institutional review board. The following data were collected: epidemiologic data, tumor type, surgical procedure and reconstruction, postoperative complications, and the use of an ocular prosthesis. Clinical follow-up was performed until July 2012. Recurrences were identified through direct contact with the dermatologists. All patients had undergone preoperative cervicofacial computed tomography (CT) to identify orbital cavity wall lysis, bony involvement, or possible locoregional metastasis. We followed the Declaration of Helsinki guidelines in the present investigation. SURGICAL TECHNIQUE
The technique for total exenteration was as follows. A 360 incision was created using a scalpel. This incision was completed by subcutaneous tissue dissection until the periosteum was reached using monopolar cautery. Next, the periosteum was elevated using a periosteal elevator. It is important to remember that the roof and medial wall of the orbital cavity are very thin; thus, it is necessary to avoid abrupt maneuvers, which could lead to an opening of the dura mater or a communication with the nasal region. Hemostasis of ethmoid packets should be performed progressively. Once the pedicle was dissected, it was ligated. Residual fragments at the apex or sutures were finally removed. The specimen was marked and sent for histopathologic analysis.
Results A total of 26 patients underwent surgery during the study period, with 27 exenterations. The population included 10 women and 16 men. The average age was 68 years (range, 19 to 89). Of the 26 patients, 11 had been diagnosed with basal cell carcinoma, 9 with squamous cell carcinoma, 3 with melanoma, and 1 patient each with orbital rhabdomyosarcoma, meningioma of the optic nerve, intraorbital schwannoma (Fig 1). The principal localizations were palpebral in 15, including the medial canthus in 5 and the lateral canthus in 5 (Fig 2). The CT scan data revealed an orbital metastasis in 13 patients, bony destruction in 6, and lymph node involvement (parotid) in 1 patient. Of the 27 procedures, 13 were total exenteration, 13 were radical exenteration, and 1 was subtotal exenteration. The repair was performed in 20 patients using an ipsilateral temporal muscle flap with a skin graft (Fig 3), including 1 patient with an associated forehead flap. In 1 patient, a temporalis fascia flap (Fig 4) was used, and in 6 patients, free flaps were used for reconstruction.
ORBITAL EXENTERATION AND PERIORBITAL SKIN CANCER
FIGURE 1. Pie chart showing the distribution of the tumor types. Qassemyar et al. Orbital Exenteration and Periorbital Skin Cancer. J Oral Maxillofac Surg 2014.
Three cases of recurrence were detected at an average onset of 28 months (range, 12 to 60), with contralateral exenteration indicated for 1 patient. Local complications were marked by partial necrosis of the temporalis muscle flap in 3 patients and 1 case of a hematoma under the skin graft. The only 2 general postoperative complications were 1 case of acute pulmonary edema and 1 case of meningitis. Histologic examination showed incomplete excision posteriorly in 10 patients, of whom 6 had had bony destruction on the preoperative CT scan. These 10 patients underwent adjuvant radiotherapy, as did the patient with orbital rhabdomyosarcoma. The data collection showed 6 patients with an ocular prosthesis. The prosthesis was either glued or mounted on glasses (Fig 5). Of the 6 patients, 4 could no longer tolerate their prosthesis, 3 because of the instability of the prosthesis and 1 because of irritative dermatitis. The results are listed in Table 1.
Discussion Orbital exenteration is a surgical procedure with limited indications. The main indication highlighted in our study was the management of periorbital tumors at an advanced stage when they are not
FIGURE 2. Primary location of the tumors. Qassemyar et al. Orbital Exenteration and Periorbital Skin Cancer. J Oral Maxillofac Surg 2014.
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QASSEMYAR ET AL
FIGURE 3. Reconstruction using a grafted temporalis muscle flap. Qassemyar et al. Orbital Exenteration and Periorbital Skin Cancer. J Oral Maxillofac Surg 2014.
eligible for other treatment. Frezzotti et al1 proposed a classification system that divides exenteration into 6 types, from subtotal exenteration to radical exenteration (Table 2). The tumors in our series, and in several large series,2-5 were most frequently basal cell carcinoma. Many techniques have been described to reconstruct the orbital cavity. Spontaneous epithelialization has been the simplest technique, but also has required the longest period for healing. An alternative has been epithelialization using split-thickness or full-thickness skin grafts to accelerate healing. These methods have the advantage of better rehabilitation, including the placement of bone-anchored implants (without radiotherapy) to allow for better oncologic monitoring.6,7 Locoregional reconstruction options have included the temporalis muscle flap,8-10 cervicofacial flaps,11 temporoparietal fascia flaps,12 forehead flaps,13-15
FIGURE 4. Reconstruction using a temporalis fascia flap. Qassemyar et al. Orbital Exenteration and Periorbital Skin Cancer. J Oral Maxillofac Surg 2014.
FIGURE 5. Rehabilitation with a glued prosthesis. Qassemyar et al. Orbital Exenteration and Periorbital Skin Cancer. J Oral Maxillofac Surg 2014.
temporofrontal flaps,16 musculocutaneous free flaps for ocular cavity filling,17,18 and fasciocutaneous flaps.19,20 The method commonly used by our team has been immediate reconstruction using a skin-grafted temporalis muscle flap. This procedure is straightforward, and, when performed at once, allows rapid healing of the orbital cavity, especially for early radiotherapy in the case of bone metastasis and/or incomplete excision. However, this technique offers limited satisfaction in terms of rehabilitation. The advantages and disadvantages of the different orbital cavity reconstruction methods are summarized in Table 3. Having an ocular prosthesis allows patients to maintain a satisfactory social life. The temporalis muscle flap and the free flaps can result in an inconvenient overfilling of the orbital cavity, giving difficulties later on in the use of an ocular prosthesis. Bone-anchored implants provide good stability compared with a glued prosthesis or those mounted on glasses.21 The indications for bone-anchored implants must be correctly determined and preferably should not be implanted after radiotherapy. Many teams have used sessions of hyperbaric oxygen therapy to improve the integration of implants in an irradiated medium, when the doses have exceeded 50 Gy, to stimulate bone formation in the irradiated field.22,23 The management of orbital exenteration requires suitable reconstruction. We noted 2 categories. The first category is when radiotherapy is planned and for which coverage by a flap is required. The second category is when radiotherapy is not indicated and
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Table 1. PATIENT DATA
Tumor
Primary Site
Exenteration Type
1 2
M M
BCC BCC
External canthus Mediofacial
Total Radical
3 4 5 6
M F F M
BCC SCC SCC SCC
Inferior eyelid Conjunctiva Conjunctiva Superior eyelid
7 8
M F
SCC BCC
9
M
BCC
10
M
11
Reconstruction Method
Postoperative RT
Rehabilitation
Complications
TMF, STSG TMF, STSG
No Yes
No No
Radical Total Total Total
TMF, STSG TFF, STSG TMF, STSG TMF, STSG
No No No No
No No Glued No
External canthus External canthus
Total Total
TMF, STSG TMF, STSG
Yes No
No No
Internal canthus
Total
TMF, STSG
No
Meningioma
Parasellar
Total
TMF, STSG
No
F
Schwannoma
Intraorbital
Total
No
12 13 14
M M F
SCC BCC SCC
External canthus External canthus Inferior eyelid
Radical Radical Total
TMF, STSG, forehead flap TMF, STSG TMF, STSG TMF, STSG
15 16 17
F M M
BCC BCC BCC
Internal canthus Internal canthus Mediofacial
Radical Radical Radical
18 19 20 21 22
M F M F F
Melanoma Melanoma SCC SCC SCC
Retrobulbar Superior eyelid Conjunctiva Internal canthus Intraorbital
Radical Total Total Radical Radical
TMF, STSG TMF, STSG Anterolateral thigh flap TMF, STSG TMF, STSG TMF, STSG TMF, STSG Anterolateral thigh flap
Mounted on glasses Mounted on glasses Glued
Yes No No
No No No
Yes Yes No
No No No
Yes No No No Yes
No No Glued No No
Follow-Up (yr)
Recurrence
Partial flap necrosis Tumor recurrence (reoperated*) None None None Acute pulmonary edema; partial flap necrosis None Hematoma under skin graft None
2 2
No 12 mo
5 3 1 9
No No No No
5 5
No No
2
No
Meningitis
9
12 mo
None
6
No
None None Partial flap necrosis None None None
5 1 3
No No No
1 6 2
No 60 mo No
None None None None None
5 4 3 1 4
No No No No No
(Continued on next page)
ORBITAL EXENTERATION AND PERIORBITAL SKIN CANCER
Gender
Pt. No.
815 Table 2. CLASSIFICATION BY STAGE OF DIFFERENT EXENTERATION TYPES
Type
Type
Surgical Technique
I
Eyelids and palpebral and bulbar conjunctiva sparing Eyelids and palpebral conjunctiva sparing Eyelid skin and deeper muscle layer sparing Eyelid resection Resection of orbit cavity bones Extension to adjacent structures
Subtotal exenteration
II III Total exenteration Radical exenteration
IV V VI
Data from Frezzotti et al.1 Qassemyar et al. Orbital Exenteration and Periorbital Skin Cancer. J Oral Maxillofac Surg 2014.
Qassemyar et al. Orbital Exenteration and Periorbital Skin Cancer. J Oral Maxillofac Surg 2014.
Yes No Yes TAPF TMF, STSG Lateral arm flap Radical Total Radical Internal canthus Inferior eyelid Nasofacial angle BCC Melanoma BCC F M M 24 25 26
Abbreviations: BCC, basal cell carcinoma; F, female; M, male; RMS, rhabdomyosarcoma; RT, radiotherapy; Pt. No, patient number; SCC, squamous cell carcinoma; STSG, split-thickness skin graft; TAPF, thoracodorsal artery perforator flap; TFF, temporal fascia flap; TMF, temporal muscle flap. * Tumor recurrence within 1 year underwent contralateral radical exenteration and reconstructed by anterolateral thigh flap.
No No No 1 1 1 None None None
No 7 None
Mounted on glasses No No No Yes Lateral arm flap Subtotal Intraorbital 23
M
RMS
Reconstruction Method Gender Pt. No.
Table 1. CONT’D
Tumor
Primary Site
Exenteration Type
Postoperative RT
Rehabilitation
Complications
Follow-Up (yr)
Recurrence
QASSEMYAR ET AL
the healing time can be extended in favor of more space for better retention of any prosthetic rehabilitation. These categories are not for cases of exenteration with dural exposure or sinus communication, because the latter have very different implications. From our results, we have proposed a decision tree to facilitate the treatment of these patients (Fig 6). In conclusion, orbital exenteration is a surgical procedure used more often in elderly patients with severe comorbidities. The main indication is the treatment of periorbital tumors at an advanced stage for which surgery alone will not be sufficient treatment. Reconstruction by flaps provides rapid healing, suitable for patients requiring adjuvant radiotherapy. If
Table 3. ADVANTAGES AND DISADVANTAGES OF DIFFERENT RECONSTRUCTION METHODS
Method
Radio- RehabiliHealing Volume therapy tation
Spontaneous Very long Small epithelialization Skin graft Uncertain Small Temporalis fascia flap Temporalis muscle flap Free flap
Fast
Not suitable Not suitable Medium Suitable
Fast
Large
Fast
Large
EOI EOI EOI
Suitable
More difficult Suitable Difficult
Abbreviation: EOI, extraoral implantation. Qassemyar et al. Orbital Exenteration and Periorbital Skin Cancer. J Oral Maxillofac Surg 2014.
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ORBITAL EXENTERATION AND PERIORBITAL SKIN CANCER
FIGURE 6. Decision tree for treatment of patients requiring exenteration. breach.
Radical exenteration with sinus communication or dura mater
Qassemyar et al. Orbital Exenteration and Periorbital Skin Cancer. J Oral Maxillofac Surg 2014.
radiotherapy is not required, it is preferable to extend the healing period to allow for better prosthetic rehabilitation.
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12. Levin PS, Ellis DS, Stewart WB, Toth BA: Orbital exenteration: The reconstructive ladder. Ophthal Plast Reconstr Surg 7:84, 1991 13. Dortzbach RK, Hawes MJ: Midline forehead flap in reconstructive procedures of the eyelids and exenterated socket. Ophthalmic Surg 12:257, 1981 14. 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, 1988 15. Price DL, Sherris DA, Bartley GB, Garrity JA: Forehead flap periorbital reconstruction. Arch Facial Plast Surg 6:222, 2004 16. Gola R, Laurent-Fyon C, Waller PY: [Repair of orbital exenteration cavities]. Ann Chir Plast Esthet 34:353, 1989 17. Uusitalo M, Ibarra M, Fulton L, et al: Reconstruction with rectus abdominis myocutaneous free flap after orbital exenteration in children. Arch Ophthalmol 119:1705, 2001 18. Donahue PJ, Liston SL, Falconer DP, Manlove JC: Reconstruction of orbital exenteration cavities: The use of the latissimus dorsi myocutaneous free flap. Arch Ophthalmol 107:1681, 1989 19. Tahara S, Susuki T: Eye socket reconstruction with free radial forearm flap. Ann Plast Surg 23:112, 1989 20. Wax MK, Burkey BB, Bascom D, Rosenthal EL: The role of free tissue transfer in the reconstruction of massive neglected skin cancers of the head and neck. Arch Facial Plast Surg 5:479, 2003 21. Nerad JA, Carter KD, LaVelle WE, et al: The osseointegration technique for the rehabilitation of the exenterated orbit. Arch Ophthalmol 109:1032, 1991 22. Benateau H, Crasson F, Labbe D, et al: [Extra-oral implants and irradiation: Current trends]. Rev Stomatol Chir Maxillofac 102: 266, 2001 23. Granstr€ om G, Jacobsson M, Tjellstr€ om A: Titanium implants in irradiated tissue: Benefits from hyperbaric oxygen. Int J Oral Maxillofac Implants 7:15, 1992