An algorithmic approach to reconstructive surgery and prosthetic rehabilitation after orbital exenteration

BACKGROUND: The authors' goal was to describe an algorithm for surgical reconstruction and prosthetic rehabilitation after orbital exenteration. METHODS: A review of 79 patients who underwent orbital exenteration between 1999 and 2007 was performed. Reconstructions were classified as resulting in an "open" cavity when a concave orbital socket facilitating prosthetic retention was created or a "closed" cavity when the orbit was filled with soft tissue to the level of the orbital rim. RESULTS: Reconstructive procedures included skin grafts (n = 18), regional flaps (n = 6), and microvascular free flaps (n = 55). Open cavities were created in 34 patients and closed cavities were created in 45 patients. Twenty-one patients (27 percent) experienced surgical complications. There were no significant differences in complication rates among various reconstructive techniques (skin graft versus regional flap versus free flap) or types of cavities created (open versus closed). Of the 17 patients who use prostheses, eight (47 percent) wear their prostheses regularly. Fourteen patients (82 percent) who received an orbital prosthesis had open cavities (p = 0.001). Thirty-nine percent of patients with a skin graft received orbital prostheses, and 17 percent with a regional flap and 15 percent with a free flap received orbital prostheses (p = 0.01). CONCLUSIONS: The reconstructive method should be tailored to the defect and the patient's needs. When a prosthetic is planned, the goal should be to create an open cavity with a skin graft, regional flap, or thin free flap. Bulky free flaps are indicated when a closed cavity is preferred, such as when no prosthetic is planned or the defect is extensive.