**13. Reconstruction following extended orbital exenteration**

Reconstruction of the defects that result from extended orbital exenteration is a challenge. There are basically two methods, first is open method and second is closed method (**Table 4**). In open method, healing occurs by secondary

**Figure 56.** *Surgical defect with cheek flap.*

**Figure 57.** *Surgical defect with retracted cheek flap.*


#### **Table 4.**

*Reconstruction of the orbital cavity.*

intention, as the depth of the orbit is left open for granulation with regular dressings [18]. This is time consuming process and this option is suboptimal if the patient is to have postoperative radiation which in most cases needs to be started within 4 weeks post-surgery [18]. Other option is to layer the orbital cavity with a split thickness skin graft. It is usually harvested from the thigh with a humby's knife or a dermatome, placed directly on the bone and sutured to the skin edges around the socket. It maintains a deeper socket in comparison to the secondary healing as it reduces wound contracture. Due to donor site morbidity and failure of graft uptake in particularly diabetic patients, split thickness grafts are used in conjunction with other flaps like pericranial periosteal flaps from forehead. Since pericranial are vascular, it enhances the uptake of split thickness skin graft.

In Closed method of reconstruction, the orbital cavity is reconstructed either with the residual preserved lid, cheek advancement, locoregional flaps or microvascular free tissue transfer [19–30]. We prefer to close orbit directly in case of adequate amount of lid tissue has been preserved or with cheek advancement. It is the modification of the cervicofacial flap and offers a one-stage, reliable, and safe method of reconstruction following orbital exenteration [19]. Subcutaneous cheek dissection can be performed to various levels usually to a level just below the oral commissure and 2–3 cm below the angle of the mandible avoiding injury to the branches of facial nerve. It can also be used in conjunction with other methods of reconstruction like peri-cranial flap. Other loco-regional options include: a cheek fascio-cutaneous V-Y flap, galeal flap, pericranial flap, cutaneous flap from the forehead and temporalis muscle flap [31–33]. Cutaneous forehead flap based on the frontal branch of the temporal artery described by Rodrigues ML et al. can be used effective to cover the orbital defect [20]. Apart from being a single stage procedure, this flap can obliterate the orbital defect immediately and adequately [20]. This method is easy, less time consuming and flap has a reliable blood supply and is reproducible. In cases where lateral orbital wall has also been resected, temporalis muscle flap can be used to reconstruct the orbital defect [21]. Menon NG et al. illustrated the method where temporalis muscle can be used to reconstruct the orbital defect with intact lateral wall of the orbit [30]. They transposed entire temporalis muscle to orbit after creating a large window in the lateral orbit, without resection of the lateral orbital rim [30]. Prefabricated myocutaneous - temporalis muscle flap was describe by Altindas M et al. for the reconstruction of eyelids and periorbital skin [22]. Scalp skin island is kept attached to the temporalis muscle for the reconstruction of lid margins and eyelashes and the neighboring bare temporoparietal fascia is used for the augmentation of the periorbital soft tissues [22]. Microvascular free tissue transfer is the ideal reconstructive option for the large and complex defects particularly resulting from extended orbital exenterations. Various free flaps like anterolateral thigh, radial fore-arm, parascapular, rectus abdominis muscle and gracilis muscle free flaps have been described for orbital reconstruction [25–29]. The modified radial forearm flap described by Purnell et al. provides abundant thin, pliable tissue, facilitating resurfacing of the entire orbit [29].

All the reconstructive methods described till now provide a good cover only and prosthetic reconstruction is needed to improve the appearance beyond that of an eyepatch. Using only prothesis without osseointegration have drawback like poor fit and discoloration over time [33, 34]. With introduction of the osseo-integrated implants, there has been a significant improvement in fixation of prosthetics, with associated improvements in quality of life and compliance [35–40].
