Reconstructive Options and Strategies for the Orbital Region after Total Maxillectomy
Sean S Li MD1, Jean F Honart MD2, Nicolas Leymarie MD2, Ryan Orosco MD3, Frederic J Kolb MD1,2 1UC San Diego Division of Plastic Surgery 2Plastic Surgery Department, Gustave Roussy Cancer Campus, Villejuif, France 3UC San Diego Division of Head & Neck Surgery
Background: The orbital region is arguably the most challenging part of the reconstructive process after total maxillectomy. It has the highest rate of adverse long-term sequelae such as diplopia, enophthalmos, and ectropion etc. (Figure 1). The most significant short-term complication after reconstruction is infection. Here we present our 20-year experience addressing this challenge.
Methods: A retrospective series of 52 total maxillectomy patients, including 10 pediatric cases were reviewed. All patients were reconstructed using a chimeric flap from the scapula-dorsal region. The orbital contour and floor were recreated using a carved autologous osteo-cartilaginous graft in 38 cases (costal cartilage = 37 cases, calvarium = 1 case). The other 14 cases utilized 3D-printed custom titanium, PEEK and Medpore (9, 3 and 2 respectively) orbital prostheses.
Results: For autologous reconstructions (Figure 2) the short-term complication rates was 12% and were predominantly infections. Long-term complication rate was 50% and were mainly ocular in nature. For prosthetic reconstructions the rate of short-term complications was similar. Long-term complication rate was much higher than in autologous reconstruction; specifically, 100% of the titanium prostheses developed periorbital soft tissue atrophy and retracted scars that degraded the final functional and cosmetic result. An analysis of the mechanism of infection led us to change the shape of the construct by removing the medial wall component (Figures 3 & 4).
Conclusion: The short- and long-term complications of the orbital reconstruction after total maxillectomies have the highest impact on quality of life and functional scores. As many patients require adjuvant radiotherapy, long-term side-effects and gradual degradation of the reconstruction is noted over time. In our experience, we have decreased infection, the most important early post-operative complication, by eliminating the medial orbital wall extension of our hardware construct. Intraorbital lipofilling has been described to address long term orbital volume complications.
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