gms | German Medical Science

Introduction: Skin cancers of the head and neck region are daily business for plastic surgeons and usually the treatment is straightforward. Rarely, such cancers, when neglected or recurring can require extended surgical procedures, such as orbital exenteration. The removal of soft tissue and eventually bone of the orbit is an extreme and disfiguring operative procedure, resulting in a serious deformity and posing a challenge for surgical reconstruction.

Material and methods: We retrospectively reviewed all cases of orbital exenteration at our institution from 2001 to 2015 (n=7) with regards to patient demographics, tumor characteristics, reconstructive methods and complications. We further compared local reconstructive measures with free tissue transfer in terms of complication rates and created a suggestion for a treatment algorithm.

Results: 7 patients, 3 female, 4 male, received an orbital exenteration. Mean age at time of orbital exenteration was 65.8 years (range 39 to 81). Main causative tumors were melanoma (n=4), followed by basal cell carcinoma (n=2) and one adnexal tumor. Of the melanoma, 3 were conjunctival melanomas, one was a melanoma of the skin, originally localized on the lid. Both basal cell carcinomas were recurring tumors. Reconstructive surgical methods used were local transposition flaps in 3 cases (2 temporalis, temporalis + pericranium), free flaps in 4 cases (2 lateral arm, 1 radial forearm, 1 anterolateral tigh). Split skin grafting was performed in 1 case, which had to be reconstructed with a free flap due to non-conservatively treatable local infection. Of the local and free flaps performed, there were no flap failures or major complications recorded.

Conclusion: Treatment of neglected or recurring skin cancers of the head and neck region with orbital exenteration is a disfiguring procedure resulting in a considerable soft tissue defect. Reconstruction with free flaps does not show increased complication rates when compared to local transposition flaps and seems to be a safe surgical method to reconstruct and fill the empty orbit and allow for satisfactory prosthetic rehabilitation. Our proposed treatment algorithm is the reconstruction with local flaps in case of orbital exenteration without removal of bone. If an extended exenteration with bone removal is required, or if the patient has previously been irradiated, we suggest the reconstruction with a microvascular free flap.