orbitofacial reconstruction

Three-step orbextended totaland expandedcartilage grafts

a*, K

Recon

; rece

KEYWORDSMaxillectomy;

Cervicofacial flap;

deformities to reconstruct aesthetically, because the defect is not only large but also three-

In the first step, a free RAM flap was transplanted to the defect after extended total max-

the third step was performed. The inferior part of the external skin island of the RAM flapee,r-o-

y.dus

refive points that should be formed; the eye socket, the groundwork of the eye socket, the

* Presented at the 49th Annual Meeting of Japan Society of Plastic and Reconstructive Surgery in Okayama, Japan, 14 April 2006, and atthe 51st in Nagoya, Japan, 9 April 2008.* Corresponding author. Tel.: 81 24 547 1111; fax: 81 24 548 9700.E-mail address: [email protected] (A. Kajikawa).

1748-6815/$-seefrontmatter2009BritishAssociationofPlastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.doi:10.1016/j.bjps.2009.09.024

Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 1608e1614was raised and sutured to the superior margin of the skin island to create a pouch for theye socket. Costal cartilage was grafted to reconstruct the orbital floor and malar prominencand auricular cartilage was grafted to reconstruct the tarsal plates. Finally, the expanded cevicofacial flap was rotated to cover this construct. Two weeks after reconstruction, the neeyelids were divided to form the lid fissure.

We performed the three-step reconstruction on six cases after extended total maxillectomIn all cases, a deep and stable eye socket was reconstructed. The reconstructed eyelids ancheek were natural in appearance with good colour and texture match without conspicuoscars.

To obtain symmetry and natural appearance in the orbitomaxillary reconstruction, there aTissue expander illectomy. In the second step, tissue expanders were placed under the skin of the cheek andneck a year after the RAM flap transplantation. After expansion of the cheek and neck skin,Orbitofacialreconstruction;Eye socket;Rectus abdominismyocutaneous flap;

dimensional. Although free-flap reconstruction is useful, the patchwork-like scar, bad colourmatch and poor texture match are major problems. The contracture and displacement ofthe reconstructed eyelids and eye socket are also serious matters. To resolve these problems,we have performed a three-step reconstruction using a free rectus abdominis myocutaneous(RAM) flap and an expanded cervicofacial flap with cartilage grafts.Akiyoshi Kajikaw

Department of Plastic and

Received 25 November 2008itofacial reconstruction aftermaxillectomy using free RAM flapcervicofacial flap with*

azuki Ueda, Yoko Katsuragi, Taro Hirose, Emiko Asai

structive Surgery, Fukushima Medical University, Fukushima, 960-1295, Japan

ived in revised form 23 September 2009; accepted 23 September 2009

Summary Facial defect after an extended total maxillectomy is one of the most difficult

inealato reee-ofved

skin island to create a pouch for the eye socket. To

inferior part of the RAM flap. Tplates, auricular cartilage was grathe skin pouch (Figure 1e). Thecartilage grafts should be more ththe tarsal plates should be desig

positio

Three-step orbitofacial reconstruction 1609healthy side in the standingpace after elevating theo reconstruct the tarsalfted on the dermal side ofheight of the auricularan 8 mm. The position ofned symmetrically to then before surgery. Finally,

The following are the representative cases in our series.

Case 1

A 62-year-old man underwent extended total maxillectomyafter radiation therapy of 30 Gy and arterial injectionchemotherapy with CDDP 150 mg for right maxillary SCCreconstruct the orbital floor and malar prominence, costalcartilage was grafted into the s

patient eats a soft diet with dentures.orbital floor and malar promWe do not reconstruct the pisland in the nasal cavity. Tresults, we propose this thr 2009 British AssociationElsevier Ltd. All rights reser

The facial defect after the extended total maxillectomy isone of the most difficult deformities to reconstructaesthetically, because the defect is not only large but alsothree-dimensional. Although immediate reconstructionprocedures using various free flaps have been reported,1e6

the patchwork-like scar, bad colour match and poor texturematch are big problems. The contracture and displacementof the reconstructed eyelids and eye socket are also seriousmatters. To resolve these problems, we have performeda three-step reconstruction using a free rectus abdominismyocutaneous (RAM) flap and an expanded cervicofacialflap with cartilage grafts. To obtain symmetry and naturalappearance in the orbitomaxillary reconstruction, wepropose five points that should be formed; the eye socket,the groundwork of the eye socket, the orbital floor andmalar prominence, the tarsal plates and the surface of theeyelids and cheek. This article describes the three-steporbitofacial reconstruction for the above-mentioned indis-pensable five points to achieve satisfying results.

Surgical procedures

In the first step, a free RAM flap with a large volume of softtissue was transplanted to the large surface area and largevolume defect after total maxillectomy with orbital exen-teration. The facial artery and vein were used as recipientvessels. The RAM flap was made into a two-skin-island flapwith a de-epithelised zone. The first skin island of the flapwas adapted to the defect of the lateral wall of the nasalcavity, and the second skin island was adapted to the skindefect of the eyelids and cheek (Figures 1a, 1b and 2a).

In the second step, tissue expanders were placed underthe cheek and neck skin a year after the RAM flap trans-plantation (Figure 1c). The expanders were rectangular andhad a double-chamber structure (PMT Inc., Chanhassen,MN, USA). The sizes of the expanders were determinedfrom the size of the cervicofacial flap designed lateral tothe skin island of the RAM flap. The tissue expanders wereinflated for 3 months and were left for a month.

In the third step, the inferior part of the external skinisland of the RAM flap was raised and thinned to suit for theinner lining of the eyelids (Figures 1d and 2b). The thin flapwas folded back and sutured to the superior margin of thence, the tarsal plates and the surface of the eyelids and cheek.e to set prosthetic dentures and to clean the surface of the skinconstruct the indispensable five points and achieve satisfyingstep reconstruction.Plastic, Reconstructive and Aesthetic Surgeons. Published by.

the expanded cervicofacial flap was rotated to cover theskin pouch, the auricular cartilage grafts and the costalcartilage grafts, reconstructing the external surface of theeyelids and the cheek (Figures 1f and 2c). The area for theeyelids was defatted before covering the auricular carti-lage. Two weeks after the surgery, the neo-eyelids weredivided, under local anaesthesia, to form the lid fissure tocomplete the eye socket, and a temporary artificial eye wasplaced into it (Figure 2d). If necessary, some cosmeticoperations were performed. The eyelashes of the uppereyelid were reconstructed using a strip of eyebrow-com-positae graft. A permanent artificial eye was set after theshape of the eyelids and eye socket had become stable.

Results

We performed the three-step orbitofacial reconstruction onsix cases after extended total maxillectomy between 2001and 2007. They were five men and one woman ranging inage from 44 to 71 years (mean 56.7 years). The patientsincluded four maxillary carcinomas, one nasal carcinomaand one ethmoidal carcinoma. They underwent radiationtherapy of 30e50 Gy and arterial injection chemotherapywith CDDP (cisplastin) before surgery.

The patients had defects of type IIIb, according to theclassification reported by Drs. Cordeiro and Santamaria.7

Three cases had thedefect of the lower eyelid and the orbitalcontents, and three cases had the defect of the upper andlower eyelids and the orbital contents. The case of thelargest defect lacked the entire maxilla, the orbitalcontents, the upper and lower eyelids and the external nose.

The average volume of saline injected to the expanderswas 195 ml for the cheek and 225 ml for the neck. No skinnecrosis was observed in the series, and only minor touch-upsurgeries such as a canthoplasty or an eyelid margin plastywas performed in three patients to get good balancewith thehealthy side. The follow-up periods have ranged from 1 yearto 6 years. In all cases, a deep and stable eye socket wasreconstructed, and natural appearance of the eyelids andcheek was obtained with good colour and texture matchwithout conspicuous scars. Postoperative constriction anddrooping of the eye socketwere avoided in all our patients. Inall cases, speech was normal with prosthetic dentures. Fivepatients were able to eat an unrestricted diet and one

AMord wkinsutal fl

1610 A. Kajikawa et al.Figure 1 Three-step orbitofacial reconstruction using a free Rthe first step, a two-skin-island RAM flap was transplanted to thethe defect of the nasal lateral wall (a), and the second skin islanstep, tissue expanders were placed under the cheek and neck spart of the external skin island of the RAM flap was raised andsocket (d). Costal cartilage was grafted to reconstruct the orbit(Figure 3a). After resection of the entire maxilla, theorbital contents and the lower eyelid, a free RAM flap insize of 8 20 cm with two skin islands was transplanted. Itwas placed to fill the defect of the lateral wall of the nasalcavity and the skin defect of the lower eyelid and cheek asthe first step in primary reconstruction (Figure 3b). A yearafter surgery, rectangular tissue expanders of 320 ml and200 ml were placed under the cheek skin and the neck skinas the second step, and the expanders were inflated withsaline of 320 ml and 196 ml in 3 months (Figure 3c). A monthafter the full expansion, the eye socket was createdaccording to the third step described above (Figure 3d).Conchal cartilage was grafted for the tarsal plate and costalcartilage was grafted for the orbital floor and malarprominence (Figure 3e). The eyelids were divided 2 weeksafter surgery and an artificial eye was inserted. The lateralcanthoplasty was added 6 months after the third step. Thepatient has obtained a good contour of the cheek andeyelid with good colour and texture match 2 years after thereconstruction (Figure 3f). He can speak well and eat anunrestricted diet with prosthetic dentures. The patientenjoys his daily life without masking his reconstructed face.

Case 2

A 71-year-old man underwent extended total maxillectomyafter radiation therapy of 40 Gy and arterial injectionchemotherapy with CDDP 130 mg for right maxillary SCC(Figure 4a). After resection of the entire maxilla, the

to reconstruct the tarsal plates (e). Finally, the expanded cervicofawere divided to form the lid fissure two weeks after surgery.flap and an expanded cervicofacial flap with cartilage grafts. Inbitomaxillary defect. The first skin island was used to resurfaceas used to resurface the external skin defect (b). In the second(c) and inflated in three months. In the third step, the inferiorured to the superior margin to create a skin pouch for the eyeoor and malar prominence, and auricular cartilage was graftedorbital contents and the upper and lower eyelids, a two-skin-island RAM flap in the size of 7 20 cm was trans-planted to the orbitomaxillary defect as the first step. Inthe second step, two rectangular tissue expanders of200 ml volume were inserted and inflated with saline of195 ml to the cheek and 205 ml to the neck (Figure 4b). Inthe third step, the eye socket was created 4 months afterthe second step (Figures 4c and d). After creating a skinpouch for the eye socket, two pieces of scapha cartilagewere grafted for the tarsal plates of the upper and lowereyelids and the costal cartilage was grafted for the orbitalfloor and malar prominence (Figure 4e). The lid fissure wascreated 2 weeks after surgery. Six months after the thirdstep, a strip of eyebrow-compositae tissue was grafted tothe upper eyelid margin for the eyelashes. The patientshows natural appearance of the eyelids and cheek withstable eye socket for an artificial eye 2 years after surgery(Figure 4f). His speech is clear, and he can have an unre-stricted diet with prosthetic dentures. Although thereconstructed cheek leaned a little after he lost weight bymore than 10 kg after reconstruction, he has a peaceful lifewithout sunglasses to camouflage his restored face.

Discussion

Drs. Cordeiro and Santamaria reported a classification ofmidfacial defects after maxillectomy and an algorithm forreconstruction.7 In their classification, the defect after theextended total maxillectomy (total maxillectomy with

cial flap was rotated to cover this construct (f). The neo-eyelids

Three-step orbitofacial reconstruction 1611orbital exenteration) is classified type IIIb. This type has thedefects of total maxilla, globe, cheek skin and externaleyelid, which make a large volume and a large surface-arearequirement.

The free RAM flap is most useful to fill a defect of thistype. However, the patchwork-like scar and bad colourmatch and poor texture match of the skin island are veryconspicuous in the face. In addition, although somesurgeons have reported the secondary reconstruction of theeye socket using skin grafts or thin skin flaps,8e16 its post-operative deformity is another problem. To resolve these

Figure 2 Three-step orbitofacial reconstruction to form importafirst step, a larger RAM flap was transplanted to the orbitomaxillarythe second step, the cervicofacial flap was expanded using expandstep, the inferior part of the RAM flap skin island was raised and suCostal cartilage was grafted inferior to the pouch, and auricular caflap was then rotated to cover this construct (c). Two weeks aftorbitofacial reconstruction (d). The indispensable 5 points of orbitofeye socket (B), the orbital floor and malar prominence (C), the tareconstructed.problems, we propose the three-step reconstruction in thisreport. The five points (AeE) shown in Figure 2d areimportant and necessary to be constructed to restorenatural orbitofacial appearance after extended total max-illectomy. We describe the essentials of each point.

Groundwork of eye socket

For better fitting and easier wearing of a thinner artificialeye, sufficient volume of tissue is necessary to fill upa large orbitomaxillary defect and create the groundwork

nt 5 points (sagittal section of the orbitomaxillary part). In thedefect (a) after total maxillectomy with orbital exenteration. Iners (T) under the skin of the cheek and cervix (b). In the thirdtured to the superior margin of the skin flap to create a pouch.rtilage was grafted on the pouch. The expanded cervicofacialer the surgery, the lid fissure was created to accomplish theacial reconstruction; the groundwork of the eye socket (A), thersal plates (D) and the surface of eyelids and cheek (E) were

1612 A. Kajikawa et al.of the eye socket. Although the volume of the RAM flap issufficient to augment the orbitomaxillary region, the thickflap would frequently droop and deform by gravity andpostoperative contracture. A certain amount of time isrequired to achieve good balance of the eye socket withthe healthy side. We transplanted a larger RAM flap to theorbitomaxillary defect in the first-step surgery, andcreated an eye socket in the second and third step afterthe RAM flap had become stable more than 1 year after thefirst surgery.

Eye socket

Many methods have been described to create an eye socketusing skin grafts or thin skin flaps.8e16 However, it has often

Figure 3 Case 1. A 62-year-old man underwent extended total mand eyelashes of the upper eyelid was preserved, but the lower eyRAM flap was transplanted to the orbitomaxillary defect as the pcolour and texture match to the face without the eye socket (b). Inwith tissue expanders (c). The inferior part of the skin island was ra(d). The 3D-CT shows conchal cartilage (green) grafted for the tarsathe orbital floor and malar prominence (e). The patient showed natwo years after reconstruction (f).resulted in the contraction and reducing of the eye socketby these conventional methods.

In our method, the inner linings of the eyelids arereconstructed with a thin and well-vascularised flap, whichis the inferior part of the skin island folded back. Thereconstructed fornix is deep and stable by wide fixation tothe main body of the RAM flap, and the postoperativecontraction is prevented.

Orbital floor and malar prominence

Titanium mesh and split calvarium are thin and are goodmaterials for reconstruction of the orbital floor, but in theorbitofacial reconstruction after total maxillectomy withorbital exenteration, the infraorbital margin and malar

axillectomy for excision of a maxillary SCC (a). The tarsal plateelid was resected with orbital exenteration. A two-skin-islandrimary reconstruction. The skin island of the flap showed badthe second step, the lateral cheek and neck skin was expandedised and sutured to the superior margin to create a skin pouchl plate of the lower eyelid and costal cartilage (blue) grafted fortural appearance of the eyelid and cheek with an artificial eye

Three-step orbitofacial reconstruction 1613prominence should also be reconstructed for aestheticresults. To reconstruct them, adequate volume and rigidityare required, and costal cartilage and vascularised bone fitwell. However, when either costal cartilage or vascularisedbone was grafted with a large free-flap transfer in theprimary reconstruction, postoperative deformity of theeyelid and displacement of the eye socket was then oftenobserved. In the primary surgery, there is not enough spaceto place a large bone or cartilage graft in the right positionunder a thick flap, the pedicle of which should not becompressed. Forceful insertion of the large hard tissueoften results in displacement of the orbital floor anddeformity of the eye socket. To resolve this problem, wegraft costal cartilage in the third step after the RAM flap

Figure 4 Case 2. A 71-year-old man underwent extended total maeyelids were resected with orbital exenteration. A year after the pand neck skin was expanded with tissue expanders (b). After creatifor the orbital floor and malar prominence (c). After grafting birotated to cover the skin pouch and the cartilage grafts (d). The 3D-tarsal plates of the upper and lower eyelids and costal cartilage (bleyelashes of the upper eyelid were reconstructed using a strip ofleaned a little with his weight loss, the patient shows rather naturafter surgery (f).had become stable. In this method, the cartilage ofadequate size and shape can be placed in the right positionin the space after elevating the inferior part of the RAM flapto create a pouch of the eye socket. We consider that thecostal cartilage can survive without vascular pedicle ascartilage graft does in the nose or auricular reconstruction.The circulation of the recipient bed is important to save thecartilage graft.

Tarsal plate and eyelid margin

The framework of the eyelid margin should be recon-structed to create a stable eye socket and prevent

xillectomy for excision of a maxillary SCC (a). Upper and lowerrimary reconstruction using a free RAM flap, the lateral cheekng a skin pouch for the eye socket, costal cartilage was graftedlateral scapha cartilage, the expanded cervicofacial flap wasCT shows two pieces of scapha cartilage (green) grafted for theue) grafted for the orbital floor and malar prominence (e). Theeyebrow composite graft. Although the reconstructed cheekal appearance of the eyelids with stable eye socket two years

ectropion of the eyelids. The auricular cartilage is elasticand suitable for reconstructing the tarsal plate. We graft

for orbitofacial reconstruction after the extended totalmaxillectomy.

1614 A. Kajikawa et al.the cartilage from the concha or scapha as large a piece oftissue as possible. The grafted cartilage height should bemore than 8 mm to support the eyelid margin.

In all cases, the lower eyelid was resected. Whether toresect the upper eyelid was decided by the head and necksurgeons, depending on the location and grade of thetumour. Two pieces of auricular cartilage were grafted forthe tarsal plate of the upper and lower eyelids in the caseof the resection of both lids. The eyelashes of the uppereyelid were reconstructed using a compositae graft of theeyebrow tissue after the third stage of the reconstruction.

Surface of eyelids and cheek

The facial skin is, of course, the best material in facialreconstruction for good colour and texture match. However,in conventional methods using small local flaps,15,16 thepatchwork-like scars are still conspicuous. The cervicofacialflap17 is a good technique to avoid the patchwork-like scarand reconstruct the eyelids and cheek skin with good colourand texture match. The marginal scar of the flap is incon-spicuous, because it fits to the margin of aesthetic unit. Toreconstruct the large skin defect from the eyelids to thecheek,we used the cervicofacial flapwith tissue expanders.18

Expanded skin has the problem of postoperativeretraction. To resolve this problem, we placed tissueexpanders a little laterally to avoid expanding the skin,which would be transferred to the new eyelid. Theexpanded cervicofacial flap was not transferred superiorlybut was rotated medially towards the nose to preventpostoperative retraction and lagophthalmos.

The thickness of the cheek skin was reduced by theexpansion, but enough fat tissue of the RAM flap under theexpanded skin produced natural thickness of the cheek.Only in the case of significant weight loss after recon-struction, the reconstructed cheek leaned more than thehealthy side.

Palate

We do not reconstruct the palate in our patients. The openpalate is useful to set prosthetic dentures. Our patients hadclear, normal speech with prosthetic dentures, and diet wasunrestricted (in five out of six patients) or a soft diet wasadvised (in one case). When a palate is closed with a bulkyflap hanging downward, the dentures would be pusheddown, which would lead to a poor bite. In addition, the openpalate is useful to clean the surface of the skin island in thenasal cavity. For these reasons, we do not consider that thehard palate must be reconstructed in the orbitofacialreconstruction after extended total maxillectomy.

The demerit of the three-step reconstruction is the longreconstruction period, but the method can restore a morenatural appearance than the conventional methods. Ourpatients have achieved peaceful lives without sunglasses tomask their faces. We believe the three-step reconstructionfor the indispensable five points is the ideal procedureI hereby certify that

No financial support or benefits have been received by meor any co-author, by any member of our immediate familyor any individual or entity with whom or with which wehave a relationship from any commercial source which isrelated directly or indirectly to the scientific work which isreported on in the article.

None of the authors has a financial interest in any of theproducts, devices or drugs mentioned in this article.

References

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16. Yanaga H, Mori S. Eyelids and eye socket reconstruction usingthe expanded forehead flap and scapha compositae grafting.Plast. Reconstr. Surg 2001;108:8e16.

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Three-step orbitofacial reconstruction after extended total maxillectomy using free RAM flap and expanded cervicofacial flap with cartilage graftsSurgical proceduresResultsCase 1Case 2

DiscussionGroundwork of eye socketEye socketOrbital floor and malar prominenceTarsal plate and eyelid marginSurface of eyelids and cheekPalate

I hereby certify thatReferences