Conical Modification of Forearm Free Flaps for Single-Stage Reconstruction After Total Orbital Exenteration

Orbital exenteration is a significant reconstructive challenge for plastic surgeons. Options described for these defects range from healing by secondary intention to free tissue transfer. The authors present our preferred reconstruction of orbital defects with free forearm-based flaps, which provides quality soft tissue and orbital contouring in 1 stage to consistently allow placement of bone-anchored implants for eventual orbital prosthesis.

This conical shape of the orbit is deconstructed into a "Pac-Man" type shaped flap that leaves adequate depth for a prosthesis. A retrospective chart review was performed of 2 separate patients receiving orbital exenteration reconstruction by the senior author (MFE).

Two patients presented with adenoid cystic carcinoma of the orbit. Both patients underwent nonlid sparing orbital exenteration with adjuvant chemotherapy and radiation. Each patient subsequently developed delayed wound healing after prior local flap reconstruction. Vascularized radial forearm flaps in a Pac-Man shape were used in both patients. Both patients were discharged from the hospital on postoperative day 3. No partial or total flap loss was encountered. To date, each patient has undergone planning for osseointegrated implants.

The authors present a simplified method of orbital reconstruction that provides high-quality vascularized tissue for resurfacing in 1 stage. This type of open-cavity flap reconstruction avoids the need for flap debulking procedures and facilitates 2-stage placement of osseointegrated implants.