The "Pacman Flap with Tongue" for Secondary Orbital Reconstruction in Osteoradionecrosis: A Case Series

Background and Objectives: Orbital exenteration performed for advanced malignancies often results in complex defects that are difficult to reconstruct, particularly in patients treated with adjuvant radiotherapy who subsequently develop osteoradionecrosis. This study describes the preliminary results of a surgical technique for secondary orbital reconstruction using a combined scalp flap and temporalis muscle flap (TMF), referred to as the "Pacman flap with tongue," performed prior to prosthetic rehabilitation. Materials and Methods: Five elderly patients with multiple comorbidities and osteoradionecrosis following orbital exenteration and radiotherapy underwent secondary orbital reconstruction using the "Pacman flap with tongue" technique. The clinical outcomes, flap viability, complications, and feasibility of subsequent prosthetic rehabilitation were assessed. After stabilization of healing, digitally planned ocular epitheses were fabricated using cone-beam computed tomography (CBCT), computer-aided design, and three-dimensional printing. Results: Healing was uneventful in all patients. No flap necrosis, wound dehiscence, or recurrent bone exposure was observed. The reconstructed orbital sockets provided a stable, well-vascularized prosthetic bed, enabling satisfactory prosthetic rehabilitation. Conclusions: The "Pacman flap with tongue" may be considered a feasible option for secondary orbital reconstruction in selected high-risk patients, particularly in the setting of osteoradionecrosis.