Post-Exenteration Orbital Wall Reconstruction With Paramedian Forehead Flap

Orbital exenteration is a mutilating surgery that involves the total removal of the orbital contents with partial or total excision of the eyelids. It is usually associated with an extremely disfiguring cosmetic outcome which requires some degree of reconstruction before an artificial eye can be placed into the socket. Often times, the orbital cavity needs to be filled with a soft tissue cover especially if the orbital fissures and optic canal is exposed. Free tissue transfer is thought to be the best option in reconstructing complex defect. However, some conditions do not permit a free flap reconstruction to be performed like in a previously irradiated bed as it increases the risk of vascular complications. We present a case of post orbital exenteration who is not suitable for a free flap and wound coverage was done with a paramedian forehead flap as an alternative.

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Naso- or Orbitocutaneous Fistulas after Free Flap Reconstruction of Orbital Exenteration Defects: Retrospective Study, Systematic Review, and Meta-Analysis

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0037-1600135 ◽

2017 ◽

Vol 78 (04) ◽

pp. 337-345 ◽

Cited By ~ 4

Author(s):

Kurren Gill ◽

David Hsu ◽

Gurston Nyquist ◽

Howard Krein ◽

Jurij Bilyk ◽

...

Keyword(s):

Risk Factors ◽

Systematic Review ◽

Free Flap ◽

Meta Analysis ◽

Fistula Formation ◽

Wound Complications ◽

Orbital Exenteration ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Orbital Wall

Objective Naso- or orbitocutaneous fistula (NOF) is a challenging complication of orbital exenteration, and it often requires surgical repair. We sought to identify the incidence and risk factors for NOF after orbital exenteration. Study Design Retrospective chart review, systematic review, meta-analysis. Setting Tertiary care center. Participants Patients undergoing free flap reconstruction following orbital exenteration. Records were reviewed for clinicopathologic data, operative details, and outcomes. Main Outcome Measures Univariate analysis was used to assess risk factors for incidence of postoperative NOF. PubMed and Cochrane databases were searched for published reports on NOF after orbital exenteration. Rates of fistula and odds ratios for predictive factors were compared in a meta-analysis. Results Total 7 of 77 patients (9.1%) developed NOF; fistula formation was associated with ethmoid sinus involvement (p < 0.05) and minor wound break down (p < 0.05). On meta-analysis, pooled rates of fistula formation were 5.8% for free flap patients and 12.5% for patients receiving no reconstruction. Conclusion Immediate postoperative wound complications and medial orbital wall resection increased the risk for NOF. On review and meta-analysis, reconstruction of orbital exenteration defects decreased the risk for fistula formation, but published series did not demonstrate a significant decrease in risk with free flaps compared with other methods of reconstruction.

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Use of the Anterolateral Thigh in Cranio-Orbitofacial Reconstruction

Plastic Surgery International ◽

10.1155/2011/941742 ◽

2011 ◽

Vol 2011 ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

William J. Parkes ◽

Howard Krein ◽

Ryan Heffelfinger ◽

Joseph Curry

Keyword(s):

Free Flap ◽

Case Series ◽

Free Tissue Transfer ◽

Free Flaps ◽

Tissue Loss ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Anterolateral Thigh ◽

The Many ◽

Soft Tissue Loss

Objective. To detail the clinical outcomes of a series of patients having undergone free flap reconstruction of the orbit and periorbita and highlight the anterolateral thigh (ALT) as a workhorse for addressing defects in this region. Methods. A review of 47 patients who underwent free flap reconstruction for orbital or periorbital defects between September 2006 and May 2011 was performed. Data reviewed included demographics, defect characteristics, free flap used, additional reconstructive techniques employed, length of stay, complications, and follow-up. The ALT subset of the case series was the focus of the data reviewed for this paper. Selected cases were described to highlight some of the advantages of employing the ALT for cranio-orbitofacial reconstruction. Results. 51 free flaps in 47 patients were reviewed. 38 cases required orbital exenteration. The ALT was used in 33 patients. Complications included 1 hematoma, 2 wound infections, 3 CSF leaks, and 3 flap failures. Conclusions. Free tissue transfer allows for the safe and effective reconstruction of complex defects of the orbit and periorbital structures. Reconstructive choice is dependent upon the extent of soft tissue loss, midfacial bone loss, and skullbase involvement. The ALT provides a versatile option to reconstruct the many cranio-orbitofacial defects encountered.

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Prelaminated paramedian forehead flap for subtotal nasal reconstruction using three-dimensional printing

BMJ Case Reports ◽

10.1136/bcr-2020-238146 ◽

2021 ◽

Vol 14 (1) ◽

pp. e238146

Author(s):

John P Ziegler ◽

Samuel L Oyer

Keyword(s):

Three Dimensional ◽

Free Tissue Transfer ◽

Patient Specific ◽

Nasal Reconstruction ◽

Subtotal Resection ◽

Forehead Flap ◽

Three Dimensional Printing ◽

Paramedian Forehead Flap ◽

Internal Lining ◽

3D Printed

Nasal reconstruction following a total or subtotal resection presents a challenging clinical scenario. Ample external skin coverage is readily available using the paramedian forehead flap (PMFF), but restoring adequate internal lining of sufficient size and pliability is a major limitation. Intranasal mucosal flaps or free tissue transfer is often employed for this purpose, each with their own sets of limitations. Prelamination of the PMFF with a skin graft prior to transfer is a method to create a composite flap with both internal and external lining. Another challenge in subtotal nasal reconstruction centres around restoring adequate dimensions to the nose without an existing template to work from. Three-dimensional (3D) printing has become an increasingly popular tool in reconstructive surgery as it captures precise patient-specific dimensions to guide reconstruction. Herein, we describe a case of subtotal nasal reconstruction using a prelaminated PMFF using a patient-specific 3D printed model as a template for reconstruction.

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Faculty Opinions recommendation of Imaging findings of recurrent tumors after orbital exenteration and free flap reconstruction.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.718421810.793501470 ◽

2014 ◽

Author(s):

Gene Howard

Keyword(s):

Free Flap ◽

Orbital Exenteration ◽

Imaging Findings ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Recurrent Tumors

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Combination of Mustardè cheek advancement flap and paramedian forehead flap as a reconstructive option in orbital exenteration

European Journal of Ophthalmology ◽

10.1177/1120672120976550 ◽

2020 ◽

pp. 112067212097655

Author(s):

Rosa Alessia Battista ◽

Leone Giordano ◽

Antonio Giordano Resti ◽

Alessandro Bordato ◽

Matteo Trimarchi ◽

...

Keyword(s):

Head And Neck ◽

Excellent Result ◽

Advancement Flap ◽

Orbital Exenteration ◽

Forehead Flap ◽

Paramedian Forehead Flap ◽

Aesthetic Results ◽

Colour Match ◽

Reconstructive Option ◽

Ocular Components

Purpose: To describe a combinatory technique made of Mustardè cheek advancement flap and paramedian forehead flap as a reconstructive option after orbital exenteration. Methods: We retrospectively reviewed all patients who underwent orbital exenteration and subsequent reconstruction with this technique at our Head and Neck Department, Divisions of Ophthalmology and Otolaryngology, at San Raffaele Hospital, Milan, Italy. Results: Three patients were treated with the aforementioned technique, following orbital exenteration due to malignancies. All of them were affected by recurrent diseases arising from the ocular components or periorbital structures: one basal cell carcinoma and two squamous cell carcinomas. Excellent result was achieved considering skin texture and colour match, aesthetic results and intra and post-operative complications (only minor, surgically controlled haemorrhage and minimal dehiscence subsequent to defective healing occurred). Conclusion: The proposed technique can be considered by the head and neck reconstructive surgeon as a good option in extended orbital exenteration.

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Vascular Complications After Radiotherapy in Head and Neck Free Flap Reconstruction

Annals of Plastic Surgery ◽

10.1097/sap.0000000000000081 ◽

2015 ◽

Vol 75 (3) ◽

pp. 309-315 ◽

Cited By ~ 18

Author(s):

Jael Tall ◽

Tinna Christersdottir Björklund ◽

Ann-Charlott Docherty Skogh ◽

Claes Arnander ◽

Martin Halle

Keyword(s):

Head And Neck ◽

Free Flap ◽

Vascular Complications ◽

Flap Reconstruction ◽

Free Flap Reconstruction

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Medial femoral condyle free flap in combination with paramedian forehead flap for total/subtotal nasal reconstruction: Level of evidence: IV (therapeutic studies)

Microsurgery ◽

10.1002/micr.30532 ◽

2019 ◽

Vol 40 (3) ◽

pp. 343-352 ◽

Cited By ~ 1

Author(s):

Mario Cherubino ◽

Chiara Stocco ◽

Federico Tamborini ◽

Francesca Maggiulli ◽

Davide Sallam ◽

...

Keyword(s):

Free Flap ◽

Femoral Condyle ◽

Medial Femoral Condyle ◽

Nasal Reconstruction ◽

Forehead Flap ◽

Level Of Evidence ◽

Paramedian Forehead Flap

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S110 – Free Tissue Transfer Reconstruction of Fistula after ACDF

Otolaryngology ◽

10.1016/j.otohns.2008.05.283 ◽

2008 ◽

Vol 139 (2_suppl) ◽

pp. P114-P114

Author(s):

Sarah R. Rossmiller ◽

Tamer Ghanem ◽

Mark K Wax

Keyword(s):

Free Flap ◽

Free Tissue Transfer ◽

Fistula Formation ◽

Flap Reconstruction ◽

Esophageal Diverticulum ◽

Free Flap Reconstruction ◽

Incision And Drainage ◽

Tissue Transfer ◽

Radial Forearm

Objectives Pharyngeal injury post-anterior cervical disc fusion (ACDF) repair is a well-recognized postoperative complication. It can lead to abscess formation, pharyngocutaneous fistula, and esophageal diverticulum. Various reconstructive procedures have been proposed, including primary repair or pedicled muscle flaps. In recalcitant cases, free tissue transfer can be used. We review our experience with patients undergoing free tissue transfer for repair of pharyngeal defects. Methods Retrospective data review from January 2002 to February 2008 of patients undergoing pharyngeal repair following ACDF surgery. Results 5 patients were identified for total of 6 reconstruction procedures. Presentation of the pharyngeal leak occurred from 8 days to 3 years after the ACDF procedure. 3 patients presented acutely with cervical abscesses requiring incision and drainage. 2 patients underwent hardware removal at the time of incision and drainage. 2 patients presented with dysphagia and a contained esophageal diverticulum. 4 of the patients underwent radial forearm fasciocutaneous free flap reconstruction, and 1 underwent anterolateral thigh musculocutaneous free flap reconstruction. One patient had a revision surgery for recurrent fistula formation after radial forearm free flap with rectus free flap reconstruction. There were no immediate postoperative leaks; however, on 1–51 months follow-up, 4 out of 6 cases developed a diverticulum, with one of them developing a second fistula. 3 out of 5 patients had no evidence of diverticulum or fistula at last follow-up, for a success rate of 60%. Conclusions Pharyngo-esophageal perforation following an ACDF approach is difficult to repair even with free tissue transfer.

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Free Tissue Transfer Optimizes Stump Length and Functionality Following High-Energy Trauma

Journal of Reconstructive Microsurgery Open ◽

10.1055/s-0039-3399573 ◽

2019 ◽

Vol 04 (02) ◽

pp. e96-e101

Author(s):

Merisa L. Piper ◽

Dominic Amara ◽

Sarosh N. Zafar ◽

Charles Lee ◽

Hani Sbitany ◽

...

Keyword(s):

Lower Extremity ◽

San Francisco ◽

Free Flap ◽

Free Tissue Transfer ◽

High Energy ◽

Limb Length ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

High Energy Trauma ◽

Tissue Transfer

Abstract Background Advances in medicine and surgery have allowed patients, who in the past would have required more aggressive amputations, to maintain longer stump lengths. Microvascular free tissue transfer has become increasingly popular to preserve limb length and optimize functionality. We present our experience using microvascular free flap reconstruction to preserve lower extremity limb length in the setting of high-energy trauma. Methods We conducted an Institutional Review Board-approved retrospective review of patients at three San Francisco hospitals who underwent free flap reconstruction after high-energy trauma between 2003 and 2015. We included all patients who underwent free flap reconstruction for lower extremity limb length preservation. We reviewed patient demographics, preoperative variables, intraoperative details, and postoperative outcomes, including complications, functional status, reoperation rates, and need for revision amputation. Results Twelve patients underwent microvascular free tissue transfer for limb length preservation. Overall, the patients had similar preoperative comorbidities and a mean age of 44. Six patients had postoperative complications: three minor complications and three major complications. Seven patients had additional surgeries to improve the contour of the flap. One patient required revision amputation, while the remaining 11 patients preserved their original limb length. The majority of patients were fully ambulatory, and four used a prosthesis. Conclusion Microvascular free tissue transfer can be used to effectively maintain lower extremity stump length following trauma. Although these patients often require multiple surgeries and face lengthy hospital courses, this technique enables preservation of a functional extremity that would otherwise require a more proximal amputation.

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