Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 1103e1109

Orbital exenteration for advanced periorbital skin cancers: 20 years experience

Reza S. Nassab, Sunil S. Thomas*, Douglas Murray
West Midlands Regional Burns and Plastic Surgery Unit, University Hospital Birmingham NHS Foundation Trust, Selly Oak Hospital, Raddlebarn Road, Birmingham B29 6JD, UK Received 18 July 2006; accepted 19 February 2007

KEYWORDS
Orbital exenteration; Split skin graft; Reconstruction; Periorbital cancer

Summary Purpose: Orbital exenteration is a disguring procedure that results in a signicant deformity which poses a reconstructive challenge, especially in elderly patients with signicant comorbidities. We reviewed our experience of orbital exenteration. Methods: A retrospective analysis was conducted identifying all patients undergoing orbital exenteration over a 20-year period. Patient demographics, tumour characteristics and reconstructive techniques used were recorded. Results: Thirty-two patients were treated by orbital exenteration. The majority of these were for basal cell carcinomas (53%). Most patients (62.5%) were ASA grade II or more. Reconstructive techniques included split skin grafting (63%), forehead (25%), scalp (6%) and cervicofacial (6%) aps. Following reconstruction of the exenterated orbit, 29 patients had a prosthesis. Twenty-six of these rated their nal result with their denitive prosthesis as good. Conclusions: Though there are various options available for reconstruction after orbital exenteration, a split skin graft and orbital prosthesis provide a simple solution for a very difcult problem of advanced periorbital skin cancer in the elderly population with signicant comorbidities. The nal outcome is comparable to that of more complex ap reconstruction with comparable satisfaction rates. 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Orbital exenteration is the removal orbital contents within the bony procedures may involve partial or the eyelids or resection of the bony

of the eye and other socket. More radical complete excision of walls of the orbit and

* Corresponding author. Address: Department of Plastic Surgery, University Hospital Birmingham, Selly Oak Hospital, Raddlebarn Road, Birmingham B29 6JD, UK. E-mail address: sunil.thomas@uhb.nhs.uk (S.S. Thomas).

neighbouring sinuses.1 Exenteration is often performed for malignant tumours of the orbit, tumours that have spread to the orbit from contiguous structures, or as a palliative procedure.2,3 The procedure has also been used for benign conditions such as life-threatening orbital infections and inammations, disguring orbital abnormalities and benign tumours with malignant potential.2,4 This procedure results in a signicant deformity which poses a reconstructive challenge, especially in elderly patients with signicant

1748-6815/$ - see front matter 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.02.012

1104 comorbidities. The primary goals of reconstruction are to allow for detection of recurrent disease, restoration of boundaries between the orbit and surrounding cavities, and an acceptable aesthetic outcome.5 Reconstructive options range from local aps to distant free aps.5 The other, simpler, option is the use of split skin graft with an orbital prosthesis. We reviewed patients undergoing orbital exenteration at our unit over a 20-year period. The aim of the study was to assess the indication, reconstruction and outcome of these patients.
Table 1

R.S. Nassab et al.

Histological diagnosis and primary tumour site Number of cases Basal cell carcinoma Medial canthus Lateral canthus Nose Eyelids Cheek Malignant melanoma Eye Eyelids Cheek Forehead Sebaceous carcinoma Eyelids Lateral canthus Squamous cell carcinoma Lateral canthus Eyelids Cheek Leiomyosarcoma Medial canthus Adenocarcinoma Nose Total 17 8 3 3 2 1 6 2 2 1 1 4 3 1 3 1 1 1 1 1 1 1 32

Methods
A retrospective analysis was conducted identifying all patients undergoing orbital exenteration over a 20-year period. The case notes were reviewed and data collected, including patient demographics, presenting complaints, procedure performed and outcome. The duration of the presenting complaints was noted. Information regarding the referral pattern of patients, delay in presentation and treatment prior to referral was also recorded. Information was obtained regarding clinical stage according to the TNM classication, and histological diagnosis. Pre-existing comorbidities were noted and patients classied according to the American Society of Anaesthesiologists (ASA) grade. The procedures undertaken, including resection of adjacent structures, and reconstructive technique used were documented. Complications were classied as local and systemic. The duration of follow up, details of prosthetic rehabilitation, and recurrence of tumour were also recorded. Patient compliance and satisfaction were assessed by the opinion of the patient, response from immediate family and social acceptance.

Results
Thirty-two patients were treated by orbital exenteration during the study period. The study population consisted of 20 males and 12 females, with a mean age of 68 years (range 33e86 years). Histopathological examination revealed that the majority of tumours (17) were basal cell carcinomas (53%). Other diagnoses included six malignant melanomas (19%), four sebaceous carcinomas (13%), three squamous cell carcinomas (9%), and an adenocarcinoma (6%). The eyelids and medial canthus were the most commonly affected primary tumour sites, with 28% of tumours arising from each of these sites (Table 1). General practitioners (41%) or ophthalmologists (31%) referred the majority of patients. Radiotherapists (16%), dermatologists (6%) and an otolaryngologist (3%) referred the remainder of patients.

females). The medial canthus was the most frequently affected site, followed by the lateral canthus, nose, eyelids, and cheek (Table 1). All patients complained of an ulcerating lesion, which had been present for a mean duration of 5 years and 6 months (range 9 monthse15 years). Eight patients presented with other complaints such as bleeding, discharge, pain and visual impairment. The duration of these symptoms ranged from 2 to 12 months. In the 17 patients with basal cell carcinoma, eight had no treatment prior to presentation. Three had biopsies, two surgical excision and of these three had radiotherapy. Four other patients underwent only radiotherapy. Recurrence of tumour, prior to presentation to our unit, following surgery or radiotherapy occurred in ve patients.

Malignant melanoma
Malignant melanoma was histologically diagnosed in six patients (three males and three females). The mean age of these patients was 71.3 years (range 61e86 years). Affected sites were the cheek, forehead, medial canthus, lower eyelid, conjunctiva and choroid. Most patients (four cases) presented with a noticeable swelling of the local area. A history of bleeding, ulceration and visual impairment was also noted. The duration of these symptoms ranged from 2 to 12 months. Five patients had had previous surgery and two had adjuvant radiotherapy. Only one patient had no previous treatment prior to presentation. Two cases were diagnosed as having recurrences at the time of presentation.

Basal cell carcinoma

Seventeen of the 32 cases were histologically diagnosed as basal cell carcinomas. The mean age of these patients at the time of operation was 68.9 years (range 54e88 years old), with males more commonly affected (11 males, six

Orbital exenteration for periorbital skin cancers

1105 melanoma that was only amenable to palliative surgical excision. Reconstructive techniques included split skin grafts in 20 patients (63%), and local aps in the remaining patients. These local aps consisted of eight forehead, two scalp and two cervicofacial aps.

Sebaceous gland carcinoma

Four cases were diagnosed with sebaceous gland carcinoma (two males and two females). The mean age of these patients was 71.5 years (range 62e83 years). Three tumours affected the eyelids and one the lateral canthus. Two patients presented with swelling and visual impairment, the other two cases with swelling or ulceration. There was a wide range of duration of symptoms (2 monthse20 years). One patient had undergone surgery with incomplete excision, two had biopsies and one radiotherapy prior to presentation.

Split skin graft (n Z 20)

Twelve of the 20 patients treated with split skin graft had a graft take of 95% or more (Figs. 1e4). Five of those with graft takes less than 95% were due to local infection or haematoma. Two of these patients, with graft takes of 75% and 60%, required repeat grafting. Three patients had transient cerebrospinal uid (CSF) leaks that settled spontaneously. Two patients had systemic complications: a chest infection and delirium tremens. There was no postoperative mortality. The mean duration of hospital stay was 18 days (range 8e42 days). The mean duration of follow up after surgery was 48 months (range 1e106 months). Five patients developed local recurrence, these being three patients with malignant melanoma and two with basal cell carcinoma. The mean duration of time to detection of local recurrence was 15 months (range 3e34 months). One patient with malignant melanoma developed regional lymphadenopathy requiring a radical neck dissection.

Squamous cell carcinoma

Squamous cell carcinoma occurred in three cases (all male). The mean age was 70.3 years (range 64e75 years). Presenting complaints included swelling (two cases) and ulceration (one case). The mean duration of symptoms was 9.6 months (range 5e12 months). One patient had previous surgery and two cases had prior radiotherapy.

Other cancers
A 33-year-old male presented with an 18 month history of swelling at the medial canthus, histologically diagnosed as a leiomyosarcoma. A 56-year-old male presented with a 12 month history of a swelling on the nose that was an adenocarcinoma. All tumours were staged using the TNM classication. At initial clinical presentation all tumours were invading local structures with no regional lymph nodes and therefore were classied as T4N0M0 (stage III disease). During follow up, however, one patient with malignant melanoma developed regional lymphadenopathy and subsequently underwent a parotidectomy and neck dissection. Patient classication according to the ASA scale (Table 2) revealed that 20 of the patients (62.5%) were grade II or more. Four (12.5%) of these were classied as grade IV or V.

Flap reconstruction (n Z 12)

Twelve patients had reconstruction using local aps. Seven of these 12 developed one or more complications. These were those local complications which included an infection, minor ap necrosis, and a transient CSF stula. Two patients developed systemic complications (chest infection and myocardial ischaemia). The mean duration of hospital stay was 14 days (range 10e21 days). The mean duration of follow up was 80 months (range 10e240 months). Three patients required correction of dog ears following their local ap reconstructions. Two patients developed local recurrence at 12 and 34 months following exenteration. One patient with squamous cell carcinoma developed systemic metastatic disease 4 months after the reconstructive procedure.

Surgical procedure
Twenty left and 12 right exenterations were performed during the study period. Sixteen of these patients required a more radical procedure to include one or more adjacent anatomical sites, such as maxillectomy (eight), ethmoidectomy (seven), excision of the frontal sinus (ve) and nose (ve). Complete histological excision was achieved in 31 of the 32 patients. One patient had an aggressive malignant

Orbital prosthesis and outcome

The majority of patients (62.0%) had their orbital prosthesis made within 6 months of their orbital exenteration and

Table 2

Classication of patients according to ASA grade and histological tumour type BCC 6 7 3 1 0 Malignant melanoma 2 2 0 2 0 Sebaceous carcinoma 1 0 2 0 1 SCC 1 2 0 0 0 Adenocarcinoma 1 0 0 0 0 Leiomyosarcoma 1 0 0 0 0 Total 12 11 5 3 1

Histological type ASA grade I II III IV V

1106

R.S. Nassab et al.

Figure 1 A patient with a basal cell carcinoma following exenteration and reconstruction using (a) split skin graft and (b) orbital prosthesis.

Figure 2 A patient with a malignant melanoma following exenteration and reconstruction using (a) split skin graft and (b) orbital prosthesis.

reconstruction. The mean duration from surgery to tting of orbital prosthesis was 5.5 months (range 1e12 months). Three patients preferred to wear an eye patch instead of an orbital prosthesis.16 Most prostheses (75.9%) were made of polymethylmethacrylate and tted using Nissell irides to a constructed scleral unit (Figs. 1e4). One patient had a polymethylmethacrylate prosthesis that was tted using magnets to a dental obturator. Spectacle-bearing prostheses were most commonly used because of their simplicity and patient compliance. Four patients had biomechanically retained prostheses. Twenty-six (89.6%) patients considered the prosthesis as good, with two rating their prosthesis as fair and one poor.

Discussion
Orbital exenteration is a radical procedure that is performed for a number of indications. Our study is consistent with other series where the main indication for exenteration was the treatment of malignancy that was not amenable to local excision without compromising the eye, irradiation or other topical treatment modalities (Table 3).6e16 The most frequent indication for exenteration in this series was basal cell carcinoma, which accounted for 53% of all tumours. Basal cell carcinoma was also the most common eyelid malignancy for which exenteration was performed in a number of series (Table 3).6e8,10 Studies report that basal cell carcinomas constitute

80e90% of all malignant tumours situated on the eyelids,17e19 the most commonly affected sites being the lower eyelid and medial canthus, which corroborates our results.19e21 Despite this, only between 0.8 and 3.7% of these lesions invade the orbit and consequently require exenteration.17,18,20 Malignant melanoma was the second most common tumour requiring exenteration in our series. Two cases were intraocular or conjunctival malignant melanomas. Most series have found intraocular or conjunctival malignant melanomas to be a less common indication for exenteration, with the exception of one report.14 Current trends now indicate early surgery and adjunctive cryo- or radiotherapy for the management of conjunctival melanomas, with exenteration being reserved as a palliative procedure for advanced disease.22 Sebaceous carcinoma of the eyelid is a rare malignant tumour, accounting for between 1 and 5% of all eyelid malignancies.23 This tumour is more prevalent amongst older adults, females and has a propensity for the upper eyelid.24 Our cases, however, showed no difference in gender distribution, with both upper and lower lids being affected equally. Squamous cell carcinoma is the second most common malignant neoplasm of the eyelids, accounting for 5e10% of all eyelid malignancies.25 In our series, three cases (9.4%) of squamous cell carcinoma were identied. Squamous cell carcinoma, however, has been reported by a number of

Orbital exenteration for periorbital skin cancers

1107 more recent series to be the most prevalent tumour for which exenteration was performed.9,11e13,15,16 This may represent a trend towards early diagnosis and treatment of basal cell carcinomas, the introduction of Mohs micrographic surgery, or extensive surgery required for perineural invasion associated with squamous cell carcinomas.16 There have been many techniques described for the reconstruction of the exenterated orbit. Local options include spontaneous granulation, split or full thickness skin grafts.26e29 Spontaneous granulation provides a simple technique that offers good cosmetic results. The main disadvantage is that healing by spontaneous granulation often takes several months, and there is a risk of infection that can delay the nal cosmetic result for the patient.26 Skin grafting of the exenterated orbit results in more rapid healing and hence earlier application of the orbital prosthesis.27 Split thickness dermal grafts and dermis fat grafts have also been described.28,29 Twenty patients (62.5%) in this series were treated using split skin grafts. Regional options consist of temporalis muscle aps,30e32 cervicofacial aps,33 temporoparietal fascial,5 forehead34,35 and frontal aps.36,37 Distant reconstructive options include free tissue transfer aps using the rectus abdominis,38 latissimus dorsi,39 radial forearm,40 or lateral arm ap.41 Twenty (62.5%) patients were classied as ASA grade II or more. This highlights that patients with advanced periorbital tumours requiring orbital exenteration often have signicant comorbidities and pose a high anaesthetic risk. Many orbital reconstructive techniques often involve long and staged procedures, which may not be suitable for these elderly patients, although safer anaesthesia and increasing

Figure 3 A patient with a sebaceous carcinoma following exenteration and reconstruction using (a) split skin graft and (b) orbital prosthesis.

Figure 4 A patient with a basal cell carcinoma following extensive exenteration, rhinectomy, left maxillectomy, ethmoidectomy, and excision of frontal sinus with reconstruction using (a, b) split skin graft and (c, d) orbital prosthesis.

1108
Naquin Rathburn Simons Bartley de Concilis Levin Moriaux Goldberg Shields Pushker Simon Nassab 1927e1953 1940e1971 1951e1964 1967e1986 1976e1986 1969e1988 1981e1993 1983e1999 2001 1990e2000 1999e2003 2005

R.S. Nassab et al. experience in microvascular techniques makes single stage free ap reconstruction a possible option. In these elderly patients, however, with high ASA grades the simple and relatively less complex procedure of orbital exenteration with split skin graft and orbital prosthesis should be considered as a viable treatment option. There have also been advances in orbital prostheses and their application. These include hydroxyapatite implants42 and osseointegrated techniques.43 Most patients in our series had polymethylmethacrylate prostheses. The majority of patients rated their prostheses as good. In conclusion, a split skin graft reconstruction of an exenterated socket provides a simple solution for the difcult problem of advanced periorbital skin cancer in the elderly population with signicant comorbidities. There are a number of advantages for the use of this technique. Firstly, it is a technically simple procedure which takes less time compared to a more complex ap reconstruction that exposes patients to a higher anaesthetic risk. Secondly, it provides a socket that is easily accessible for clinical examination allowing early detection of recurrent disease. An orbital prosthesis used as a form of reconstruction is highly acceptable amongst patients. Though other complex ap reconstructions are available to patients in the plastic surgical repertoire, the simple option of exenteration with split skin graft and orbital prosthesis must not be forgotten as a readily available treatment option.

Comparison of orbital exenteration series from the literature, showing duration of studies, number of cases and indications6e16

99 8 32 18 6 15 2 6 12

44 11 15 7 0 0 2 0 9

25 2 7 6 3 7 0 0 0

56 4 5 31 3 0 0 0 13

26 2 10 5 6 1 0 1 1

34 6 9 9 3 1 0 0 6

32 17 3 6 4 2 0 0 0

Acknowledgements
We would to thank the Maxillofacial Prosthesis Department at the West Midlands Regional Plastic Surgery Unit, formerly at Wordsley Hospital and now at University Hospital Birmingham, for their input in making the prostheses and the continuing prosthetic care of these patients.

102 21 33 16 6 9 2 1 14

39 9 7 8 0 10 2 0 3

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Total no. of cases Basal cell carcinoma Squamous cell carcinoma Malignant melanoma Sebaceous carcinoma Other epithelial tumours Rhabdo-myosarcoma Infection Other

Indication

Table 3

48 11 4 12 0 6 2 1 12

48 14 6 8 1 8 5 0 6

31 11 3 7 0 5 2 0 3

Orbital exenteration for periorbital skin cancers

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