Orbital Floor Reconstruction in Orbital-Preserving Maxillectomy
For orbital-preserving maxillectomy, the recommended surgical approach involves reconstruction of the orbital floor using nonvascularized bone grafts (split ribs, split calvaria, or iliac crest) combined with soft-tissue free flap coverage, most commonly a rectus abdominis myocutaneous free flap. 1
Primary Reconstruction Strategy
The surgical procedure must address four critical components:
- Provide rigid support to the orbital contents to prevent enophthalmos and maintain globe position 1
- Obliterate communication between the orbit and nasopharynx to prevent orbital contamination 1
- Reconstruct the palatal surface for functional restoration 1
- Achieve facial symmetry and acceptable aesthetic outcomes 1
Orbital Floor Reconstruction Options
Bone graft selection for orbital floor support:
- Split ribs are used in approximately 43% of cases, providing adequate structural support 1
- Split calvaria is equally common (43% of cases), offering excellent rigidity and biocompatibility 1
- Iliac crest graft represents an alternative option (14% of cases) 1
Modern titanium mesh techniques have emerged as an alternative approach, particularly for extensive orbital defects. A titanium mesh "hammock" suspension provides both orbital support and volume correction, articulated with a layered fibula osteocutaneous free flap 2. This technique achieves unrestricted eye function in all patients with mean follow-up of 48 months 2.
Patient-specific orbital reconstruction implants (PSORI) represent the newest option, though complications including hardware extrusion (25%) and diplopia occur, particularly after total maxillectomy with radiation 3. A modified low-profile implant design combined with midface-degloving approach significantly reduces extrusion rates 3.
Soft Tissue Coverage
The rectus abdominis myocutaneous free flap is the gold standard for soft-tissue reconstruction, used in approximately 86% of cases 1. This flap provides:
- Adequate bulk for orbital support 1
- Reliable vascular pedicle with high success rates 1
- Sufficient tissue for palatal resurfacing 1
Temporalis muscle transposition may be considered in elderly patients as a simpler alternative, though it provides less optimal results 1.
Critical Technical Considerations
When the orbital floor is resected:
- Only 17% of patients retain significant ipsilateral eye function 4
- Local recurrence rates reach 44%, regardless of postoperative radiotherapy 4
- Strong consideration should be given to orbital exenteration rather than preservation when the orbital floor requires complete resection, especially if postoperative radiation fields will include the eye 4
When the bony orbital floor is retained:
- Problems are minimal if radiation fields exclude the eye 4
- Functional outcomes are significantly better 4
Expected Outcomes and Complications
Functional vision:
- All patients with adequate reconstruction maintain functional vision 1
- Vertical dystopia is rare (less than 8% of cases) 1
- Enophthalmos should not occur with proper orbital floor support 1
Common complications:
- Ectropion is the most frequent undesirable result (77% of cases): mild in 40%, moderate in 40%, severe in 20% 1
- Minor revisions may be necessary for lower lid ectropion and exposed titanium hardware 2
- Adipofascial free flap coverage may be required for exposed intraoral bone after radiation therapy 2
Speech and chewing function:
- Speech is normal or near-normal in 92% of cases 1
- Chewing function is good (soft to unrestricted diet) in over 90% of cases 1
Surgical Timing and Approach
Primary reconstruction should be performed immediately at the time of maxillectomy 1. Patients are routinely extubated on postoperative day 1 and begin oral intake by postoperative day 3 2.
For extensive orbital defects (Brown class III), the titanium mesh sling with layered fibula free flap technique provides excellent restoration of eye position and function while allowing for implant-based prosthetic rehabilitation 2.