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Reconstruction With Rectus Abdominis Myocutaneous Free Flap After Orbital Exenteration in Children
Marita Uusitalo, MD, PhD;
Michael Ibarra, MD;
Lilia Fulton, BA;
Michael Kaplan, MD;
William Hoffman, MD;
Chen Lee, MD;
Susan Carter, MD;
Joan O'Brien, MD
Arch Ophthalmol. 2001;119:1705-1709.
ABSTRACT
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Objective To present a 1-stage technique for orbital reconstruction after exenteration with the use of myocutaneous rectus abdominis free flap in children.
Surgical Technique After orbital exenteration, a myocutaneous rectus abdominis free flap with long vascular pedicle is harvested from the abdomen. The flap is transferred to the orbit and the vascular pedicle is passed through an opening made in the lateral orbital wall, where it is anastomosed to superficial temporal vessels. The skin of the flap is trimmed to correspond to the eyelid defect and the incisions are closed.
Methods After informed consent was obtained, 2 children, 3 and 8 years old, underwent orbital reconstruction with a rectus abdominis free flap after exenteration for orbital rhabdomyosarcoma and orbital osteosarcoma in the setting of retinoblastoma.
Results This technique allowed easy postoperative wound care. Viability of the flap was excellent. The technique provided sufficient volume to fill the orbit, with improved aesthetic results and minimal donor site deformity.
Conclusions The postoperative care and aesthetic outcome in patients with rectus abdominis free flap after exenteration are much improved over those provided with traditional surgical techniques. This primary reconstruction is recommended for any patient requiring orbital exenteration, but particularly for pediatric patients who tolerate debridement of traditional exenteration sites poorly.
INTRODUCTION
SURGICAL management of extensive malignant neoplasms in the orbital region poses complex resection and reconstruction problems. Traditionally, an open cavity lined with split-thickness skin graft is used, or the exenteration cavity is left unlined to granulate primarily. Recently, pedicled muscle flaps derived from the temporalis and pectoralis major have been used. Unfortunately, transposition of these flaps on their native short vascular pedicles results in a restricted arc of rotation and limits the volume of tissue effectively transferred to the orbit.1-2
Reconstructive limitations imposed by the transposition of flaps tethered by their native vascular pedicle have been largely addressed with novel advances in microsurgery. A well-planned, single-stage free microvascular flap transfer can yield an aesthetically pleasing reconstruction with well-vascularized tissue of desired composition and volume. The rectus abdominis free flap has been used for many purposes, including repair of large head and neck defects as well as skull base cerebrospinal fluid leaks.1-10 Costochondral cartilage may be included in rectus abdominis free flaps as a supplement for bone loss.10 No report of this technique exists in the ophthalmic literature, and many ophthalmologists are unaware of this approach as a surgical option in both adults and children requiring exenteration.1-2,5-10 In this article, we present a technique for orbital reconstruction after exenteration by means of the rectus abdominis free flap in 2 children, 3 and 8 years of age.
REPORT OF CASES
CASE 1
Bilateral retinoblastoma was diagnosed in a 3-month-old girl. She underwent enucleation of the left eye and received radiation therapy to the right eye. Four months later, she received chemotherapy and additional radiation therapy for relapse in the right eye. When conservative treatment proved unsuccessful 3 years later, the right eye was enucleated.
At the age of 8 years, the patient was referred to University of California, San Francisco, for further management. At this time, the right orbit was unusually firm and inflamed, and a magnetic resonance image showed a mass in the right orbit that invaded the orbital roof and the dura (Figure 1A-B). Osteogenic sarcoma was diagnosed by biopsy. Two cycles of chemotherapy with carboplatin (total dose, 1.48 g), cyclophosphamide (0.9 g), and etoposide (16.75 g), followed by 2 cycles with doxorubicin (0.092 g) and cyclophosphamide (3.72 g), resulted in reduction in tumor size, after which the remaining tumor and affected dura were resected. Duraplasty with free rectus abdominis myocutaneous flap reconstruction was performed to repair and replace volume in the orbit through a 1-stage operation. The patient tolerated the procedure well and was disease free after 2 years of follow-up (Figure 1C-D).
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Figure 1. An 8-year-old girl previously treated for bilateral retinoblastoma and subsequent osteogenic sarcoma within the radiation field in the right orbit. A, Preoperative photograph showing inflamed eyelid in the right orbit. B, Preoperative magnetic resonance image showing an enhancing tumor (arrow) in the right orbit. C and D, Aesthetic outcome 1 year after reconstruction with rectus abdominis free flap. Right side has some orbital hypoplasia (arrow) attributable to previous radiation therapy. Left orbit shows an ocular prosthesis in place after enucleation.
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CASE 2
A 3-year-old boy was diagnosed as having rhabdomyosarcoma in the left orbit. Magnetic resonance imaging showed tumor invading the medial and lateral rectus muscles, optic nerve compression, marked proptosis, and destruction of the posterior orbital roof (Figure 2A). Bone marrow biopsy and lumbar puncture were negative for malignant cells. The patient underwent exenteration of the left orbit. The surgical defect was reconstructed with a rectus abdominis free flap in a 1-stage operation. The patient received adjuvant chemotherapy with vincristine sulfate (total dose, 42.7 g), dactinomycin (0.0063 g), etoposide (0.5 g), cyclophosphamide (12-17.27 g), and doxorubicin (0.265 g) for 6 months preoperatively and 1 year postoperatively. Preoperative and postoperative radiation therapy was also administered. Two months after the operation, an area of recurrence in the lateral superior aspect of the orbit was suspected and treated with gamma knife radiosurgery. At 1 year of follow-up, the patient remained disease free (Figure 2B-C).
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Figure 2. A 3-year-old boy with left orbital rhabdomyosarcoma involving the posterior orbital roof. A, Preoperative magnetic resonance image shows a tumor (arrow) in the left orbit compressing the optic nerve and producing massive proptosis. B, Postoperative photograph 2 months after reconstruction with rectus abdominis free flap. C, Aesthetic outcome 1 year after surgery.
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SURGICAL TECHNIQUE
After orbital exenteration including the eyelid, a hemicoronal incision is extended anteriorly in the preauricular sulcus to expose the superficial temporal vessels for vascular access. Alternatively, the facial artery and vein, superficial thyroid artery and vein, or internal jugular vein may be used. Eyelid skin may be preserved if it is free of tumor.
A paramedian vertically oriented skin island is planned on the abdomen (Figure 3A). This island is incised down to the muscular fascia, and the anterior rectus sheath is incised. The muscle is divided superiorly and reflected from superior to inferior, dividing the intercostal neurovascular bundles as they are encountered by means of bipolar electrocautery. The incision is carried inferiorly in a hockey-stick pattern to expose the inferior epigastric vessels. The deep inferior epigastric vessels are identified and traced to their origins at the external iliac vessels, where they are divided, allowing transfer of the entire musculotaneous unit with a long vascular pedicle.
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Figure 3. Surgical technique of orbital reconstruction using rectus abdominis free flap (RAFF). A, The RAFF is harvested from the abdomen. B, The RAFF is brought to the orbit and the vessels are passed through an opening made in the lateral orbital wall. An end-to-end anastomosis is performed between superficial temporal vessels and inferior epigastric vessels. C, The RAFF in place in the exenterated orbit. The muscle flap fills the orbit, eliminating the defect. Skin has been de-epithelialized to correspond to the eyelid defect. Flap muscle is sutured to orbicularis muscle. D, Skin is closed.
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The rectus abdominis free flap is transferred to the orbit. The vascular pedicle is brought through an opening created in the lateral or inferior orbital wall (Figure 3B). An end-to-end anastomosis between the divided superficial temporal vessels or other vessels, as described above, and the inferior epigastric vessels is performed under the operating microscope. One artery and 1 vein, each approximately 1.0 mm in diameter, are anastomosed using interrupted sutures. Blood flow to the flap is monitored. Total ischemia time for the flap should be 1 hour or less.
The skin of the flap is trimmed to correspond to the defect in the eyelid, approximately 2.0 cm wide and 4.0 cm long. The muscle of the flap lies against the orbital bone and any exposed dura, providing volume to the orbit (Figure 3C). The orbit is actively drained. The muscle of the flap is sutured to the orbicularis oculi muscle and all incisions are closed (Figure 3D). Any tension caused by the flap or pressure related to the closure of the skin incisions on the newly anastomosed vessels is minimized. Fast-absorbing catgut is often preferred for skin closure in children to eliminate the need for suture removal. Total surgical time for this reconstruction is approximately 10 to 12 hours.
COMMENT
Compared with surgical procedures that leave the bone exposed to heal by granulation or covered with a split-thickness skin graft, the advantages of this 1-stage rectus abdominis free flap reconstruction operation are myriad. Postoperatively, the 1-stage operation allows for simpler wound care, as the overlying skin obviates the need for orbital debridement. Especially in pediatric patients, this is a great advantage, as debridement is tolerated poorly by children and may even require repeated anesthesia.
In contrast to procedures that use the temporalis or the pectoralis major muscles as pedicle flaps, the use of the rectus abdominis free flap permits reconstruction with larger volumes of well-vascularized tissue and greater flexibility in placement without associated orientation problems.1-2 In contrast, the pectoralis pedicle does not always reach the orbit easily, it may be associated with excessive bulk in the neck, and the donor site deformity can be remarkable. In addition, these pedicle flaps may not fill the orbit sufficiently to assist in the sealing of cerebrospinal fluid leaks, whereas the rectus abdominis free flap has been used effectively in this situation.1-2,7, 9 The use of a free flap also avoids undesirable jaw movement changes that may be observed in association with the temporalis muscle pedicle flap. With free tissue transfer techniques, the reconstructive surgeon has a greater range of options in designing the physical geometry, as well as in selecting the composition of the tissue specifically needed to achieve a robust reconstruction. For example, the rectus abdominis free flap can be combined with costal cartilage to reconstruct orbital bone defects.10 The durable coverage and excellent vascular perfusion provided by a free muscle flap decrease the risk of subsequent osteoradionecrosis4 in children who are likely to receive postoperative radiation therapy.
Reliable anatomy and vasculature have made the following donor muscles popular for free flap reconstruction: rectus abdominus, latissimus dorsi, serratus anterior, and gracilis muscles. In our pediatric orbital reconstructions, we have favored the rectus abdominus muscle, because it can be easily tailored to the volume of the orbit and yet has a sufficiently narrow proximal base to be inconspicuous as it sweeps anteriorly from the perfusing vessels of the face. Since the flap can be harvested with the patient in a supine position, simultaneous free flap procurement and orbital tumor excision is possible in older children. The viability of the rectus abdominis free flap is excellent; reports of flap failure are extremely rare. The rectus abdominis free flap after orbital exenteration produces very good aesthetic results immediately after the 1-stage procedure. This is an important psychological consideration in growing children as well as in adults. When the rectus abdominis free flap is used for very large facial defects, some deformities may remain6 despite the flap. In these cases, reconstruction of bone is important for an optimal outcome.2 Immediate or secondary ocular prosthetic placement is not precluded by this technique,6 although it has not been widely described. It is also possible to use existing eyelid skin to minimize the size of the skin defect if this skin can be safely preserved during tumor resection. Some skin must be included within the flap, as this provides a mechanism whereby flap viability may be monitored.
Deformity at the donor site is generally minimal. Use of the rectus abdominis free flap, however, can be associated with abdominal tightening or the development of abdominal hernias if repair at the donor site is not sufficient.9 In obese patients, thinning of the abdominal flap may be required.2, 9
We prefer a 1-stage operation to 2 separate operations for tumor resection and subsequent reconstruction. Depending on the extent of the tumor, this surgery demands a multidisciplinary approach, which may include an ophthalmic plastic surgeon, a head and neck surgeon, a microvascular plastic surgeon, and a neurosurgeon. In addition, radiation and pediatric oncologists are involved in the preoperative and postoperative treatment of these tumor patients.
We do not believe that potential for tumor recurrence is any barrier to primary reconstruction; advances in magnetic resonance imaging allow small tumor recurrences to be readily detected.4, 8 As demonstrated in case 2, a suspected recurrence may be successfully treated while the flap remains viable. We recommend a magnetic resonance image be obtained after the operation to establish a baseline for future comparison.
In conclusion, a rectus abdominis free flap provides an alternative approach to reconstruction for patients requiring orbital exenteration, and this approach may be particularly useful in pediatric patients.
AUTHOR INFORMATION
Accepted for publication April 11, 2001.
This study was supported by the Mary and Georg C. Ehrnrooth Foundation (Helsinki, Finland), Finnish Eye Foundation (Helsinki), Academy of Finland (Helsinki), That Man May See Foundation (San Francisco, Calif), Research to Prevent Blindness (New York, NY), and core grant EY02162 from the University of California, San Francisco.
Presented in part at the 1999 Annual Meeting of the American Academy of Ophthalmology, Orlando, Fla, October 24, 1999.
We are grateful to Walter Denn for his medical illustrations, generously provided as Figure 3.
Corresponding author and reprints: Joan O'Brien, MD, Department of Ophthalmology, University of California, San Francisco, 10 Kirkham St, Campus Box 0730, San Francisco, CA 94143-0730.
From the Departments of Ophthalmology (Drs Uusitalo, Ibarra, Carter, and O'Brien and Ms Fulton), Otolaryngology (Dr Kaplan), and Surgery (Drs Hoffman and Lee), University of California, San Francisco; and Department of Ophthalmology, Helsinki University Central Hospital, Helsinki, Finland (Dr Uusitalo).
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