• Excision of the orbital contents by orbital exenteration is required in the treatment of some eyelid and orbital carcinomas. Allowing the orbit to heal spontaneously with granulation tissue has several advantages over the popular technique of lining the orbital walls with a split-thickness skin graft. The use of granulation tissue is simpler, since it avoids the needs for obtaining a skin graft, and the final result is cosmetically more acceptable, because a shallower cavity occurs compared with the skin graft technique. The main disadvantages are that it takes longer for the orbit to heal and dressing changes are required more frequently. The spontaneous granulation technique has provided excellent results in 12 patients with exenterated orbits.

Orbital exenteration with spontaneous granulation

Purpose Tumors that recur following orbital exenteration may not be evident on clinical examination, highlighting the need for imaging surveillance. The goal of this study was to report the imaging characteristics of recurrent tumors following orbital exenteration and free flap reconstruction. Methods The authors retrospectively reviewed the records of 48 patients who underwent orbital exenteration for the treatment of orbital malignancy and identified 17 recurrent tumors in 17 patients. The lesions were assessed for the presence of a soft tissue mass, imaging characteristics, and fluorodeoxyglucose avidity. Results The recurrent tumors were detected 1 month to 6 years 10 months (median, 1 year 3 month) after orbital exenteration. On both CT and MRI, all 17 lesions were soft tissue masses at presentation. On CT, the lesions demonstrated heterogeneous to homogeneous to centrally necrotic enhancement; on MRI, the lesions were T1 hypointense to isointense and T2 hypointense to hyperintense. Twelve of the 15 recurrent tumors with available preoperative imaging had an enhancing appearance similar to that of the original tumor. Thirteen of the 17 recurrent tumors were at the margin of a flap placed for reconstruction; the other 4 lesions were remote from the operative site. Conclusion Recurrent tumors following orbital exenteration and free flap reconstruction demonstrate a wide range of imaging appearances but most often appear as a soft tissue masses often similar in appearance to the primary tumor and arising near the flap margin. Awareness of the imaging features of recurrent disease is important because failure to diagnose recurrence can delay appropriate treatment.

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

Objectives This study presents the role of the temporalis muscle flap in primary reconstruction after orbital exenteration Methods A retrospective nonrandomized study of orbital exenterations performed between 1990 and 2010 for malignant tumors of the skin, paranasal sinus, and nasal cavity is presented Results The study included 13 patients (nine men, four women; age range, 30-82 years) with paranasal sinus, nasal cavity, or skin carcinomas Primary reconstruction of the cavity was performed in all patients after orbital exenteration No visible defects in the muscle flap donor site were present Local recurrences were readily followed up with nasal endoscopy, whereas radiology helped to diagnose intracranial involvement in three patients Two patients died of systemic metastases and five died for other reasons Conclusion The temporalis muscle flap is readily used to close the defect after orbital exenteration, and does not prevent the detection of recurrence

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Reconstruction of the Orbit With a Temporalis Muscle Flap After Orbital Exenteration

Recurrent arachnoid cysts secondary to spinal adhesive arachnoiditis successfully treated with a ventriculoperitoneal shunt.

Orbital exenteration is a surgical procedure which typically involves removal of the entire contents of the orbit including the periorbit, appendages, eyelids and, sometimes, a varying amount of surrounding skin This operation is reserved for the treatment of potentially life-threatening malignancies arising from the orbit, paranasal sinuses or periocular skin We have reviewed the cases that underwent orbital exenteration and reconstructive techniques for closing the defect Twenty-six patients, who underwent orbital exenteration from April 2001 to September 2010, were retrospectively analyzed, and data including patient demographics, tumor location and characteristics were collected The reconstructive techniques were reviewed The study consisted of 16 males and 10 females with a mean age of 688 years (range 50 to 89 years) Fourteen left and 12 right exenterations were performed The location of the tumor was most commonly at the medial canthus followed by the lateral canthus, nose, eyelids and cheek Twenty-one out of 26 cases (8076 %) were basal cell carcinomas and the remaining (1923 %) were squamous cell carcinomas Reconstructive techniques included superficial temporal artery-based forehead flap (7307 %), the scalp flap (1153 %), and the latissimus dorsi free flap (1558 %) Among various options available for the reconstruction of the orbital exenteration, the superficial temporal artery-based forehead flap is a relatively simple one and the final outcome, according to our experience, is comparable to that of more complex flap procedures, providing an acceptable cosmetic result with minimal donor site morbidity and short operating time Level of Evidence: Level IV, therapeutic study

Orbital exenteration for the treatment of advanced periocular skin cancer

Exenteration of the orbit is a disfiguring and destructive procedure; it is generally performed for orbital malignancies and often provides a significant reconstructive challenge. Our purpose was to evaluate the clinical indications for orbital exenteration in a tertiary referral center and to assess the reconstructive options employed. A retrospective nonrandomized analysis was performed, selecting all patients undergoing orbital exenteration over a 5-year period, between January 2005 and January 2010. Patient demographics, tumor characteristics, and reconstructive techniques used were evaluated. Twenty patients with a mean age of 76.5 years underwent total orbital exenteration. Basal cell carcinoma was the main operative indication (45%), followed by squamous cell carcinoma (15%). Reconstructive techniques included cover of the raw orbital cavity with a temporal muscular flap in all cases followed with split skin grafting (25%), bilaterally pedicle V-Y advancement flap (10%) and a fasciocutaneous island flap of the retroauricular region (65%). Twenty percent of patients had local complications and all were treated in a satisfactory fashion. Eyelid skin tumors remain an important cause of orbital exenteration. Temporal muscle flap is a reliable and stable reconstructive solution after orbital exenteration and additional aid is supplied with skin grafts or local flaps. This technique ensures a good aesthetic outcome and better situation for later complementary treatments and minimal associated donor site morbidity.

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Orbital exenteration for eyelid skin carcinoma

Seasonal Impact in Burn Profiles in a Dedicated Burn Unit

The management of burn sequelae is a major challenge for every plastic surgeon. The benefits of Integra® Dermal Regeneration Template in the management of burn injuries have been well documented but there is still a paucity of data regarding its use in reconstructive procedures. The aim of this study is to evaluate its effectiveness in the surgical treatment of post-burn scars. We performed a retrospective review of burn patients with major burn sequelae treated with Integra® at our hospital during 2016–2017 period. A modified Vancouver Scar Scale (mVSS) was used to provide a more objective measurement of burn scars. All patients were submitted to a two-stage procedure. The first one consisted in complete excision of the lesions and implantation of Integra and the second one in resurfacing the neodermis with a split thickness skin graft. The average wound size covered with Integra was 741.6 cm2. Follow-up ranged from 9 to 16 months. There were no early complications. In all cases, we achieved satisfactory cosmetic results with significant improvements in functionality and quality of life. mVSS score post-op was significantly lower than pre-op in all patients. Our results suggest that Integra is a very versatile tool for the treatment of burn sequelae. It yields good cosmetic and functional results in most cases with very little donor site morbidity. We believe that Integra should be viewed as one of the best current options for reconstructive procedures in burn patients. Level of Evidence: Level IV, therapeutic study.

Versatility of dermal regeneration templates in the treatment of burn sequelae

Hidrosadenitis supurativa is a chronic inflammatory disease with great physical and psychological impact Although conservative treatments may be effective in mild forms of the disease, extensive surgical resection and reconstruction are necessary in more severe forms of the disease The purpose of this paper is to describe our two-stage reconstructive procedure regarding this kind of disease We present a clinical case of a patient with severe, bilateral axillary hidrosadenitis In the first surgical step we excised the lesions and applied the artificial dermis secured with negative pressure wound therapy In the second step we used a split thickness skin graft to close the wound and again applied negative pressure wound therapy The graft take was very good, without complications The cosmetic outcome is acceptable and shoulder mobility was not compromised No recurrence was detected (nine months follow up)

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[Hidradenitis Suppurativa: Combined Treatment with Dermal Template, Skin Graft and Negative Pressure Wound Therapy, a Case Study].

Introduction Osteomyelitis of the hand is a rare entity and almost always occurs after catastrophic injuries. Streptococcus anginosus is a part of the normal microbial flora of the oral cavity and the gastrointestinal tract. It is frequently associated with purulent infections in several anatomic locations but rarely harms bony structures. The occurrence of osteomyelitis of the hand caused by this microorganism is very unusual. Case report We report the clinical case of a 58-year-old Caucasian male, ex-smoker, with a medical history of a chronic hepatitis C virus infection, liver cirrhosis, and diabetes mellitus that developed extensive osteomyelitis of the middle and distal phalanx of his right ring finger caused by S. anginosus and needed amputation for infection control. He had suffered a cut with a steel grinder on that finger 2 weeks before coming to the emergency department. He was also had been submitted to a dental procedure (tooth extraction) the exact day before the trauma. We believe that the most likely origin of the osteomyelitis was a transient bacteremia caused by the dental procedure that led to hematogenous seeding of several oral commensal microbes, including S. anginosus, that ended up infecting an area with low immune capacity due to the trauma. Conclusion S. anginosus causes purulent infections in multiple locations and affects more often immunocompromised patients, especially those with cirrhosis and diabetes mellitus. Even though it is not often associated with osteomyelitis, we should have a high level of suspicion if the patient has an intraoral disease or a history of dental or gastrointestinal procedures. The infection is severe, often leading to the need for radical debridements.

Ana Silva Guerra

Papers

Orbital exenteration for eyelid skin carcinoma

Seasonal Impact in Burn Profiles in a Dedicated Burn Unit

Versatility of dermal regeneration templates in the treatment of burn sequelae

[Hidradenitis Suppurativa: Combined Treatment with Dermal Template, Skin Graft and Negative Pressure Wound Therapy, a Case Study].

Streptococcus anginosus and Phalangeal Osteomyelitis: An Unusual Presentation