Commentary “Prevention of Postexenteration Complications by Obliteration of the Orbital Cavity”

This article by Spiegel and Varvares reiterates a long-standing philosophy of surgeons who perform free-tissue transfers. There has been an historical precedent set for local regional flaps for orbital exenterations. As treatment has become more aggressive over the past couple of decades, so have the post-treatment complications. Tumors that have undergone exenteration of the orbit have been treated in the past with skin grafts or even temporoparietal fascia flaps. If this is followed with radiation, there is a predilection to osteoradionecrosis, which can lead to locoregional infections and exposure of the intracranial content. This article brings forward, once again, the problems with these types of flaps. The patients that have been presented show good examples of the complications that may occur with radiation treatment to the orbit without adequate soft-tissue compromise. There must be due consideration for postoperative treatment and adjuvant treatment rather than trying to make the orbit functional. In Patient 3, a skin graft is performed along with an osseointegrated implant followed by radiation. This particular patient outlines the difficulties in postoperative care for these types of patients. This may be “putting the cart before the horse.” Because of the concern with placement of the prosthesis, the complication rate may have been increased. It has been our general consensus to be quite aggressive with free-tissue transfers in this particular area; thus to be quite aggressive is actually the more conservative route with regard to free-tissue transfers. With the advent of free-tissue transfer, wide local resections do not have as great an impact on reconstruction as local flaps did. The resection site would have possibly needed to be limited in order to provide a safe closure. Free-tissue transfers have become routine at major medical centers and therefore the extirpative surgery can be more aggressive with the resection, which is more conservative from an oncologic perspective. These flaps can later be modified to accommodate a prosthesis in the future. However, the primary concerns in these patients are to eradicate the disease and also to provide an adequate bed for adjuvant radiation, if not therapeutic radiation.

I would like to commend the authors for presenting these complications and bringing to light, once again, the complications that can occur. The goal of reconstruction should be more aggressive with a flap of some type, rather than concentrating on a post-exenteration prosthesis.