We would like to thank Dr. Putterman for correctly pointing out our omission of the technique he has previously described for reconstruction after orbital exenteration: allowing the orbital socket to granulate spontaneously. This is certainly a reasonable reconstructive option in select patients who undergo orbital exenteration alone or an orbital exenteration with removal of the lateral orbital wall only. Judging by the figures in Dr. Putterman’s letter, this results in a relatively closed cavity that is still deep enough to accommodate an orbital prosthesis without excessive protrusion from the face.
We would not recommend the granulation technique in patients who undergo more extensive resections, such as extended orbital exenterations involving the superior, medial, or inferior orbital walls, or orbital exenteration with maxillectomies. In such cases, the risk exists for (1) meningitis or other intracranial complication when dura is exposed superiorly or (2) chronic sinonasal fistula when the medial or inferior orbital walls are absent. For these patients, we would recommend regional or microvascular free flap reconstruction.
In addition, many of our patients (27 percent in the series we described) received preoperative radiation therapy to the orbital region, and spontaneous healing would be impaired in these cases, leaving exposed bone and a tendency for developing osteoradionecrosis.1 In patients receiving postoperative radiation, the granulation technique may also not be a good option because either adjuvant treatment must be delayed while waiting for spontaneous healing, or slow or incomplete granulation may result if radiation therapy is administered before the orbital socket has completely healed.
Finally, in addition to needing an extended period to heal, the depth of the orbital cavity using the granulation technique appears to be somewhat shallow. Our anaplastologists, who create and fit the orbital prostheses, prefer a deeper socket to work with when the patient desires prosthetic rehabilitation. A deep open cavity more securely retains an orbital prosthesis, which is certainly a desirable quality, as sudden detachment of a prosthesis can be socially awkward for the patient.
In summary, with the caveats listed above, we would add spontaneous healing of the orbital socket as a reconstructive option for patients undergoing orbital exenteration alone or orbital exenteration with removal of the lateral wall only. Such patients should have no history of orbital irradiation and no indications for postoperative irradiation. In addition, although the granulation technique is much more straightforward and the patients are spared the morbidity associated with skin graft or flap harvest, they must be prepared for longer healing times and potentially less secure fitting prostheses if they ultimately desire one.
Matthew M. Hanasono, M.D.
Johnson C. Lee, B.A.
Justin S. Yang, B.S.
Roman J. Skoracki, M.D.
Gregory P. Reece, M.D.
Bita Esmaeli, M.D.
Department of Plastic Surgery and Section of Ophthalmology
University of Texas M. D. Anderson Cancer Center
None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this reply or the article being discussed.
1. Hanasono MM, Lee JC, Yang JS, Skoracki RJ, Reece GP, Esmaeli B. An algorithmic approach to reconstructive surgery and prosthetic rehabilitation after orbital exenteration. Plast Reconstr Surg.
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