Frühe chirurgische Rehabilitation durch modifizierte orbitale Exenteration

Zusammenfassung

Hintergrund: Die orbitale Exenteration ist eine in die körperliche Integrität einschneidende Chirurgie, die schwere funktionelle, ästhetische und psychologische Folgen hat. Die möglichst rasche ästhetische und psychosoziale Rehabilitation des Patienten ist neben der korrekten Tumorversorgung von höchster Relevanz. Wir evaluieren die Ursachen, die zu Exenterationen führen, stellen neue Operationsoptionen vor und dokumentieren den postoperativen Verlauf. Der Einsatz lokaler Schwenklappen im anterioren Orbitabereich beschleunigt die Wundheilung, erlaubt die frühzeitige Epithesenanpassung und damit raschere Rehabilitation des Patienten.

Patienten und Methode: Zwischen 2007 und 2011 wurde an der Augenklinik des UniversitätsSpitals Zürich bei 7 Patienten mit malignen Orbitatumoren (1 × Plasmozytom, 1 × Melanom, 1 × Sarkom, 1 × squamöses Karzinom und 3 × Basalzellkarzinom) eine radikale orbitale Exenteration durchgeführt. Die Krankengeschichten wurden retrospektiv evaluiert nach Gründen für die Exenteration, Operationstechniken und postoperativem Verlauf.

Die unmittelbare Rekonstruktion des anterioren Orbitarands erfolgte mit lokalen Schwenklappen (Mustardé, Glabella und andere, modifizierte gestielte Vollhautverschiebelappen). Die posterioren Defekte deckten wir mittels Thiersch vom Oberschenkel.

Ergebnisse: Bereits knapp 3 Wochen nach der Operation war der Orbitarand vollständig abgeheilt dank der gut durchbluteten Schwenklappen. Dies erlaubte die frühe Anpassung sowie das Tragen der Epithese und somit auch die rasche soziale Rehabilitation des Patienten.

Schlussfolgerung: Der Einsatz lokaler Lappenplastiken reduziert das Risiko der Transplantatnekrose selbst bei antikoagulierten Patienten und verkürzt die Rehabilitationszeit. Dies ermöglicht eine kürzere Hospitalisationszeit und raschere soziale Reintegration.

Abstract

Background: Orbital exenteration is a life intruding surgical procedure with severe functional, aesthetic and psychological consequences. Apart from the correct tumor treatment, early aesthetic and psychosocial rehabilitation is crucial for the well-being of the patient. We discuss reasons leading to exenteration and present new surgical techniques. Local flaps in the anterior socket improve wound healing allowing early placement of the prosthesis and therefore faster social rehabilitation of the patient.

Patients and Methods: Between 2007 and 2011 seven patients with malignant orbital tumors (1 × plasmocytoma, 1 × melanoma, 1 × sarcoma, 1 × squamous cell carcinoma and 3 × basal cell carcinoma) received a radical orbital exenteration at the Department of Ophthalmology of the Zurich University Hospital. The medical histories were evaluated according to reasons for exenteration, surgical techniques and postoperative follow-up.

Reconstruction of the anterior socket border succeeded using local flaps (Mustardé, Glabella and combined with further modified pedicled local full thickness skin flaps). The central defects were covered with split skin graft from the thigh.

Results: Three weeks after surgery the anterior border of the socket was completely healed without problems by local flaps with good blood supply. This allowed the early prosthetic fitting and wearing as well as quick social rehabilitation of the patient.

Conclusions: The use of local flaps improves wound healing even in anticoagulated patients. This reduces the time of hospitalization and rehabilitation, and allows an early, satisfactory, social reintegration of the patient.

Schlüsselwörter

orbitale Exenteration - lokale Schwenklappen - Operationstechnik - Epithese - soziale Rehabilitation - Orbitatumor

Key words

orbital exenteration - regional flaps - prosthesis - orbital surgery - social rehabilitation - orbital tumours

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