Orbital Outcomes after Periorbital Free Flap Reconstruction

Objective: To identify the rate of orbital complications after orbit sparing periorbital microvascular free flap reconstruction, to identify the rate of subsequent postoperative exenteration, and to identify risk factors for poor orbital outcomes following periorbital microvascular free flap reconstruction.

Study Design: Retrospective review.

Methods: Single-institution retrospective review of 53 patients requiring periorbital microvascular free flap reconstructions between December 2006 and December 2017. The primary outcome was orbital complications. Univariable and multivariable logistic regression was performed to identify risk factors for orbital complications following periorbital free flap reconstruction.

Results: Fifty-three patients underwent periorbital microvascular free flap reconstruction including 30 (56.6%) anterolateral thigh free flap, 10 (18.9%) radial forearm free flaps, 5 (9.4%) fibula free flaps, 5 (9.4%) osteocutaneous radial forearm free flap, 2 (3.8%) scapula free flaps, and 1 (1.9%) latissimus dorsi flap. Median follow-up was 17.5 months (range, 1.0–139.2 months). Orbital complications were found in 33 of 53 (62.3%) of patients. Median time to first complication was 4 months (range, 0–58 months). Early complications (<3 months) were noted in 14 of 53 (26.4%) patients, while late complications occurring after 3 months were noted in 19 of 53 (35.8%). Orbital complications included external eye defects in 28 (52.8%) patients, orbit malposition in 7 (13.2%) patients, cancer recurrence/ new primary in 7 (13.2%) patients, wound dehiscence in 4 (7.5%) patients, infection in 4 (7.5%) patients, vision loss in 1 (1.9%) patient, implant exposure in 1 (1.9%) patient, and orbital rim necrosis in 1 (1.9%) patient. Twenty-one (39.6%) patients underwent 31 operations for orbital complications. Procedures included 9 repair procedures for external eye defects, 8 local flap reconstructions due to eyelid and canthal defects, 3 recurrent or new primary cancer resections, 2 orbital implant removal in setting of infection, 2 free flap revisions to increase volume and contour, 1 implant placement for hypoglobus, 1 dacryocystorhinostomy for recurrent dacryocystitis, and 1 debridement for orbital rim necrosis. Four (7.5%) patients ultimately required orbital exenteration.

Conclusion: Orbital complications following periorbital microvascular free flap reconstruction are common. In a majority of patients with complications subsequent surgery is required.

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