HEAD AND NECK SURGERY The Prefabricated Temporal Island Flap for Eyelid and Eye Socket Reconstruction in Total Orbital Exenteration Patients A New Method Muzaffer Altındas, MD, Akin Yucel, MD, Guncel Ozturk, MD, Mesud Sarac, MD, and Ali Kilic, MD Abstract: Anophtalmic socket reconstruction is a challenging problem in plastic surgery. We had described a prefabricated superficial temporal fascia island flap and used this technique in 50 enucleation patients with severe socket contraction ending in excellent or good results for 28 years (Altın- das-1 procedure). However, the flap was not suitable for the exenteration patients with complete eyelid loss. The technique was modified and used in exenteration patients (Altındas-2 procedure). In this 2-staged procedure, the temporoparietal fascia is prefabricated with a full-thickness skin graft from the retroauricular area, and a strip of scalp is preserved at the middle of the flap. The flap is transferred to the orbit through a subcutaneous tunnel at the second stage. The prefabricated flap is used for the reconstruction of eyelids and periorbital skin; scalp island is used for the reconstruction of lid margins and eyelashes; and the neighboring bare temporoparietal fascia is used for the augmentation of the periorbital soft tissues. The orbital lining is elevated as a centrally based skin flap and used for the reconstruction of the eye socket, fornicles, and posterior lining of the eyelids. The technique was used successfully in 5 total exenteration patients with complete eyelid loss. In 1 patient, the ipsilateral temporal island flap was used previously, and the flap was prepared from the contralateral site and transferred to the anophtalmic orbit as a free flap 5 weeks later. By this procedure, it is possible to reconstruct a stable eye socket that is suitable for ocular prosthesis, upper and lower fornicles, periorbital skin with good color matching, naturally looking eyelids with eyelashes and lid margins, and medial and lateral canthal areas. It is also possible to improve periorbital soft tissue atrophy, which is an important problem in patients who had radiotherapy previously. Free transfer of the flap provides a new solution for the reconstruction of cases that were operated previously. Key Words: orbital exenteration, eye lid reconstruction, eye socket reconstruction, Altındas procedures (Ann Plast Surg 2010;65: 177–182) T he presence of eyelids is important to achieve a satisfactory result in eye socket reconstruction. Despite mutilating conse- quences of surgery and radiotherapy, successful results can be obtained in eye socket reconstruction if eyelids are preserved. When eyelids are removed surgically, both periorbital skin, eye lid mar- gins, eyelashes, conjunctiva, upper and lower fornicles, tarsal plates, canthal ligaments, and canthal angles are lost. While doing socket reconstruction in total exenteration cases, all these elements have to be replaced to get satisfactory results. However, such replacements are not possible with current surgical technique. It is wise to divide socket reconstruction patients into 2 groups, patients with intact eyelids and patients with complete eyelid loss. 1,2 Each group has its own problems, and reconstruction options are different. The senior author has described a prefabricated temporal island flap for the reconstruction of severely contracted eye socket with intact eyelids (Altındas-1 procedure). 3,4 In this 2-staged technique, first a full- thickness skin graft is placed over the superficial temporal fascia, and 7 weeks later, the prefabricated temporal island flap is trans- ferred into the orbit through a subcutaneous tunnel and a bone window that is created at the lateral orbital wall. Both the eye socket and the fornicles are reconstructed by the prefabricated flap. This technique has been successfully used in 50 patients for the past 28 years (Fig. 1). Half of the patients were retinoblastoma patients who had radiotherapy previously, and the results were satisfactory even in those difficult cases. However, this technique was not useful for the total exenteration cases. The design of the flap has been modified, and a new surgical technique is described for the reconstruction of patients who lost their eyes together with their eyelids and periorbital tissues because of tumor removal or trauma. In this article, this new method (Altındas-2 procedure) is described, and cases that were treated by this technique are presented. PATIENTS AND METHODS Upper and lower eyelids along with eye socket have been reconstructed simultaneously with prefabricated temporal island flap in 5 patients since 2003 (Table 1). Three of the patients were men. There were 2 retinoblastoma cases that lost periorbital tissues after exenteration, radiation therapy, and previous unsuccessful surgical attempts for eye socket reconstruction. One of the patients had gone through exenteration procedure because of melted metal burn, and another was a congenital anophtalmic patient. Two patients had not gone through any reconstructive procedures before, but 3 patients had experienced unsuccessful surgical attempts. None of the patients were able to use prosthetic eyes. The mean period of time that patients lived without ocular prosthesis was 6.2 years. As all patients had severe tissue deficiencies, their pathology could not be classified according to the classifications described by either Guyuron et al 5 or Heinz and Nunery. 6 Surgical Technique The surgical procedure is performed in 2 stages. In the first stage, the flap prefabrication is performed, and in the second stage, the flap is transferred to the orbit. First Stage The hair is shortened, the temporal artery is palpated and marked on the scalp. A point just anterior to the helical crura is also marked. That point would be the pivot point, while transferring the island flap at the second stage. The prefabricated flap measuring 4  5 cm is marked over the superficial temporal artery. The length of the vascular pedicle should be 1 to 2 cm longer than the distance Received April 6, 2009, and accepted for publication, after revision, November 8, 2009. From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Cerrah- pasa Medical Faculty, Istanbul University, Turkey. Reprints: Guncel Ozturk, MD, Department of Plastic, Reconstructive, and Aes- thetic Surgery, Cerrahpasa Medical Faculty, Istanbul University, Turkey. E-mail: drguncel@yahoo.com. Copyright © 2010 by Lippincott Williams & Wilkins ISSN: 0148-7043/10/6502-0177 DOI: 10.1097/SAP.0b013e3181c9dd17 Annals of Plastic Surgery • Volume 65, Number 2, August 2010 www.annalsplasticsurgery.com | 177