Radical excision and reconstruction

A general explanation of the resection and reconstruction of each anatomic area can be found in the section "Postablative reconstruction".

The patient presented with a fullness of the left upper eyelid and eyebrow.

CT scan demonstrated fibrous dysplasia at the left superior orbit and cranial base.

Note the ground glass appearance with cystic changes involving the orbital roof, superior-lateral orbital wall and temporal bone.

As the area involved was fairly limited, a decision was made to completely resect and reconstruct the region.

In this case virtual surgical planning was used. Using planar and 3D scans the area to be resected (indicated in red) was defined.

CAD-CAM lateral orbital resection guide…

…and cranial resection guide were created.

a) Patient specific resection guide for the lateral orbit:

• Fixation hole diameter: 2.2 mm (suitable for 1.5 mm drill, 2.0 mm screws)
• Fixation holes are intended for temporary fixation of the guide

b) Patient specific resection guide for the cranium:

• Fixation hole diameter: 2.2 mm (suitable for 1.5 mm drill, 2.0 mm screws)
• Fixation holes are intended for temporary fixation of the guide

Virtual surgical planning also defined the area to be reconstructed (indicated in green).

The patient was given the choice to reconstruct this with either a custom implant or cranial bone grafts and she chose the latter.

An acrylic model of the skeleton was made mirroring the normal right orbit on the left to simulate the ideal reconstruction.

This model was used in the operating room after the resection to precisely contour titanium mesh to reconstruct the orbital roof and lateral wall.

A coronal approach to the superior orbit was performed, with a reflection of the temporalis laterally and a deep dissection into the superior orbit.

The area to be resected was then marked with the resection guides and a frontal craniotomy above this area was performed. The anterior and middle cranial fossae were exposed and the resection guides placed in the area to be resected was outlined.

After removal of the guides, the resection was completed with a saw and osteotomes.

Split cranial bone grafts were harvested from the inner surface of the unaffected cranial bone flap.

The custom bent titanium mesh to reconstruct the anterior orbit and cranial base was placed.

Cranial bone grafts were placed to reconstruct the lower forehead and temple.

Additional bone grafts were placed above the mesh to separate it from the brain. All of the bone grafts were fixated with midface plates and screws.

The craniotomy flap was replaced, the temporalis muscle was resuspended and the incision was closed.

Planar images…

…and 3D images of the reconstruction demonstrate the craniotomy, the reconstructed orbit and the associated hardware.

Aftercare involves neuro and visual monitoring. Antibiotics and drain management per routine.