Deciding when and when not to reconstruct the orbit: How I do it

Abstract

Deciding whether to reconstruct the orbit after combined transcranial and orbital surgery is uniquely challenging. Although frequently debated, upfront reconstruction is critical for lesions that have not caused bony remodeling, orbital wall hyperostosis, or periorbital tissue stiffening. A 50-year-old man developed pulsatile enophthalmos two years after planum sphenoidale meningioma resection. We detail the staged orbital reconstruction technique and discuss indications. Lesions not involving the orbital tissues themselves but compressing the orbit require orbital reconstruction to prevent delayed pulsatile enophthalmos. Additionally, even when upfront reconstruction is deferred, a delayed, staged approach can treat specific postoperative complications.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00701-026-06782-x.

Relevant surgical anatomy

Surgical access to the orbit is generally categorized into orbitocranial (e.g., lateral orbitotomy, transconjunctival) or cranio-orbital approaches (e.g., pterional, orbitozygomatic, endoscopic endonasal) [1]. Although approach selection is dictated by the pathology and location of the lesion, successful reconstruction relies on a precise understanding of the architecture of the cranio-orbital junction.

The superior and lateral orbital walls—the primary sites for reconstruction in this technique—are composed of the frontal bone, the greater and lesser wings of the sphenoid, and the zygoma. These bony confines maintain the position of the globe and orbital volume [6].

The critical surgical interface lies between the bony walls and the periorbita (orbital periosteum). The periorbita is generally loosely attached to the bone, allowing for safe dissection; however, it becomes firmly adherent at the suture lines (particularly the frontosphenoidal suture), the orbital rim, the optic canal, and the superior orbital fissure. A vital landmark during lateral dissection is the meningo-orbital band, which tethers the temporal dura to the periorbita near the superior orbital fissure.

In the context of redo surgery, the plane between the frontal dura and the periorbita along the orbital roof is often obscured by scar tissue. Recognizing these zones of physiological adhesion is essential, because sharp dissection is frequently required to separate these layers without breaching the dura (causing cerebrospinal fluid leak) or the periorbita (causing fat prolapse). Meticulous dissection is also required to protect the complex neurovascular array traversing the superior orbital fissure—including cranial nerves III, IV, VI, and V1—which are particularly vulnerable when normal anatomical planes are distorted.

Description of the technique

Video 1 demonstrates our reconstruction technique. A 50-year-old man with Parkinson disease who had undergone planum sphenoidale meningioma resection via a right pterional craniotomy with superior and lateral orbitotomies at another institution two years earlier presented with pulsatile enophthalmos. Imaging demonstrated a substantial defect in the roof and lateral wall of the right orbit (Fig. 1), with orbital fat herniating out of the lateral aspect of the defect (Fig. 2). The pulsatile movement resulted from the transmission of intracranial pulsations through the bony defect onto the globe, causing posterior displacement and rhythmic movement of the eye. Given this presentation, we performed a redo right pterional craniotomy for orbital defect reconstruction.

Fig. 1.

Axial (left) and coronal (right) CT imaging of the orbits demonstrating right-sided enophthalmos (arrow, left) and bony defects involving the lateral orbital wall and orbital floor (arrows, right) with herniation of orbital fat

Fig. 2.

Axial CT imaging showing a defect in the right lateral orbital wall with herniation of orbital fat through the bony defect (arrow)

The patient was placed supine with his head turned slightly to the left and his neck extended. The head was placed in a Mayfield head holder with 3-pin fixation to allow gravity to retract the frontal lobe off of the orbit. The prior craniotomy flap had ossified since the previous surgery; its removal required careful drilling until the dura was encountered. The orbital contents were then meticulously dissected from the adherent frontal dura with an A-microdissector (Mizuho, Tokyo, Japan), a dural separator, and microscissors to reach the bony defect. A large prolapse of periorbital fat protruded through a defect in the periorbita (Fig. 3). A titanium Medpor implant (Stryker, Portage, Michigan, USA), which had been contoured for a right-sided orbital reconstruction, was secured to the orbital roof and lateral wall with titanium screws (Fig. 4). The implant was designed using computed tomography scan data to approximate the premorbid anatomy and enhance reconstruction efficiency. After implant placement, the prior craniotomy flap was reaffixed with titanium plates and screws, and a Medpor cranioplasty was placed to reconstruct the temporal fossa and prevent settling of the temporalis muscle. Postoperative imaging showed the superior and lateral orbital defect were well reconstructed, and the patient’s enophthalmos resolved immediately (Fig. 5).

Fig. 3.

Intraoperative photograph demonstrating herniation of orbital fat through a defect in the lateral orbital wall

Fig. 4.

Intraoperative photograph demonstrating custom titanium plate reconstruction of the lateral orbital wall defect

Fig. 5.

Postoperative coronal (left) and sagittal (right) CT images demonstrating reconstruction of the superior and lateral orbital walls using a custom implant

Indications

The decision process for undertaking orbital reconstruction is complex and depends on the lesion type, extent of bony removal, and integrity and involvement of the periorbita. There is little clear evidence to suggest when bony reconstruction is required.

Generally, if the orbital bone or periorbital tissues themselves are directly involved with tumor, such as meningioma, we do not recommend upfront reconstruction [3]. In cases of hyperostotic orbital or spheno-orbital meningioma, we contend that resection appropriately expands orbital volume, and thus routine orbital wall reconstruction can be avoided. In addition, we suspect that the tumor itself encourages stiffening of the periorbita and surrounding tissues, preventing the formation of true enophthalmos. In primary orbital tumors and in tumors involving the orbital contents without extensive removal of bony orbit and periorbita, multiple studies and systematic reviews have demonstrated no difference in postoperative enophthalmos with or without reconstruction, supporting a conservative upfront approach [4, 8, 9].

Conversely, if the bony orbit or periorbita are not formally invaded, forgoing reconstruction often leads to pulsatile enophthalmos. Thus, in the setting of vascular lesions, or for tumors that do not involve the orbit but for which the approach requires removal of the bony orbit, orbital reconstruction is recommended. Series describing cavernous hemangiomas and other intraconal vascular tumors have shown that orbital reconstruction decreases the incidence of postoperative enophthalmos [7, 10]. Additionally, expert consensus within the cavernous hemangioma exclusively endonasal resection staging framework indicates that, for advanced vascular lesions, most panelists “always” or “almost always” recommend orbital reconstruction [5].

This case highlights a circumstance in which a non-orbital tumor was approached with removal of the bony orbit, leading to downstream pulsatile enophthalmos, thus requiring a delayed reconstruction.

Limitations

Even in settings of hyperostotic spheno-orbital meningioma where upfront orbital reconstruction is not required, some patients require reconstruction later. A single case report, by its nature, is susceptible to publication bias, cannot establish a generalizable cause-and-effect relationship, and may overinterpret findings. The rarity of this complication and the infrequency of these complex redo procedures make large, prospective, randomized studies impractical. Despite a growing body of literature, management of complex skull base conditions ultimately requires a high degree of surgical judgment that cannot be fully captured algorithmically.

How to avoid complications

Successfully navigating this complex redo procedure requires a meticulous surgical technique and a proactive approach to complication avoidance. Dense scar tissue from the prior surgery can prolong the procedure and increase the risk of iatrogenic injury to the dura or underlying critical structures. Preoperative planning with thin-slice computed tomography scans is valuable for visualizing the extent of the bony defect.

Critical aspects of reconstruction are the precise contouring and placement of the implant. The use of patient-specific implants is a major technological advancement; these implants are designed to precisely restore the premorbid orbital volume, minimizing the need for intraoperative contouring and reducing operative time [2]. It is essential to avoid constriction of the orbital space, which could lead to postoperative proptosis or diplopia. In cases where there is concern for muscle involvement, it is important to perform a forced duction test after implant insertion and before closure to ensure there is no muscle entrapment or impingement [2]. Postoperative complications can also include cranial nerve injury and cerebrospinal fluid leaks, so delicate tissue handling, proper retraction, and meticulous closure are imperative. Adhering to a strict epidural plane is the primary strategy for avoiding complications. By staying outside the dura, the risk of postoperative cerebrospinal fluid leak and parenchymal injury is reduced. The importance of a multidisciplinary approach involving neurosurgeons and craniofacial surgeons for achieving optimal functional and aesthetic outcomes in these complex reoperations cannot be overstated.

Specific information for the patient

When undergoing approaches to the orbit, the patient should be aware of the risks and benefits of upfront orbital reconstruction based on their lesion and other factors. A realistic preoperative discussion about the risk of vascular and neurologic injury, as well as the potential for alteration of the reconstruction plan based on surgical findings, is needed. Patients must be counseled that although the goal of surgery is to restore the bony anatomy and improve eye position, the resolution of enophthalmos may not be absolute. Scarring, fat atrophy from previous surgeries, or soft tissue changes may limit the aesthetic outcome even with perfect bony reconstruction. Managing these expectations preoperatively is vital. It is also important to inform patients and their families of potential complications because studies have shown that approximately one-third of patients undergoing open skull base surgery may experience one. Patients may feel a variety of emotions when preparing for a second surgery, and they should be encouraged to discuss their concerns with their surgical team.

Key points

• Upfront reconstruction is often unnecessary for hyperostotic spheno-orbital meningiomas and primary orbital tumors because tissue stiffening and bone removal allow appropriate orbital volume restoration.

• Orbital reconstruction for vascular lesions or non-orbital tumors is critical because their removal creates a sudden increase in orbital volume, which must be addressed to prevent postoperative enophthalmos.

• A staged, delayed approach can be used to effectively manage rare postoperative complications like pulsatile enophthalmos.

• Redoing cranio-orbital surgery presents unique challenges because dense scar tissue may require meticulous and time-consuming dissection to prevent iatrogenic injury to the dura and orbital contents.

• A thorough understanding of the cranio-orbital junction's surgical anatomy is essential for both preoperative planning and safe execution of the reconstruction procedure.

• Preoperative planning with thin-slice CT scans or MRI is important for visualizing the extent of the bony defect and informing the surgical strategy.

• The use of patient-specific implants is a major technological advancement that enables the precise restoration of orbital volume and contour.

• Key intraoperative steps include proper patient positioning to enhance surgical exposure and, if needed, performing a forced duction test to prevent muscle impingement by the implant.

• Maintaining a purely epidural plane is beneficial. This protects the intradural contents, minimizes the risk of cerebrospinal fluid leak, and avoids the need for intracural cerebral retraction.

• A multidisciplinary approach involving neurosurgeons and craniofacial surgeons is paramount for achieving optimal functional and aesthetic outcomes in complex cases.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

JA and WTC conceived of and designed the project; JA, JN, and TZ wrote the main manuscript text; WTC prepared the video and images; all authors reviewed the final version of the manuscript.

Funding

The authors received no funding for this project.

Data Availability

No datasets were generated or analysed during the current study.

Declarations

Ethical approval

Approval from the institutional review board is waived for case reports. All procedures performed in studies involving human participants were in accordance with the ethical standards of the University of Utah and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Consent to participate

The patient consented to participate.

Consent for publication

The patient consented to the publication of her case in this paper.

Competing interest

The authors declare no competing interests.