Abstract

Background: The orbit is a complex anatomical region. Cocaine-induced midline destructive lesions (CIMDL) can severely damage the orbital walls. This study evaluates the effectiveness of the pericranial flap in reconstructing orbital defects in CIMDL patients, focusing on its proper positioning, stretching, and anchoring to the orbital bone.

Case Description: We present the case of a 57-year-old male with a history of chronic cocaine use, who presented with enophthalmos, diplopia, and reduced vision in the left eye. Imaging revealed extensive destruction of orbital walls. After a prolonged period of cocaine abstinence, the patient underwent reconstructive surgery using a pericranial flap to restore orbital integrity. Postoperative imaging confirmed correct placement of the pericranial flap, which successfully restored orbital integrity and sealed the sinus communication. Clinically, the patient showed significant improvement in enophthalmos, resolution of diplopia, and enhanced vision.

Conclusion: Harvesting and positioning the pericranial flap under the eyeball, appropriately stretched and anchored to the orbital bone, are a feasible and effective technique for complex orbital reconstruction in CIMDL cases. This approach successfully restores anatomical structure, improves eye alignment, and resolves diplopia, supporting both anatomical restoration and functional recovery.

Keywords: Autologous pericranial flap, Cocaine abuse, Enophthalmos, Orbital reconstruction

The orbit is a complex anatomical region that houses the eyeball, optic nerve, vascular structures, and extrinsic ocular muscles. The orbital floor consists of the orbital portion of the maxillary bone, the orbital surface of the zygomatic bone, and the orbital process of the palatine bone. Due to its thinness, the floor is particularly vulnerable to injury and forms the roof of the maxillary sinus.[ 5 ] At the junction between the orbital roof and the medial wall, we find the anterior and posterior ethmoidal foramina, through which the anterior and posterior ethmoidal arteries run[ 5 ] [ Figure 1 ].

Figure 1:

Anatomic illustration of the orbit. The anterior and posterior ethmoidal arteries are branches of the ophthalmic artery.

Chronic cocaine abuse can lead to severe ischemic and necrotic lesions of nasal and sinus structures, resulting in a condition known as cocaine-induced midline destructive lesion.[ 1 , 7 ] This condition may cause resorption of soft and hard tissues, including the orbital floor and medial wall, presenting clinically with enophthalmos, hypovision, diplopia, and a high risk of infection due to communication with the maxillary sinus.

As described in the literature, reconstructive procedures of lost soft and hard tissues are sometimes necessary, involving the use of local, regional, or free revascularized flaps.[ 1 - 4 , 6 , 7 ] Reconstruction of orbital defects, particularly in cocaine-addicted patients, poses unique challenges due to tissue fragility and the increased risk of infection. Autologous flaps, such as the pericranial flap, offer a well-vascularized solution to these problems, enabling effective tissue regeneration and reducing postoperative complications.[ 2 ]

PATIENT HISTORY

We present the case of a 57-year-old male with a long history of cocaine abuse presenting with persistent diplopia, enophthalmos, and decreased vision in the left eye. Computed tomography (CT) revealed severe destruction of the nasal septum, maxillary sinuses, and the left orbital floor, with direct communication between the orbit and the maxillary sinus [ Figure 2 ].

Figure 2:

Computed tomography preoperative. Defect in the medial wall and orbital floor with direct communication with the maxillary sinus. (a) Coronal. (b) Axial.

The patient also showed signs of infection in the left orbit, which was confirmed by a biopsy testing positive for methicillin-sensitive Staphylococcus aureus. Following a course of antibiotics and after abstaining from cocaine for a year and a half, the patient’s inflammatory condition improved significantly, as shown by a follow-up magnetic resonance imaging [ Figure 3 ].

Figure 3:

Magnetic resonance imaging preoperative showing the inflammatory and infectious condition of the left orbit. (a) Coronal. (b) Axial. T1-weighted sequences.

A neurosurgical evaluation was performed, and the patient was found to have persistent enophthalmos and a downward displacement of the left eyeball, accompanied by paresis of the left medial rectus muscle and diplopia in all directions of gaze. Given the patient’s prolonged abstinence from cocaine and the absence of active infection, surgical intervention was recommended to reconstruct the orbital floor and correct the ocular misalignment.

The patient underwent a left fronto-orbito-zygomatic craniotomy. After a bicoronal skin incision and interfascial dissection of the temporalis muscle, the left fronto-orbitozygomatic bone flap was removed. A large pedicled pericranial flap was harvested from the right frontal region and rotated to cover the defects in the left orbital floor, medial, and lateral walls [ Figure 4 ].

Figure 4:

Anatomic illustration (a) The pericranial flap is anchored to two tubular drains that are passed under the orbit. (b) The flap is slid under the orbit, applying enough tension to shift it upwards. (c) The flap is then secured to the bone by titanium screws. The orbital rim is repositioned and fixed.

Two tubular drains were used to manipulate the pericranial flap into place beneath the eyeball. The flap was then anchored to the orbital bones using titanium screws, providing adequate support to the eyeball to correct both its upward and forward displacement [ Figure 5 ].

Figure 5:

Intraoperative image. (a) The pericranial flap is anchored to two tubular drains. (b) The pericranial flap is flipped applying the necessary tension to reconstruct the orbital floor.

The orbital rim was repositioned and secured with microplates and screws.

RESULTS

The reconstruction successfully restored the orbital floor and sealed the communication with the maxillary sinus. The patient had an uneventful postoperative recovery.

A CT scan confirmed the proper positioning of the pericranial flap and the successful reconstruction of the orbital floor [ Figure 6 ].

Figure 6:

(a) Postoperative computed tomography (coronal view) shows the reconstruction of the orbital floor using the pericranial flap (red arrow). (b) Postoperative photograph of the patient (red arrow: Left eye).

Clinically as shown in the postoperative photograph of the patient, there was marked improvement of enophthalmos, diplopia resolved, and vision in the left eye improved significantly [ Figure 6 ]. The patient was discharged with no signs of infection or inflammatory complications.

DISCUSSION

Reconstruction of the orbital floor in cases of cocaine-induced destruction presents unique challenges, particularly due to the associated risks of infection and tissue fragility.

Reconstruction strategies for such cases vary depending on the extent of tissue destruction.[ 2 , 3 ] Local flaps (e.g., lingual, or pharyngeal flaps), regional flaps (e.g., galeal or pericranial flaps), and free revascularized flaps (e.g., forearm flaps) are commonly used.[ 1 ] Pericranial flaps offer the added advantage of better integration with the host tissues, reducing the risk of postoperative complications compared to the previous other techniques.[ 1 ]

The goals of surgery in our patient were threefold: to reduce the risk of infection by closing the communication between the orbit and maxillary sinus, to correct enophthalmos by repositioning the eyeball outward, and to restore proper eye alignment by elevating the eyeball.

The use of autologous pericranial flaps offers several advantages over synthetic materials or heterologous grafts. Autologous tissue is highly vascularized, promoting faster healing and reducing the risk of immune rejection or inflammatory reactions.[ 2 ] In our case, the use of a pericranial flap was particularly advantageous due to its elasticity, strength, adaptability, and extensibility. We recommend an optimal preparation of the pericranial flap to exploit its maximum thickness and avoid lacerations during its harvesting. Furthermore, the placement of the pericranial flap using tubular drains provided an effective and minimally traumatic method to slide the flap under the eyeball [ Figure 4 ]. By stretching and anchoring the flap, we were able to provide the necessary tension to correct both the enophthalmos and dystopia, restoring the patient’s ocular function [ Figure 5 ].

However, the limitations of the pericranial flap may include its thin structure and potentially limited corrective capacity compared to other reconstructive methods. This issue was addressed using anchoring sutures, securing the flap with screws after stretching it along the medial, inferior, and lateral orbital walls, and positioning it under the appropriate tension [ Figures 4 and 5 ].

CONCLUSION

The use of a pedicled autologous pericranial flap appropriately positioned, stretched, and anchored allowed us to reconstruct the orbital defect while providing the upward and forward tension necessary to correct both dystopia and enophthalmos. The harvesting of the pericranial flap is easily practicable in comparison to other reconstructive methods and we were also able to create a hermetic separation between the orbital cavity and the maxillary sinuses, significantly reducing the risk of postoperative inflammation and infection.

Ethical approval:

Institutional review board approval is not required.

Declaration of patient consent:

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation:

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

Acknowledgments:

Carlo Mandelli (CM) is the primary author of this article. Cinzia Mura (CM) contributed to the writing and created the anatomical illustrations. Ervin Karaj (EK) and Andrea Bisoglio (AB) contributed with literature review. Pietro Mortini (PM) is the primary surgeon of the surgical procedure, supervised and approved the final version of the article.

References

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