Reconstruction of the Orbit after Resection of Spheno-Orbital Meningiomas: A Novel Technique

Background: Spheno-orbital meningiomas (SOMs) are complex tumors involving the middle cranial fossa and orbit. With improvement in microsurgical techniques, total or near-total resection of these tumors is increasingly possible, but reconstruction of the orbit remains challenging. Inadequate reconstruction may lead to cosmetic deformities, persistent exophthalmos or enophthalmos, or limited extraocular motility. Traditional methods of reconstruction involve the use of bone autograft, titanium mesh, or customized patient-specific implants, and some surgeons advocate performing no reconstruction at all. Each of these methods has potential limitations related to technical challenges, interference with postoperative imaging, cosmetic deformities, and cost. We sought to develop a technique for orbital reconstruction that is technically straightforward and cost-effective, with an excellent functional and cosmetic outcome.

Technique: Twelve patients with SOMs underwent a modified orbital-zygomatic craniotomy with orbital osteotomies based on individual tumor location. In each case, the lateral orbital wall was removed, and the orbital roof was resected in 3/12 cases to obtain adequate exposure to the tumor. After tumor resection, these structures were reconstructed using a malleable 1-mm porous polyethylene sheet, customized to reconstruct the bony anatomy of the lateral and superior orbit. The implant was molded to reproduce the natural cone-shaped orbit and secured with 1.5 mm × 4 mm titanium screws into the remaining orbital roof and rim. Preparation and placement of the implant required approximately 15 minutes of operative time in each case. The hospital cost of the polyethylene sheet was $420/case, and the average total implant cost was $1,238/case.

Results: All patients demonstrated stabilization or improvement of vision and satisfactory cosmetic outcomes. One complication (surgical site infection) was noted. Follow-up imaging was obtained at regular intervals. The resection cavity was easily visualized without interference from the implant in each case. One patient developed tumor recurrence requiring re-operation 20 months after the initial procedure.

Conclusions: Use of a 1-mm porous polyethylene sheet for reconstruction of the lateral orbit offers an excellent functional and cosmetic outcome, does not interfere with postoperative imaging, is technically straightforward, and is cost-effective.