This paper aims to discuss the microvascular reconstruction of the orbit and adjacent regions and to propose a checklist to aid the reconstructive surgeon in this challenging undertaking. The discussion is based on a literature review that includes 32 retrospective case series, 5 case reports published in the last 34 years in PubMed, and 3 textbook chapters. Additionally, it relies on the senior author\'s expertise, described in a case series, and two case reports published elsewhere. Classifications and treatment algorithms on microvascular orbit reconstruction generally disregard patient-related factors. A more holistic approach can be advantageous: patient-related factors, such as age, comorbidities, prognosis, previous interventions, radiotherapy, and the wish for maximal dental rehabilitation and a prosthetic eye, have the same importance as defect-related considerations and can inform the choice of a reconstructive option. In this manuscript, we examine defect- and patient-related factors and new technologies, provide a checklist, and examine future directions. The checklist is intended as a tool to aid in the decision-making process when reconstructing the orbital region with microvascular flaps.

Spheno-orbital meningioma (SOM) is a rare intracranial pathology with intraosseous hypertrophy and intraorbital extension.
We described a middle-aged female with SOM who was managed in a micro-neurosurgical manner. The titanium implant was customized and applied to rebuild the orbital wall to prevent postoperative enophthalmus.
Despite technical demands, favorable cosmetic, and clinical outcomes without complications can be achieved by meticulous surgical technique following radical resection.
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UNASSIGNED: Meningiomas correspond to one-third of all primary central nervous system tumors. Approximately 9% of them are spheno-orbital meningiomas (SOMs), presenting significant clinical symptoms as visual impairment and orbital esthetics. This article aims to evaluate exophthalmos\' improvement in a surgical series without orbital reconstruction.
UNASSIGNED: We consecutively included all patients diagnosed with SOM, admitted to a single institution for 10 years. Surgical resection was the standard of care, associated or not with adjuvant radiation therapy. The radiological investigation included preoperative and postoperative head CT or MRI. We quantified proptosis through imaging.
UNASSIGNED: Forty patients composed this series, 87.5% were female. Proptosis was the most common presentation (90%), followed by decreased visual acuity (65%), motility deficit (20%), and headache (20%). Gross total resection was achieved in 65% of the procedures. In late outcomes, 78% of the patients maintained or improved visual acuity and 85% maintained or improved headache. Proptosis significantly improved after surgery and along with the follow-up (P < 0.001). Ten patients were submitted to adjuvant RT, six of them after a subtotal resection. All patients of this subgroup had proptosis. It was observed a higher frequency of worse in visual acuity in patients submitted to RT (71% vs. 28%, P = 0.038).
UNASSIGNED: Resection of SOM was sufficient to stop the evolution of visual deficit and allowed the improvement of proptosis. Orbital reconstruction does not seem to be an essential step in reducing enophthalmos.

Reconstruction of post traumatic orbital defects has undergone a stepwise evolution following developments in reconstructive materials and surgical techniques. Advances in communication between surgical teams and design technicians have allowed provision of bespoke surgical plates with a high degree of accuracy and surgical relevance in an appropriate timeframe. We present a case series of 41 consecutive patients treated in London and BernBern Switzer between March 2019 and September 2020 with extensive defects reconstructed with patient specific orbital plates. Complexity of fracture was risk adjusted using the Jaquiery scale with one patient (J3), 14 patients (J4), and 26 Patients (J5). Outcome was assessed by accuracy of fit at the surgical margins and was 94.5%. The study group was statistically tested against a previous series by the same group and was statistically different with respect to the case complexity (p<0.001) and accuracy of fit (p<0.001) (Fisher\'s exact test). Complications included the removal on one plate due to patient choice, with perfect surgical position and resolving diplopia. Only one plate articulation was poor, this mitigated by the size of the defect and the orbital soft tissue swelling which prohibited seating the implant. The patient remains well with acceptable function and satisfactory aesthetics. We present design considerations including the use two part plates, and surgical pearls to achieve predictable placement. We believe that the use of custom plates for reconstruction of Jaquiery 4 and 5 should be considered. We regard this technology as a game changer in surgical management of the complex high risk orbit.

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BACKGROUND: The author\'s goal was to present an approach for serial surgical reconstruction of anophthalmic orbits with \'bag-shaped\' flaps and cartilage transplantation.
METHODS: A review was performed of 53 patients who underwent serial physiological orbital reconstruction between 2006 and 2013. Orbital reconstruction was performed serially in stages, including \"bag-shaped\" flap transplantation, medial and lateral canthoplasty, tarsus reconstruction, and improvement of the strength of the levator palpebrae superior muscles. Curative effects were evaluated by the surgeons and patients jointly.
RESULTS: Among the total of 53 cases, the curative effects were assessed as excellent in 28 patients, good in 17 patients, moderate in 6 patients, and poor in 2 patients. Two cases suffered necrosis of the bag-shaped flap, which was remedied with a frontal island flap and skin grafting; 4 cases experienced shallowness of the lower fornix, of which three were remedied by deepening of the lower fornix and the other by lower eyelid suspension. The appearance of the reconstructed eye socket was acceptable, natural and persistent.
CONCLUSIONS: This procedure offers staged and serial reconstruction of anophthalmic orbits, according to the orbital shape and the volume loss of the orbital soft tissue. It is an ideal approach to reconstruct eye sockets, with a high survival rate of the flaps, acceptable appearance of the reconstructed eye socket, and stable depth of the upper and lower eyelid fornices.