title: En bloc resection of lacrimal sac tumors and simultaneous orbital reconstruction: surgical and functional outcomes.
abstract: OBJECTIVE
  To describe a surgical technique of en bloc resection of lacrimal sac tumors by the shared expertise of 2 specialists to achieve optimal tumor margin clearance and the simultaneous reconstruction of the bony defect to preserve ocular functions and cosmesis.
  
  
  METHODS
  All patients who had resection of malignant nasolacrimal drainage system tumors using the combined technique and posttreatment protocol between 1997 and 2011 were studied in this retrospective, noncomparative, interventional case series. A combined medial maxillectomy and medial orbitotomy for en bloc resection of the lacrimal sac tumor was followed by reconstruction with a tailored contoured titanium mesh to support the globe and eyelid. Disease relapse, disease survival, ocular functions (vision loss, motility, globe dystopia, and diplopia), and cosmesis (medial canthal tendon dystopia and eyelid retraction) were documented.
  
  
  RESULTS
  Fourteen patients with malignant lacrimal sac tumors underwent en bloc resection. Postoperative radiation was ultimately administered to 9 patients. All patients but one were alive at last follow up. Tumor recurred locally in 2 patients with a regional recurrence in a third patient. Complications from radiation therapy included skin breakdown over the mesh (9/14 patients) with nasocutaneous fistula, medial canthal tendon dystopia (2/14 patients), and corneal perforation in a patient with recurrent disease. Despite removal of the tear drainage system, only 7 of 14 patients reported epiphora. None of the patients developed diplopia after resection and radiation therapy.
  
  
  CONCLUSIONS
  The combined sinus-orbit approach is an effective method of managing lacrimal sac tumors to achieve optimal tumor clearance from the orbit and nasal cavity. Simultaneous reconstruction of the bony defect with a contoured titanium mesh provides a fixation anchor for the medial canthal tendon and globe support and serves as a supporting platform for the lower eyelid and cheek to minimize midface collapse. Postoperative radiation is associated with skin flap breakdown and nasocutaneous fistula formation.
authors.affiliation: *Department of Ophthalmology, Bascom Palmer Eye Institute, †Department of Otolaryngology, and ‡Department of Radiation Oncology, University of Miami, Miller School of Medicine, Miami, Florida, U.S.A.
authors.forename: Chrisfouad R
authors.initials: CR
authors.lastname: Alabiad
authors.forename: Donald T
authors.initials: DT
authors.lastname: Weed
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Walker
authors.forename: Richard
authors.initials: R
authors.lastname: Vivero
authors.forename: Georges A
authors.initials: GA
authors.lastname: Hobeika
authors.forename: Georges F
authors.initials: GF
authors.lastname: Hatoum
authors.forename: Erin M
authors.initials: EM
authors.lastname: Shriver
authors.forename: David T
authors.initials: DT
authors.lastname: Tse
mesh_terms: D000236:Adenoma / Q000473:pathology / Q000601:surgery; D000328:Adult; D000368:Aged; D003528:Carcinoma, Adenoid Cystic / Q000473:pathology / Q000601:surgery; D018277:Carcinoma, Mucoepidermoid / Q000473:pathology / Q000601:surgery; D002294:Carcinoma, Squamous Cell / Q000473:pathology / Q000601:surgery; D002295:Carcinoma, Transitional Cell / Q000473:pathology / Q000601:surgery; D005134:Eye Neoplasms / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D007766:Lacrimal Apparatus Diseases / Q000473:pathology / Q000601:surgery*; D008297:Male; D008443:Maxillary Sinus / Q000601:surgery; D008875:Middle Aged; D013508:Ophthalmologic Surgical Procedures; D009915:Orbit / Q000601:surgery; D018714:Radiotherapy, Adjuvant; D019651:Plastic Surgery Procedures; D012189:Retrospective Studies; D013524:Surgical Flaps