Management of extended oncologic orbital exenteration reconstruction: a collaboration between surgeons and prosthetists for optimized results.

Extensive orbital exenteration requires complex reconstructive strategies to restore both function and aesthetic form while allowing for durable prosthetic rehabilitation. This retrospective study analyzed reconstructive outcomes following orbital exenteration at the Gustave Roussy Institute, while emphasizing the importance of prosthesis-driven surgical planning through close collaboration between surgeons and prosthetists. Seventy-eight patients who underwent orbital exenteration between 2000 and 2023 were included. Demographic characteristics, oncological data, reconstructive techniques, complications, and surgical and prosthetic outcomes were collected and analyzed descriptively. The cohort had a mean age of 58 years (female/male ratio 30/48). Squamous cell carcinoma was the most frequent diagnosis (36 %). Neoadjuvant or adjuvant radiotherapy was administered in 61.5 % of patients, and 41 % underwent extended exenterations associated with maxillectomy. Free flaps were the predominant reconstructive method (73 %). Twenty-five patients (32 %) were rehabilitated with an epithesis, including 12 implant-supported prostheses. Based on long-term institutional experience and representative clinical cases, five reconstructive principles were identified to optimize outcomes: selection of the thinnest feasible flap according to defect extent and radiotherapy status; prioritization of orbital concavity and malar projection over anatomic reconstruction of the orbital frame; strategic timing and positioning of osseointegrated implants; avoidance of eyelid preservation in extensive defects with loss of bony support; and proactive management of dyschromia. An epithesis-first approach to reconstruction may improve functional, aesthetic, and patient-reported outcomes following extensive orbital exenteration.