Cost-effective reconstruction of long-standing lateral orbital rim defect with bone-prelaminated forehead flap using iliac crest

RATIONALE: Reconstructing composite lateral orbital rim defects after high-energy trauma remains challenging, particularly after infected alloplastic failure and in settings where microsurgery or patient-specific implants are unavailable. Autologous regional reconstruction may restore soft tissue coverage and bony support while avoiding additional hardware. PATIENT CONCERNS: A 33-year-old man presented with a long-standing post-traumatic right orbital deformity after ballistic injury, including globe loss and composite defects of the lateral orbital rim, temporal bone, and adjacent soft tissues. A previously placed metallic mesh had become exposed and infected, causing pain, deformity, and an inability to proceed with prosthetic rehabilitation. DIAGNOSES: Infected exposed alloplastic reconstruction with an anophthalmic right orbital deformity and composite lateral orbital rim, temporal, and soft tissue loss. INTERVENTIONS: Management was staged. After mesh removal, culture-directed infection control, crane flap preparation, delayed transfer, supragaleal retrieval, and split-thickness skin grafting, definitive repair was performed using a contralateral forehead flap measuring 6 cm × 6 cm with a 12-cm pedicle, prelaminated with an iliac crest bone graft in a narrow distal subcutaneous pocket. The flap reconstructed the lateral orbital rim, and lateral canthal support was restored using nylon loop-suture suspension anchored through the graft, without rigid alloplastic hardware. OUTCOMES: Distal venous congestion resolved after superficial suture release and leech therapy, without necrosis. Early imaging confirmed stable graft positioning, and the socket was anatomically suitable for future ocular prosthesis placement; however, prosthetic fitting had not yet been completed. LESSONS: This technique may represent a cost-conscious option in resource-limited settings, but longer follow-up is needed.