A 15-year review of midface reconstruction after total and subtotal maxillectomy: part I. Algorithm and outcomes.
ABSTRACT Reconstruction of complex midfacial defects is best approached with a clear algorithm. The goals of reconstruction are functional and aesthetic.
Over a 15-year period (1992 to 2006), a single surgeon (P.G.C.) performed 100 flaps to reconstruct the following midfacial defects: type I, limited maxillectomy (n = 20); type IIA, subtotal maxillectomy with resection of less than 50 percent of the palate (n = 8); type IIB, subtotal maxillectomy with resection of greater than 50 percent of the palate (n = 8); type IIIA, total maxillectomy with preservation of the orbital contents (n = 22); type IIIB, total maxillectomy with orbital exenteration (n = 23); and type IV, orbitomaxillectomy (n = 19). Free flaps were used in 94 cases (94 percent), and pedicled flaps were used in six (6 percent).
One hundred flaps were performed in 96 patients (69 males, 72 percent; 27 females, 28 percent); four patients underwent a second flap reconstruction due to recurrent disease (n = 4, 4 percent). Average patient age was 49.2 years (range, 13 to 81 years). Free-flap survival was 100 percent, with one partial flap loss (1 percent). Five patients suffered systemic complications (5.2 percent), and four died within 30 days of hospitalization (4.2 percent). Over 50 percent of patients returned to normal diet and speech. Almost 60 percent were judged to have an excellent aesthetic result.
Free-tissue transfer offers the most effective and reliable form of reconstruction for complex maxillectomy defects. Rectus abdominis and radial forearm free flaps in combination with immediate bone grafting or as osteocutaneous flaps consistently provide the best functional and aesthetic results.
- [show abstract] [hide abstract]
ABSTRACT: BACKGROUND:: Management of maxillary defects is among the most challenging and controversial areas of head and neck reconstruction. Our objective was to develop a treatment algorithm based on outcomes following free flap reconstruction of various maxillary defects. METHODS:: A review of 246 maxillary free flap reconstructions was performed. RESULTS:: Our analysis demonstrated that the palatoalveolar resection predicted use of soft tissue (n=200) versus osteocutaneous (n=46) free flaps, depending on the location and extent of the defect. Whether the orbital floor or the entire orbital contents were resected also had implications for flap choice and whether bone grafts or alloplasts were needed.The perioperative complication rate was 37.8%, including a 3.3% incidence of flap loss. The long-term complication rate was 12.1%, including a 7.5% fistula rate. Complications related to orbital floor reconstruction were not dependent on the material used (p=0.18). Greater than 80% speech intelligibility was achieved by 95.1% of patients, and 90.6% tolerated an unrestricted or soft diet. CONCLUSIONS:: To restore both midfacial form and function, the palatoaveloar defect as well as the status of the orbital floor and orbital contents must be each be addressed. Palatoalveolar defects that involve the anterior maxilla should be addressed with osteocutaneous free flaps if possible, while posterior defects can often be reconstructed with soft tissue free flaps. The orbital floor requires rigid reconstruction, with either bone grafts or alloplasts, unless the orbital contents have also been exenterated, in which case a soft tissue free flap should be used to close the orbital cavity. LEVEL OF EVIDENCE:: Therapeutic, IV.Plastic and reconstructive surgery 09/2012; · 2.74 Impact Factor
- Plastic and reconstructive surgery 01/2013; 131(1):61-2. · 2.74 Impact Factor