Midface, Post-maxillectomy Reconstruction

Abstract

This chapter, authored by Prof. Matthew Hanasono, details a clear algorithmic approach to the management of defects in this anatomically complex region. As these defects are comparatively uncommon, majority of reconstructive surgeons lack requisite experience, rendering this chapter extremely important.

The most fundamental tenets of midface and post-maxillectomy reconstruction are as follows:

• Achieving midfacial projection in order to preserve facial appearance

• Oronasal separation

• Patency of nasal passages permitting nasal respiration

• Preserving mastication, speech, and swallowing functions

• Providing support to the globe wherever orbital floor needs resection

In all patients, it is essential to determine the most pragmatic option that achieves the above objectives as completely as possible.

Defects of the palate alone (preserving the soft palate) are most readily obturated, provided there is adequate dentition available. If fashioning an obturator is not possible, a local palatal rotation flap suffices with limited, lateralized defects, while larger defects would need a fasciocutaneous free flap such as the FRAFF, or even a pedicled temporalis muscle flap.

With defects encompassing the alveolar process, the reconstructive alternatives depend upon the extent of alveolar resection.

Defects posterior to the canine tooth, with adequate dentition can be effectively obturated if a 3-point support is available through both canines and contralateral molar teeth.

If the patient desires reconstruction or if a stable prosthesis cannot be planned, reconstruction can be readily accomplished with soft tissue flaps, the ALT being the most popular choice. If dental rehabilitation is desired, the osteocutaneous free fibula would represent the most favored option currently.

With palatomaxillary defects extending to the midline and beyond, adequate projection of the midface can only be attained with bony reconstruction. The osteocutaneous fibula is the current first choice for all such defects.

All the above situations are covered by suitable case studies.

With defects involving the orbital floor, globe support has to be assured and is achieved either with a bone-containing flap or a titanium mesh.

A detailed algorithmic approach is suggested for defects of varying sizes and complexity.