Microsurgical reconstruction of complex midfacial and maxillectomy defects is among the most challenging procedures in plastic surgery, and it often requires composite flaps to improve functional and aesthetic results. Various factors have been identified as having influence in the outcome of microsurgical reconstruction. In this article, the authors present their experience with immediate and delayed reconstruction of complex maxillectomy defects in a tertiary center in Mexico. The authors present a total of 37 patients with microsurgical reconstruction of a complex maxillectomy defect; 13 patients had immediate and 24 had delayed reconstructions. The authors recommend doing immediate reconstruction when feasible.
Key points
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Free flaps have become the first option for reconstruction of maxillectomy and midfacial defects, with successful functional and aesthetic outcomes, particularly when performed immediately.
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Delayed reconstruction of maxillectomy defects is associated with significantly higher rates of complication probably secondary to radiotherapy and recurrent infections from long-term oral or nasal cavity communication.
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Therefore, multiple free and local flaps are required in this group of patients to address wound dehiscence with hardware exposure, orocutaneous fistula, and upper lip or partial nasal retraction and to provide stable skeletal and soft tissue reconstruction.
Introduction
Reconstruction of maxillectomy and midfacial defects are among the most challenging procedures in plastic surgery. Defects in this anatomic area frequently have suboptimal aesthetic and functional outcomes, affecting speech, oral competence, eye globe position and function, among others. Microsurgical free tissue transfer is currently the treatment of choice for the reconstruction of complex midfacial defects. The overall success rate of microsurgical transfer of tissue in the head and neck is reported to be more than 90%. Various factors and patients’ characteristics have been identified as having an influence in the outcome of microsurgical reconstruction. Apart from patients’ medical conditions, preoperative treatment with radiotherapy is one of the main factors that influences postoperative outcomes. The introduction of radiotherapy has resulted in increased survival of patients diagnosed with head and neck malignancies; therefore, current treatment involves a combination of surgical resection with either immediate or delayed reconstruction and radiotherapy.
In the year 2000, Cordeiro and Santamaria published a classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Flap selection was determined by the type of bony resection and missing soft tissue volume and skin surface and is described as follows: type I , limited maxillectomy; type II , subtotal maxillectomy; type IIIa , total maxillectomy with preservation of orbital contents; type IIIb , total maxillectomy with orbital exenteration; and type IV , orbitomaxillectomy. This classification system helps to determine the best approach for microsurgical free flap reconstruction based on the type of defect.
The objective of this article is to describe the common pitfalls encountered in delayed and immediate microsurgical reconstruction of complex maxillectomy and midfacial defects. The authors present the most commonly used free flaps, complications, and functional and aesthetic outcomes in complex midfacial reconstruction in a tertiary center in Mexico.
Introduction
Reconstruction of maxillectomy and midfacial defects are among the most challenging procedures in plastic surgery. Defects in this anatomic area frequently have suboptimal aesthetic and functional outcomes, affecting speech, oral competence, eye globe position and function, among others. Microsurgical free tissue transfer is currently the treatment of choice for the reconstruction of complex midfacial defects. The overall success rate of microsurgical transfer of tissue in the head and neck is reported to be more than 90%. Various factors and patients’ characteristics have been identified as having an influence in the outcome of microsurgical reconstruction. Apart from patients’ medical conditions, preoperative treatment with radiotherapy is one of the main factors that influences postoperative outcomes. The introduction of radiotherapy has resulted in increased survival of patients diagnosed with head and neck malignancies; therefore, current treatment involves a combination of surgical resection with either immediate or delayed reconstruction and radiotherapy.
In the year 2000, Cordeiro and Santamaria published a classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Flap selection was determined by the type of bony resection and missing soft tissue volume and skin surface and is described as follows: type I , limited maxillectomy; type II , subtotal maxillectomy; type IIIa , total maxillectomy with preservation of orbital contents; type IIIb , total maxillectomy with orbital exenteration; and type IV , orbitomaxillectomy. This classification system helps to determine the best approach for microsurgical free flap reconstruction based on the type of defect.
The objective of this article is to describe the common pitfalls encountered in delayed and immediate microsurgical reconstruction of complex maxillectomy and midfacial defects. The authors present the most commonly used free flaps, complications, and functional and aesthetic outcomes in complex midfacial reconstruction in a tertiary center in Mexico.
Methods
Over a 16-year period (1999–2015), 37 patients were reconstructed for complex midfacial defects using 52 free flaps that were performed by a single surgeon (E.S.) at a tertiary center, Hospital General Dr Manuel Gea Gonzalez, in Mexico City. The authors conducted a retrospective chart review to record demographic data, reconstructive procedures, and complications and compared the functional and aesthetic outcomes between delayed and immediate reconstruction groups. The measurements were exported to the Statistical Package for Social Sciences (IBM SPSS Statistics 23.0) for statistical analyses. The differences in the immediate and delayed reconstruction groups were compared using a 2-sample t test, with a 95% confidence level. P values less than .05 were considered significant. The institutional review board of Hospital General Dr Manuel Gea Gonzalez approved this study.
Results
A total of 37 patients were included in this study (immediate reconstruction group: 13, delayed reconstruction group: 24). The diagnoses of each group are presented in Table 1 . The average patient age was 52 years (range 35–68 years) and 44 years (range 23–71 years) in the immediate and delayed reconstruction group, respectively. Patient characteristics and demographics are presented in Table 2 . No statistically significant differences were observed between both groups regarding sex, smoking, diabetes, hypertension, and other comorbidities. The delayed reconstruction group had statistically significant ( P = .003) more preoperative radiotherapy (66.7%) than the immediate reconstruction group (15%).
| Diagnosis | Immediate Reconstruction n = 13 (%) | Delayed Reconstruction n = 24 (%) |
|---|---|---|
| Malignant tumor | 8 (61.5) | 16 (66.7) |
| Benign tumor | 4 (30.8) | 6 (25.0) |
| Trauma | 1 (7.7) | 2 (3.0) |
| Patient Characteristics | Immediate Reconstruction (n = 13) | Delayed Reconstruction (n = 24) |
|---|---|---|
| Age (mean) | 52 (range 35–68 y) | 44 (range 23–71 y) |
| Sex: | ||
| Male/female | 9/4 | 16/8 |
| Smoker | 3 | 5 |
| Diabetes | 1 | 2 |
| Hypertension | 5 | 3 |
| Radiotherapy a | 2 | 16 |
| Other comorbidities | 2 | 2 |
Types of free flaps used for reconstruction of midfacial defects based on the authors’ classification system described in 2000 are listed in Table 3 . The most commonly used was the fibula osteocutaneous free flap (n = 24), followed by the rectus abdominis myocutaneous free flap (n = 15). In contrast to the authors’ previous algorithm treatment, the radial forearm osteocutaneous and fasciocutaneous free flaps were rarely used (n = 6). In addition to using multiple free flaps, some patients required one or more local flaps for reconstruction of complex structures, such as eyelids, lips, and nose. The delayed group required more local flaps for reconstruction of these complex structures (n = 12) compared with the immediate group (n = 4). These flaps included 9 forehead flaps for eyelids (n = 3) and partial nasal (n = 6) reconstruction, 3 lower lip to upper lip switch-flap procedures, 2 naso-labial flaps for partial nasal reconstruction, and 2 facial artery myomucosal flaps for upper lip inner lining.
| Maxillectomy Defect Type | No. of Patients | No. of Free Flaps | Rectus Abdominis Myocutaneous | Radial Forearm Fascio-Cutaneous | Radial Forearm Osteo-Cutaneous | Fibula Osteo-Cutaneous | ALT | Other (Local Flaps) a |
|---|---|---|---|---|---|---|---|---|
| Immediate reconstruction | ||||||||
| I | 2 | 2 | — | 2 | — | — | — | — |
| II | 3 | 3 | — | — | 1 | 2 | — | — |
| IIIa | 7 | 10 | 2 | — | — | 5 | 3 | 3 |
| IIIb | 1 | 1 | 1 | — | — | — | — | 1 |
| IV | 0 | 0 | — | — | — | — | — | — |
| Total | 13 | 16 | 3 | 2 | 1 | 7 | 3 | 4 |
| Delayed reconstruction | — | |||||||
| I | 1 | 1 | — | 1 | — | — | — | — |
| II | 4 | 4 | — | — | 1 | 3 | — | 1 |
| IIIa | 16 | 27 | 9 | 1 | — | 13 | 4 | 10 |
| IIIb | 1 | 1 | 1 | — | — | — | — | 1 |
| IV | 2 | 3 | 2 | — | — | 1 | — | — |
| Total | 24 | 36 | 12 | 2 | 1 | 17 | 4 | 12 |
| Total | 37 | 52 | 15 | 4 | 2 | 24 | 7 | 16 |
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