Background: This paper describes our special considerations in virtual surgical planning for maxillary reconstruction with vascularized fibular osteomyocutaneous flap and our revised surgical design for maxillary reconstruction.

Methods: Twenty-six patients with different maxillary defects according to Brown’s revised classification underwent virtual surgical planning for accurate reconstruction. For different horizontal class defects, the fibular was osteomized to match maxillary alveolar arch by using the mirror image of the contralateral alveolar ridge or the curve of mandibular arch and dentition.

Results: Maxillary reconstruction was performed with the guidance of preoperative virtual planning and using fibular osteotomy and reposition guide templates to replicate the virtual planning intraoperatively. Virtual surgical planning was replicated intraoperatively in all patients. The fibulae were osteotomized into four segments in three patients with the horizontal class d2 defect and three segments in twenty-three patients with the horizontal class b, c and d1 defects, respectively. Overall success rate for 26 flaps was 100%. Good bony unions and wound closure were observed and intelligible speech was achieved in 26 patients. Maximum incisal opening ranged from 3.0 to 4.0 cm. All patients tolerated a regular diet postoperatively. Postoperative mid-facial appearance was good in all patients.

Conclusion: We recommend that the horizontal class d defect in Brown’s revised classification of maxilla and mid-face be divided into two subtypes according to whether it involves the contralateral canine or not. Special considerations in virtual surgical planning are helpful to perform accurate maxillary reconstruction with vascularized fibular osteomyocutaneous flap.