This study evaluated the advantages and complications associated with immediate reconstruction of maxillary defects after maxillectomy and the relationship between defect tissues classification and postoperative results after using the temporalis muscle flap. In this retrospective study, the records of 39 patients who underwent immediate reconstruction surgery using temparolis myofascial flap following maxillectomy from April 1989 to February 2009 were reviewed. Demographic data, features of the disease, follow-up, outcome and complications were analysed. Patients were classified into three groups, to ascertain the influence between defect classification and functional results, aesthetic outcomes and complications in each group. Of the 39 cases, all tissue flaps survived. 5 patients underwent postoperative radiotherapy, which did not seem to influence the outcome of the reconstructive procedure. There was one case of oroantral fistula, which could easily be obturated with the prosthesis. One patient developed haematoma in the donor site 5 days after surgery. Postoperative speech was good, facial appearance was normal and ocular function remained unchanged. Postoperative aesthetic and functional results were satisfying. The temporalis muscle flap can be considered as a first-line reconstructive option for maxillary defects. Acceptable functional and aesthetic outcomes can be expected in high rates.
Maxillary defects are a complex problem owing to many factors, such as anatomical specific aspects in the maxillary area, multiple pathological conditions, variability of the aetiologies, the large number of surgical techniques, and the poor knowledge about their effective functional results. Whether caused by tumours or trauma, maxillary defects may cause facial disfigurement, compromised oral functions and psychological problems. Obturation has been the traditional method of rehabilitation for maxillectomy, but the variety of reconstructive options that are now available challenge the traditional view.
Conventional obturators ideally require access to a restorative dental service and are often associated with problems of poor fit and oronasal reflux that requires frequent adjustment. They can be bulky and difficult to insert in the presence of trismus or poor manual dexterity, and require daily cleaning to remove crusting. The temporalis muscle is thin and pliable and because its vascular pedicle is close and superior to the surgical defect the problems caused by the defects are overcome. The temporalis muscle flap (TMF) was first described by Lentz in 1895 who used it after resection of the condylar neck for temporomandibular joint ankylosis. Golovine used the flap to repair an orbital exenteration defect. In the oral cavity, the TMF has been used specifically for reconstructing the palate, floor of the mouth, tongue, retromolar trigone, and oropharynx.
The objectives of this study were: to evaluate the advantages of the TMF in the immediate reconstruction of maxillary defects after maxillectomy and analyse the complications; to correlate the relationship between defect tissue classification and postoperative results; to recommend some suggestions about these indications (some topics such as relation between age, gender and outcomes, or age and outcomes, will not be discussed here).
Materials and methods
The study protocol was reviewed and approved by the Medical Ethical Committee of the Academic Medical Centre, Wuhan University, China. All patients gave informed consent for use of their clinical data.
The authors retrospectively reviewed 39 consecutive patients who had undergone subtotal maxillectomy and immediate reconstruction with TMF from April 1989 to February 2009. All surgical operations were carried out by the same clinician. Demographic data, features of the disease, follow-up, outcome and complications were analysed. Patients were eligible if they had a maxillary defect and reconstruction was performed using TMF tissue transfer. There were 39 cases in the study, 21 males and 18 females, with an average age of 43.9 years (range 17–72 years). No eligible patients declined enrolment in the study. To characterize the extent of the bony and tissues defect(s), the classification introduced by Brown et al 3 was used. Classes 1–4 define the vertical component of the defect: Class 1 involves maxillectomy without an oro-antral fistula; Class 2 is low maxillectomy not including orbital floor or contents; Class 3 includes high maxillectomy involving orbital contents; and Class 4 encompasses radical maxillectomy including orbital exenteration. Classes 2–4 are also qualified by adding the letters a, b, or c. The horizontal or palatal component is classified as follows: (a) unilateral alveolar maxillectomy; (b) bilateral alveolar maxillectomy; (c) total alveolar maxillary resection. Patients were classified into three groups (Class 1, Class 2 and Class 3) according to the defect classification of Brown et al., to ascertain the influence between defect classification and functional results, aesthetic outcomes and complications in each group.
The coronal approach is the best surgical approach for this area because it provides excellent access. The patient should be shaved in the area of the surgical incision. The patient should be placed in a supine position. Routine disinfection of the operative field is required. The patient is draped with good access to the operative field. A coronal incision is made through the skin, subcutaneous tissue and temporalis myofascia. After elevation of the anterior and posterior wound margins, haemostatic clips are applied or bleeding vessels are isolated and cauterised. A malleable retractor may be used to avoid damage to the vascular structures that lie posteromedially. Anteriorly, the superficial layer of the temporalis fascia is included with the skin flap to protect the temporal branch of the facial nerve, which crosses the midpoint of the zygomatic arch. The muscle is then separated from the temporal fossa with an elevator. Care must be taken to remain in the subperiosteal plane in order to avoid injury to the deep temporal vessels. When less bulk is required, especially for mid-adult patients, the TMF can be sectioned coronally whilst maintaining adequate blood supply to both anterior and posterior halves. After rotating the anterior part, the posterior part can be brought forward, thus avoiding a temporal depression. The fascia attachment to the zygomatic arch is incised and elevated. A tunnel through the infratemporal fossa into the oral cavity is created by blunt dissection and the muscle is guided into the oral cavity. In some cases the authors performed coronoidectomy to increase the access for moving the muscle, especially when tissue defects require the full length and width of the temporalis muscle for reconstruction. If further length is required for reconstructing contralateral or anterior defects, the coronoid process may be osteotomized transorally, gaining a further centimetre of pedicle length. Once transposed into the oral cavity, the muscle flap is sutured into the defect. The temporal fascia faces into the mouth and undergoes epithelialisation after 2–3 weeks. Finally, the donor site is irrigated with physiological saline and sutured; a suction drain is inserted and bandaged with moderate compression ( Figs. 1–7 ).
This retrospective study included 39 patients (21 males and 18 females). They ranged in age from 17 to 72 years (mean 43.9 years). Most of the pathological diagnoses were malignant: squamous cell carcinoma (21%), adenoid cystic carcinoma (18%), mucoepidermoid carcinoma (13%); the remainder were benign ( Table 1 ). The size of the tumours ranged from 1 cm × 2 cm to 5 cm × 7 cm. In this study, according to the classification of Brown et al., most of the maxillary defects were Classes 2a, 2b, 3a and 3b.
|Diagnosis||Number of patients|
|Squamous cell carcinoma (SCC)||8 (20.52%)|
|Adenoid cystic carcinoma (ACC)||7 (17.95%)|
|Mucoepidermoid carcinoma (MEC)||5 (12.82%)|
|Myoepithelial carcinoma||4 (10.26%)|
|Ossifying fibroma||3 (7.69%)|
|Odontogenic myxoma||3 (7.69%)|
|Recurrent odontogenic keratocyst||3 (7.69%)|
|Recurrent ameloblastoma||3 (7.69%)|
Functional and aesthetic outcomes were evaluated by physical examination at a minimum 3 months after surgery. Facial aesthetic results were graded as normal or abnormal based on facial symmetry, malar prominence, cheek contour, scars and eyelid position. Speech, taste, ocular function, and complications were evaluated and graded according to the clinicians’ point of view.
Of the 39 cases, all tissue flaps survived. Some marginal necrosis was observed, but the flap blood supply was good with a red colour. Neither partial nor total flap losses were observed in this series. Only 5 patients underwent postoperative radiotherapy, which did not seem to influence the outcome of the reconstructive procedure. Postoperative functional results and aesthetic outcomes were normal and some remained unchanged. The results are summarized in Tables 2 and 3 . All the patients improved postoperatively and were discharged. There were no deaths within 30 days of surgery. The epithelialisation of the fascia in the nasal and oral cavities was completed in 4–6 weeks, depending on the width of the surface. All the mucosal defects healed completely, and no contracture occurred restricting mouth opening. No exposure of titanium mesh or bone grafts to the oral or nasal cavity occurred. The postoperative follow-up ranged from 2 weeks to 2 years, with an average follow-up of 10 months.