ORIGINAL ARTICLE Microvascular Free Flap Reconstructive Options in Patients With Partial and Total Maxillectomy Defects Rudy J. Triana, Jr, MD; Vedran Uglesic, MD; Miso Virag, MD; Sinisa G. Varga, DDS; Predrag Knezevic, MD; Aleksandar Milenovic, MD; Naranja Aljinovic, MD; Craig S. Murakami, MD; Neal D. Futran, MD, DMD Objective: To evaluate and discuss the free flap reconstructive options for patients with partial and total maxillectomy defects. Design: Retrospective review of cases. Setting: Two tertiary referral centers. Patients: Fifty-one patients had partial or total maxil- lectomy defects resulting from oncologic surgical resection, and 7 had partial maxillectomy defects resulting from trauma. Inferior or partial maxillectomy defects included 10 anterior arch and hemipalate defects and 12 subtotal or total palate defects. Total maxillectomy defects with and without orbital exenteration included 36 maxilla defects with hemipalate and malar eminence. Intervention: There were 11 fibula, 14 rectus abdominis, 9 scapular, 10 radial forearm, 5 latissimus dorsi, and 13 combination latissimus dorsi and scapular flaps. Main Outcome Measures: Separation of the oral cav- ity from the sinonasal cavities, diet, type of dental restoration, type of orbital restoration, speech intelligibility, and complications. From the Department of Otolaryngology–Head and Neck Surgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill (Dr Triana); the Department of Otolaryngology–Head and Neck Surgery, Wake Medical Center, Raleigh, NC (Dr Triana); the Department of Maxillofacial Surgery, University of Zagreb School of Medicine, Zagreb, Croatia (Drs Uglesic, Virag, Varga, Knezevic, Milenovic, and Aljinovic); and the Departments of Otolaryngology–Head and Neck Surgery, Virginia Mason Clinic (Dr Murakami) and University of Washington School of Medicine (Dr Futran), Seattle, Wash. Results: Only 1 flap failure was reported. There was loss of bone in 2 flaps and loss of the skin paddle in 1 flap. All palatal defects were sealed by the separation of the oral and sinonasal cavities. Thirty-eight patients were able to eat a regular diet while the remaining patients maintained a soft diet. All patients conversed on the telephone without difficulty in intelligibility. Eight patients had an implant-borne dental prosthetic, and 30 patients had a conventional partial prosthetic. Orbit restoration was achieved in 2 patients with an implant-borne prosthetic, and 6 patients retained a standard orbit prosthetic. Conclusions: Free flap reconstruction of the maxilla cre- ates reproducible permanent separation of the oral and sinonasal cavities in a single-stage procedure. In addition, there exists the potential for dental rehabilitation with restoration of masticatory and phonatory function. Free flap reconstruction also provides a good cosmetic result, which improves patients’ outlook and contributes to their overall well-being. Reconstructive flaps are designed to fit specific maxillary defects and patient needs to provide optimally functional and cosmetic results. Arch Facial Plast Surg. 2000;2:91-101 T UMORS of the maxilla involve 2 main sites: the palate (oral cavity) and the maxillary sinus. Malignancies of the paranasal sinuses represent 0.2% of all malignancies and 3% of all cancers of the upper aerodigestive tract. Tumors of the palate represent 8% of oral cavity cancers and 5% of all upper aerodigestive tract malignancies.1,2 Treatment of these tumors usually requires a combination of surgical extirpation followed by radiation therapy. The resultant defects involve the disruption of the soft and bony tissues of the palate and midface. Loss of these key structures has significant functional and cosmetic consequences. These consequences may include the creation of large oronasal and (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 2, APR-JUNE 2000 91 oromaxillary fistulae, loss of significant tooth-bearing segments (which may impair oral alimentation and speech), loss of lip and cheek support, and loss of midface projection.3 Traditionally, these defects were reconstructed using skin grafts to line the postresection cavity and using some type of bulky dental obturative prosthesis. By using an obturator, the oral and sinonasal cavities can be separated. However, the patients are required to use the prosthesis for speaking and swallowing. The prosthesis must be removed and cleaned on a regular basis.4,5 Several different surgical options to seal the palate, separating the oral and nasal cavities, have been described.6-10 These include local palatal, pharyngeal, and nasal septal flaps for small defects, and temporalis, forehead, and distant WWW.ARCHFACIAL.COM ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 05/29/2022 PATIENTS AND METHODS We evaluated a retrospective series of 58 patients who underwent free flap reconstruction of the maxilla at the University of Washington, Seattle, and the University of Zagreb, Zagreb, Croatia, between January 1, 1993, and December 31, 1998. Defects were classified as inferior or partial maxillectomy, including defects of the hemipalate and anterior arch; inferior or partial maxillectomy with subtotal or total palate defects; and total maxillectomy with and without orbital exenteration (Figure 1 and Figure 2). Plans for palatal, dental, and orbital rehabilitation were made preoperatively by the oral and maxillofacial prosthedontist. Patient follow-up ranged from 3 months to 5 years. The type of defect, free flap(s) used in the reconstruction, and complications were identified for each patient. In addition, closure between the sinonasal and oral cavities, type of diet, and type of dental restoration were examined in each patient. Orbit restoration in patients who had total maxillectomy with orbital exenteration was identified. Speech was evaluated, and the findings were based on the patient’s ability to converse intelligibly on the telephone. tubed flaps, typically used for larger defects. These techniques, however, have been limited by the amount of tissue available and/or pedicle length. Microvascular free tissue transfer has been described as a unique alternative for reconstruction of the palate, midface, and maxilla. Microvascular free tissue reconstruction allows for the transfer of adequate amounts of soft tissue and bone in a single-stage procedure, without the limitations of pedicle length or flap geometry. A variety of free tissue transfers have been used for palate, midface, and maxilla reconstruction, including scapula,11-14 fibula,15-21 radial forearm,22-25 rectus abdominis,26,27 iliac crest,13,14,28 and latissimus dorsi29,30 flaps. In this article, we present a series of patients with various maxillectomy defects who underwent free flap reconstruction. We describe successful separation of oral and sinonasal cavities, complications, types of oral diet, dental rehabilitation, and speech intelligibility. We evaluate the success of these techniques with specific case presentations and identify factors that may aid in the selection of flaps for specific maxillectomy defects. RESULTS Forty-two patients underwent primary reconstruction at the time of tumor resection; 5 patients underwent primary reconstruction within several days following their facial injury; and 11 patients underwent secondary reconstruction. Of the 58 patients, 2 had sustained a past facial injury with subsequent soft tissue and bone defect. There were 10 patients with inferior or partial maxillectomy defects involving the hemipalate and/or the anterior arch. Twelve patients had inferior or partial A B C D Figure 1. A, Anteroposterior view of an inferior partial maxillectomy defect. B, Lateral view of the defect in A. Hatched lines indicate more of the hemipalate that could be resected (also includes anterior arch defects). C, Anteroposterior view of an inferior partial maxillectomy defect with total palate defect. D, Lateral view of the defect in C. A B C D Figure 2. A, Anteroposterior view of a total maxillectomy defect. Hatched lines indicate the amount of additional malar bone and zygomatic arch that could be included in the resection. B, Lateral view of the defect in A. C, Anteroposterior view of a total maxillectomy defect with orbital exenteration. Hatched lines indicate additional malar bone and zygomatic arch that could be included in the resection. D, Lateral view of the defect in C. maxillectomy defects involving a subtotal or total palate defect. There were 36 patients with total maxillectomy defects including the hemipalate and malar eminence. Of the 36 patients, 25 underwent orbital exenteration with maxillectomy, and 11 did not. Table 1 lists the characteristics of the patient population, matching defect type with age, sex, and diagnosis. Postsurgical defect and free flap choice are presented in Table 2. For inferior maxillectomy palatal (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 2, APR-JUNE 2000 92 WWW.ARCHFACIAL.COM ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 05/29/2022 Table 1. Demographics and Diagnosis of 58 Patients Who Underwent Microvascular Free Flap Reconstructive Surgery Total Maxillectomy Inferior Maxillectomy Characteristics Partial With Hemipalate or Partial Palate Defect With Subtotal or Total Palate Defect Without Orbital Exenteration With Orbital Exenteration 10 52 (16-78) 7/3 12 49 (28-66) 9/3 11 44 (28-65) 8/3 25 57 (23-86) 15/10 1 1 (Palate), 2 (maxillary sinus) 0 0 0 0 0 0 2 1 1 0 21 (Maxillary sinus) No. of patients Age, y, mean (range) Male/female, No. Diagnosis, No. Gunshot wound Squamous cell carcinoma Adenocarcinoma Verrucous carcinoma Mucoepidermoid carcinoma Carcinoma x pleomorphic adenoma* Adenoid cystic carcinoma Basal cell carcinoma (face with bony invasion) Osteogenic carcinoma (maxillary sinus) Fibrosarcoma (maxillary sinus) Melanoma (maxillary sinus) 4 2 (Palate) 2 7 1 1 1 1 0 0 0 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 1 (Maxillary sinus) 2 1 0 0 *x indicates tumor changed from benign to malignant. Table 2. Free Flaps and Defects in 58 Patients Who Underwent Microvascular Free Flap Reconstructive Surgery Inferior Maxillectomy Total Maxillectomy Partial With Hemipalate or Partial Palate Defect With Subtotal or Total Palate Defect (Midface Defect) Without Orbital Exenteration With Orbital Exenteration 10 10 12 14* 11 11 25 26† 8 2 6 2 1 1 2 0 2 0 0 0 Fibula (osteocutaneous) Scapula (osteocutaneous) Latissimus dorsi 0 0 0 11 2 0 0 0 0 3 0 2 (With cranial bone grafts) 1 (Without cranial bone grafts) 0 6 5 (Myocutaneous) Combination‡ 0 0 0 0 0 9 0 5 (With cranial bone grafts) 4 (Without cranial bone grafts) 0 1 1 (With scapula [osteomyocutaneous]) 0 No. of patients No. of free flaps Type of flap, No. Radial forearm Osteocutaneous Fasciocutaneous Rectus abdominis Myofacial Myocutaneous 12 *Two patients required 2 free flaps to reconstruct the defect. †One patient required reconstruction with 2 free flaps. ‡Latissimus dorsi (myocutaneous) with scapula (osteocutaneous). defects, decisions to use a bone-containing flap were based on the quality and position of the patient’s residual dentition and/or denture-bearing alveolar arch. All 12 patients with subtotal and total palate defects received bone-containing free flaps; 2 of these patients required an additional free flap (radial forearm) to cover a soft tissue defect of the face. In patients who underwent a total maxillectomy, 20 of the 36 received a bone-containing flap to reconstruct both the malar eminence and alveolar ridge, and 16 received a soft tissue flap. Of the 16 patients, bone reconstruction was performed at the time of the free flap reconstruction (soft tissue) using cranial bone grafts in 7. Cranial bone was primarily used to reconstruct the orbital floor and malar eminence. The use of different myocutaneous and myofascial flaps was based on the volume of the soft tissue defect and the surgeon’s preference. Improved aesthetic contour was achieved when using a bone-containing flap, specifically in those patients with anterior arch defects who needed better support of the upper lip and in those who had a loss of the malar eminence. Vein grafts were needed in 9 of the 12 subtotal or total palate defects that were reconstructed with bonecontaining flaps: 11 fibula and 1 scapula. In these cases, the vein grafts were needed to allow the flap pedicle to reach the recipient neck vessels. Vein grafts were not needed for the free flaps used for the total maxillectomy defects. (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 2, APR-JUNE 2000 93 WWW.ARCHFACIAL.COM ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 05/29/2022 Table 3. Complications Following Microvascular Free Flap Reconstructive Surgery in 58 Patients Table 4. Functional Results in 58 Patients Who Underwent Microvascular Free Flap Reconstructive Surgery* No. of Patients Complication Flap failure Partial flap failure with loss of bone or skin Return to operating room for flap salvage Wound infection and dehiscence Donor site hematoma Neck hematoma and seroma Postoperative pneumonia Postoperative meningitis Postoperative death (within 1 mo) 1 3 5 3 1 3 3 1 1 Five flaps required urgent return to the operating room on the first postoperative day: 3 for arterial compromise and 2 for venous compromise (Table 3). In both cases of venous compromise, poor pedicle geometry was identified. Proper vessel alignment was achieved and venous outflow restored. In the cases of arterial compromise, one patient disrupted the arterial anastomoses upon awakening from anesthesia. This was quickly recognized, the neck opened, the anastomosis revised, and the flap saved. In the other 2 cases, arterial compromise was suspected because of apparent partial loss of the skin paddle of these 2 flaps (1 scapula and 1 fibula). In each of these cases, the anastomosis was evaluated and found to be patent. The partial skin loss was attributed to poor skin perforators of these 2 flaps. In the case of the fibula flap, the skin loss was in the area of the palate. The patient was returned to the operating room 10 days following the first reconstructive procedure, and a radial forearm flap was used to line the palate (Table 2). There were 2 cases of scapula–latissimus dorsi (osteomyocutaneous) flaps that exhibited delayed bone loss requiring operative debridement; the wounds completely healed. There was 1 case of complete flap failure in this series that involved a scapula flap (osteocutaneous) that failed within the first postoperative week and was replaced with a latissimus dorsi (myocutaneous) flap. Other complications included 1 neck hematoma, 1 donor site hematoma, and 2 neck seromas that were drained percutaneously at the bedside and resolved without complication (Table 3). Three patients developed partial dehiscence of the palate wound within 10 days of the reconstructive procedure. Two patients were treated with local wound care and were subsequently returned to the operating room for delayed wound closure, one on postoperative day 14 and one on postoperative day 22. Both wounds healed completely, although 1 wound healed by secondary intention. Postoperative pneumonia occurred in 3 patients. Two cases resolved with intravenous antibiotic therapy. One patient developed a pneumothorax and a pulmonary abscess and died after 2 months in the hospital. One patient developed meningoencephalitis, which resolved with intravenous antibiotic therapy, but left the patient with significant functional deficits. Functional results are presented in Table 4. The data represent those patients with a minimum of 6 months of follow-up after the primary reconstructive proce- No. of Patients (%) Functional Result Closure between sinonasal and oral cavity Diet (n = 56) Regular Soft Speech (n = 56) Ability to be understood in telephone conversation Dental restoration (n = 56) Implant-borne prosthesis Conventional partial prosthesis None Orbit restoration (n = 25)† Implant-borne prosthesis Conventional orbital prosthesis 58 (100) 37 (66) 19 (34) 56 (100) 9 (16) 30 (54) 17 (30) 2 (8) 6 (24) *Two patients died, 1 and 2 months postoperatively. †Of the 25 patients who underwent a total maxillectomy with orbital exenteration, only 8 underwent orbit restoration. dure. All 58 patients had wound closure and successful separation between the oral and sinonasal cavities. Of the 56 patients who lived, 37 were able to eat a regular diet and 19 were able to eat a soft diet. Although formal speech evaluations were not performed, 56 patients were able to be understood on the telephone. Dental rehabilitation is described in Table 4. Nine patients had placement of osseointegrated implants. In 2 patients with partial palate defects, the implants were placed in the remaining native bone, and they were able to wear an implant-borne prosthesis. In the other 7 patients, those with subtotal or total palate defects, osseointegrated implants were placed into the free flap bone, which supports an implant-borne prosthesis. Thirty patients were able to wear a conventional partial prosthesis, and 17 patients did not choose dental rehabilitation. Orbit restoration is presented in Table 4. Of the 25 patients who underwent a total maxillectomy with orbital exenteration, 2 had implant-borne orbital prostheses and 6 were able to use a conventional prosthesis. The majority (n=21) of total maxillectomies with orbital exenteration were performed in Croatia, and financial limitations may account for the low number of patients receiving any form of orbit restoration. Financial limitations also restricted the use of osseointegrated implants for dental restoration in the Croatian patients, even though bonecontaining flaps were implanted. COMMENT Reconstruction of partial and total maxillectomy defects may have variable soft tissue and bony requirements, which are determined by the extent of the resection. Many of these defects result in significant functional and aesthetic sequelae. These may include collapse of the lip, cheek, and infraorbital soft tissues, loss of the hemipalate with compromise of the oral phase of swallowing, difficulty with speech articulation, and orbital complications.31 In some cases in which the globe is spared, the lack of infraorbital rim and orbital floor support can (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 2, APR-JUNE 2000 94 WWW.ARCHFACIAL.COM ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 05/29/2022 result in hypophthalmos, enophthalmos, vertical dystopia, diplopia, and ectropion.32 The goals of reconstructing defects of the maxilla include (1) consistently obtaining a healed wound; (2) restoring palatal competence and function (separation of oral and sinonasal cavities); (3) supporting the orbit or filling the orbital cavity in cases of exenteration; (4) obliterating the maxillectomy defect; and (5) restoring facial contours.33 The traditional method of reconstructing palatal and maxillary defects involves a split-thickness skin graft to line the defect cavity and placement of an obturator (prosthesis) to seal the palate and separate the oral and sinonasal cavities.4,5,34,35 The advantages include a shorter operative case following the reconstruction and the ability for the oncologic surgeon to follow the wound cavity for tumor recurrence. To date, there are no studies in the literature documenting any increased delay in detection of recurrent tumors in patients undergoing some type of reconstruction of a maxillectomy defect.1,36 In fact, advanced imaging techniques, such as computed tomography and magnetic resonance imaging, have aided the oncologic surgeon in detecting tumor recurrence earlier in these areas.37 The obvious disadvantages of an obturator are the inherent problems of leakage, cleaning, and repeated prosthesis refinement. Elderly patients or those patients with impaired manual dexterity and poor vision may find it exceptionally difficult to clean, maintain, and manipulate the prosthesis.38 As the wound heals, usually in the presence of postoperative radiotherapy, the prosthesis often becomes loose. This results in leakage of food and secretions into the nasal cavity and creates further problems with speech and oral hygiene. Surgical management of these defects and their functional problems originally involved the use of a variety of pedicled autogenous tissues. In the 19th century, von Langenbeck39 described the use of local palatal flaps for reconstructing small defects. For larger palatal and maxillary defects, the pharyngeal, forehead, temporalis, and distant flaps (such as the deltopectoral and upper arm flaps) have been used.6-10,31,40,41 Vascularized cranial bone grafts also have been used in a small series of patients. Most of the success of these procedures has been in reconstructing isolated, limited defects such as the orbital floor and rim, or zygomatic and malar complexes.42-44 However, each of these techniques is limited by a paucity of tissue to fill the defect, by the length of the vascular pedicle, and/or by the need for multiple stages to achieve a final result. With the advent of microvascular free tissue transfer, most large defects (postoncologic resection or posttraumatic) of the palate, maxilla, and midface can be reconstructed with a single-stage procedure. Abundant soft tissue and bone can be transferred without limitations of vascular pedicle length or tissue orientation.30,45 A variety of donor sites have been described in the literature. In 1987, MacLeod et al22 reported 3 cases of palatal fistulae reconstructed with radial forearm free flaps with and without bone. In 1992, Chen et al46 reported 4 cases of palatal fistulae that were closed with a radial forearm free flap. In both studies, all patients had palatal fistulae following a failed cleft palate repair; closure of the fistulae occurred in all 7 patients. Hatoko et al23 de- scribed 3 palatal defects following tumor ablation that were successfully closed with a fasciocutaneous radial forearm free flap; 2 of these patients were able to use a dental prosthesis. More recently, McLoughlin et al47 used an osteocutaneous radial forearm free flap to reconstruct the orbital rim and soft tissues of the cheek, and to obliterate the maxillary sinus cavity. In 1998, Cordeiro et al24 described the “sandwich” radial forearm osteocutaneous free flap for reconstruction of the subtotal maxillectomy defect. The bone was used to recreate the maxillary arch with the skin paddle folded around it, allowing both the palatal and nasal linings to be restored. Both patients refused osseointegrated implants, and both used dentures and maintained a regular diet. In addition, both patients had near normal speech and had an acceptable aesthetic result without retraction of the upper lip.23 Larger case series of palatal and maxillary defects reconstructed with myocutaneous free flaps, primarily the latissimus dorsi and rectus abdominis, have been reported. Shestak et al29,30 found the latissimus dorsi free flap to be very versatile. In all of the patients in the study, the palates were sealed and an aesthetically satisfactory recontouring of the face and cheek soft tissues was achieved. In addition, the ample pedicle length allowed microvascular anastomoses in the neck without the need for vein grafts. The rectus abdominis free flap demonstrates similar flap attributes and similar postoperative results.26,27,48 Olsen et al27 described a series of 11 patients with massive sino-orbital defects, achieving success using the rectus abdominis free flap in 9. Of the 11 patients, 6 had successful reconstruction of the palate, and all patients exhibited excellent speech and deglutition. In a similar study, Yamamoto et al48 described the use of the “boomerang” rectus abdominis free flap. The skin paddle is designed in the shape of a boomerang, allowing each leaf to be folded into its respective defect, that is, orbit and palate or orbit and soft tissues of the cheek. The majority of studies recommending free tissue transfers for maxillary reconstruction describe the use of the scapula osteocutaneous flap.11-13,49-52 This flap is advantageous in that the soft tissue component can be rotated around the bone stock with greater freedom than the other composite flaps. It is particularly useful in defects in which both the orbital floor–zygomatic arch and palate need to be reconstructed. If the angular branch of the thoracodorsal vessel is included in the flap harvest, both the tip and the lateral border of the scapula can be harvested. When appropriate osteotomies are made, the palate and infraorbital regions can be restored.53 Uglesic et al36 described an osteomyocutaneous free flap based on the subscapular system of flaps for reconstruction of the total maxillectomy defect with orbital exenteration. This type of flap has good bone stock that can be used for the infraorbital area and palate, a muscle component (latissimus dorsi) for cavity obliteration, and a skin component for filling soft tissue deficits of the midface, cheek, and palate. Another free flap option that provides an adequate volume of bone for palatal reconstruction and midface support is the fibula free flap. Multiple case studies describe the ease with which the flap can be harvested, the (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 2, APR-JUNE 2000 95 WWW.ARCHFACIAL.COM ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 05/29/2022 A B C D Figure 3. A, A preoperative anterior arch defect, partial upper lip defect, and total rhinotomy following resection of a squamous cell carcinoma involving the nasal vestibule. B, A radial forearm (osteocutaneous) free flap was inset to recreate the anterior arch. C, The palate defect was closed with a portion of the skin paddle, while the remaining skin was used to line the nose. D, Postoperative result, showing closure and separation of the nasal-oral cavities and nasal prosthesis in place. excellent bone stock, and the soft, pliable skin paddle that can be used for either intraoral or cutaneous reconstruction. In addition, the vascular pedicle may be lengthened to avoid the possible need for vein grafts.15-20,54 Three patients received implant-borne dentures in these studies.16,20,54 The iliac crest free flap provides an excellent bone source for palate and maxillary reconstruction. Brown28 presented 3 cases of palatal reconstruction using this flap and reported favorable functional results. Others have discouraged the use of the iliac crest free flap in the maxilla because of its excessive bulk, poor skin paddle mobility in relationship to bone, and short pedicle length.14 Finally, some authors advocate the use of dual free flaps to reconstruct these complex defects.21,25 Although success has been observed in a small series of patients, the advantages of 2 separate free flaps have not been demonstrated. This complex and time-consuming effort has not been proven to be more beneficial than the use of a properly designed single free flap in providing excellent bone stock and pliable soft tissue. Schusterman et al13 recommended a bone-containing free flap for maxillary reconstruction when bony support was needed and previous irradiation precluded the use of nonvascularized grafts. Cordeiro et al32 showed the successful use of nonvascularized bone grafts to recon- struct the orbital floor in conjunction with a vascularized free flap of soft tissue in patients with total maxillectomy defects. Coleman14 emphasized the importance of functional reconstruction when addressing defects of the midface and the orbits. The loss of bone support of the midface, either from oncologic resection or trauma, results in the contraction of the wound, with forces pulling toward the center of the defect during healing. The needs of the wound (ie, skin, soft tissue, mucosa, and bone) need to be carefully matched to the characteristics of the appropriate flap prior to undertaking the reconstructive procedure. These factors include the length of the vascular pedicle; the thickness or thinness of skin, muscle, and subcutaneous fat; the volume of the soft tissue available; the durability and thickness of bone; and donor site morbidity. Davison et al35 recommended free tissue transfer closure of maxillectomy defects when substantial associated sino-orbital and/or soft tissue defects existed. They concluded their review, however, by stating “refinement of microsurgical techniques with free vascularized bone may provide an ideal answer in providing surgical reconstruction that could support an implant-borne prosthesis.” As microsurgical techniques have become more refined, much more attention has been given to the function and aesthetics of this complex wound closure. (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 2, APR-JUNE 2000 96 WWW.ARCHFACIAL.COM ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 05/29/2022 A B C D E F Figure 4. A, A total palatectomy specimen following resection of an invasive squamous cell carcinoma of the right lateral hard palate (right side, inferior). B, Fibula (osteocutaneous) free flap with vein graft. C, The palate 6 months following completion of radiation therapy. It is closed, and osseointegrated implants have been placed in the fibula. D, Dental rehabilitation is complete, with implant-borne prosthesis in place. E and F, Postoperative results, showing good anterior arch and midface projection. In a series of maxillary reconstructions using primarily the rectus abdominis flap, Olsen et al27 reported acceptable palatal closure, with the majority of patients exhibiting excellent masticatory function. They also noted that implantation of osseointegrated prostheses or dentures eliminated any major problems with mastication in the remaining patients. Funk et al53 described a series of patients who underwent free tissue transfer reconstruction of midfacial and cranio-orbital facial defects. A subset of 5 patients had closure of large palatal defects with a variety of soft tissue and composite free flaps. Criteria for palate closure with a soft tissue free flap included sufficient residual dentition to retain a dental pros- thesis or, if the anatomy of the reconstruction would allow, retention of an upper denture despite the absence of teeth. When placement of osseointegrated implants was anticipated, the scapula osteocutaneous flap was preferred.55 In our series of patients, all of the above-mentioned flaps except the iliac crest have been used. Free tissue transfer has been demonstrated to be a reliable single-stage procedure to achieve separation of the oral and sinonasal cavities. In addition, deglutition, speech, physical appearance, and an acceptable quality of life have been restored for most patients. Flap selection has been determined by a variety of factors. The amount, location, and quality of residual (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 2, APR-JUNE 2000 97 WWW.ARCHFACIAL.COM ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 05/29/2022 A B C D E F G Figure 5. A and B, Postoperative views of a patient who underwent left total maxillectomy without orbital exenteration for adenoid cystic carcinoma of the maxillary sinus. Following neutron beam radiation therapy, the patient developed a sino-nasal-oral fistula. C, Defect involving the left hemipalate, anterior maxilla, orbital floor, and a portion of the zygomatic arch. D, The design of the rectus abdominis free flap. E, Cranial bone grafts used to reconstruct the orbital rim, orbital floor, and malar eminence. F and G, 6-Month postoperative result, showing closure of the palatal defect and cheek. Cheek projection is acceptable. bone of the midface, dentition, and/or denture-bearing alveolar arch largely determined the selection of a bonecontaining flap. In most patients with hemipalate defects, retention was sufficient to support a conventional dental prosthesis so that fasciocutaneous or myocutaneous free flaps could be used in 8 of the 10 patients. In 2 of the 10 patients, radial forearm (osteocutaneous) free flaps were used to improve anterior arch contour. How- (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 2, APR-JUNE 2000 98 WWW.ARCHFACIAL.COM ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 05/29/2022 A B C D E F Figure 6. A, Postoperative view of a patient who underwent left total maxillectomy with orbital exenteration for squamous cell carcinoma of the maxillary sinus. B, Scapula–latissimus dorsi flap based on the subscapular artery, showing the latissimus dorsi with the thoracodorsal artery (right) and the scapula (osteocutaneous) portion of the flap with the circumflex scapular artery (left). C, Postoperative computed tomographic scan with scapula bone in position, creating adequate cheek projection. D, Postoperative result, showing closure of the palate. E and F, 6-Month postoperative results, with the orbital prosthesis in place. (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 2, APR-JUNE 2000 99 WWW.ARCHFACIAL.COM ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 05/29/2022 ever, the osteocutaneous free flaps were not considered suitable for placement of osseointegrated implants (Figure 3). In patients who underwent an inferior maxillectomy with subtotal or total palatectomy, very little retentive surface was available for a conventional prosthesis. These patients also lacked significant midface projection resulting from loss of the anterior maxilla and palate and therefore received a bone-containing flap (11 fibula and 1 scapula). Bone-containing flaps create the potential for implant-borne dental restoration. Of the 12 patients, 2 required an additional free flap (radial forearm) to cover the additional soft tissue deficit (posttraumatic). These also were the most complex reconstructions, and 9 of the patients required vein grafts to achieve adequate pedicle length to reach the recipient vessels. At the time of this report, 6 of the patients had undergone full restoration with dental prostheses (Figure 4). Total maxillectomy defects are challenging from both a functional and an aesthetic perspective. These defects result in a loss of a significant amount of bone and sometimes soft tissues of the cheek. Bone-containing flaps were used in 20 of the 36 patients. The bone was used to reconstruct the orbital floor and the anterior arch. A scapula– latissimus osteomyocutaneous flap was used in 12 of the 25 patients who underwent total maxillectomy with orbital exenteration. The addition of the latissimus dorsi muscle was useful for both obliterating the large cavity of the defect and improving facial contour. In 7 of 17 patients for whom a myocutaneous flap was used for reconstruction (either rectus abdominis or latissimus dorsi), cranial bone grafts were used to carefully reconstruct the orbital floor or malar eminence. Rectus abdominis fascia was used to recreate the floor of the orbit in 4 of the 11 patients who underwent a total maxillectomy without orbital exenteration. At the time of this report, 3 of these patients had undergone full restoration with dental prostheses (Figure 5 and Figure 6). Although maxillofacial prostheses have a role in primary reconstruction of palatal and maxillary defects, free tissue transfers have been successful and are well accepted by a variety of patients. Excellent facial contour and acceptable cosmetic results can be achieved consistently in a single-stage procedure. Functionally, patients enjoy the possibility for full dental restoration, masticatory function, and near normal phonation. The choice of free tissue transfer and the type of flap required should be tailored to the specific defect; denture-bearing potential of the native tissues; remaining supporting bone of the midface, cheek and palate; and most importantly, the patient’s needs. Accepted for publication February 25, 2000. Presented at the fall meeting of the American Academy of Otolaryngology–Head and Neck Surgery and the American Academy of Facial Plastic Reconstructive Surgery, New Orleans, La, September 23-25, 1999. Corresponding author: Rudy J. Triana, Jr, MD, Otolarygology Department, Wake Medical Center, 3024 New Bern Ave, Suite 305, Raleigh, NC 27610. REFERENCES 1. Sisson G, Toriumi D, Atiyah RA. Paranasal sinus malignancy: a comprehensive update. Laryngoscope. 1975;99:143-150. 2. Mashberg A. 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