Microsurgical reconstruction of maxillary defects after limited resections for malignant tumors

Introduction. Partial maxillectomy involves resection of 1 or 2 walls of the upper jaw, usually medial and anterior ones. The main purposes of reconstruction include the formation of an adequate support for the eyeball; isolation of the orbit from the nasal cavity, nasopharynx, and anterior skull base; normal symmetry; good aesthetic result.

Materials and methods. Between 2014 and 2020, we followed up 13 patients. Nine of them (69 %) had combined defects involving the inferior orbital, anterior, and medial walls of the maxilla (class V according to according to the Brown–Shaw classification, 2010), as well as skin on the buccal and zygomatic areas; 1 patient also had lower eyelid affected. Four individuals (31 %) had isolated defects involving the inferior orbital, anterior, and medial walls of the maxilla (class V according to according to the Brown–Shaw classification, 2010). Twelve patients have undergone preoperative 3D-computer simulation. We divided patients into 2 groups according to the size of their defects and resection areas in the anterior wall of the maxillary sinus. Group 1 included 5 patients with partial maxillary defects (involving 25–40 % of the total area), whereas Group 2 comprised 7 patients with limited maxillary defects (involving 25–40 % of the total area).

Five patients have undergone reconstructive surgeries with fasciocutaneous flaps, including anterolateral thigh flaps used in 4 individuals (31 %) and thoracodorsal flap used in 1 individual (8 %). Eight patients had their defects repaired using radial fasciocutaneous flaps. The inferior orbital wall was reconstructed using an individual titanium mesh implant.

Results. All patients from Group 1 after defect repair with anterolateral thigh flaps and thoracodorsal flaps (4 individuals) had satisfactory aesthetic result. One patient had an unsatisfactory aesthetic result after reconstruction with a radial fasciocutaneous flap due to mesh implant protrusion and formation of an opening in the nasal cavity. The assessment of the eyeball position demonstrated that symmetry was achieved in 4 patients (80 %) after reconstruction using anterolateral thigh flaps (3 patients) and thoracodorsal flap (1 patient). Five patients from Group 2 (72 %) had excellent results, while 2 patients (28 %) had satisfactory results. The assessment of the eyeball position demonstrated that symmetry was achieved in 5 patients (70 %); two participants (28 %) had lower eyelid ectropion.

Conclusion. Patients with large maxillary defects (involving 41–60 % of the total area of the anterior wall of the maxillary sinus and the alveolar process of the maxilla) should undergo reconstructive surgeries with fasciocutaneous anterolateral thigh flaps. In case of relatively small defects (involving 25–40 % of the total area of the anterior wall of the maxillary sinus and the alveolar process of the maxilla) the best option is defect repair with radial fasciocutaneous flaps. Such strategy ensures excellent aesthetic and functional results in 75 % of patients.

1. Piazza C., Paderno A., Taglietti V., Nicolai P. Evolution of complex palatomaxillary reconstructions: the scapular angle osteomuscular free flap. Head Neck Oncol 2013;21(2):95–103. DOI: 10.1097/MOO.0b013e32835e8445.

2. Modest M.C., Moore E.J., Abel K.M. et al. Scapular flap for maxillectomy defect reconstruction and preliminary results using three-dimensional modeling. Laryngoscope 2017;127(1):E8–E14. DOI: 10.1002/lary.26351.

3. Meland N.B., Maki S., Chao E.Y., Rademaker B. The radial forearm flap: a biomechanical study of donor-site morbidity utilizing sheep tibia. Plast Reconstr Surg 1992;90:763–73.

4. Niranjan N.S., Watson D.P. Reconstruction of the cheek using a “suspended” radial forearm free flap. Br J Plast Surg 1990;43(3):365–6. DOI: 10.1016/0007-1226(90)90091-d.

5. Muhlbauer W., Herndl E., Stock W. The forearm flap. Plast Reconstr Surg 1982;70(3):336–44. DOI: 10.1097/00006534-198209000-00007.

6. Cordeiro P.G., Chen C.M. A 15-year review of midface reconstruction after total and subtotal maxillectomy: part I. Algorithm and outcomes. Plast Reconstr Surg 2012;129(1):124–36. DOI: 10.1097/PRS.0b013e318221dca4.

7. Futran N.D., Wadsworth J.T., Villaret D., Farwell D.G. Midface reconstruction with the fibula free flap. Arch Otolaryngol Head Neck Surg 2002;128(2):161–6. DOI: 10.1001/archotol.128.2.161.

8. Swartz W.M., Banis J.C., Newton E.D. et al. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 1986;77:530–45. DOI: 10.1097/00006534-19860400000003.

9. Coleman J.J., Sultan M.R. The bipedicled osteocutaneous scapula flap: a new subscapular system free flap. Plast Reconstr Surg 1991;87:682–92. DOI: 10.1097/00006534-199104000-00013.

10. Clark J.R., Vesely M., Gilbert R. Scapular angle osteomyogenous flap in postmaxillectomy reconstruction: defect, reconstruction, shoulder function, and harvest technique. Head Neck 2008;30(1):10–20. DOI: 10.1002/hed.20649.

11. Miles B.A., Gilbert R.W. Maxillary reconstruction with the scapular angle osteomyogenous free flap. Arch Otolaryngol Head Neck Surg 2011;137(11):1130–5. DOI: 10.1001/archoto.2011.187.

12. Boorman J.G., Green M.F. A split chinese forearm flap for simultaneous oral lining and skin cover. Br J Plast Surg 1986;39(2):179–82. DOI: 10.1016/0007-1226(86)90079-2.

13. De la Ries S., Noordenbos G., Donker M., van Furth E. The patient’s view on quality of life and eating disorders. Int J Eat Disord 2007;40(1):13–20. DOI: 10.1002/eat.20338.