RECONSTRUCTION OF COMPLEX MIDFACIAL DEFECTS

Modern treatment of complex midfacial defects has evolved over the pas t 5 years, primarily with the advent of reliable vascularized bone fla ps and osseointegrated implants. To determine the effectiveness of the se advances, 26 consecutive patients with complex midfacial defects tr eated from 1991 through 1995 with immediate muscle-flap coverage were evaluated. The etiology of the defect included neoplasm (n = 23) and t rauma (n = 3). Seventy eight percent of the patients received adjuvant radiation therapy. Follow-up ranged from 3 months to 4 years, with a mean of 18 months. Twenty-three patients (88 percent) were reconstruct ed with a single major procedure. All patients had free-flap reconstru ction, and 100 percent of the flaps survived. Late tumor recurrence wa s seen in 5 of 23 patients (22 percent) and was detected promptly. Aes thetic and functional results were rated good or excellent in 77 and 8 8 percent of the patients, respectively, as determined by patient ques tionnaires and physical examinations. Fourteen of 18 patients (78 perc ent) undergoing partial or complete alveolar ridge resection received dental rehabilitation, 43 percent of whom received osseointegrated imp lants into either a bone flap or remaining native bone. Osseointegrate d implants were inset during the initial reconstruction 50 percent of the time. A treatment algorithm for free-flap selection based on the s ize of the defect and the bony requirement for reconstruction is prese nted. Bony restoration is only required in those areas where osseointe grated implants need to be placed. In such cases, the fibula osteocuta neous free flap is the flap of choice. Otherwise, soft-tissue flaps ar e selected based on wound size. Immediate free-flap coverage provides effective, single-stage treatment, both aesthetically and functionally , for complex midfacial defects.