RECONSTRUCTION OF TOTAL MAXILLECTOMY DEFECTS WITH PRESERVATION OF THEORBITAL CONTENTS

Reconstruction after total maxillectomy with preservation of the orbit al contents is technically more challenging than when the maxillectomy is combined with orbital exenteration. Reconstruction of such defects should (1) provide support to the orbital contents, (2) obliterate an y communication between the or bit and nasopharynx, (3) reconstruct th e palatal surface, and (4) achieve facial symmetry and a good aestheti c result. We report our experience in performing reconstructive surger y on 14 patients who had a total maxillectomy and preservation of the orbital contents using nonvascularized bone grafts for reconstruction of the orbital floor and maxilla, in conjunction with a soft-tissue fr ee nap or pedicled muscle flap. The orbital floor was reconstructed us ing split ribs in six cases (42.9 percent), split calvaria in six case s (42.9 percent), and iliac crest graft in two cases (14.3 percent). A myocutaneous rectus abdominis free flap was used for soft-tissue reco nstruction and resurfacing of the palatal mucosa in twelve patients (8 5.7 percent), and a temporalis muscle transposition was used in two el derly patients (14.3 percent). One patient died 2 days after surgery. Mean follow-up and aesthetic and functional results were assessed in t he remaining 13 patients a minimum of 6 months postoperatively, In 9 o f these 13 patients (69.2 percent), postoperative radiotherapy was adm inistered. No reexplorations or free flap failures were observed. One rectus flap developed partial necrosis of the skin island intraorally without affecting the final result. All patients had adequate function al vision. One patient had a mild vertical dystopia; there were no cas es of enophthalmos, Ectropion was the most common undesirable result a nd was present in 10 of 13 cases (76.9 percent). It was graded as mild in four cases (40.0 percent), moderate in four cases (40.0 percent), and severe in the remaining two cases (20.0 percent). Speech was consi dered normal in six cases (46.2 percent), near normal in six cases (46 .2 percent), and intelligible in one case (7.7 percent). Chewing funct ion was considered good (soft to unrestricted diet) ill all cases exce pt for one patient who was only able to eat a pureed diet. Aesthetic r esults after immediate reconstruction were considered good in nine cas es (69.2 percent) and fair in four cases (30.8 percent). Primary recon struction of total maxillectomy defects with orbital content preservat ion remains a complex problem without a perfect solution. The combinat ion of nonvascularized bone grafts for orbital/maxillary reconstructio n with a soft-tissue free flap is a safe, reliable, and effective meth od of maximizing postoperative functional and aesthetic results.