A classification system and algorithm for reconstruction of maxillectomy and midfacial defects

Maxillectomy defects become more complex when critical structures such as t he orbit, globe, and cranial base are resected, and reconstruction with dis tant tissues becomes essential. This study reviews all maxillectomy defects reconstructed immediately using pedicled and free flaps to establish (1) a classification system and (2) an algorithm for reconstruction of these com plex problems. Over a 5-year period, 60 flaps were used to reconstruct defects classified as the following: type I, limited maxillectomy (n = 7); type II, subtotal m axillectomy (n = 10); type IIIa, total maxillectomy with preservation of th e orbital contents (n = 13); type IIIb, total maxillectomy with orbital exe nteration (n = 18); and type TV, orbitomaxillectomy (n = 10). Free flaps (4 5 rectus abdominis and 10 radial forearm) were used in 55 patients (91.7 pe rcent), and the temporalis muscle was transposed in five elderly patients w ho were not free-flap candidates. Vascularized (radial forearm osteocutaneo us) bone flaps were used in four of the 60 patients (6.7 percent) and nonva scularized bone grafts in 1? (28.3 percent). Simultaneous reconstruction of the oral commissure using an Estandler procedure was performed in 10 patie nts with maxillectomy and through-and-through soft-tissue defects. Free-flap survival was 100 percent, with reexploration in five of 55 patien ts (9.1 percent) and partial-flap necrosis in one patient. Seven of the 60 patients (11.7 percent) had systemic complications, and four died within 30 days of hospitalization. Fifty patients had more than 6 months of follow-u p with a mean time of 27.7 (+/-15.6) months. Postoperative radiotherapy was administered in 32 of these patients (64.0 percent). Chewing and speech fu nctions were assessed in 36 patients with type II, IIIa, and IIIb defects. A prosthetic denture was fixed in 15 of 36 patients (41.7 percent). Return to an unrestricted diet was seen in 16 patients (44.4 percent), a soft diet in 17 (47.2 percent), and a liquid diet in three (8.3 percent). Speech was assessed as normal in 14 of 36 patients (38.9 percent), near normal in 15 (41.7 percent), intelligible in six (16.7 percent), and unintelligible in o ne patient (2.8 percent). Globe and periorbital soft-tissue position was as sessed in 14 patients with type I and IIIa defects. There were no cases of enophthalmos, and one patient had a mild vertical dystopia. Ectropion was o bserved in 10 of 14 patients (71.4 percent). Oral competence was considered good in all 10 patients with excision/reconstruction of the oral commissur e; however, two patients (20 percent) developed microstomia after receiving radiotherapy. Aesthetic results were evaluated at least 6 months after rec onstruction in 50 patients. They were good to excellent in 29 patients (58 percent) for whom cheek skin and lip were not resected, and poor to fair (4 2 percent) when the external skin or orbital contents were excised. Seconda ry procedures were required in 16 of 50 patients (32.0 percent). Free-tissue transfer provides the most effective and reliable form of immed iate reconstruction for complex maxillectomy defects. The rectus abdominis and radial forearm flaps in combination with immediate bone grafting or as osteocutaneous flaps reliably provide the best aesthetic and functional res ults. An algorithm based on the type of maxillary resection can be followed to determine the best approach to reconstruction.