SURGICAL ONCOLOGY AND RECONSTRUCTION

Rec

and

Am

Challenges in the Reconstructionof Bilateral Maxillectomy Defects

eived

Recon

rita Un

*Assista

yAssocizAssistaxProfeskProfes{Profes

Shawn T. Joseph, MS, DNB,* Krishnakumar Thankappan, MS, DNB, MCh,yRahul Buggaveeti, MS,z Mohit Sharma, MS, MCh,x Jimmy Mathew, MS, MCh,k

and Subramania Iyer, MCh{

Purpose: Bilateral maxillectomy defects, if not adequately reconstructed, can result in grave esthetic

and functional problems. The purpose of this study was to investigate the outcome of reconstruction of

such defects.

Materials andMethods: This is a retrospective case series. The defects were analyzed for their compo-

nents and the flaps used for reconstruction. Outcomes for flap loss and functional indices, including oral

diet, speech, and dental rehabilitation, also were evaluated.

Results: Ten consecutive patients who underwent bilateral maxillectomy reconstruction received 14

flaps. Six patients had malignancies of the maxilla, and 4 patients had nonmalignant indications. Ten

bony free flaps were used. Four soft tissue flaps were used. The fibula free flap was the most common

flap used. Three patients had total flap loss. Seven patients were alive and available for functional evalua-

tion. Of these, 4 were taking an oral diet with altered consistency and 2 were on a regular diet. Speech wasintelligible in all patients. Only 2 patients opted for dental rehabilitation with removable dentures.

Conclusions: Reconstruction after bilateral maxillectomy is essential to prevent esthetic and functionalproblems. Bony reconstruction is ideal. The fibula bone free flap is commonly used. The complexity of

the defect makes reconstruction difficult and the initial success rate of free flaps is low. Secondary recon-

structions after the initial flap failures were successful. A satisfactory functional outcome can be achieved.

� 2015 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 73:349-356, 2015

Extensive defects of the maxilla result after surgical

resection of malignancies involving themaxillary sinus

and adjacent structures. Rarely, such defects also can

be a result of nonmalignant conditions or trauma.

Often, the defect can cross the midline to involve a

major part of the opposite maxilla or it can be a total

bilateral defect. Bilateral maxillectomy defects, if notadequately reconstructed, can result in grave esthetic

and functional problems. The purpose of this study

was to investigate the outcome of bilateral maxillary

reconstruction in a series of patients. The specific

aims of the study were to evaluate the components

of defect and the flaps used.

from the Department of Head and Neck Surgery, Plastic

structive Surgery, Amrita Institute of Medical Sciences,

iversity, Kochi, Kerala, India.

nt Professor.

ate Professor.

nt Professor.

sor.

sor.

sor and Head.

349

Materials and Methods

This is a retrospective descriptive review. The study

population consisted of 10 consecutive patients whounderwent bilateral maxillectomy reconstruction

over a period of 6 years, from January 2006 to

December 2012. To be included in the study, a patient

must have had a maxillectomy defect crossing the

midline. Malignant and nonmalignant cases were

included. The electronic medical records, including

clinical details, surgical details, and follow-up details,

were studied. Defects were analyzed for their compo-nents and the flaps used for reconstruction. Outcomes

Address correspondence and reprint requests to Prof

Thankappan: Department of Head and Neck Surgery, Amrita

Institute of Medical Sciences, Kochi, Kerala, India 682041; e-mail:

drkrishnakumart@yahoo.co.in

Received May 24 2014

Accepted August 30 2014

� 2015 American Association of Oral and Maxillofacial Surgeons

0278-2391/14/01408-6

http://dx.doi.org/10.1016/j.joms.2014.08.036

350 BILATERAL MAXILLECTOMY RECONSTRUCTION

for flap loss and functional indices, including diet,

speech, and dental rehabilitation, also were evaluated.

The complexities of bilateral maxillectomy defect

reconstruction are discussed. Institutional review

board approval was obtained for this review.

Results

Ten patients (5male and 5 female; mean age, 40.6 yr;

age range, 16 to 70 yr) received 14 flaps for reconstruc-

tion of bilateral maxillectomy defects during the study

period. Six patients had malignancies of the maxilla, 1

patient had recurrent pleomorphic adenoma of the

maxilla, 1 patient had post-traumatic necrosis of themaxilla involving the right and left sides, 1 patient

had resolved actinomycosis, and 1 patient was treated

for mucormycosis. The details of the defects are listed

in Table 1. Nine patients had palate and alveolus defects

in addition to other components, nasal bone support

was removed in 3 patients, 5 patients had defects

involving the unilateral orbital floor, and infratemporal

fossa clearance was performed in 3 patients. Accordingto the classification of maxillary defects by Brown and

Shaw,1 4 patients had Class IId defects (infrastructure

maxillectomy involving greater than half), 5 patients

had Class IIId defects (defects involving the orbital

floor, involving greater than half), and 1 patient (patient

10) had a defect involving the entire hard and soft

palate, but not the alveolus. This patient could not be

specifically categorized in any of the specified classes.Ten bony free flaps were used. This included 7 flaps

in primary cases and 3 flaps performed as salvage after

the failure of the first free flap. Four soft tissue flaps

were used in 3 patients. One radial forearm flap was

used to salvage a skin paddle loss in the fibula.

Tables 2 and 3 list the diagnoses of the 10 patients

and the flap characteristics.

Three patients had total flap loss (fibula free flap in2 patients and rectus abdominis free flap in 1 patient).

All these cases had orbital floor defects and attempts

Table 1. DETAILS OF DEFECT COMPONENTS IN 10 PATIENTS

Defect Component 1 2 3 4

Palate + + + +

Alveolus + + + +

Nasal bones + +

Orbital floor—unilateral + + +

ITF defect

Unilateral +

Bilateral + +

Brown class IId IIId IIId IIId

Abbreviation: ITF, infratemporal fossa.

Joseph et al. Bilateral Maxillectomy Reconstruction. J Oral Maxillofac Su

were made to reconstruct them. A separate segment

of fibula was used in 2 and a nonvascularized tenth

rib was used in addition to the rectus abdominis flap.

The rectus abdominis flap was salvaged with a fibula

free flap. The lost fibula flaps were salvaged with a

tensor-fascia-lata flap with iliac crest bone and a deep

circumflex iliac artery flap with iliac crest bone. One

patient with a fibula flap developed skin paddle necro-sis, which was salvaged with a adipose-fascial radial

forearm free flap.

The fibula free flap was the most common choice.

The skin paddle of the flap served as the palatal cover,

providing oronasal and oroantral separation. Osteo-

tomized segments (usually 2 or 3 osteotomies and 3

or 4 segments) formed the alveolus. The muscle com-

ponents of the flap filled the cavity to provide contour.This flap was plated and fixed to the zygoma on both

sides. Pre-molded reconstruction plates based on skull

models were used in 3 patients to shape the fibula.

Titanium miniplates were used in 5 patients and wires

were used in 1 patient. Anastomosis usually was to the

facial artery and common facial vein. Vein grafts were

used in 4 cases. A separate iliac crest bone placed on

top of the fibula to support the external nasal frame-work was used in 5 patients; otherwise the framework

would have collapsed. This reconstruction provided

the option for dental implants.

Of the 6 patients with malignancy, 1 died of recur-

rence, 1 was lost to follow-up, and 4 patients were

alive and free of disease (mean follow-up, 25 months).

Of patients with nonmalignancy, 7 were alive and

available for functional evaluation. Of these, 4 weretaking an oral diet with altered consistency and 2

were on a regular diet. Speech was intelligible in all

patients, as assessed subjectively by the clinician and

the patient’s relatives. Only 2 patients opted for dental

rehabilitation with removable dentures.

Figure 1 shows a patient with recurrent chondrosar-

coma and a history of maxillectomy with fibula recon-

struction (Fig 1A, B). Reconstruction was performed

5 6 7 8 9 10

+ + + + + +

+ + + + +

+

+ +

IIId IId IIId IId IId unspecified

rg 2015.

Table 2. DIAGNOSIS, FLAP USED, AND SALVAGE FLAP USED IN CASE OF FLAP FAILURE

Patient Diagnosis Flap Salvage Flap

1 sarcoma fibula

2 carcinoma fibula

3 sarcoma rectus + rib (flap failure) fibula

4 pleomorphic adenoma fibula (flap failure) TFL with iliac crest

5 sarcoma fibula (skin paddle failure) radial forearm

6 trauma with necrosis maxilla fibula

7 squamous cell carcinoma fibula with orbital mesh

8 actinomycosis fibula (flap failure) DCIA

9 mucormycosis anterolateral thigh

10 adenoid cystic carcinoma radial forearm

Abbreviations: DCIA, deep circumflex iliac artery; TFL, tensor-fascia-lata.

Joseph et al. Bilateral Maxillectomy Reconstruction. J Oral Maxillofac Surg 2015.

JOSEPH ET AL 351

using a rectus abdominis free flap (Fig 1C, D). A skin

paddle was used for the palatal defect. The musclemass was used to obliterate the maxillary ethmoid

defect. A tenth rib harvested with the flap with its peri-

osteal blood supply andwired to the zygomatic stumps

was used to form the maxillary arch. Figure 2 shows a

patient with squamous cell carcinoma of the left

maxilla involving the left orbital floor. He underwent

bilateral maxillectomy with removal of the entire infra-

structure and the orbital floor on the left side. The re-sulting defect (Brown Class IIID) was reconstructed

with a fibula free flap. A titaniummeshwas used to sup-

port the orbital floor. Figure 3 shows 3-dimensional

reconstructed computed tomograms of a patient with

bilateral maxillectomy defects reconstructed with a

free fibula flap.

Discussion

Surgical resection of malignancies involving the

maxillary sinus and adjacent structures, nonmalignant

Table 3. DETAILS OF FLAPS USED

Bony free

flap

free fibula 8 (7 primary +

1 salvage)

TFL with iliac crest 1 (salvage)

DCIA 1 (salvage)

Soft tissue

flap

free rectus abdominis 1

anterolateral thigh flap 1

radial forearm flap 2 (1 primary +

1 salvage)

Total 14

Abbreviations: DCIA, deep circumflex iliac artery; TFL,tensor-fascia-lata.

Joseph et al. Bilateral Maxillectomy Reconstruction. J Oral

Maxillofac Surg 2015.

conditions, or, rarely, trauma can result in large de-

fects. This study specifically investigated the defectsand outcomes of reconstructed bilateral maxillectomy

defects. The goals of reconstruction in a bilateral max-

illectomy defect include 1) adequate oronasal separa-

tion, 2) providing the alveolar arch, 3) preservation

of speech and mastication functions, and 4) structural

support to the midface, providing the facial height and

midfacial projection while maintaining the nasal

airway patency and providing support to the contentsof the orbit if there is loss of the same.

In a conventional unilateral maxillectomy, it can be

argued that reconstruction is not absolutely essential

and an obturator can provide adequate oronasal and

oroantral separation. However, in a case of bilateral

maxillectomy, this argument does not stand. Place-

ment of an obturator is nearly impossible, except

when one uses a long zygomatic implant. Such im-plants are not easily available and are technically diffi-

cult. The esthetic problems in a bilateral maxillectomy

defect are due to the loss of the central arch, leading to

collapse of the nose owing to lack of support of the

columella at the anterior nasal spine. If the orbital floor

is lost, enophthalmos and dystopia also can occur.

Functional problems include feeding and speech. If

the defect is not reconstructed, patients will requirelifelong feeding tube support.

Reconstruction of the lost components of the bilat-

eral maxillectomy defect is a challenge. Providing nasal

support and reconstructing the anterior alveolar arch

together with a single bone strut is difficult because

of the posterior position of the anterior nasal spine

in relation to the anterior alveolar arch. The nasal sup-

port, if lost, is provided by a bone strut, but placingit and covering it adequately with a thin soft tissue to

prevent exposure is difficult. Maintenance of the nasal

cavity also is difficult; because the usually used bone

flap, with a bulky soft tissue cover, will result in oblit-

eration of the cavity. Providing the orbital bone

FIGURE1. A,A patient with recurrent chondrosarcoma and a history of maxillectomywith fibula reconstruction. B, Intraoral view showing thetumor.C, Reconstructed outcome with a rectus abdominis free flap with rib, frontal view. D, Reconstructed outcome, intraoral view, showing thepalatal cover.

Joseph et al. Bilateral Maxillectomy Reconstruction. J Oral Maxillofac Surg 2015.

352 BILATERAL MAXILLECTOMY RECONSTRUCTION

support with the alveolus requires a separate piece of

bone, which is technically challenging. Lack of

adequate bone length, possible twisting and kinking

of the pedicle, and shortness of the pedicle are the

challenges.The fibula flap has been a flap of choice for recon-

struction of unilateral maxillectomy defects.2 The ad-

vantages of the fibula free flap in this clinical

situation include a long vascular pedicle; the provision

of bone, skin, and muscle tissue; relatively easy flap

harvesting; the possibility of a 2-team approach; and

a good recipient for the implant.3 A fibula osteocutane-

ous free flap performs the crucial function of

providing structural support to the midface. The

height of the fibula may not be sufficient for the alve-olus and nasal tip support. Providing support to the

external nasal framework while retaining the option

for a dental implant becomes difficult because of the

suboptimal fibular height. This view is shared by

Brown and Shaw1 who stated that, if there is loss of

FIGURE 2. A, A patient with squamous cell carcinoma of the maxilla extending to the orbital floor on the left side. Computed tomogram in thecoronal view shows the extent of tumor. B, Resected specimen. C, Reconstructed outcome, frontal view. D, Reconstructed outcome, intraoralview.

Joseph et al. Bilateral Maxillectomy Reconstruction. J Oral Maxillofac Surg 2015.

JOSEPH ET AL 353

alar support, bones of smaller dimension, such as the

radius and fibula, might not provide sufficient height

to reliably support the oronasal region. In the absence

of any single bone flap that can provide enough height

for alveolar reconstruction and for nasal framework

support, the authors believe the fibula remains the

best option. However, the authors have used an iliaccrest bone graft above the fibula in these cases to

support the external nasal framework and the fibula

to form the new alveolus.

Greater than expected flap loss (3 of 14; 21%) could

be explained by the complexity, extensiveness,

distance of the defect from the neck, and the short

pedicle of the available flaps. It is noteworthy that all

these patients with flap failures had additional orbital

floor defects. Moreover, it is remarkable that these

3 flap losses could be salvaged successfully with a

second free flap.

It is true that an ideal maxillary reconstructionwould be complete only with dental rehabilitation.

Only 2 patients in this series opted for dental rehabili-

tation. The primary aim of such reconstruction is to

allow oral feeding and to achieve near-normal speech

without the help of an obturator. This would be

FIGURE 3. Computed tomograms of a patient with a bilateral maxillectomy defect reconstructed with a fibula free flap. A, Anterior view.(Fig 3 continued on next page.)

Joseph et al. Bilateral Maxillectomy Reconstruction. J Oral Maxillofac Surg 2015.

354 BILATERAL MAXILLECTOMY RECONSTRUCTION

achieved by the flap reconstruction. Dental rehabilita-

tion, for the patient, could be a secondary consider-

ation after prolonged cancer treatment. Such

preferences and choices could be known only through

properly designed quality-of-life studies.

Reconstruction of large bilateral maxillectomy de-

fects have seldom been reported, which appears to

be due to the lack of enough cases. Futran et al,4 in

their series of midface reconstruction, described 8

cases of bilateral maxillectomy defects, whereas

FIGURE 3 (cont’d). B, Lateral view.

Joseph et al. Bilateral Maxillectomy Reconstruction. J Oral Maxillofac Surg 2015.

JOSEPH ET AL 355

some of the other large series of maxillectomy defect

reconstruction included even fewer of these defects.1

There also have been some isolated case reports on the

reconstruction of this defect using a fibula free flap

and a maxillofacial prosthesis, with good result.5-8

However, the defects and methods of reconstruction

have varied in these cases.

Thestudy is limitedbecauseof its retrospectivenature

and small sample. It is difficult to derive strong conclu-sions from this small study. However, the authors have

described the options in such complex reconstructive

situations and highlighted the difficulties.

Reconstruction after bilateral maxillectomy is essen-

tial to prevent esthetic and functional problems. Bony

356 BILATERAL MAXILLECTOMY RECONSTRUCTION

reconstruction is ideal. The fibula bone free flap is

commonly used. The complexity of the defect makes

the reconstruction difficult and the success rate of

the free flaps is initially low. Second reconstructions

after initial flap failures were successful. Satisfactory

functional outcomes were achieved. Very few patients

opted for dental rehabilitation.

References

1. Brown JS, Shaw RJ: Reconstruction of the maxilla and midface:Introducing a new classification. Lancet Oncol 11:1001, 2010

2. Peng X, Mao C, Yu GY, et al: Maxillary reconstruction with thefree fibula flap. Plast Reconstr Surg 115:1562, 2005

3. Futran ND, Haller JR: Considerations for free flap reconstructionof the hard palate. Arch Otolaryngol Head Neck Surg 125:665,1999

4. FutranND,Wadsworth JT, Villaret D, et al: Midface reconstructionwith the fibula free flap. Arch Otolaryngol Head Neck Surg 128:161, 2002

5. Nakayama B, Matsuura H, Ishihara O, et al: Functional reconstruc-tion of a bilateral maxillectomy defect using a fibula osteocutane-ous flap with osseointegrated implants. Plast Reconstr Surg 96:1201, 1995

6. Mukohyama H, Haraguchi M, Sumita YI, et al: Rehabilitation of abilateral maxillectomy patient with free fibula osteocutaneousflap. J Oral Rehabil 32:541, 2005

7. Anthony JP: Reconstruction of a complex midfacial defect withthe folded fibula free flap and osseointegrated implants. Ann PlastSurg 37:204, 1996

8. Barnouti L, Caminer D: Maxillary tumours and bilateral recon-struction of the maxilla. Aust N Z J Surg 76:267, 2006

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