Maxillectomy Reconstruction with Various Flaps:

Preliminary Results and Suggested Algorithm Heejin Kim¹, Jungirl Seok¹, Wonjae Cha¹, Dong-Young Kim¹,

Chae-Seo Rhee², Myung-Whun Sung¹, J. Hun Hah¹

Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Hospital¹

Department of Otorhinolaryngology–Head and Neck Surgery , Seoul National University Bundang Hospital²

Maxillectomy and midfacial defects

Due to resection of tumors involving orbit, nasal cavity,

palate, paranasal sinuses, intraoral mucosa

Cause major functional consequences

• Deglutition, speech, orbital function

Cause esthetic sequelae

Dental rehabilitation

Prosthesis (obturator) vs. Free-tissue transfer

Surgical reconstruction

Soft tissue: radial forearm(RF), anterolateral thigh(ALT),

latissimus dorsi(LD), rectus abdominis(RA)

Bone & soft tissue: iliac crest(IC), fibula, scapula

Reconstruction of maxillary defects caused by tumor

resection or trauma in the head and neck area

The presence of a healed wound

Separation of the oral and nasal cavities

Restoration of maxillary buttresses

Restoration of functional dentition, mastication, and

deglutition

Restoration of the midfacial contours (Futran ND and Mendez E, 2006; Triana RJ et al, 2000)

Approach to reconstruction

Extent of resection

• Volume vs. surface area requirements

Assessment of critical structures

• Palate, oral commissure, nasal airway, eyelids

Need for bone replacement

• Orbital floor

• Anterior arch of maxilla

Need for soft tissue bulk or resurfacing (Santamaria E and Cordeiro PG, 2006)

Background

To introduce the experience of the usage of free flaps for

maxillectomy reconstruction

To share our reconstruction algorithm

Objectives

During 18 months

Feb. 2009 ~ Aug. 2009, Mar. 2012 ~ Jan. 2013

13 cases of maxillectomy reconstruction

Male 11 : Female 2

Mean age: 58.8 (41~72) years old

Retrospectively medical records reviewed

Types of defects, reconstruction methods, and outcomes

Materials and Methods

The content, especially the orbital content and bony

structure, and size of the maxillectomy defect, tumor

characteristics and patient’s prognosis should be considered

in the selection of maxillectomy reconstruction.

The iliac crest free flap might be one of the best options to

reconstruct the bony defect after maxillectomy.

Conclusion

Result

The types of defects

Vertical classification

Horizontal classification

(Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new classification.

Lancet Oncol 2010;11:1001-8.)

No Sex Age Pathology RTx Orbital

exenteration

Intracranial

extension

Skin

defect

Defect

class

1 M 64 PNST + IIId

2 F 55 ACC IIId

3 M 63 ACC IIId

4 M 57 SCC + IIIb

5 M 55 SCC IIIb

6 M 55 PTCL + IId

7 M 52 SCC + IIa

8 M 62 SCC + + + V

9 M 72 SC + + + IVb

10 F 70 MFH + + + + IVb

11 M 60 ACC + + + IVd

12 M 59 MFS + IVd

13 M 41 SNUC + + + V

Table. 1. General characteristics

RTx, Radiotherapy; PNST, malignant peripheral nerve sheath tumor; SCC, squamous cell

carcinoma; ACC, adenoid cystic carcinoma; PTCL, peripheral T-cell lymphoma, maxillary defect

due to radionecrosis; SC, sebaceous carcinoma; MFH, malignant fibrous histiocytoma; MFS,

myofibroblastic sarcoma; SNUC, sinonasal undifferentiated carcinoma; *defect class, Brown

classification;

Orbit

(N=11)

Eye ball involve

(N=6)

Orbit wall only

(N=5)

Soft tissue flap

(RF, RA, LD)

Bone & Soft

tissue flap (IC)

Defect (IVb, IVd, V)

Orbit exenteration

Defect (IIIb, IIId)

Palate

(N=11)

Small defect (a,b)

(N=5)

Large defect (d)

(N=6)

IC, RF, RA

IC, RA, LD

Fig. 3. Type of defect vs. flap selection. (RF, radial forearm; LD, latissimus

dorsi; RA, rectus abdominis: IC, iliac crest)

Flaps used for maxillary reconstruction

Soft tissue:

Radial forearm: 2

Rectus abdominis: 3

Latissimus dorsi: 2

Bone & soft tissue:

Iliac crest: 5

0

5

10

15

20

25

30

35

RF

RA

LD

IC

Fig. 4. Average length(days) of hospital stay (RF, radial forearm; RA, rectus

abdominis: LD, latissimus dorsi; IC, iliac crest)

Complications related with flap surgery

Wound dehiscence: 3 (RA, LD)

Seroma (IC), hematoma (LD)

Orbital exenteration

Latissimus dorsi

Rectus abdominis

Radial forearm

Iliac crest

Defects of alveolar ridge and/or orbit

Iliac crest

Fibula

Radial forearm

Yes No

Yes No

Fig. 7. Current personal options of free flaps in maxillary reconstruction.

Fig. 5. A case of M/72, sebaceous carcinoma patient. Total maxillectomy and

reconstruction with rectus abdominis free flap was done.

Fig. 6. A case of M/57, adenoid cystic carcinoma patient. The bony defect

including alveolar ridge and orbital rim. Total maxillectomy and reconstruction

with iliac crest osteomusculocutaneous free flap was done.