ORIGINAL ARTICLE Orbitomaxillary Reconstruction Using the

ORIGINAL ARTICLE

Orbitomaxillary Reconstruction Using the LayeredFibula Osteocutaneous FlapTaha Z. Shipchandler, MD; Heather H. Waters, MD; P. Daniel Knott, MD; Michael A. Fritz, MD

Objective: To describe a surgical technique for total pala-tomaxillary and orbital reconstruction using a fibula os-teocutaneous free flap in a layered fashion.

Methods: Case series from a tertiary care facial plasticand reconstructive surgical practice including patientswith postextirpative Brown 3a and 3b orbitopalatomax-illary defects undergoing immediate microvascular re-construction. Application of the layered fibula free flapto composite maxillary defects permits single-stage,optimal reconstruction of contiguous orbitomaxillarydefects, reconstitution of midface 3-dimensional con-tour, and restoration of the anterior alveolar arch withrobust bone, thereby providing for potential sequential

dental rehabilitation with osseointegrated implants.

Results: This technique demonstrates excellent long-term symmetry, support, function, and aesthetic con-tour. Although patients may need minor, adjunctive pro-cedures, this technique is flexible in design and offersreliable outcomes with a minimum of morbidity.

Conclusion: The fibula osteocutaneous free flap, be-cause of its design flexibility and ability to provide struc-tural support, is an excellent reconstructive option for totalmaxillary defects, including those that involve the orbit.

Arch Facial Plast Surg. 2012;14(2):110-115

A ESTHETICALLY PLEASING AND

structurally sound maxil-lary reconstruction is ex-traordinarily challenging.The maxilla is a unique

bone that provides height and width to themidface and contributes greatly to overallaesthetic facial contour. In addition, it pro-vides support to the orbital contents andserves as a bony framework for maxillarydentition. Functionally, the maxilla alsocontributes to the oral phase of swallow-ing and speech articulation via palatal andalveolar arch integrity. Failure to accountfor each of these variables when compos-ing an overall reconstructive strategy mayresult in significant quality of life issues.

Total palatomaxillary reconstructionpresents surgeons with the difficult tasksof re-establishing a complex 3-dimen-sional form and providing vascular pediclereach into the neck. The challenge of re-construction increases with the amount ofvertical and horizontal bone loss and risesto a different order of magnitude when or-bital walls and/or floor are also absent.

Numerous techniques have been usedto reconstruct maxillary defects. Over thelast decade, contouring of various soft-tissue and bony free flaps including fibula,scapula, rectus abdominis, radial forearm,anterolateral thigh, and latissimus dorsihave gained popularity for maxillary re-

construction.1 All of these free flaps havebeen noted for their advantages and disad-vantages.2 The scapular free flap has beenthe technique of choice for reconstructingtotal maxillectomy defects owing to its mul-tiple skin paddle potential and ease of soft-tissue mobility around the bone.3,4 Thefibula free flap has shown promise for re-construction of lower palatal and alveolardefects with the advantage of allowing forosseointegrated dental implants but hasbeen cited for having limited application fortotal maxillectomy defects including the or-bital floor and greater than 50% of the pal-ate and alveolar arch.5

This article describes a surgical tech-nique using the fibula free flap for recon-struction of total maxillectomy and or-bital defects, which provides both excellentaesthetic and functional results.

METHODS

A retrospective review of cases performed at theCleveland Clinic between 2005 and 2010 wasperformed. During this time, 7 patients with totalmaxillectomy defects (age range, 18-72 years)including greater than 50% of the palate, alveo-lar arch, and lower orbit (Brown 3a and 3b de-fects) were reconstructed using a layered fibulafree-flap reconstruction technique.6 This retro-spective study was approved by the institu-tional review board of the Cleveland Clinic.

Author Affiliations: FacialPlastic & ReconstructiveSurgery, Department ofOtolaryngology–Head & NeckSurgery, Indiana UniversitySchool of Medicine,Indianapolis (Dr Shipchandler);Division of Facial Plastic &Reconstructive Surgery, Headand Neck Institute, ClevelandClinic, Cleveland, Ohio(Drs Waters and Fritz); andFacial Plastic & ReconstructiveSurgery, Department ofOtolaryngology, University ofCalifornia, San Francisco(Dr Knott).

ARCH FACIAL PLAST SURG/ VOL 14 (NO. 2), MAR/APR 2012 WWW.ARCHFACIAL.COM110

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All patients underwent total maxillary and inferior orbitalreconstruction at the time of tumor resection. A layered fibulatechnique was applied using 3 to 5 bone segments. Simultane-ous orbital reconstruction was performed in all patients usingvascularized bone and vascularized fascia flap underlay. Tita-nium mesh was anchored to native bone and fibula and usedfor orbital floor and lower wall reconstruction in 5 patients.Vascular anastomosis to the ipsilateral facial artery and vein wasperformed in all cases without the use of vein grafts. Six pa-tients underwent postoperative radiation therapy, and fol-low-up ranged from 6 to 71 months (mean, 30 months).

RESULTS

Demographic information including patient age, sex,pathologic subtype, Brown classification, adjuvant therapy,complications, current status, and follow-up time is listedin the Table. There were no partial or complete flap losses.All patients returned to soft (no remaining dentition) orregular diets within 6 weeks of reconstruction. Aes-thetic facial reconstruction with excellent midface sym-metry was accomplished in all patients. Regarding or-bital reconstruction, 1 patient had aesthetically significantenophthalmos; no patients experienced orbital move-ment restriction or diplopia postoperatively.

Additional complications included ectropion requir-ing tarsal strip repair (3 patients), native cheek skin break-down after radiation with plate exposure (1 patient), na-sal obstruction requiring flap debulking (2 patients),trismus requiring secondary coronoidectomy (1 pa-tient), midface/orbital contour distortion following fa-cial trauma (1 patient), and postoperative visual impair-ment due to retinopathy (presumed ischemic) (1 patient).Two patients have undergone placement of osseointe-grated implants, and 3 additional patients are in the plan-ning stages of dental rehabilitation.

Length of postoperative hospital stay ranged from 7to 11 days, with a mean of 8.42 days. The first 2 patientsin our series underwent tracheotomy with decannula-tion prior to discharge. As comfort levels with this pro-cedure have increased, all subsequent patients have beentreated with nasal trumpets, which provided the 2-foldbenefit of airway protection and stenting of the recon-structed nasal airway. As a result, no further patients haverequired tracheotomy.

SURGICAL TECHNIQUE: CASE 1

A 63-year-old woman diagnosed as having a large ad-enoid cystic carcinoma of the left maxilla required resec-tion of the entire orbital rim, anterior floor and lower me-dial wall, body of the maxilla, and greater than 50% of thehard palate and alveolar arch (Figure 1). The approachwas via lateral rhinotomy with Weber-Ferguson exten-sion sparing the skin-soft tissues of the face. After exci-sion, bony reconstructive templates consisting of carvedsterile tongue depressors were used to design fibula seg-ments to provide a bony scaffold that would restore theheight (lip commissure to inferior orbital rim) and width(anterior alveolar arch remnant to malar prominence) ofthe maxillary defect using facial symmetry as a guide.

A fibula free flap was harvested from the left leg witha moderately sized, long skin paddle (7-cm width by18-cm length). Maximum length of the fibula bone washarvested sparing 6 cm proximally and distally to main-tain joint stability. Next, sterile tongue depressors wereused to plan the 5 fibula segments necessary to achieve3-dimensional aesthetic contour of the midface as wellas restore the orbital defects and alveolar arch (Figure2).

Double closing osteotomies were then created in thefibula to achieve the desired facial contour and maximizebone-to-bone contact. These were then plated into the pa-

Table. Patient Demographics Including Brown Classification, Adjuvant External Beam Radiation Therapy, Length of Follow-up,and Current Status

Age/SexPathologic

SubtypeMaxillary

Defect Orbital Defect Radiation Complications StatusFollow up,

mo

69/F Squamous cell carcinoma 3a Rim, floor, medial wall Postop Enophthalmos, nasalobstruction

Alive without disease 11

65/M Squamous cell carcinoma 3a Rim, floor,medial/lateral wall

Postop Ectropion, loss cheekskin, nasal obstruction

Alive without disease 10

72/F Adenoid cystic carcinoma 3b Rim, floor, medial wall Postop Ectropion Alive without disease 7118/F Osteosarcoma 3a Rim, floor, medial wall No Ectropion Alive without disease 5326/M Myofibroblastic sarcoma 3a Rim, floor,

medial/lateral wallPostop None Alive with disease 6

52/F Odontogenic sarcoma 3b Rim, floor, medial wall Postop Orbital/facial trauma Alive without disease 4524/F Osteosarcoma 3a Floor Preop Retinopathy, trismus Died with disease 14

Abbreviations: Postop, postoperative; Preop, preoperative.

Figure 1. Midface defect following extirpation of left maxillary adenoid cysticcarcinoma involving the orbital floor, maxilla, palate, and alveolar arch.




tient with distal bone at the upper lateral limit of recon-struction (Figure 3). Of note, 7 cm of pedicle withoutadherent bone exist between segments 3 and 4 to achieveoptimal pedicle and bone segment geometry. The distalfibula skin paddle was used to provide lining and closureof the palate (Figure 4). Proximally, the skin paddle wasde-epithelialized and used to obliterate the maxillary cav-ity. The peroneal artery of the fibula and vena comitantewere anastomosed to the facial artery and vein.

At a follow-up visit 5 years after surgery and postop-erative radiation therapy, this patient had normal articu-lation and was eating a regular diet. In addition, she hadno diplopia and was happy regarding her aesthetic ap-pearance (Figure 5).

SURGICAL TECHNIQUE: CASE 2

An 18-year-old woman with osteosarcoma of the left max-illa underwent resection following preoperative chemo-therapy and was left with a similar defect to case 1, in-cluding partial involvement of the lateral nasal wall anda large inferior orbital floor and rim defect (Figure 6).

A fibula free flap was harvested from the left leg simi-lar to case 1. In this case, the fibula skin paddle was de-epithelialized partially to allow obliteration of the spacepreviously occupied by the maxillary sinus and to pro-vide a vascularized underlay for the orbital floor(Figure 7). The skin graft to repair the fibula harvestsite defect was taken from the fibula skin paddle to avoida thigh donor defect.

The osteotomy segments were designed to achievemaximal aesthetic contour while providing orbital rimsupport and lateral nasal wall and alveolar arch recon-struction. In addition, owing to the large orbital floor de-fect, the fibula served as a rigid structure on which to placefirm titanium mesh posteriorly to recreate the orbital floor(Figure 8 and Figure 9).

Four years later this patient was disease free with nor-mal speech articulation. Her intraoral reconstruction in-cluding her palate and alveolar arch was stable, and shehad obtained osseointegrated implants for dental reha-bilitation (Figure 10). A postoperative panoramic ra-diograph (panorex) at her most recent follow-up visitdemonstrated preservation and union of bony structure

Figure 2. Illustration of the placement of fibula segments to restore3-dimensional midface volume relationships with vascular pedicle geometry.Note orientation of bone segments allows for subsequent dental rehabilitation.

12

3

4 5

Figure 3. Numerical representation of planned fibula segments starting inthe superolateral quadrant and thereafter arranged in a counterclockwisefashion. Approximately 2 cm of bone between segments 3 and 4 wasremoved to prevent pedicle compromise.

Figure 4. Composite maxillary reconstruction with the orbital floorsupported with fibula segments and the skin paddle used for palatal liningwith the proximal fibula segments reconstituting the alveolar arch.

Figure 5. Five-year posttreatment frontal view after reconstruction of leftmaxillectomy using the layered fibula free flap in a patient withpostreconstruction external beam radiation therapy.




with implants in position at the reconstituted anterioralveolar arch (Figure 11).

COMMENT

The maxilla represents a critical functional and aes-thetic component of the midface. Historically, prosthe-ses were the mainstay of reconstruction, followed morerecently by free-tissue transfer.1,2 The fibula free flap pro-vides a reliable platform for reconstruction of lower max-illary defects, but its utility for orbitozygomatic supporthas been questioned.7 Using 1 free flap for reconstruc-tion of the orbitozygomatic buttress, hard palate, and an-terior alveolar arch while providing a framework for den-tal implants is ideal. The technique described herein, usinga layered osteocutaneous fibula free flap, accomplishesthese goals while maintaining swallowing and speechfunctions and providing excellent aesthetic contour.

The fibula free flap has several advantages during max-illary reconstruction.First,harvestingof the fibula free flapcan be accomplished simultaneously with cancer extirpa-tion, thereby shortening operative time and facilitating a2-team extirpation and reconstruction approach. In addi-tion, patient positioning during the harvest does not com-promise the ablative surgeon’s efforts. Second, the fibulaprovidesexcellentbonestockandsignificant lengthofbone.This allows forcreationofmultiple independent segments,each designed to restore the complex contour of both or-bital and maxillary defects, yet maintain vascular reach toneckvesselswithout theuseofveingrafts. Inaddition,bonyrestorationof theanterioralveolararchpermits subsequentplacement of secure osseointegrated dental implants.

Several key aspects of the method described are worthnoting. The critical anchor points for the fibula in thetechnique described are the plating portions to the rem-nant zygoma (or zygomatic arch) and the remnant con-tralateral alveolar arch. These 2 rigid structures providethe bony foundation necessary to support the fibula freeflap during maxillary reconstruction and provide for boneunion to maintain long-term stability. Plating also spansthe ascending process of the maxilla to the nasal boneswhen possible, but this buttress provides less support,given inherent limitations of nasal bone strength.

Notably, the nonanatomic lower bony reconstructionaims to provide sufficient anterior arch to support im-plants for stable prosthetic rehabilitation, and no attemptis made to reconstruct the posterior arch or articulate withthe pterygomaxillary buttress for several reasons. First andmost importantly, the pterygoid plates are included in theoncologic resection of the majority of cancer cases in ourinstitution. Second, posterior displacement of the proxi-mal bone segment would undermine facial contour cor-rection and also require further pedicle reach and com-plicate already difficult pedicle geometry. Third, we believethat complete obliteration of the maxillary sinus and un-derlay of orbital floor construct with vascularized flap isa key to successful postoperative healing and minimiza-tion of long-term complications; articulation of the fibulasegment posteriorly cannot be accomplished simultane-ously. Lastly, we do not believe that the pterygomaxillarybuttress provides reliable rigid fixation.

Although no reconstructions required vein grafts inthis series, pedicle length and geometry are among thegreatest challenges in this technique. If facial vessels areto be used for anastomosis, reconstruction begins withthe upper lateral segment and proceeds lateral to medialsuperiorly then medial to lateral inferiorly as the pediclepasses in a subcutaneous tunnel into the neck. Commu-nication with the extirpative surgeon is essential for main-tenance of recipient vessels. In all of our cases, the facialartery and vein were used as donor and recipient ves-sels, either originating within the soft tissues of the cheekor just inferior to the body of the mandible. For the lat-ter, a minimal access (3-cm incision) approach is effec-tive in minimizing required pedicle reach when neck dis-section is not performed. Special attention must be givento avoid kinking of pedicle vessels; removal of several cen-timeters of intersegmental bone may be necessary to al-low folding of different fibula osteotomy segments for ap-propriate contouring.

Orbital reconstruction requires the provision of boneto restore aesthetic rim contour, to support the lower lidto minimize ectropion risk, and to act as an anchor pointfor mesh reconstruction of the remaining defect. The lat-ter process does not attempt to recreate contour of absentorbital walls (if medial and/or lateral walls are included),

Figure 6. Intraoperative view of osteosarcoma involving the left maxilla,including orbital floor, lateral nasal wall, palate, and alveolus.

Figure 7. Ipsilateral fibula free flap with 4 distinct osseous segments andskin paddle with partially de-epithelialized surface.




but rather to restore orbital volume relationships to main-tain globe position and function. Critically, vascularizedtissue coverage of the orbital plate is provided with theproximal portions of the cutaneous paddle, and the un-

derlying maxillary sinus volume defect is completely oblit-erated with this tissue, which then drapes inferiorly to re-store palatal or gingivobuccal continuity. The medial aspectof this flap also mucosalizes to the restored lateral nasalwall.

Several adjunctive procedures may be necessary dur-ing the time of reconstruction or postoperatively includ-ing lower lid-tightening procedures to avoid or correctectropion, dacryocystorhinostomy, and debulking or re-contouring of the cheek soft-tissue envelope. Proximityof the lateral reconstruction to the coronoid process ofthe mandible may necessitate its removal to allow for fullmandibular excursion.

As with all extensive facial reconstructions, aggres-sive soft-tissue suspension on closure is important to mini-mize ectropion risk and midface ptosis. However, giventhe extensive orbital reconstruction and aggressive vol-ume correction during flap reconstruction, simultane-ous lid-tightening procedures were avoided to mini-mize risk of exacerbation of orbital edema or compression.Typically, ectropion was either corrected as a postopera-tive office procedure under local anesthesia or at the samesetting as oral flap debulking if this was required to op-timize the milieu for dental implant placement.

Lastly, though the senior author (M.A.F) initially usedsyntheticmodels toplanreconstructive techniques formax-illary defects, subsequent cases have not used these mod-els because the size of tumor extirpation defects can oftenbe unpredictable and the utility of modeling did not jus-tify the cost. Maintenance of facial symmetry while re-storing critical bone loss and contour (orbital rim, mid-

A B

Figure 8. Illustrations of fibula segment placement and orbital floor replacement. A, Illustration of the placement of fibula segments to restore 3-dimensionalmidface volume relationships with vascular pedicle geometry. B, Sagittal view illustration of orbital floor replacement with titanium mesh folded overreconstructed orbital rim (fibula bone) and maxillary dead space obliterated with de-epithelialized skin paddle.

Figure 9. Intraoperative view of left midface after osteofaciocutaneous fibulafree-flap reconstruction. Note bony contact at the zygomatic arch, the centralalveolus, and the nasal bones.




face, andalveolus)provides theguide for template creation.In conclusion, the goals of complex maxillary recon-

struction focus on maintenance of speech, swallowing,dentition, orbital support, and aesthetic contour. Ac-complishing this requires adequate bone stock, flexibil-ity of shape, a mobile cutaneous or fasciocutaneous paddle,and adequate pedicle reach. The technique using a lay-ered fibula osteocutaneous free flap achieves these goalsand should be considered an excellent option and po-tential method of choice for reconstructing large maxil-lary defects with or without orbital involvement.

Accepted for Publication: November 3, 2011.Correspondence: Michael A. Fritz, MD, Division of Fa-cial Plastic and Reconstructive Surgery, Head and NeckInstitute, Cleveland Clinic, 9500 Euclid Ave, Desk A71,Cleveland, OH 44195 ([email protected]).Author Contributions: Dr Fritz had full access to all ofthe data in the study and takes responsibility for the in-

tegrity of the data and the accuracy of the data analysis.Study concept and design: Shipchandler, Waters, Knott,and Fritz. Acquisition of data: Shipchandler, Waters, Knott,and Fritz. Analysis and interpretation of data: Shipchan-dler, Waters, Knott, and Fritz. Drafting of the manu-script: Shipchandler, Waters, and Knott. Critical revi-sion of the manuscript for important intellectual content:Shipchandler, Waters, and Fritz. Statistical analysis: Ship-chandler and Waters. Administrative, technical, and ma-terial support: Shipchandler, Waters, Knott, and Fritz.Study supervision: Shipchandler, Knott, and Fritz. Dr Fritzis responsible for surgical concept and served as pri-mary reconstructive surgeon in all cases.Financial Disclosure: None reported.Previous Presentation: This study was presented orally atthe 10th International Symposium for Facial Plastic & Re-constructive Surgery; May 2, 2010; Hollywood, Florida.

REFERENCES

1. Triana RJ Jr, Uglesic V, Virag M, et al. Microvascular free flap reconstructive op-tions in patients with partial and total maxillectomy defects. Arch Facial Plast Surg.2000;2(2):91-101.

2. Dalgorf D, Higgins K. Reconstruction of the midface and maxilla. Curr Opin Oto-laryngol Head Neck Surg. 2008;16(4):303-311.

3. Bidros RS, Metzinger SE, Guerra AB. The thoracodorsal artery perforator-scapular osteocutaneous (TDAP-SOC) flap for reconstruction of palatal and max-illary defects. Ann Plast Surg. 2005;54(1):59-65.

4. Urken ML, Bridger AG, Zur KB, Genden EM. The scapular osteofasciocutaneous flap:a 12-year experience. Arch Otolaryngol Head Neck Surg. 2001;127(7):862-869.

5. O’Connell DA, Futran ND. Reconstruction of the midface and maxilla. Curr OpinOtolaryngol Head Neck Surg. 2010;18(4):304-310.

6. Brown JS, Rogers SN, McNally DN, Boyle M. A modified classification for the max-illectomy defect. Head Neck. 2000;22(1):17-26.

7. Futran ND, Wadsworth JT, Villaret D, Farwell DG. Midface reconstruction with thefibula free flap. Arch Otolaryngol Head Neck Surg. 2002;128(2):161-166.

A B

Figure 10. Four-year posttreatment frontal view of the patient after reconstruction (A) and intraoral view of the patient (B). Note the remucosalized palatal surfaceand reconstitution of the alveolar arch with dental implants in place.

Figure 11. Four-year postoperative panoramic radiograph (panorex)demonstrates preservation and union of bone segments with implants inplace in reconstructed arch. Notably, the medial 2 plates have been removedto facilitate dental implant and prosthetic placement.




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ORIGINAL ARTICLE Orbitomaxillary Reconstruction Using the