Midface and Palatomaxillary Reconstruction

Midface and Palatomaxillary Reconstruction

No Results

No Results


Midface reconstruction has undergone numerous recent advancements. Key among these advances has been the availability of biocompatible, versatile, rigid internal fixation hardware. Further, improvement in osteocutaneous free tissue transfer has allowed surgeons to bring moderate-to-large amounts of well-vascularized composite tissue into the midface for reconstruction. Lastly, the availability of experienced prosthodontists who are able to obturate postsurgical defects continues to provide a robust and scalable adjunct or alternative to nonsurgical closure of palatomaxillary defects.

An image depicting a midface and palatomaxillary defect can be seen below.

Midfacial reconstruction is typically required following extirpative cancer surgery of the palate and sinonasal tumors. Alternatively, panfacial trauma can result in significant amounts of bone and soft tissue loss requiring midface reconstruction. These situations often represent high-energy traumatic injuries resulting in additional trauma to other organ systems. Reconstruction of the midface, regardless of the etiology, is complicated by its central and conspicuous position and its complex contour. Further, the palate and alveolar ridges are crucial for proper mastication, control of deglutition, and velopharyngeal speech control.

Palatomaxillary reconstruction related to oncologic surgery results most commonly after removal of a squamous cell carcinoma of the oral cavity or sinonasal mucosa. [1] However, removal of minor salivary tumors and adenocarcinoma, among others, can also result in defects requiring midface reconstruction. Again, palatomaxillary reconstruction can also be required following high-energy trauma and often is concurrent with reconstruction of other craniofacial injuries.

See Etiology.

Midface reconstruction is required when extirpative defects result in functional impairment, significant bone and soft tissue loss that cannot be reconstituted primarily with local tissue, open communication between the oral and sinonasal cavity, or significant cosmetic deformity. In addition to the above indications, posttraumatic unstable injuries, especially comminuted fractures or those with bone loss, and injuries that are too large or positioned such that nonsurgical obturation is not adequate to reconstitute function can require reconstruction with composite tissue.

The midface is composed of the hard and soft palate, the alveolar ridge, and the maxilla and maxillary sinus, as well as the overlying skin and soft tissue envelope. In addition to the importance in cosmesis, the maxilla plays a crucial role in separation of the oral and sinonasal cavities, speech production, and mastication, acting as a stable platform for dentition. Structures that are critical in preoperative planning include the number of teeth and quality of residual dentition. Firstly, successful obturation requires existing dentition to anchor the prosthesis. Secondly, the presence of dentition and need for dental reconstruction are indications for osteocutaneous free tissue transfer, as the fibula free flap can accommodate osseointegrated implants.

In the patient with cancer, few contraindications to palatomaxillary reconstruction exist, except in those patients with unresectable disease or patients that cannot tolerate the initial extirpative surgery. Markers of unresectable disease include skull base/dura/brain parenchyma or prevertebral fascia involvement, orbital apex involvement, extension into the nasopharynx or clivus, and encasement of the carotid artery. Many patients with small-to-moderate defects who are willing and able to undergo frequent follow-up are good candidates for obturation.

However, obturation can be contraindicated in those patients with large defects, edentulous patients, or those patients with defects that preclude stable anchorage of the prosthesis. Lastly, patients must have an adequate donor site of soft tissue or composite osteocutaneous tissue to be candidates for free tissue transfer reconstruction.

Particularly in the patient with peripheral vascular disease, fibula osteocutaneous flap harvest might be contraindicated because of compromised peripheral vasculature. However, given the diverse donor site options, including fibula osteocutaneous, radial forearm osteocutaneous, fasciocutaneous, and scapula osteocutaneous free tissue transfer, one is usually able to find adequate donor tissue. Lastly, although rare, patients who do not have adequate recipient vessels due to prior trauma or surgery are not good candidates for free tissue transfer. However, given the ability to obtain vessels from the contralateral side, this too is an unusual scenario.

In the patient with multiple traumas, reconstruction is typically contraindicated in the unstable patient or in the patient with multiple severe injuries, such as intracranial trauma, requiring more immediate management.

Hassanein AG. Continuous Validity of Temporalis Muscle Flap in Reconstruction of Postablative Palatomaxillary Defects. J Craniofac Surg. 2017 Mar. 28 (2):e130-7. [Medline].

Robb GL, Marunick MT, Martin JW, et al. Midface reconstruction: surgical reconstruction versus prosthesis. Head Neck. 2001 Jan. 23(1):48-58. [Medline].

Futran ND, Wadsworth JT, Villaret D, et al. Midface reconstruction with the fibula free flap. Arch Otolaryngol Head Neck Surg. 2002 Feb. 128(2):161-6. [Medline].

Kim JH, Rosenthal EL, Ellis T, et al. Radial forearm osteocutaneous free flap in maxillofacial and oromandibular reconstructions. Laryngoscope. 2005 Sep. 115(9):1697-701. [Medline].

Coleman SC, Burkey BB, Day TA, et al. Increasing use of the scapula osteocutaneous free flap. Laryngoscope. 2000 Sep. 110(9):1419-24. [Medline].

Shipchandler TZ, Waters HH, Knott PD, Fritz MA. Orbitomaxillary reconstruction using the layered fibula osteocutaneous flap. Arch Facial Plast Surg. 2012 Mar-Apr. 14(2):110-5. [Medline].

Mertens C, Löwenheim H, Hoffmann J. Image data based reconstruction of the midface using a patient-specific implant in combination with a vascularized osteomyocutaneous scapular flap. J Craniomaxillofac Surg. 2012 Oct 13. [Medline].

Wang Y, Cheng J, Yuan C, et al. Reconstruction of palatomaxillary defects following cancer ablation with temporalis muscle flap in medically compromised patients: a 15-year single institutional experience. Clin Oral Investig. 2014 Jul. 18(6):1663-70. [Medline].

Piazza C, Paderno A, Taglietti V, et al. Evolution of complex palatomaxillary reconstructions: the scapular angle osteomuscular free flap. Curr Opin Otolaryngol Head Neck Surg. 2013 Apr. 21(2):95-103. [Medline].

Piazza C, Paderno A, Del Bon F, et al. Palato-maxillary reconstruction by the angular branch-based tip of scapula free flap. Eur Arch Otorhinolaryngol. 2017 Feb. 274 (2):939-45. [Medline].

Futran ND, Mendez E. Developments in reconstruction of midface and maxilla. Lancet Oncol. 2006 Mar. 7(3):249-58. [Medline].

Urken ML, Roche AM, Kiplagat KJ, et al. Comprehensive approach to functional palatomaxillary reconstruction using regional and free tissue transfer: report of reconstructive and prosthodontic outcomes of 140 patients. Head Neck. 2018 Mar 14. [Medline].

Ghaheri BA, Kim JH, Wax MK. Second osteocutaneous fibular free flaps for head and neck defects. Laryngoscope. 2005 Jun. 115(6):983-6. [Medline].

Skoner JM, Bascom DA, Cohen JI, et al. Short-term functional donor site morbidity after radial forearm fasciocutaneous free flap harvest. Laryngoscope. 2003 Dec. 113(12):2091-4. [Medline].

Stephen M Weber, MD, PhD, FACS Facial Plastic and Reconstructive Surgeon, Weber Facial Plastic Surgery, PC

Stephen M Weber, MD, PhD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Mark K Wax, MD Professor and Program Director, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University; Service Chief, Department of Surgery, Section of Otolaryngology, Veterans Affairs Medical Center

Mark K Wax, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Head and Neck Society, Canadian Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Bronchoesophagological Association, American College of Surgeons, American Rhinologic Society, American Society for Laser Medicine and Surgery, North American Skull Base Society, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Dominique Dorion, MD, MSc, FRCSC, FACS Deputy Dean and Associate Dean of Resources, Professor of Surgery, Division of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, Université de Sherbrooke, Canada

Disclosure: Nothing to disclose.

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.

B Viswanatha, DO, MBBS, PhD, MS, FACS, FRCS(Glasg) Professor of Otolaryngology (ENT), Sri Venkateshwara ENT Institute, Victoria Hospital, Bangalore Medical College and Research Institute, India

B Viswanatha, DO, MBBS, PhD, MS, FACS, FRCS(Glasg) is a member of the following medical societies: Association of Otolaryngologists of India, Indian Medical Association, Indian Society of Otology

Disclosure: Nothing to disclose.

Midface and Palatomaxillary Reconstruction

Research & References of Midface and Palatomaxillary Reconstruction|A&C Accounting And Tax Services