- Email: [email protected]
Microsurgical reconstruction of the maxilla: Algorithm and concepts
Accepted Manuscript Microsurgical Reconstruction Of The Maxilla – Algorithm And Concepts Horácio Costa, Horácio Zenha, Consultant Plastic Surgeon, Hugo Sequeira, Senior Registrar in Plastic Surgery, Gustavo Coelho, Senior Registrar in Plastic Surgery, Nuno Gomes, Registrar in Plastic Surgery, Cristina Pinto, Registrar in Plastic Surgery, João Martins, Registrar in Plastic Surgery, Diana Santos, Registrar in Plastic Surgery, Carolina Andresen, Registrar in Plastic Surgery
PII:
S1748-6815(14)00704-9
DOI:
10.1016/j.bjps.2014.12.002
Reference:
PRAS 4454
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 12 March 2014 Accepted Date: 6 December 2014
Please cite this article as: Costa H, Zenha H, Sequeira H, Coelho G, Gomes N, Pinto C, Martins J, Santos D, Andresen C, Microsurgical Reconstruction Of The Maxilla – Algorithm And Concepts, British Journal of Plastic Surgery (2015), doi: 10.1016/j.bjps.2014.12.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT MICROSURGICAL RECONSTRUCTION OF THE MAXILLA – ALGORITHM AND CONCEPTS
CORRESPONDING AUTHOR: HORÁCIO COSTA
CONTACT DETAILS: [email protected];
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Centro Hospitalar de Gaia – Oporto University
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AUTHOR: HORÁCIO COSTA
Plastic Reconstructive Craniomaxillofacial and Microsurgical Unit
4434-502 Gaia Co-authors:
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Rua Conceição Fernandes, s/n
Horácio Zenha – Consultant Plastic Surgeon
Hugo Sequeira – Senior Registrar in Plastic Surgery
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Gustavo Coelho - Senior Registrar in Plastic Surgery Nuno Gomes – Registrar in Plastic Surgery Cristina Pinto - Registrar in Plastic Surgery João Martins - Registrar in Plastic Surgery
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Diana Santos - Registrar in Plastic Surgery
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Carolina Andresen - Registrar in Plastic Surgery
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ACCEPTED MANUSCRIPT Abstract Introduction: The main purpose of this article is to point out free tissue transfers as the first choice method for 3D maxillary reconstruction, particularly in providing enough bone for palate and maxillary arch reconstruction and consequently an implant-retained prosthesis. To achieve this, the myosseous free iliac crest was selected whenever possible as the first choice inside the reconstructive algorithm and free flap armamentarium. A new maxillectomy classification and algorithm reconstruction are proposed.
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Technical modifications and improvements accomplished over time are discussed, considering palate, dental implants and prosthesis, nasal sidewall, cranial base and dura, as well as recipient vessels. We present functional and aesthetic outcomes of the senior author’s last 24-year experience (H. C.) with complex midface reconstructions.
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Material and methods: The authors report and analyze a 24-year experience with 57 midface defects in 54 patients (30 males and 24 females). A total of 57 maxillary defects, classified in Class I (limited maxillectomy) = 12, Class II (subtotal maxillectomy) = 15, Class III (total maxillectomy) = 19, Class IV (orbitomaxillectomy) = 11, were analyzed regarding sex, age, tumour recurrence, free flap, reconstruction and necrosis. Also, functional outcomes were evaluated regarding diet, speech, globe position and vision, while aesthetic outcomes were evaluated by Patient and Surgeon scores. Results: 52 free flaps were performed in 47 patients; three patients were operated twice; other two patients needed two sequentially linked flow-through flaps. Free flap survival was 96% with two total flap losses (4%). The other 7 patients had a soft tissue retained obturator prosthesis.
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Conclusions: Microsurgical vascularized osteomyocutaneous free flaps are actually the goldstandard for reconstruction of complex defects following maxillectomy. This algorithm is based on the anatomofunctional defect of the maxilla and facilitates the flap selection, which is a must.
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Maxillectomy, osteomyocutaneous free flaps, maxilla reconstruction, microsurgery, reconstructive algorithm, intraoral microvascular anastomosis, sequentially linked flow through flaps, bone growing centre, prefabricated flap
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ACCEPTED MANUSCRIPT INTRODUCTION
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The past history of maxillectomy is remarkably poor. In a historical review and management of maxilla-ethmoidal malignant tumours, Öhngren, in 1933, pointed out that the earliest descriptions didn’t distinguish tumours arising in the nasal cavity from those arising in the maxilla. This author is recognised for his contributions to antral tumour topographical classification: anterior-inferior tumours with a more benign behaviour and superior-posterior (1). tumours with a more malignant behaviour Myhre and Michaels in their review paper ascribed (2) earliest recorded maxillectomies to Dupuytren 1820, Gensaul 1824 and Liston in 1841
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Attempts have been made by surgeons and prosthodontists to classify the maxillectomy defects. MacGregor and MacGregor (1986) have suggested a classification based on the (3-5) vertical component of the maxillary defect. However, the first major contribution was done by Spiro et al. (1997), when they reported a retrospective study of 403 maxillectomies in which they designated the terms: limited maxillectomy as the removal of one wall of the antrum; subtotal maxillectomy as the removal of at least two walls including the palate and excluding the orbital floor; and total maxillectomy as the complete removal of the maxilla, usually including (6) orbital exenteration.
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In the year 2000, two classification systems were put forward, idealised by Brown et al. and Cordeiro and Santamaria, which really modified the thinking and approaching of the (7,8) 10 years later Brown and Shaw based on 147 maxillectomy defect and its reconstruction. maxillectomy cases, and 12 years later Cordeiro and Chen based on 96 cases, presented modified maxillectomy classifications and reconstructive algorithms with particular refinements (9,10) to improve functional and aesthetic outcomes.
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Until the nineties, complex reconstructions had no place in the management of patients requiring maxillectomy. The goals were to create a clean, skin-grafted cavity to facilitate surveillance and to restore oral competence with a dental obturator when the palate was (3,6) resected.
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In a recent past, a wide variety of reconstructive options turned available, putting the free flap transfers as the first choice. Several authors in retrospective non-randomized studies have attempted to compare functional and aesthetic outcomes in terms of obturation and reconstruction, usually with free flaps, having concluded that reconstruction has advantages (7-14) that are more assured in larger defects.
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This paper has a three-fold purpose. First, we present functional and aesthetic outcomes of the senior author’s last 24-year experience (HC) with complex midface reconstructions. Second, we introduce a new classification system of maxillectomy defects. And third, we describe an algorithm for midface reconstruction based on this acquired experience.
M ATERIAL AND METHODS Classification system for maxillectomy/ Midfacial defects Type I defects (limited maxillectomy) include resection of 1 or 3 walls of the maxilla, including or not the palate. This type of defect can be further subdivided into those that exclude (Type Ia) or include (Types Ib and c) the nasomaxillary structure. Type Ia is the true horizontal maxillary defect where the horizontal palate is the only anatomical structure removed, with preservation of
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ACCEPTED MANUSCRIPT the maxillary arch. The nasomaxillary defects course with preservation (Type Ib) or resection of the anterior maxillary arch and palate (Type Ic).(Fig. 1) Type II defects (subtotal or infrastructural maxillectomy) include resection of the lower 5 walls of the maxilla – maxillary arch and palate, anterior, posterior, lateral and medial walls with preservation of the orbital floor. Type II defects can be further subdivided into those that include less than 50% of the hard palate (Type IIa) or greater than 50% of the hard palate (Type IIb).(Fig. 2)
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Type III defects (total maxillectomy) include resection of all 6 walls of the maxilla. This type of defect is subdivided into those that preserve (Type IIIa) or exenterate (Type IIIb) the orbital contents. Type III defects can be further subdivided into those that include mandible resection (Types IIIam and bm).(Fig. 3)
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Finally, Type IV defects (orbito or suprastructural maxillectomy) include resection of the upper 5 walls of the maxilla with exenteration of the orbital contents and with preservation of the palate and maxillary arch. Type IV defects can be further subdivided into those that preserve (Type IVa) or remove (Type IVb) the orbital roof. Type IVa implies leaving to exposure of the cranial base and Type IVb adds the exposure of the dura and brain.(Fig. 4)
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Patients Cohort
The authors report and analyse a 24-year experience with 57 midface defects in 54 patients. Three patients were operated twice by recurrent disease. For reconstruction 52 free flaps were performed in 47 patients. Two midface defects needed two sequentially linked flow-through flaps for reconstruction of extensive defects of the midface. There was a slight male predominance, with 30 males and 24 females.
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6 patients (3 males and 3 females) had a soft tissue retained obturator prosthesis; one female patient was reconstructed with a free calvarial bone graft; the maxillectomy classification of these last 7 patients was Class I = 3 patients (Ia = 2, Ib = 1) and Class IIa = 4 patients, being smaller maxillary defects compared with the free flap reconstructed cases.
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A total of 57 maxillary defects, classified in Class I (limited maxillectomy) = 12, Class II (subtotal maxillectomy) = 15, Class III (total maxillectomy) = 19, Class IV (orbitomaxillectomy) = 11, were analysed regarding sex, age, etiology, tumour recurrence, free flap reconstruction and necrosis. Whenever possible, the palate was reconstructed with vascularised bone. This concept was idealised to address 3 problems: 1-the sagging or bulging into the mouth of the soft tissue flaps; 2- the preservation of the upper gengivobuccal sulcus and 3- the maintenance of the maxillary bony arch. Functional outcomes were evaluated regarding diet type (unrestricted, soft, liquid), speech (normal, perceptible, imperceptible) and eye globe position and vision (ectropion, entropion, enophtalmos, diplopia, dystopia). Aesthetic outcomes were evaluated through a scale from 1 to 10 (0-2 poor, 3-5 fair, 6-8 good, 9-10 excellent) with Patient and Surgeon scores, which were determined by pre and post-operative clinical photographs and interview with direct examination of the patient. Other measurement tools which were used to measure functional and aesthetic ourcomes included pre and post operative maxillofacial 3D CAT Scans in all patients and ENT evaluation when judged necessary. (Fig. 5-10) All outcomes were evaluated and graded by all the paper co-authors. This study was approved by the Institutional Ethical Board of Centro Hospitalar Vila Nova de Gaia, Medical School, Oporto University.
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ACCEPTED MANUSCRIPT RESULTS
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In this cohort, the 57 midface defects were classified in Class I - 20% (Ia = 2, Ib = 5, Ic = 5), Class II – 26% (IIa = 12, IIb = 3), Class III 34% IIIa = 8, IIIb = 9, IIIam = 1, IIIbm = 1) and Class IV – 20% (IVa = 4, IVb = 7). An exhaustive table with detailed patients’ data is included for better analysis (Table 1). The median age was 48 (range 9-81) and gender distribution was 30 males – 24 females. A variety of free flaps was used for midface reconstruction, as shown in Table 1. There was a total of 2 flap failures (4%) The most common selected flap was the myocutaneous rectus abdominis. Since 2006, the myosseous iliac crest flap (8 cases) was particularly selected, when the palatal bone resection extended to or beyond the midline. (Fig. 6-9)
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Functional and aesthetic outcomes were evaluated by direct patient interview with a response rate of 41% (21 patients). Functional results
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Diet: evaluated as liquid, soft or unrestricted. 38% referred only soft diet, while 62% were unrestricted Speech: classified as imperceptible, perceptible and normal - 62% of patients referred normal speech Globe Position and Vision: 7 out of 8 patients with Class III defect were interviewed. 4 of them referred normal vision and eye globe position, while 2 had ectropion and 1 ectropion plus diplopia.
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Aesthetic results
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Discussion
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Of the 21 patients who underwent evaluation of the aesthetic outcomes, the Average Score given by the patients was 7.61, (range 5 to 10), while the Average Score given by the Surgeon was slightly higher - 7.71 (range 4 – 10).
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Traditionally, maxillectomy defects have been managed with prosthetic options, but over the past 24 years the role of free tissue transfers has become the gold standard. Several reports have attempted to compare functional and aesthetic outcomes in terms of obturation and reconstruction, particularly with free flaps. All of these studies indicate that reconstruction has advantages over prosthetic rehabilitation, especially as far as larger maxillary defects are (6-14) concerned. Related to this point, our experience also demonstrates that reconstruction provides a better outcome for swallowing and speech, particularly regarding larger defects in the horizontal component of the maxilla. One can speak about advantages of obturation, like simple surgery, cavity surveillance and rapid restoration of patient appearance with the immediate new dentition. However, other problems might arise, such as Radiotherapy issues, further surgical operations for obturator refinement during healing and contraction of the maxillary cavity and poor functional and aesthetic end results. Prosthetic options may be enhanced by the use of zygomatic implants which can help in denture retention in larger defects, although consensus has not been reached: long term results are in doubt, the experience is small and in their reports only patients from Class I and II were treated. (15) Actually, in our own practice, obturation is offered to Class Ia, Class IIa posterior defects or the unfitted or unwilling patient for 5
ACCEPTED MANUSCRIPT flap reconstruction. Free tissue transfer is the first choice method for 3D maxillary reconstruction. (Table 1) The vascularized DCIA flap with internal oblique muscle was popularized by Urken et al. (1998) and also applied in the sequentially linked flow-through flap concept for oromandibular (16,17) reconstruction.
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We agree with Brown et al. (2002) that the DCIA flap is unique in being able to provide sufficient height and depth of bone to restore contour of the face and mouth in high as well as low (18) maxillectomy defects with an adequate basis for implant retention.
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Although we also agree that the internal oblique muscle is a good lining for the nasal cavity, it is surely not the ideal tissue for palate reconstruction. Differently, we recommend it to fill the antrum cavity and support the orbit floor (fig, 7-9). The lining of the oral cavity should be done with the periosteum of the outer concave wall of the iliac bone which becomes thinly epithelialised. This technical refinement creates an anatomic bone palate and a natural oral environment allowing retention of dentures and implant rehabilitation, as well the support for the alar base and the upper lip by the iliac arch crest. These are the reasons why we always use the horizontal orientation of the bone strut of the DCIA flap with the internal oblique muscle, facing superiorly and so lying adjacent to the nasal sidewall, filling the antrum cavity and supporting the orbital floor, still adding a better anatomical location of the vascular flap pedicle related to the facial vessels. (Fig. 6-9)
(19-27)
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Several free flap transfers were reported for anatomofunctional maxillary reconstructions. Serafin et al (1980) described the free rib periosteal osteocutaneous flap, followed by Baker (1984) with the myocutaneous latissimus dorsi, Swartz et al. (1986) with the free osteocutaneous scapula, Early (1989) with the latissimus dorsi with rib and Fasciocutaneous radial forearm, Fisher and Jackson (1989) with the rectus abdominus myocutaneous and omentum, Bridger and Baldwin (1989) with the tensor fascia lata, Schusterman et al (1993) with the osteofasciocutaneous radial forearm, Nakayama et al. (1994) with the fibula osteocutaneous, and Schmelzeisen and Schliephake (1998) with the jejunum and gracilis flaps.
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Cordeiro and Chen’s algorithm (2012) to reconstruct complex midface defects is based on the extent to which the maxillary bone is resected and consequently a certain free flap is selected. In their work, the palate was always reconstructed with soft tissue component of the Fasciocutaneous (Class IIa) or osteofasciocutaneous (Class IIb) radial forearm flap, respectively. For larger defects, like Class IIIa, IIIb and IV, these authors recommended the bulky myocutaneous rectus abdominis flap. With this concept the maxillary cavity can be closed or obliterated, but a complete oromaxillary rehabilitation is not possible, and palate redundancy (10, 28-31) or sagging is a time problem. We agree that in oncologic resections soft tissue and skin is usually deficient, having been or about to be irradiated. In this clinical field, overfilling the soft tissues of the cheek is a way to counteract its contraction and also collapse of skin, entropion, ectropion and contour irregularities. However, we must prioritise the skeletal reconstruction, particularly the need for palatal closure and in this anatomofunctional point, the iliac crest flap is the best option, allowing a reconstruction almost like with like. In our reconstructive algorithm, soft tissue doesn’t always take priority and we consider two critical points of bone reconstruction: 1- the support of the orbit by iliac or calvarial bone grafts to maintain globe position and 2- the palate reconstruction by the iliac crest free flap whenever possible. (Table 2a-2b)
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ACCEPTED MANUSCRIPT The iliac crest free flap allows a better anatomical reconstruction with a concave palate covered by the periosteum, which is left to mucolise. Besides, the shape of the crest is appropriate to become the maxillary arch (Fig. 6-9). Therefore, the difficult task of attaching the skin island flap to the cranial base to minimise collapse of the roof, as advocated by Cordeiro and Chen, is no (8,10,28, 30-32) longer a problem.
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The myocutaneous free flaps may effectively close the oronasal fistula but reliable support for the cheek and orbit is less likely to be achieved. As a matter of fact, sagging of the midfacial soft tissues is a time problem. Clearly, the skeleton is the key building block of the structure of the (8,10,33,34) midface, so the bony defect must be addressed first, under the hexahedron concept. Consequently, vascularised bone is paramount in maxillary reconstruction in order to provide anterior projection of the midface, maxillary arch for osteointegrated dental implants and an anatomical palate shape. For this, we consider the myosseous iliac crest free flap as the gold standard technique.
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Type IIIm is a distinct 3D defect that includes mandible segmental resections in which we don’t follow the principle of palate bone reconstruction. In this clinical scenario, we prioritise the mandible reconstruction using the soleus muscle to reconstruct the palate, nasal lining and anterior cranial base, and the fibula strout to span the mandible defect.
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When the maxilla is resected in combination with the nose, the resulting defect is massive and we don’t agree with Cordeiro and Santamaria (2000) statement advocating nose delayed (8) On the contrary, we advocate primary nose reconstruction and the answer is reconstruction. applying two reconstructive concepts: 1- the pre-fabrication of flaps and 2- the sequentially linked flow-through flaps. These concepts give the plastic and reconstructive surgeon great capacity to overcome difficult anatomofunctional aspects in such complex reconstructions: the first one creates head and neck 3D anatomical structures, particularly the nose with good size, shape and tissue components; and the second supplies further tissue components plus vessels into the head and neck region, turning microvascular anastomosis more predictable, easier and (17,35-37) safer.
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In this paper, four new concepts are introduced: 1- a modified classification system of maxillectomies; 2- a related algorithm for midface reconstruction; 3 - a different Management of the pedicle anastomosis with the intraoral submucous dissection of the facial vessels and the application of the flow-through sequentially linked free flap concept for maxillary reconstruction which facilitates the microvascular anastomosis and 4 - The 3D Biomodelling Technique for (38.39) .(Fig. 5 and 9) better bone tailoring of the osteocutaneous free flaps
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Cordeiro and Chen (2012) stated in their last letters of their paper – Part II – that there are still (28) many unsolved problems that leave the path open for future advances. Gaia’s Plastic Reconstructive Craniomaxillofacial and Microsurgical Unit is striving to walk along this path for other advances to come. Conclusion
Free tissue transfer is the first choice method for 3D maxillary reconstruction. In selected cases, the myosseous iliac crest flap is the gold standard technique. Maxillectomy classification and related reconstructive algorithm are useful tools in the decision making process for patient evaluation and treatment.
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ACCEPTED MANUSCRIPT Acknowledgement: The authors would like to thank Susana Ferreira – Unit Secretary – for her help, support and typing of this paper. Their thanks also go to the architect Maria Pais de Sousa, for the drawings.
Funding: none Conflicts of interest: none declared
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Ethical approval: page 3
References
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1. Ohngren L.G, (1933) Malignant tumors of the maxilla-ethmoidal region. Acta Otolaryngol (Supply) 19: 1476 2. Myhre M. Michaels L. (1987). Nasopharyngeal adenofibroma treated in 1841 by maxillectomy. J Otolaryngol 16: 390-392 3. Aramany MA (1978). Basic principles of obturator design for partially edentulous patients. Part I: classification. J Prosthet Dent 40:554-557 4. MacGregor IA, Macgregor F (1986). Cancer of the face and mouth .Edinburgh: Churchill Livingstone; 544-568 5. Umino S, Masuda G, Ono S, Fujita K (1998). Speech intelligibility following maxillectomy with and without prosthesis: analysis of 54 cases. J Oral Rehabilitation 25:153-158 6. Spiro RH, Strong E.W., Shah J.P. (1997). Maxillectomy and its classification. Head & Neck 309-314 7. Brown J. S., Rogers S. N., McNally D.N., Boyle M. (2000) A modified classification for the maxillectomy defect. Head & Neck 17-26 8. Cordeiro PG, Santamaria E. (2000). A Classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg;105:2331-46 9. Brown J. S., Shaw RJ (2010) Reconstruction of the maxilla and midface: introducing a new classification. Personal View The Lancet/oncology, vol. 11: 1001-1008 10. Cordeiro P. G, Chen C. M (2012) A 15-year review of midface reconstruction after total and subtotal maxillectomy: Part I. Algorithm and outcomes. Plast Reconstr Surg vol. 129, 124-136 11. Rogers SN, Lowe D, Mcnally D, Brown JS, Vaughn ED. (2003). Health-related quality of life after maxillectomy: a comparison between prosthetic obturation and free flap. J Oral Maxillofac Surg 61:174-81 12. Genden EM, Okay D, Stepp MT, et al. (2003). Comparison of functional and quality and quality-of-life outcomes in patients with and without palatomaxillary reconstruction: a preliminary report. Arch Otolaryngol Head Neck; 129: 775-80 13. Moreno MA, Skoracki RJ, Ehab Y., Hanna MD, Hanasano MM (2010) Microvascular Free Flap Reconstruction Versus Palatal Obturation For Maxillectomy Defects, Head Neck 32: 860-868 14. Gomes N. Zenha H., Azevedo L., et al. (2013) Microsurgical reconstruction of maxillectomy defects: Experience of 24 cases. Eur J Plast R Surg Vol. 36, Issue 10: 619-626 15. Boyes-Varley JG, Howes DG, Davidge-Pitts KD, Branemark I, McAlpine JA (2007). A Protocol for maxillary reconstruction following oncologic resection using zygomatic implants. Int J Prosthodont 20: 521-31
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16. Urken ML, Vickery C, Weinberg H, Buchbinder D, Lawson Wk, Biller HF. (1989). The internal oblique-iliac crest osseomyocutaneous free flap in oromandibular reconstruction. Arch Otolaryngol Head Neck Surg; 115:339-349 17. Costa H, Zenha H., Azevedo L., Rios L., Barroso ML., Cunha C. (2012) Flow through sequentially linked free flaps in head and neck reconstruction EJPS 35: issue 1 pp 3141 18. Brown J. S., Jones D.C, Summerwill A., et al. (2002) Vascularized iliac crest with internal oblique muscle for immediate reconstruction after maxillectomy. Br J Oral Maxillofac Surg 40,183-190 19. Serafin, D, Riejkohl R, Thomas I, Georgiade, NG (1980). Vascularized rib-periosteal and osteocutaneous reconstruction of the maxilla and mandible: an assessment. Plast. Reconstr Surg; 94:236-239 20. Baker SR (1984) Closure of large orbital-maxillary defects with free latissimus dorsi myocutaneous flaps. Head Neck 6: 828-35 21. Swartz, WM, Banis JC, Newton ED, Ramasastry, SS, Jones, Nf, Acland, R (1986). The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast. Reconstr Surg; vol 77, n. 4: 530-544 22. Early M. (1989). Primary maxillary reconstruction after cancer excision. Br J Plast Surg; 42:628-637 23. Fisher J, Jackson IT. (1989) Microvascular surgery as an adjunct to Craniomaxillofacial reconstruction. Br J Plast Surg; 42: 146-154. 24. Bridger GP, Baldwin M. (1989) Anterior craniofacial resection for ethmoid and nasal cancer with free flap reconstruction. Arch Otolaryngol Head Neck Surg 25. Schusterman Ma, Reece GP, Miller MJ (1993). Osseous free flaps for orbit and midface reconstruction. Am J Surg; 166: 341-345 26. Nakayma B, Matsuura H, Hasegawa Y, Ishihara O, HasegawsaH, Torii S. (1994) New reconstruction for total maxillectomy defect with a fibula osteocutaneous free flap. Br J Plast Surg; 47: 247-249 27. Schmelzeisen R, Schliephake H (1998) Interdisciplinary microvascular reconstruction of maxillary, midfacial and skull base defects. J Craniomaxillofac Surg; 26:1-10 28. Cordeiro P. G, Chen C. M (2012) A 15-year review of midface reconstruction after total and subtotal maxillectomy: Part II. Technical modifications to maximize aesthetic and functional outcomes. Plast Reconstr Surg vol. 129, 139-147 29. Chen CM, Cordeiro PG (2008). The tongue-in-groove technique for orbital floor reconstruction after maxillectomy. Plast Reconstr Surg; 212:225-232 30. Cordeiro PG, Santamaria E. (1999). Primary reconstruction of complex midfacial defects with combined lip-switch procedures and free flaps. Plast Reconstr Surg vol. 103: 1850-1856 31. Cordeiro PG, Santamaria E. (1997). The extended pedicled rectus abdominis free tissue transfers for head and neck reconstruction. Ann Plast Surg; 39:53-59 32. Cordeiro PG., Bacilious N., Schantz S., Spiro R. (1998) The radial forearm osteocutaneous “sandwich” free flap for reconstruction of the bilateral subtotal maxillectomy defect. Ann Plast Surg 40: 397 33. Coleman III, JJ (1994). Osseous reconstruction of the midface and orbits. Clinics in Plast Surg; vol 21, n.1: 113-124 34. McCarthy C M, Cordeiro P G. (2010). Microvascular Reconstruction of Oncologic Defects of the Midface Plast. Reconstr. Surg. 126: 1947-1959 35. Costa H, Cunha C, Guimarães I, Comba S, Malta A, Lopes A (1993). Prefabricated flaps for the head and neck: a preliminary report. Brit J Plast Surg. 46: 223-227 36. Costa H, Guimarães I, Cardoso A, Malta A, Amarante J, Guimaraes F (1991). Onestage coverage and revascularisation of traumatised limbs by a flow-through radial midforearm free flap. Brit J Plast Surg. 44: 533-537
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37. Costa H, Cunha C, Conde A, Barsdley A, McGranther DA (1997). The flow-through free flap in replantation surgery: a new concept. Eur J Plast Surg. 20: 181-185 38. Zenha H, Rios L, Pinto A, Barroso ML, Cunha C, Costa H (2011). The application of 3D Biomodelling technology in complex mandibular reconstruction Eur J Plast Surg. 34: n.4, 257-65 39. Zenha H, Barroso ML, Costa H (2012). Advanced 3D Biomodelling technology for complex mandibular reconstruction. Capítulo 11 in: Danilla, S. Ed. Selected Topics in Plastic Reconstructive Surgery InTech Publishers
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Defect
Maxillec. Type
Right naso-orbitofrontal and superior maxilla defect – External skin
IVa
Left lower conservative maxillectomy including half palate – External skin
IIa
Left orbito and maxilla preserving palate – External skin
IVb
Myocutaneous rectus abdominis Cranial bone graft
Temporal A.V.
IVb
Myocutaneous latissimus dorsi Cranial bone graft
Temporal A.V.
IIIb
Myocutaneous rectus abdominis
Facial A.V.
Total necrosis
Left maxilla preserving orbit and excision ½ palate
IIa
Fasciocutaneous Radial Forearm
Facial A.
No
Left naso orbitofrontal and maxilla, preserving palate – External Skin
IVa
Myocutaneous Rectus Abdominis
1
M
58
M
81
3
M
20
4
M
42
5
M
39
Squamous Cell Carcinoma Maxillary Sinus
Left orbita maxilla and 2/3 palate – External skin
M
55
Squamous Cell Carcinoma Maxillary Sinus
M
72
6
7
Recurrence Basal Cell Carcinoma
Recurrence Basal Cell Carcinoma
Right naso-orbitofrontal and maxilla preserving palate – External skin
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Plexiform Neurofibroma
Fasciocutaneous radial forearm flap
Fasciocutaneous radial forearm flap
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Recurrence Squamous Cell Carcinoma
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2
Recurrence Basal Cell Carcinoma
Flap/ Obturator
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Age
SC
Sex
M AN U
Ethiology
Number
Microvascular anastomosis
Temporal A.V.
Facial A.V.
External Jugular V.
Temporal A.V.
Complications
No
No
No
No
No
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11
12
13
Right nose, inner canthus, upper maxilla - External skin
Ic
Recurrence Squamous Cell Carcinoma
Right fronto orbital and maxilla, including 2/3 palate – External skin Exenteration
IIIb
34
Recurrence Squamous Cell Carcinoma
Left temporo orbito and radical maxilla including ½ palate – External skin Exenteration
M
53
Recurrence Basal Cell Carcinoma
Right fronto orbital and maxilla preserving palate – External Skin
F
72
Malignant Schwanoma
Left orbitomaxilla preserving palate – Orbital roof; External skin
40
M
56
F
Recurrence Basal Cell Carcinoma
Facial A. External Jugular V.
No
Facial A. External Jugular V.
No
Myocutaneous Latissimus Dorsi
External carotid Internal Jugular V.
No
IIIb
Myocutaneous Rectus Abdominis
External Jugular V.
No
IVb
Myocutaneous Rectus Abdominis Bone graft
Facial A. External Jugular V
No
IVb
Myocutaneous Rectus Abdominis 2-skin islands
Facial A. V.
No
IVa
Fasciocutaneous Posterior braquial flap
Facial A.V.
No
Facial A.V.
No
Fasciocutaneous radial flap
RI PT
F
Squamous Cell Carcinoma
Myocutaneous Rectus Abdominis
SC
10
IIa
42
M AN U
9
Right lower maxilla, preserving orbit, including 1/3 palate
F
TE D
8
Superior thyroid A.
27
4th degree burn
15
M
66
Recurrence Squamous Cell Carcinoma
Right nose, lower maxilla and 2/3 palate – External skin
16
F
44
Recurrence Basal Cell Carcinoma
Right fronto orbital skull base – bone graft – and maxilla External skin
IVb
Myocutaneous Rectus Abdominis
Internal carotid A. Internal jugular V.
No
17
F
71
Squamous Cell Carcinoma
Right nose, lower eyelid, face upper lip + upper maxilla preserving orbital floor and palate – External skin
Ib
ALT
Facial A. V.
No
AC C
EP
M
Radical debridment Right fronto orbital and maxilla including ocular globe, preserving palate – External skin
14
Ic
Osteofasciocutaneous Radial forearm
ACCEPTED MANUSCRIPT
M
67
Squamous Cell Carcinoma
Bilateral maxillectomy including palate and preserving orbital floors
IIb, IIb
75
Radionecrotic Ulcer post SCC
Exenteration Right orbit, maxilla and ½ palate – External skin
IIIb
40
Squamous Cell Carcinoma
Exenteration Right orbit, maxilla and ½ palate – External skin
Right 1/3 palate and lower maxilla
F
M
22
F
72
Squamous Cell Carcinoma
23
F
69
Recurrence Squamous Cell Carcinoma
24
M
43
25
F
26
27
28
Myocutaneous Rectus Abdominis
RI PT
IIIb
Myocutaneous Rectus Abdominis
SC
Exenteration Right orbito maxillectomy including palate 1/2
Myocutaneous Rectus Abdominis
M AN U
21
Recurrence Squamous Cell Carcinoma
IIIb
Fasciocutaneous radial forearm flap
Facial A. External Jugular V.
No
Facial A. External Jugular V.
No
Anterior Jugular V.
Occipital A. External Jugular V.
Superior thyroid A. Branch Internal Jugular V.
th
Death 13 day
No
Facial A. Branch Internal Jugular V.
No
Facial A.V.
No
IIa
Fasciocutaneous radial forearm flap
Central - nose, lower 1/3; Maxillectomy, including palate and upper lip – External skin
Ic
Osteomyocutaneous Iliac crest st 1 - DCIA-13/07/2006
Recurrence Sarcoma
Left floor orbit, adjacent malar bone and ½ palate
IIIa
Myocutaneous rectus abdominis iliac bone graft – left orbital floor
Facial A. Branch Internal Jugular V.
No
68
Recurrence ulcerated BCC
Left orbital Exenteration + adjacent malar and maxilla preserving palate
IVa
Myocutaneous rectus abdominis
Temporal A.V.
No
M
53
Recurrence Squamous Cell Carcinoma
IIIb
Myocutaneous retus abdominis
Facial A.
No
F
37
Adenocistic carcinoma
IIIa
Muscle rectus abdominis iliac crest Bone graft orbital floor
F
68
SCC Maxillary sinus
IIIb
Myocutaneous Latissimus Dorsi
TE D
20
65
EP
19
M
AC C
18
Right fronto orbito maxillectomy – orbital Exenteration including ½ palate – External skin Left maxillectomy including orbital floor, etmoid, nasal septum and 2/3 palate Left orbital Exenteration, maxilla including ½ palate
External Jugular V.
Facial A. External Jugular V. Lingual A. External Jugular V.
No No
ACCEPTED MANUSCRIPT
38
Adenocistic carcinoma
30
M
28
SCC maxillary sinus P.O defect + RT
31
M
54
Squamous Cell Carcinoma
Right maxilla 8including ½ palate and orbital floor preserving orbital contents
IIIa
32
M
28
Gunshot Injury – Previous multiple surgeries
Debridement Nose + Central maxilla including palate
Ic
33
M
40
Recurrence adenocistic carcinoma
34
F
31
Dentigerous cyst
35
F
77
SCC palate mucosa
Right maxillectomy including > ½ palate preserving orbital floor
F
77
Recurrence Squamous Cell Carcinoma
Left lower maxilla including < ½ palate preserving orbital floor
M
9
Juvenile active ossifying fibroma
Left maxillectomy including orbital floor and 2/3 palate
38
F
40
Recurrence Ameloblastoma
39
F
45
47
40
M
Right osteomuscular iliac crest Dental implants
Myocutaneous rectus abdominus Iliac crest bone graft orbital floor
Facial A.V.
No
Facial A.V.
No
Facial A. Branch External Jugular V.
No
Branch Internal Jugular V.
IIIb
Myocutaneous rectus abdominis Iliac crest bone graft – orbital roof
Internal Jugular V.
No
IIa
Left iliac crest osteomuscular – Dental implants
1st Intraoral Facial A.V.
No
IIb
Osteomuscular fibula
IIa
Fasciocutaneous radial forearm flap
IIIa
Left osteomuscula4r iliac crest Iliac bone graft – orbital floor Apophysis Growth Center
2nd Intraoral Facial A.V.
No
Left maxillectomy including ½ palate preserving orbital floor
IIa
Osteomuscular iliac crest – internal oblique muscle for nose lateral wall
3rd Intraoral Facial A.V.
No
Chronic osteomyelitis
Left Body mandibulectomy Maxillectomy including > ½ palate preserving orbital floor
IIIam
Osteomuscular Fibula Soleus
External Jugular V.
Squamous cell carcinoma orbitomaxillary RT
Right orbit- Exenteration Maxilla, including ½ palate
IIIb
Myocutaneous Rectus Abdominis
TE D
M AN U
Left fronto-orbital Exenteration, skull base –maxilla and ½ palate – External skin Right conservative maxillectomy, including ½ palate, preserving orbital floor
EP
37
Ic
Osteomuscular fibula - 01/02/2011
Flow-through Fasciocutameous radial forearm osteomuscular radial forearm
AC C
36
IIIa
RI PT
F
SC
Left maxillectomy, including orbital floor and 2/3 palate preserving orbital contents Central Maxillectomy preserving orbital floors including bilateral hard palate and nasal septum
29
Facial A.
Common Carotid A.
No
Superior thyroid A.
External Jugular V. Branch Internal Jugular V. Superior thyroid A.
Internal Jugular V
Facial A.
No Total necrosis
No
Superior thyroid A.
Branch Internal Jugular V.
No
ACCEPTED MANUSCRIPT
47
Recurrence Adenocystic carcinoma
Left orbit exenteration, maxilla preserving palate and parotid region – External skin
64
Sarcoma
43
M
48
Recurrence Squamous Cell Carcinoma
Left orbital Exenteration maxillectomy ½ palate – External skin
44
F
33
Chronic osteomyelitis
Right maxillectomy involving 2/3 palate preservation orbital floor
45
M
53
Squamous cell carcinoma right maxilla
46
M
56
Recurrence Squamous cell carcinoma
47
F
76
Squamous cell carcinoma
48
F
88
Neglected Squamous cell carcinoma
49
M
73
Squamous cell carcinoma
M
86
F
24
50
51
IIIa
Flow-through Nose Osteofasciocutaneous Radial forearm Maxilla Osteofasciocutaneous fibula + Hemi Soleus Bone Fibula Graft orbital floor
IIIb
Myocutaneous Latissimus Dorsi
Branch Internal Jugular V
No
Facial A.V.
No
Superior thyroid A.
Internal Jugular V.
No
4th Intraoral Facial A.V.
No
IIb
Left osteomuscular iliac crest Dental Implants
IIIa
Left osteomuscular iliac crest
5th Intraoral Facial A.V.
No
IIIa
Osteomuscular fibula
6th Intraoral Facial A.V.
No
IIa
Right osteomuscular iliac crest
7th Intraoral Facial A.V.
No
Ib
Pre-fabricated fasciocutaneous radial forearm flap + iliac bone graft
8th Intraoral Facial A.V.
No
Total nose + septum + central maxilla
Ib
Pre-fabricated osteofasciocutaneous radial forearm flap
Facial A.V.
No
Squamous cell carcinoma
Total nose + septum + central maxilla
Ib
Pre-fabricated osteofasciocutaneous radial forearm flap
Facial A. External Jugular V
No
Complex Odontoma
Posterior right maxillectomy involving ½ palate
IIa
Obturator prosthesis
____
No
TE D
Right maxillectomy involving > ½ palate including orbital floor preservation orbital contents Right maxillectomy involving ½ palate including orbital floor Preservation orbital contents Left maxillectomy involving < ½ palate Orbital floor preservation
EP
Total nose + septum + central maxillectomy Nasomaxillary defect
AC C
42
Myocutaneous Latissimus Dorsi
M AN U
F
Total nose, right maxillectomy, including orbital floor and ½ palate – External skin
Superior thyroid A.
IVa
RI PT
M
SC
41
ACCEPTED MANUSCRIPT
IIa
Obturator prosthesis
____
No
Left maxillectomy involving <1/2 palate
IIa
Obturator prosthesis
____
No
Pleomorphic adenoma
Maxillectomy Horizontal palate
Ia
Obturator prosthesis
____
No
38
Ameloblastoma
Right maxillectomy Wall + inferior turbinate
Ib
Calvarial Bone graft
____
No
M
48
Indiferentiated tumour (biopsy) Linphoma B
Right maxillectomy involving < 1/2 palate
IIa
Obturator prosthesis
____
No
F
32
Pleomorphic adenoma
Maxillectomy Horizontal palate
Obturator prosthesis
____
No
53
M
58
54
F
25
55
F
56 57
Squamous cell carcinoma Squamous cell carcinoma
AC C
EP
TE D
Table 1: Detailed patients’ data: A- Artery; V- Vein
SC
60
M AN U
M
RI PT
Right maxillectomy involving <1/2 palate
52
Ia
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
Table 2a: Algorithm for midface reconstruction Selected free flaps: FRF – Fasciocutaneous radial forearm; OFRF – Osteofasciocutaneuos radial forearm; OmIC – Osteomuscular Iliac crest; OmcIC – Osteomyocutaneous iliac crest; OmF – Osteomuscular fibula; OmcF – Osteomyocutaneous fibula
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
Table 2b: Algorithm for midface reconstruction Selected free flaps: McRA – Myocutaneous rectus abdominis McLD – Myocutaneous Latissimus Dorsi; OmIC – Osteomuscular Iliac crest; OmF – Osteomuscular fibula; OmcF – Osteomyocutaneous fibula
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
Fig. 1 Vertical and horizontal maxillectomy classification: Type I defects – limited maxillectomy include resection of 1 or 3 walls of the maxilla, comprising or not the palate. This type of defect can be further subdivided into those that exclude (Type Ia) or include (Types Ib and c) the nasomaxillary structure. Type Ia is the true horizontal maxillary defect in which the horizontal palate is the only anatomical structure removed, with preservation of the maxillary arch. The nasomaxillary defects course with preservation (Type Ib) or resection of the anterior maxillary arch and palate (Type Ic).
Fig. 2 Vertical and horizontal maxillectomy classification: Type II defects – subtotal maxillectomy include resection of the lower 5 walls of the maxilla – maxillary arch and palate, anterior, posterior, lateral and medial walls with preservation of the orbital floor. Type II defects can be further subdivided into those that include less than 50 percent of the hard palate (Type IIa) or more than 50 percent of the hard palate (Type IIb).
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
Fig. 3 Vertical and horizontal maxillectomy classification: Type III defects – total maxillectomy include resection of all 6 walls of the maxilla. This type of defect is subdivided into those that preserve (Type IIIa) or exenterate (Type IIIb) the orbital contents. Type III defects can be further subdivided into those that include mandible resection (Types IIIam and bm).
Fig. 4 Vertical and horizontal maxillectomy classification: Type IV defects – orbito or suprastructural maxillectomy include resection of the upper 5 walls of the maxilla with exenteration of the orbital contents and preservation of the palate and maxillary arch. Type IV defects can be further subdivided into those that preserve (Type IVa) or remove (Type IVb) the orbital roof. Type IVa implies cranial base exposure, while the Type IVb adds the exposure of dura and brain.
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
Fig. 5 Type Ib Defect - Female patient, 89 years old, neglected squamous cell carcinoma involving nasal and adjacent skin and nasomaxillary structure including bone, cartilaginous pyramid, septum and periform aperture. A block excision was performed. Reconstruction was achieved by iliac bone graft to nasal dorsum and a pre-fabricated radial forearm flap nourished by the intraoral dissected facial vessels.
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
Fig. 6 Type Ic defect - Pre-operative frontal and side views of a male patient, 28 years old, status post-maxillectomy and RT due to maxillary squamous cell carcinoma. 3D bio-modelling planning was used as a surgical guide, tailoring the iliac myosseous flap. An adequate Intraoperative flap inset was achieved, recreating the anterior maxillary arch. The patient underwent dental rehabilitation without immediate or late complications.
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
EP
TE D
B
AC C
Fig. 7 Type IIa defect - 31-year-old female patient with a dentigerous cyst involving the palate and the dental roots of 2.2, 2.1 and 1.1 until 1.6 teeth. The lesion was completely excised through an intrapapillary approach. Reconstruction was achieved by a myosseous iliac crest free flap, nourished by the intraoral dissected facial vessels.
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
Fig. 8 Type IIb defect - Female patient, 33 years old, with chronic osteomielytis of right maxilla. History of previous multiple infections, fistulae, intraoral drainages, curettages and hyperbaric oxygen treatments. A 3D customized sterolitographic surgical guide allowed iliac crest harvesting and a morphofunctional maxillary reconstruction. The myosseous iliac crest free flap was vascularized by the intraoral dissected facial vessels.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
Fig 9 Type IIIa defect - 9-year-old male patient with a recurrent massive juvenile active ossifying fibroma of his left maxilla, involving the orbital floor and 2/3 of the hard palate. After tumour excision, 3D bio-modelling planning was used as a surgical guide. The vascularized myosseous iliac crest included the antero-superior iliac spine growth centre.
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
Fig 10 Type IIIam defect - 45-year-old female patient, with chronic osteomielytis of her left maxilla, malar sphenoid and mandible. History of multiple curettages and hyperbaric oxygen treatments. After a superficial parotidectomy with facial nerve preservation for skeleton removal, maxillary and mandible reconstruction was achieved by a chimeric fibula flap, with soleus muscle component.
PII:
S1748-6815(14)00704-9
DOI:
10.1016/j.bjps.2014.12.002
Reference:
PRAS 4454
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received Date: 12 March 2014 Accepted Date: 6 December 2014
Please cite this article as: Costa H, Zenha H, Sequeira H, Coelho G, Gomes N, Pinto C, Martins J, Santos D, Andresen C, Microsurgical Reconstruction Of The Maxilla – Algorithm And Concepts, British Journal of Plastic Surgery (2015), doi: 10.1016/j.bjps.2014.12.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT MICROSURGICAL RECONSTRUCTION OF THE MAXILLA – ALGORITHM AND CONCEPTS
CORRESPONDING AUTHOR: HORÁCIO COSTA
CONTACT DETAILS: [email protected];
SC
Centro Hospitalar de Gaia – Oporto University
RI PT
AUTHOR: HORÁCIO COSTA
Plastic Reconstructive Craniomaxillofacial and Microsurgical Unit
4434-502 Gaia Co-authors:
M AN U
Rua Conceição Fernandes, s/n
Horácio Zenha – Consultant Plastic Surgeon
Hugo Sequeira – Senior Registrar in Plastic Surgery
TE D
Gustavo Coelho - Senior Registrar in Plastic Surgery Nuno Gomes – Registrar in Plastic Surgery Cristina Pinto - Registrar in Plastic Surgery João Martins - Registrar in Plastic Surgery
EP
Diana Santos - Registrar in Plastic Surgery
AC C
Carolina Andresen - Registrar in Plastic Surgery
1
ACCEPTED MANUSCRIPT Abstract Introduction: The main purpose of this article is to point out free tissue transfers as the first choice method for 3D maxillary reconstruction, particularly in providing enough bone for palate and maxillary arch reconstruction and consequently an implant-retained prosthesis. To achieve this, the myosseous free iliac crest was selected whenever possible as the first choice inside the reconstructive algorithm and free flap armamentarium. A new maxillectomy classification and algorithm reconstruction are proposed.
RI PT
Technical modifications and improvements accomplished over time are discussed, considering palate, dental implants and prosthesis, nasal sidewall, cranial base and dura, as well as recipient vessels. We present functional and aesthetic outcomes of the senior author’s last 24-year experience (H. C.) with complex midface reconstructions.
M AN U
SC
Material and methods: The authors report and analyze a 24-year experience with 57 midface defects in 54 patients (30 males and 24 females). A total of 57 maxillary defects, classified in Class I (limited maxillectomy) = 12, Class II (subtotal maxillectomy) = 15, Class III (total maxillectomy) = 19, Class IV (orbitomaxillectomy) = 11, were analyzed regarding sex, age, tumour recurrence, free flap, reconstruction and necrosis. Also, functional outcomes were evaluated regarding diet, speech, globe position and vision, while aesthetic outcomes were evaluated by Patient and Surgeon scores. Results: 52 free flaps were performed in 47 patients; three patients were operated twice; other two patients needed two sequentially linked flow-through flaps. Free flap survival was 96% with two total flap losses (4%). The other 7 patients had a soft tissue retained obturator prosthesis.
Key Words:
EP
TE D
Conclusions: Microsurgical vascularized osteomyocutaneous free flaps are actually the goldstandard for reconstruction of complex defects following maxillectomy. This algorithm is based on the anatomofunctional defect of the maxilla and facilitates the flap selection, which is a must.
AC C
Maxillectomy, osteomyocutaneous free flaps, maxilla reconstruction, microsurgery, reconstructive algorithm, intraoral microvascular anastomosis, sequentially linked flow through flaps, bone growing centre, prefabricated flap
2
ACCEPTED MANUSCRIPT INTRODUCTION
RI PT
The past history of maxillectomy is remarkably poor. In a historical review and management of maxilla-ethmoidal malignant tumours, Öhngren, in 1933, pointed out that the earliest descriptions didn’t distinguish tumours arising in the nasal cavity from those arising in the maxilla. This author is recognised for his contributions to antral tumour topographical classification: anterior-inferior tumours with a more benign behaviour and superior-posterior (1). tumours with a more malignant behaviour Myhre and Michaels in their review paper ascribed (2) earliest recorded maxillectomies to Dupuytren 1820, Gensaul 1824 and Liston in 1841
SC
Attempts have been made by surgeons and prosthodontists to classify the maxillectomy defects. MacGregor and MacGregor (1986) have suggested a classification based on the (3-5) vertical component of the maxillary defect. However, the first major contribution was done by Spiro et al. (1997), when they reported a retrospective study of 403 maxillectomies in which they designated the terms: limited maxillectomy as the removal of one wall of the antrum; subtotal maxillectomy as the removal of at least two walls including the palate and excluding the orbital floor; and total maxillectomy as the complete removal of the maxilla, usually including (6) orbital exenteration.
M AN U
In the year 2000, two classification systems were put forward, idealised by Brown et al. and Cordeiro and Santamaria, which really modified the thinking and approaching of the (7,8) 10 years later Brown and Shaw based on 147 maxillectomy defect and its reconstruction. maxillectomy cases, and 12 years later Cordeiro and Chen based on 96 cases, presented modified maxillectomy classifications and reconstructive algorithms with particular refinements (9,10) to improve functional and aesthetic outcomes.
TE D
Until the nineties, complex reconstructions had no place in the management of patients requiring maxillectomy. The goals were to create a clean, skin-grafted cavity to facilitate surveillance and to restore oral competence with a dental obturator when the palate was (3,6) resected.
EP
In a recent past, a wide variety of reconstructive options turned available, putting the free flap transfers as the first choice. Several authors in retrospective non-randomized studies have attempted to compare functional and aesthetic outcomes in terms of obturation and reconstruction, usually with free flaps, having concluded that reconstruction has advantages (7-14) that are more assured in larger defects.
AC C
This paper has a three-fold purpose. First, we present functional and aesthetic outcomes of the senior author’s last 24-year experience (HC) with complex midface reconstructions. Second, we introduce a new classification system of maxillectomy defects. And third, we describe an algorithm for midface reconstruction based on this acquired experience.
M ATERIAL AND METHODS Classification system for maxillectomy/ Midfacial defects Type I defects (limited maxillectomy) include resection of 1 or 3 walls of the maxilla, including or not the palate. This type of defect can be further subdivided into those that exclude (Type Ia) or include (Types Ib and c) the nasomaxillary structure. Type Ia is the true horizontal maxillary defect where the horizontal palate is the only anatomical structure removed, with preservation of
3
ACCEPTED MANUSCRIPT the maxillary arch. The nasomaxillary defects course with preservation (Type Ib) or resection of the anterior maxillary arch and palate (Type Ic).(Fig. 1) Type II defects (subtotal or infrastructural maxillectomy) include resection of the lower 5 walls of the maxilla – maxillary arch and palate, anterior, posterior, lateral and medial walls with preservation of the orbital floor. Type II defects can be further subdivided into those that include less than 50% of the hard palate (Type IIa) or greater than 50% of the hard palate (Type IIb).(Fig. 2)
RI PT
Type III defects (total maxillectomy) include resection of all 6 walls of the maxilla. This type of defect is subdivided into those that preserve (Type IIIa) or exenterate (Type IIIb) the orbital contents. Type III defects can be further subdivided into those that include mandible resection (Types IIIam and bm).(Fig. 3)
SC
Finally, Type IV defects (orbito or suprastructural maxillectomy) include resection of the upper 5 walls of the maxilla with exenteration of the orbital contents and with preservation of the palate and maxillary arch. Type IV defects can be further subdivided into those that preserve (Type IVa) or remove (Type IVb) the orbital roof. Type IVa implies leaving to exposure of the cranial base and Type IVb adds the exposure of the dura and brain.(Fig. 4)
M AN U
Patients Cohort
The authors report and analyse a 24-year experience with 57 midface defects in 54 patients. Three patients were operated twice by recurrent disease. For reconstruction 52 free flaps were performed in 47 patients. Two midface defects needed two sequentially linked flow-through flaps for reconstruction of extensive defects of the midface. There was a slight male predominance, with 30 males and 24 females.
TE D
6 patients (3 males and 3 females) had a soft tissue retained obturator prosthesis; one female patient was reconstructed with a free calvarial bone graft; the maxillectomy classification of these last 7 patients was Class I = 3 patients (Ia = 2, Ib = 1) and Class IIa = 4 patients, being smaller maxillary defects compared with the free flap reconstructed cases.
AC C
EP
A total of 57 maxillary defects, classified in Class I (limited maxillectomy) = 12, Class II (subtotal maxillectomy) = 15, Class III (total maxillectomy) = 19, Class IV (orbitomaxillectomy) = 11, were analysed regarding sex, age, etiology, tumour recurrence, free flap reconstruction and necrosis. Whenever possible, the palate was reconstructed with vascularised bone. This concept was idealised to address 3 problems: 1-the sagging or bulging into the mouth of the soft tissue flaps; 2- the preservation of the upper gengivobuccal sulcus and 3- the maintenance of the maxillary bony arch. Functional outcomes were evaluated regarding diet type (unrestricted, soft, liquid), speech (normal, perceptible, imperceptible) and eye globe position and vision (ectropion, entropion, enophtalmos, diplopia, dystopia). Aesthetic outcomes were evaluated through a scale from 1 to 10 (0-2 poor, 3-5 fair, 6-8 good, 9-10 excellent) with Patient and Surgeon scores, which were determined by pre and post-operative clinical photographs and interview with direct examination of the patient. Other measurement tools which were used to measure functional and aesthetic ourcomes included pre and post operative maxillofacial 3D CAT Scans in all patients and ENT evaluation when judged necessary. (Fig. 5-10) All outcomes were evaluated and graded by all the paper co-authors. This study was approved by the Institutional Ethical Board of Centro Hospitalar Vila Nova de Gaia, Medical School, Oporto University.
4
ACCEPTED MANUSCRIPT RESULTS
RI PT
In this cohort, the 57 midface defects were classified in Class I - 20% (Ia = 2, Ib = 5, Ic = 5), Class II – 26% (IIa = 12, IIb = 3), Class III 34% IIIa = 8, IIIb = 9, IIIam = 1, IIIbm = 1) and Class IV – 20% (IVa = 4, IVb = 7). An exhaustive table with detailed patients’ data is included for better analysis (Table 1). The median age was 48 (range 9-81) and gender distribution was 30 males – 24 females. A variety of free flaps was used for midface reconstruction, as shown in Table 1. There was a total of 2 flap failures (4%) The most common selected flap was the myocutaneous rectus abdominis. Since 2006, the myosseous iliac crest flap (8 cases) was particularly selected, when the palatal bone resection extended to or beyond the midline. (Fig. 6-9)
SC
Functional and aesthetic outcomes were evaluated by direct patient interview with a response rate of 41% (21 patients). Functional results
• •
Diet: evaluated as liquid, soft or unrestricted. 38% referred only soft diet, while 62% were unrestricted Speech: classified as imperceptible, perceptible and normal - 62% of patients referred normal speech Globe Position and Vision: 7 out of 8 patients with Class III defect were interviewed. 4 of them referred normal vision and eye globe position, while 2 had ectropion and 1 ectropion plus diplopia.
M AN U
•
Aesthetic results
EP
Discussion
TE D
Of the 21 patients who underwent evaluation of the aesthetic outcomes, the Average Score given by the patients was 7.61, (range 5 to 10), while the Average Score given by the Surgeon was slightly higher - 7.71 (range 4 – 10).
AC C
Traditionally, maxillectomy defects have been managed with prosthetic options, but over the past 24 years the role of free tissue transfers has become the gold standard. Several reports have attempted to compare functional and aesthetic outcomes in terms of obturation and reconstruction, particularly with free flaps. All of these studies indicate that reconstruction has advantages over prosthetic rehabilitation, especially as far as larger maxillary defects are (6-14) concerned. Related to this point, our experience also demonstrates that reconstruction provides a better outcome for swallowing and speech, particularly regarding larger defects in the horizontal component of the maxilla. One can speak about advantages of obturation, like simple surgery, cavity surveillance and rapid restoration of patient appearance with the immediate new dentition. However, other problems might arise, such as Radiotherapy issues, further surgical operations for obturator refinement during healing and contraction of the maxillary cavity and poor functional and aesthetic end results. Prosthetic options may be enhanced by the use of zygomatic implants which can help in denture retention in larger defects, although consensus has not been reached: long term results are in doubt, the experience is small and in their reports only patients from Class I and II were treated. (15) Actually, in our own practice, obturation is offered to Class Ia, Class IIa posterior defects or the unfitted or unwilling patient for 5
ACCEPTED MANUSCRIPT flap reconstruction. Free tissue transfer is the first choice method for 3D maxillary reconstruction. (Table 1) The vascularized DCIA flap with internal oblique muscle was popularized by Urken et al. (1998) and also applied in the sequentially linked flow-through flap concept for oromandibular (16,17) reconstruction.
RI PT
We agree with Brown et al. (2002) that the DCIA flap is unique in being able to provide sufficient height and depth of bone to restore contour of the face and mouth in high as well as low (18) maxillectomy defects with an adequate basis for implant retention.
M AN U
SC
Although we also agree that the internal oblique muscle is a good lining for the nasal cavity, it is surely not the ideal tissue for palate reconstruction. Differently, we recommend it to fill the antrum cavity and support the orbit floor (fig, 7-9). The lining of the oral cavity should be done with the periosteum of the outer concave wall of the iliac bone which becomes thinly epithelialised. This technical refinement creates an anatomic bone palate and a natural oral environment allowing retention of dentures and implant rehabilitation, as well the support for the alar base and the upper lip by the iliac arch crest. These are the reasons why we always use the horizontal orientation of the bone strut of the DCIA flap with the internal oblique muscle, facing superiorly and so lying adjacent to the nasal sidewall, filling the antrum cavity and supporting the orbital floor, still adding a better anatomical location of the vascular flap pedicle related to the facial vessels. (Fig. 6-9)
(19-27)
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Several free flap transfers were reported for anatomofunctional maxillary reconstructions. Serafin et al (1980) described the free rib periosteal osteocutaneous flap, followed by Baker (1984) with the myocutaneous latissimus dorsi, Swartz et al. (1986) with the free osteocutaneous scapula, Early (1989) with the latissimus dorsi with rib and Fasciocutaneous radial forearm, Fisher and Jackson (1989) with the rectus abdominus myocutaneous and omentum, Bridger and Baldwin (1989) with the tensor fascia lata, Schusterman et al (1993) with the osteofasciocutaneous radial forearm, Nakayama et al. (1994) with the fibula osteocutaneous, and Schmelzeisen and Schliephake (1998) with the jejunum and gracilis flaps.
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Cordeiro and Chen’s algorithm (2012) to reconstruct complex midface defects is based on the extent to which the maxillary bone is resected and consequently a certain free flap is selected. In their work, the palate was always reconstructed with soft tissue component of the Fasciocutaneous (Class IIa) or osteofasciocutaneous (Class IIb) radial forearm flap, respectively. For larger defects, like Class IIIa, IIIb and IV, these authors recommended the bulky myocutaneous rectus abdominis flap. With this concept the maxillary cavity can be closed or obliterated, but a complete oromaxillary rehabilitation is not possible, and palate redundancy (10, 28-31) or sagging is a time problem. We agree that in oncologic resections soft tissue and skin is usually deficient, having been or about to be irradiated. In this clinical field, overfilling the soft tissues of the cheek is a way to counteract its contraction and also collapse of skin, entropion, ectropion and contour irregularities. However, we must prioritise the skeletal reconstruction, particularly the need for palatal closure and in this anatomofunctional point, the iliac crest flap is the best option, allowing a reconstruction almost like with like. In our reconstructive algorithm, soft tissue doesn’t always take priority and we consider two critical points of bone reconstruction: 1- the support of the orbit by iliac or calvarial bone grafts to maintain globe position and 2- the palate reconstruction by the iliac crest free flap whenever possible. (Table 2a-2b)
6
ACCEPTED MANUSCRIPT The iliac crest free flap allows a better anatomical reconstruction with a concave palate covered by the periosteum, which is left to mucolise. Besides, the shape of the crest is appropriate to become the maxillary arch (Fig. 6-9). Therefore, the difficult task of attaching the skin island flap to the cranial base to minimise collapse of the roof, as advocated by Cordeiro and Chen, is no (8,10,28, 30-32) longer a problem.
RI PT
The myocutaneous free flaps may effectively close the oronasal fistula but reliable support for the cheek and orbit is less likely to be achieved. As a matter of fact, sagging of the midfacial soft tissues is a time problem. Clearly, the skeleton is the key building block of the structure of the (8,10,33,34) midface, so the bony defect must be addressed first, under the hexahedron concept. Consequently, vascularised bone is paramount in maxillary reconstruction in order to provide anterior projection of the midface, maxillary arch for osteointegrated dental implants and an anatomical palate shape. For this, we consider the myosseous iliac crest free flap as the gold standard technique.
SC
Type IIIm is a distinct 3D defect that includes mandible segmental resections in which we don’t follow the principle of palate bone reconstruction. In this clinical scenario, we prioritise the mandible reconstruction using the soleus muscle to reconstruct the palate, nasal lining and anterior cranial base, and the fibula strout to span the mandible defect.
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When the maxilla is resected in combination with the nose, the resulting defect is massive and we don’t agree with Cordeiro and Santamaria (2000) statement advocating nose delayed (8) On the contrary, we advocate primary nose reconstruction and the answer is reconstruction. applying two reconstructive concepts: 1- the pre-fabrication of flaps and 2- the sequentially linked flow-through flaps. These concepts give the plastic and reconstructive surgeon great capacity to overcome difficult anatomofunctional aspects in such complex reconstructions: the first one creates head and neck 3D anatomical structures, particularly the nose with good size, shape and tissue components; and the second supplies further tissue components plus vessels into the head and neck region, turning microvascular anastomosis more predictable, easier and (17,35-37) safer.
EP
In this paper, four new concepts are introduced: 1- a modified classification system of maxillectomies; 2- a related algorithm for midface reconstruction; 3 - a different Management of the pedicle anastomosis with the intraoral submucous dissection of the facial vessels and the application of the flow-through sequentially linked free flap concept for maxillary reconstruction which facilitates the microvascular anastomosis and 4 - The 3D Biomodelling Technique for (38.39) .(Fig. 5 and 9) better bone tailoring of the osteocutaneous free flaps
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Cordeiro and Chen (2012) stated in their last letters of their paper – Part II – that there are still (28) many unsolved problems that leave the path open for future advances. Gaia’s Plastic Reconstructive Craniomaxillofacial and Microsurgical Unit is striving to walk along this path for other advances to come. Conclusion
Free tissue transfer is the first choice method for 3D maxillary reconstruction. In selected cases, the myosseous iliac crest flap is the gold standard technique. Maxillectomy classification and related reconstructive algorithm are useful tools in the decision making process for patient evaluation and treatment.
7
ACCEPTED MANUSCRIPT Acknowledgement: The authors would like to thank Susana Ferreira – Unit Secretary – for her help, support and typing of this paper. Their thanks also go to the architect Maria Pais de Sousa, for the drawings.
Funding: none Conflicts of interest: none declared
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Ethical approval: page 3
References
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1. Ohngren L.G, (1933) Malignant tumors of the maxilla-ethmoidal region. Acta Otolaryngol (Supply) 19: 1476 2. Myhre M. Michaels L. (1987). Nasopharyngeal adenofibroma treated in 1841 by maxillectomy. J Otolaryngol 16: 390-392 3. Aramany MA (1978). Basic principles of obturator design for partially edentulous patients. Part I: classification. J Prosthet Dent 40:554-557 4. MacGregor IA, Macgregor F (1986). Cancer of the face and mouth .Edinburgh: Churchill Livingstone; 544-568 5. Umino S, Masuda G, Ono S, Fujita K (1998). Speech intelligibility following maxillectomy with and without prosthesis: analysis of 54 cases. J Oral Rehabilitation 25:153-158 6. Spiro RH, Strong E.W., Shah J.P. (1997). Maxillectomy and its classification. Head & Neck 309-314 7. Brown J. S., Rogers S. N., McNally D.N., Boyle M. (2000) A modified classification for the maxillectomy defect. Head & Neck 17-26 8. Cordeiro PG, Santamaria E. (2000). A Classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg;105:2331-46 9. Brown J. S., Shaw RJ (2010) Reconstruction of the maxilla and midface: introducing a new classification. Personal View The Lancet/oncology, vol. 11: 1001-1008 10. Cordeiro P. G, Chen C. M (2012) A 15-year review of midface reconstruction after total and subtotal maxillectomy: Part I. Algorithm and outcomes. Plast Reconstr Surg vol. 129, 124-136 11. Rogers SN, Lowe D, Mcnally D, Brown JS, Vaughn ED. (2003). Health-related quality of life after maxillectomy: a comparison between prosthetic obturation and free flap. J Oral Maxillofac Surg 61:174-81 12. Genden EM, Okay D, Stepp MT, et al. (2003). Comparison of functional and quality and quality-of-life outcomes in patients with and without palatomaxillary reconstruction: a preliminary report. Arch Otolaryngol Head Neck; 129: 775-80 13. Moreno MA, Skoracki RJ, Ehab Y., Hanna MD, Hanasano MM (2010) Microvascular Free Flap Reconstruction Versus Palatal Obturation For Maxillectomy Defects, Head Neck 32: 860-868 14. Gomes N. Zenha H., Azevedo L., et al. (2013) Microsurgical reconstruction of maxillectomy defects: Experience of 24 cases. Eur J Plast R Surg Vol. 36, Issue 10: 619-626 15. Boyes-Varley JG, Howes DG, Davidge-Pitts KD, Branemark I, McAlpine JA (2007). A Protocol for maxillary reconstruction following oncologic resection using zygomatic implants. Int J Prosthodont 20: 521-31
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16. Urken ML, Vickery C, Weinberg H, Buchbinder D, Lawson Wk, Biller HF. (1989). The internal oblique-iliac crest osseomyocutaneous free flap in oromandibular reconstruction. Arch Otolaryngol Head Neck Surg; 115:339-349 17. Costa H, Zenha H., Azevedo L., Rios L., Barroso ML., Cunha C. (2012) Flow through sequentially linked free flaps in head and neck reconstruction EJPS 35: issue 1 pp 3141 18. Brown J. S., Jones D.C, Summerwill A., et al. (2002) Vascularized iliac crest with internal oblique muscle for immediate reconstruction after maxillectomy. Br J Oral Maxillofac Surg 40,183-190 19. Serafin, D, Riejkohl R, Thomas I, Georgiade, NG (1980). Vascularized rib-periosteal and osteocutaneous reconstruction of the maxilla and mandible: an assessment. Plast. Reconstr Surg; 94:236-239 20. Baker SR (1984) Closure of large orbital-maxillary defects with free latissimus dorsi myocutaneous flaps. Head Neck 6: 828-35 21. Swartz, WM, Banis JC, Newton ED, Ramasastry, SS, Jones, Nf, Acland, R (1986). The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast. Reconstr Surg; vol 77, n. 4: 530-544 22. Early M. (1989). Primary maxillary reconstruction after cancer excision. Br J Plast Surg; 42:628-637 23. Fisher J, Jackson IT. (1989) Microvascular surgery as an adjunct to Craniomaxillofacial reconstruction. Br J Plast Surg; 42: 146-154. 24. Bridger GP, Baldwin M. (1989) Anterior craniofacial resection for ethmoid and nasal cancer with free flap reconstruction. Arch Otolaryngol Head Neck Surg 25. Schusterman Ma, Reece GP, Miller MJ (1993). Osseous free flaps for orbit and midface reconstruction. Am J Surg; 166: 341-345 26. Nakayma B, Matsuura H, Hasegawa Y, Ishihara O, HasegawsaH, Torii S. (1994) New reconstruction for total maxillectomy defect with a fibula osteocutaneous free flap. Br J Plast Surg; 47: 247-249 27. Schmelzeisen R, Schliephake H (1998) Interdisciplinary microvascular reconstruction of maxillary, midfacial and skull base defects. J Craniomaxillofac Surg; 26:1-10 28. Cordeiro P. G, Chen C. M (2012) A 15-year review of midface reconstruction after total and subtotal maxillectomy: Part II. Technical modifications to maximize aesthetic and functional outcomes. Plast Reconstr Surg vol. 129, 139-147 29. Chen CM, Cordeiro PG (2008). The tongue-in-groove technique for orbital floor reconstruction after maxillectomy. Plast Reconstr Surg; 212:225-232 30. Cordeiro PG, Santamaria E. (1999). Primary reconstruction of complex midfacial defects with combined lip-switch procedures and free flaps. Plast Reconstr Surg vol. 103: 1850-1856 31. Cordeiro PG, Santamaria E. (1997). The extended pedicled rectus abdominis free tissue transfers for head and neck reconstruction. Ann Plast Surg; 39:53-59 32. Cordeiro PG., Bacilious N., Schantz S., Spiro R. (1998) The radial forearm osteocutaneous “sandwich” free flap for reconstruction of the bilateral subtotal maxillectomy defect. Ann Plast Surg 40: 397 33. Coleman III, JJ (1994). Osseous reconstruction of the midface and orbits. Clinics in Plast Surg; vol 21, n.1: 113-124 34. McCarthy C M, Cordeiro P G. (2010). Microvascular Reconstruction of Oncologic Defects of the Midface Plast. Reconstr. Surg. 126: 1947-1959 35. Costa H, Cunha C, Guimarães I, Comba S, Malta A, Lopes A (1993). Prefabricated flaps for the head and neck: a preliminary report. Brit J Plast Surg. 46: 223-227 36. Costa H, Guimarães I, Cardoso A, Malta A, Amarante J, Guimaraes F (1991). Onestage coverage and revascularisation of traumatised limbs by a flow-through radial midforearm free flap. Brit J Plast Surg. 44: 533-537
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37. Costa H, Cunha C, Conde A, Barsdley A, McGranther DA (1997). The flow-through free flap in replantation surgery: a new concept. Eur J Plast Surg. 20: 181-185 38. Zenha H, Rios L, Pinto A, Barroso ML, Cunha C, Costa H (2011). The application of 3D Biomodelling technology in complex mandibular reconstruction Eur J Plast Surg. 34: n.4, 257-65 39. Zenha H, Barroso ML, Costa H (2012). Advanced 3D Biomodelling technology for complex mandibular reconstruction. Capítulo 11 in: Danilla, S. Ed. Selected Topics in Plastic Reconstructive Surgery InTech Publishers
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Defect
Maxillec. Type
Right naso-orbitofrontal and superior maxilla defect – External skin
IVa
Left lower conservative maxillectomy including half palate – External skin
IIa
Left orbito and maxilla preserving palate – External skin
IVb
Myocutaneous rectus abdominis Cranial bone graft
Temporal A.V.
IVb
Myocutaneous latissimus dorsi Cranial bone graft
Temporal A.V.
IIIb
Myocutaneous rectus abdominis
Facial A.V.
Total necrosis
Left maxilla preserving orbit and excision ½ palate
IIa
Fasciocutaneous Radial Forearm
Facial A.
No
Left naso orbitofrontal and maxilla, preserving palate – External Skin
IVa
Myocutaneous Rectus Abdominis
1
M
58
M
81
3
M
20
4
M
42
5
M
39
Squamous Cell Carcinoma Maxillary Sinus
Left orbita maxilla and 2/3 palate – External skin
M
55
Squamous Cell Carcinoma Maxillary Sinus
M
72
6
7
Recurrence Basal Cell Carcinoma
Recurrence Basal Cell Carcinoma
Right naso-orbitofrontal and maxilla preserving palate – External skin
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Plexiform Neurofibroma
Fasciocutaneous radial forearm flap
Fasciocutaneous radial forearm flap
EP
Recurrence Squamous Cell Carcinoma
AC C
2
Recurrence Basal Cell Carcinoma
Flap/ Obturator
RI PT
Age
SC
Sex
M AN U
Ethiology
Number
Microvascular anastomosis
Temporal A.V.
Facial A.V.
External Jugular V.
Temporal A.V.
Complications
No
No
No
No
No
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11
12
13
Right nose, inner canthus, upper maxilla - External skin
Ic
Recurrence Squamous Cell Carcinoma
Right fronto orbital and maxilla, including 2/3 palate – External skin Exenteration
IIIb
34
Recurrence Squamous Cell Carcinoma
Left temporo orbito and radical maxilla including ½ palate – External skin Exenteration
M
53
Recurrence Basal Cell Carcinoma
Right fronto orbital and maxilla preserving palate – External Skin
F
72
Malignant Schwanoma
Left orbitomaxilla preserving palate – Orbital roof; External skin
40
M
56
F
Recurrence Basal Cell Carcinoma
Facial A. External Jugular V.
No
Facial A. External Jugular V.
No
Myocutaneous Latissimus Dorsi
External carotid Internal Jugular V.
No
IIIb
Myocutaneous Rectus Abdominis
External Jugular V.
No
IVb
Myocutaneous Rectus Abdominis Bone graft
Facial A. External Jugular V
No
IVb
Myocutaneous Rectus Abdominis 2-skin islands
Facial A. V.
No
IVa
Fasciocutaneous Posterior braquial flap
Facial A.V.
No
Facial A.V.
No
Fasciocutaneous radial flap
RI PT
F
Squamous Cell Carcinoma
Myocutaneous Rectus Abdominis
SC
10
IIa
42
M AN U
9
Right lower maxilla, preserving orbit, including 1/3 palate
F
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8
Superior thyroid A.
27
4th degree burn
15
M
66
Recurrence Squamous Cell Carcinoma
Right nose, lower maxilla and 2/3 palate – External skin
16
F
44
Recurrence Basal Cell Carcinoma
Right fronto orbital skull base – bone graft – and maxilla External skin
IVb
Myocutaneous Rectus Abdominis
Internal carotid A. Internal jugular V.
No
17
F
71
Squamous Cell Carcinoma
Right nose, lower eyelid, face upper lip + upper maxilla preserving orbital floor and palate – External skin
Ib
ALT
Facial A. V.
No
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M
Radical debridment Right fronto orbital and maxilla including ocular globe, preserving palate – External skin
14
Ic
Osteofasciocutaneous Radial forearm
ACCEPTED MANUSCRIPT
M
67
Squamous Cell Carcinoma
Bilateral maxillectomy including palate and preserving orbital floors
IIb, IIb
75
Radionecrotic Ulcer post SCC
Exenteration Right orbit, maxilla and ½ palate – External skin
IIIb
40
Squamous Cell Carcinoma
Exenteration Right orbit, maxilla and ½ palate – External skin
Right 1/3 palate and lower maxilla
F
M
22
F
72
Squamous Cell Carcinoma
23
F
69
Recurrence Squamous Cell Carcinoma
24
M
43
25
F
26
27
28
Myocutaneous Rectus Abdominis
RI PT
IIIb
Myocutaneous Rectus Abdominis
SC
Exenteration Right orbito maxillectomy including palate 1/2
Myocutaneous Rectus Abdominis
M AN U
21
Recurrence Squamous Cell Carcinoma
IIIb
Fasciocutaneous radial forearm flap
Facial A. External Jugular V.
No
Facial A. External Jugular V.
No
Anterior Jugular V.
Occipital A. External Jugular V.
Superior thyroid A. Branch Internal Jugular V.
th
Death 13 day
No
Facial A. Branch Internal Jugular V.
No
Facial A.V.
No
IIa
Fasciocutaneous radial forearm flap
Central - nose, lower 1/3; Maxillectomy, including palate and upper lip – External skin
Ic
Osteomyocutaneous Iliac crest st 1 - DCIA-13/07/2006
Recurrence Sarcoma
Left floor orbit, adjacent malar bone and ½ palate
IIIa
Myocutaneous rectus abdominis iliac bone graft – left orbital floor
Facial A. Branch Internal Jugular V.
No
68
Recurrence ulcerated BCC
Left orbital Exenteration + adjacent malar and maxilla preserving palate
IVa
Myocutaneous rectus abdominis
Temporal A.V.
No
M
53
Recurrence Squamous Cell Carcinoma
IIIb
Myocutaneous retus abdominis
Facial A.
No
F
37
Adenocistic carcinoma
IIIa
Muscle rectus abdominis iliac crest Bone graft orbital floor
F
68
SCC Maxillary sinus
IIIb
Myocutaneous Latissimus Dorsi
TE D
20
65
EP
19
M
AC C
18
Right fronto orbito maxillectomy – orbital Exenteration including ½ palate – External skin Left maxillectomy including orbital floor, etmoid, nasal septum and 2/3 palate Left orbital Exenteration, maxilla including ½ palate
External Jugular V.
Facial A. External Jugular V. Lingual A. External Jugular V.
No No
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38
Adenocistic carcinoma
30
M
28
SCC maxillary sinus P.O defect + RT
31
M
54
Squamous Cell Carcinoma
Right maxilla 8including ½ palate and orbital floor preserving orbital contents
IIIa
32
M
28
Gunshot Injury – Previous multiple surgeries
Debridement Nose + Central maxilla including palate
Ic
33
M
40
Recurrence adenocistic carcinoma
34
F
31
Dentigerous cyst
35
F
77
SCC palate mucosa
Right maxillectomy including > ½ palate preserving orbital floor
F
77
Recurrence Squamous Cell Carcinoma
Left lower maxilla including < ½ palate preserving orbital floor
M
9
Juvenile active ossifying fibroma
Left maxillectomy including orbital floor and 2/3 palate
38
F
40
Recurrence Ameloblastoma
39
F
45
47
40
M
Right osteomuscular iliac crest Dental implants
Myocutaneous rectus abdominus Iliac crest bone graft orbital floor
Facial A.V.
No
Facial A.V.
No
Facial A. Branch External Jugular V.
No
Branch Internal Jugular V.
IIIb
Myocutaneous rectus abdominis Iliac crest bone graft – orbital roof
Internal Jugular V.
No
IIa
Left iliac crest osteomuscular – Dental implants
1st Intraoral Facial A.V.
No
IIb
Osteomuscular fibula
IIa
Fasciocutaneous radial forearm flap
IIIa
Left osteomuscula4r iliac crest Iliac bone graft – orbital floor Apophysis Growth Center
2nd Intraoral Facial A.V.
No
Left maxillectomy including ½ palate preserving orbital floor
IIa
Osteomuscular iliac crest – internal oblique muscle for nose lateral wall
3rd Intraoral Facial A.V.
No
Chronic osteomyelitis
Left Body mandibulectomy Maxillectomy including > ½ palate preserving orbital floor
IIIam
Osteomuscular Fibula Soleus
External Jugular V.
Squamous cell carcinoma orbitomaxillary RT
Right orbit- Exenteration Maxilla, including ½ palate
IIIb
Myocutaneous Rectus Abdominis
TE D
M AN U
Left fronto-orbital Exenteration, skull base –maxilla and ½ palate – External skin Right conservative maxillectomy, including ½ palate, preserving orbital floor
EP
37
Ic
Osteomuscular fibula - 01/02/2011
Flow-through Fasciocutameous radial forearm osteomuscular radial forearm
AC C
36
IIIa
RI PT
F
SC
Left maxillectomy, including orbital floor and 2/3 palate preserving orbital contents Central Maxillectomy preserving orbital floors including bilateral hard palate and nasal septum
29
Facial A.
Common Carotid A.
No
Superior thyroid A.
External Jugular V. Branch Internal Jugular V. Superior thyroid A.
Internal Jugular V
Facial A.
No Total necrosis
No
Superior thyroid A.
Branch Internal Jugular V.
No
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47
Recurrence Adenocystic carcinoma
Left orbit exenteration, maxilla preserving palate and parotid region – External skin
64
Sarcoma
43
M
48
Recurrence Squamous Cell Carcinoma
Left orbital Exenteration maxillectomy ½ palate – External skin
44
F
33
Chronic osteomyelitis
Right maxillectomy involving 2/3 palate preservation orbital floor
45
M
53
Squamous cell carcinoma right maxilla
46
M
56
Recurrence Squamous cell carcinoma
47
F
76
Squamous cell carcinoma
48
F
88
Neglected Squamous cell carcinoma
49
M
73
Squamous cell carcinoma
M
86
F
24
50
51
IIIa
Flow-through Nose Osteofasciocutaneous Radial forearm Maxilla Osteofasciocutaneous fibula + Hemi Soleus Bone Fibula Graft orbital floor
IIIb
Myocutaneous Latissimus Dorsi
Branch Internal Jugular V
No
Facial A.V.
No
Superior thyroid A.
Internal Jugular V.
No
4th Intraoral Facial A.V.
No
IIb
Left osteomuscular iliac crest Dental Implants
IIIa
Left osteomuscular iliac crest
5th Intraoral Facial A.V.
No
IIIa
Osteomuscular fibula
6th Intraoral Facial A.V.
No
IIa
Right osteomuscular iliac crest
7th Intraoral Facial A.V.
No
Ib
Pre-fabricated fasciocutaneous radial forearm flap + iliac bone graft
8th Intraoral Facial A.V.
No
Total nose + septum + central maxilla
Ib
Pre-fabricated osteofasciocutaneous radial forearm flap
Facial A.V.
No
Squamous cell carcinoma
Total nose + septum + central maxilla
Ib
Pre-fabricated osteofasciocutaneous radial forearm flap
Facial A. External Jugular V
No
Complex Odontoma
Posterior right maxillectomy involving ½ palate
IIa
Obturator prosthesis
____
No
TE D
Right maxillectomy involving > ½ palate including orbital floor preservation orbital contents Right maxillectomy involving ½ palate including orbital floor Preservation orbital contents Left maxillectomy involving < ½ palate Orbital floor preservation
EP
Total nose + septum + central maxillectomy Nasomaxillary defect
AC C
42
Myocutaneous Latissimus Dorsi
M AN U
F
Total nose, right maxillectomy, including orbital floor and ½ palate – External skin
Superior thyroid A.
IVa
RI PT
M
SC
41
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IIa
Obturator prosthesis
____
No
Left maxillectomy involving <1/2 palate
IIa
Obturator prosthesis
____
No
Pleomorphic adenoma
Maxillectomy Horizontal palate
Ia
Obturator prosthesis
____
No
38
Ameloblastoma
Right maxillectomy Wall + inferior turbinate
Ib
Calvarial Bone graft
____
No
M
48
Indiferentiated tumour (biopsy) Linphoma B
Right maxillectomy involving < 1/2 palate
IIa
Obturator prosthesis
____
No
F
32
Pleomorphic adenoma
Maxillectomy Horizontal palate
Obturator prosthesis
____
No
53
M
58
54
F
25
55
F
56 57
Squamous cell carcinoma Squamous cell carcinoma
AC C
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Table 1: Detailed patients’ data: A- Artery; V- Vein
SC
60
M AN U
M
RI PT
Right maxillectomy involving <1/2 palate
52
Ia
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Table 2a: Algorithm for midface reconstruction Selected free flaps: FRF – Fasciocutaneous radial forearm; OFRF – Osteofasciocutaneuos radial forearm; OmIC – Osteomuscular Iliac crest; OmcIC – Osteomyocutaneous iliac crest; OmF – Osteomuscular fibula; OmcF – Osteomyocutaneous fibula
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Table 2b: Algorithm for midface reconstruction Selected free flaps: McRA – Myocutaneous rectus abdominis McLD – Myocutaneous Latissimus Dorsi; OmIC – Osteomuscular Iliac crest; OmF – Osteomuscular fibula; OmcF – Osteomyocutaneous fibula
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Fig. 1 Vertical and horizontal maxillectomy classification: Type I defects – limited maxillectomy include resection of 1 or 3 walls of the maxilla, comprising or not the palate. This type of defect can be further subdivided into those that exclude (Type Ia) or include (Types Ib and c) the nasomaxillary structure. Type Ia is the true horizontal maxillary defect in which the horizontal palate is the only anatomical structure removed, with preservation of the maxillary arch. The nasomaxillary defects course with preservation (Type Ib) or resection of the anterior maxillary arch and palate (Type Ic).
Fig. 2 Vertical and horizontal maxillectomy classification: Type II defects – subtotal maxillectomy include resection of the lower 5 walls of the maxilla – maxillary arch and palate, anterior, posterior, lateral and medial walls with preservation of the orbital floor. Type II defects can be further subdivided into those that include less than 50 percent of the hard palate (Type IIa) or more than 50 percent of the hard palate (Type IIb).
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Fig. 3 Vertical and horizontal maxillectomy classification: Type III defects – total maxillectomy include resection of all 6 walls of the maxilla. This type of defect is subdivided into those that preserve (Type IIIa) or exenterate (Type IIIb) the orbital contents. Type III defects can be further subdivided into those that include mandible resection (Types IIIam and bm).
Fig. 4 Vertical and horizontal maxillectomy classification: Type IV defects – orbito or suprastructural maxillectomy include resection of the upper 5 walls of the maxilla with exenteration of the orbital contents and preservation of the palate and maxillary arch. Type IV defects can be further subdivided into those that preserve (Type IVa) or remove (Type IVb) the orbital roof. Type IVa implies cranial base exposure, while the Type IVb adds the exposure of dura and brain.
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Fig. 5 Type Ib Defect - Female patient, 89 years old, neglected squamous cell carcinoma involving nasal and adjacent skin and nasomaxillary structure including bone, cartilaginous pyramid, septum and periform aperture. A block excision was performed. Reconstruction was achieved by iliac bone graft to nasal dorsum and a pre-fabricated radial forearm flap nourished by the intraoral dissected facial vessels.
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Fig. 6 Type Ic defect - Pre-operative frontal and side views of a male patient, 28 years old, status post-maxillectomy and RT due to maxillary squamous cell carcinoma. 3D bio-modelling planning was used as a surgical guide, tailoring the iliac myosseous flap. An adequate Intraoperative flap inset was achieved, recreating the anterior maxillary arch. The patient underwent dental rehabilitation without immediate or late complications.
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Fig. 7 Type IIa defect - 31-year-old female patient with a dentigerous cyst involving the palate and the dental roots of 2.2, 2.1 and 1.1 until 1.6 teeth. The lesion was completely excised through an intrapapillary approach. Reconstruction was achieved by a myosseous iliac crest free flap, nourished by the intraoral dissected facial vessels.
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Fig. 8 Type IIb defect - Female patient, 33 years old, with chronic osteomielytis of right maxilla. History of previous multiple infections, fistulae, intraoral drainages, curettages and hyperbaric oxygen treatments. A 3D customized sterolitographic surgical guide allowed iliac crest harvesting and a morphofunctional maxillary reconstruction. The myosseous iliac crest free flap was vascularized by the intraoral dissected facial vessels.
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Fig 9 Type IIIa defect - 9-year-old male patient with a recurrent massive juvenile active ossifying fibroma of his left maxilla, involving the orbital floor and 2/3 of the hard palate. After tumour excision, 3D bio-modelling planning was used as a surgical guide. The vascularized myosseous iliac crest included the antero-superior iliac spine growth centre.
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Fig 10 Type IIIam defect - 45-year-old female patient, with chronic osteomielytis of her left maxilla, malar sphenoid and mandible. History of multiple curettages and hyperbaric oxygen treatments. After a superficial parotidectomy with facial nerve preservation for skeleton removal, maxillary and mandible reconstruction was achieved by a chimeric fibula flap, with soleus muscle component.