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Special considerations in virtual surgical planning for secondary accurate maxillary reconstruction with vascularised fibula osteomyocutaneous flap
Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 893e902
Special considerations in virtual surgical planning for secondary accurate maxillary reconstruction with vascularised fibula osteomyocutaneous flap Yi Shen a, Jian Sun a,*, Jun Li a, Mei-mei Li b, Wei Huang c, Andrew Ow d a
Department of Oral and Maxillofacial Surgery, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, 639 Zhizaoju Road, Shanghai 200011, China b Materialise China Shanghai Office, Shanghai, China c Department of Oral and Craniofacial Implantology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China d Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore, Singapore Received 21 September 2011; accepted 24 December 2011
KEYWORDS Virtual surgical planning; Secondary maxillary reconstruction; Fibular osteomyocutaneous flap; Brown’s classification of maxilla and midface
Summary Background: This article describes our special considerations in virtual surgical planning for secondary maxillary reconstruction with vascularised fibular osteomyocutaneous flap and our revised surgical design for maxillary reconstruction. Methods: Eleven patients with different maxillary defects according to Brown’s revised classification underwent virtual surgical planning for secondary accurate reconstruction. For different horizontal class defects, the fibular was osteomised to match the maxillary alveolar arch by using the mirror image of the contralateral alveolar ridge or the curve of the mandibular arch and dentition. Results: Maxillary reconstruction was performed with the guidance of preoperative virtual planning and using fibular osteotomy and reposition guide templates to replicate the virtual planning intra-operatively. Virtual surgical planning was replicated intra-operatively in all patients. The fibulae were osteotomised into four segments in three patients with the horizontal class d2 defect and three segments in eight patients with the horizontal class bed1 defects, respectively. The overall success rate for 11 flaps was 100%. Good bony unions and wound closure were observed and intelligible speech was achieved in 11 patients. Maximum incisal opening ranged from 3.0 to 4.0 cm. All patients tolerated a regular diet postoperatively. Postoperative midfacial appearance was good in all patients. Conclusion: We recommend that the horizontal class d defect in Brown’s revised classification of maxilla and midface be divided into two sub-types according to whether it involves the contralateral canine or not. Special considerations in virtual surgical planning are helpful to perform accurate secondary maxillary reconstruction with a vascularised fibular
* Corresponding author. Tel.: þ86 21 23271699x5161. E-mail address: [email protected] (J. Sun). 1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.12.035
894
Y. Shen et al. osteomyocutaneous flap. ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Maxillary reconstruction is a major challenge for head and neck reconstructive surgeons. The aims of maxillary reconstruction are to restore the contour of the maxillary buttresses for optimal aesthetic appearance and to also provide suitable conditions for oral rehabilitation.1 Composite osteomyocutaneous free flaps may achieve these aims, especially for large maxillary defects. Since 2001, our team has performed maxillary reconstructions with a fibular osteomyocutaneous flap or a fibular osteomyocutaneous flap in combination with titanium mesh. The unilateral alveolar ridge of these patients was restored with one fibular segment based on a prefabricated occlusal template as reported in our previous studies.1,2 Although the postoperative aesthetic and functional results were acceptable, the reconstructed maxillary alveolar arch or neomaxilla was not completely consistent with the normal maxillary alveolar arch and the spatial relationship between the neomaxilla and the mandible was not ideal for dental implant rehabilitation. Recent advances in computer software technology have allowed surgeons to make virtual surgical planning in the computer preoperatively, and to perform real-time surgery intra-operatively.3e8 As a result, the accuracy of tumour resection and jaw reconstruction has improved with subsequent reduction in operative time. At present, virtual surgery is often performed in mandibular reconstruction, and it is seldom used in maxillary reconstruction. Hanasono et al.9 reported their results for midfacial reconstruction with a fibular osteomyocutaneous flap using virtual planning, rapid prototype modelling and stereotactic navigation. However, in their study, there was substantial overlap between the neopremaxilla and mandible, resulting in an increased postoperative width of the neomaxillary alveolar ridge and an increased projection of bilateral cheilions. Since June 2009, our team has used virtual surgical planning
Table 1
with the aim of achieving accurate and precise maxillary reconstruction. In our experience, some special considerations in virtual surgical planning should be made for secondary maxillary reconstruction because secondary reconstruction is more difficult than primary reconstruction. In this study, we present our virtual surgical planning in secondary maxillary reconstruction in detail and describe a revised design for the reconstruction of the maxillary alveolar arch.
Patients and methods Patients From June 2009 to July 2011, 20 patients underwent maxillary reconstruction with a fibular osteomyocutaneous flap using virtual surgical planning. Surgeries were performed by one surgical team. Among these 20 patients, 11 patients underwent secondary maxillary reconstruction. This group consisted of five males and six females with an average age of 43.7 years (range, 17e63 years). Primary diagnosis of these patients included malignant tumours (n Z 9), osteoradionecrosis (n Z 1) and severe trauma (n Z 1). Clinical data of these patients are shown in Table 1. According to Brown’s revised defect classification of maxilla and midface10 (Figure 1), the maxillary horizontal defects were divided into three classes: class b (n Z 6), class c (n Z 1) and class d (n Z 4), respectively.
Virtual surgical planning All patients underwent preoperative computed tomography (CT) scans of the craniofacial skeleton and lower extremities. These CT images were then converted into three-
The clinical data of primary lesions and treatment in 11 patients.
Patient
Gender/Age
Primary lesion
Maxillectomy
Primary reconstruction
Radiotherapy
1 2 3 4 5 6 7 8 9 10 11
Male/51 yr Female/53 Female/21 Male/43 yr Male/51 yr Female/17 Female/57 Female/30 Female/47 Male/43 yr Male/43 yr
SCC Severe trauma ACC SCC ACC chondrosarcoma SCC MFH ACC Osteosarcoma ORN
Total Total þ Subtotal Total Total þ Subtotal Subtotal Total Premaxillectomy Total Total þ Subtotal Total þ Subtotal Total
Prosthesis LDMF Prosthesis e e e e e TM TM RFF þ TM
þ e þ þ þ þ þ þ þ þ þ
yr yr
yr yr yr yr
SCC: Squamous cell carcinoma, ACC: Adenoid cystic carcinoma, MFH: Malignant fibrous histiocytoma, LDMF: Latissimus dorsi myocutaneous flap, TM: Titanium mesh, RFF: Radial forearm flap.
Virtual surgical planning for secondary accurate maxillary reconstruction
895
Figure 1 Brown’s revised classification of maxillary and midfacial defect10 (with permission). Vertical classification: Iemaxillectomy not causing an oronasal fistula; IIenot involving the orbit; IIIeinvolving the orbital adnexae with orbital retention; IVewith orbital exenteration; Veorbitomaxillary defect; VIenasomaxillary defect. Horizontal classification: aepalatal defect only, not involving the dental alveolus; beless than or equal to 1/2 unilateral; celess than or equal to 1/2 bilateral or transverse anterior; degreater than 1/2 maxillectomy.
dimensional (3D) virtual models. Virtual surgical planning was performed according to the different class of maxillary defects using Surgicase 5.0 software (Materialise, Leuven, Belgium).
For horizontal class b defects (Figure 2), the 3D mirror image of the contralateral unaffected maxilla was used for reconstruction. Next, the ipsilateral 3D fibular image was superimposed on the mirror image of the contralateral
Figure 2 Patient 6 with horizontal class b defect. AeC. Virtual surgical planning at 3 planes. D. Preoperative frontal view. E. Frontal view at 4 months postoperatively. F. Postoperative CT.
896 maxilla. Based on the mirror image, maxillary reconstruction was planned by osteotomising the digitised fibula into three segments at the sites of the canine and first molar to match the curve of the maxillary alveolar ridge and pterygomaxillary buttress. The length of each fibular segment was not shorter than 1.5 cm so as to maintain the vascularity of each fibular segment. The shape of the neoalveolar ridge and neopterygomaxillary buttress was adjusted to fit the surrounding skeleton and to obtain an ideal spatial relationship to the mandible for future dental implant rehabilitation. For the horizontal class c defect (Figure 3), the mirror image of the residual maxilla was not useful because the defect was in the premaxilla. The neopremaxillary arch had to be shaped in relation to the curve of the mandibular arch and dentition. The digitised fibula was osteotomised into three segments at the sites of bilateral canines. The shape of the neoalveolar ridge was also adjusted in relation to the spatial relationship of the mandible. Care was taken to avoid an increased overbite and overjet at the bilateral canine area.
Y. Shen et al. For the horizontal class d defect, the 3D mirror image of the contralateral residual maxilla was applied to reconstruct the neopterygomaxillary buttress and posterior neoalveolar ridge. The neopremaxillary arch was shaped in relation to the curve of the mandibular arch and dentition like the horizontal class c defect. In our revised design, the horizontal class d defect was divided into two sub-types according to whether it involved the contralateral canine or not. For sub-type d1 (defect not involving the contralateral canine, Figure 4), one digitised fibular segment was used to restore the neopremaxilla from the ipsilateral canine to the contralateral residual alveolar ridge. The sites of the osteotomies of the digitised fibula were similar to that of the horizontal class b defect. For sub-type d2 (defect involving the contralateral canine, Figure 5), a third osteotomy of the fibular was performed at the contralateral region to restore the maxillary alveolar arch. Similarly, the length of each fibular segment was not shorter than 1.5 cm so as to maintain the vascularity of each fibular segment. Our revised planning protocol for reconstruction of the neomaxillary alveolar arch (Figure 6) is able to achieve
Figure 3 Patient 7 with horizontal class c defect. AeC. Virtual surgical planning at 3 planes. D. Preoperative frontal view. E. Frontal view at 10 months postoperatively. F. Postoperative CT.
Virtual surgical planning for secondary accurate maxillary reconstruction
897
Figure 4 Patient 9 with horizontal class d1 defect. AeC. Virtual surgical planning at 3 planes. D. Preoperative frontal view. E. Frontal view at 7 months postoperatively. F. Postoperative CT.
a shape and contour that is consistent with a normal maxillary alveolar arch. In all cases, care should be taken to ensure that the inferior edge of the neoalveolar ridge in each defect be about 0.5 cm cranial to the normal alveolar ridge so as to accommodate the skin paddle of the fibular osteomyocutaneous flap. The virtual planning should be examined in all three planes (coronal, sagittal and axial) to ensure the optimal neomaxillary contour, intermaxillary distance and spatial relationship between the neomaxilla and mandible. Once surgeons and bioengineer approved the virtual surgical planning, the virtual fibular osteotomy and neomaxilla repositioning guide templates were added on by the bioengineer to help surgeons replicate the virtual planning intra-operatively. The repositioning guide template must be positioned at the superior edge of the neoalveolar ridge to prevent compression of the peroneal vessels. Upon confirmation of the final plan, the stereomodels including the reconstructive model, mirror model, fibular osteotomy guide template and neomaxilla repositioning guide template were produced (Figure 7).
Pre-bending of titanium miniplates and mesh Titanium miniplates were pre-bent on the reconstructive model. For five patients with vertical class III defect and
one patient with vertical class II defect and a thin infraorbital rim, a 0.6 mm thick titanium mesh was pre-bent on the mirror model to establish bilateral midfacial symmetry and support for the eye globe. Three patients with vertical class III defect had 1.0-mm thick titanium mesh implanted in the primary operation. Titanium mesh was not used in one patient with vertical class IV defect because the midface was well-supported by a latissimus dorsi myocutaneous flap that was performed after the primary operation. Titanium mesh was also not used in one patient with vertical class II and horizontal class c defect because the defect was in the premaxilla.
Surgical technique Previous midfacial scars were incised to expose the maxillary defect. Scars tissue was released, allowing correction of the elevated nasal alar and creating sufficient space to accommodate the grafted fibular osteomyocutaneous flap. For a vertical class III defect, the hypoglobus and enophthalmic eye globe should be readdressed. Coronoidectomy was performed in the patient with serious restriction of mouth opening. Maxillary reconstruction was performed using the fibular osteotomy and repositioning guide templates (Figure 7). When a titanium mesh was used, it was fixed to the fibular and the residual bony buttress to
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Y. Shen et al.
Figure 5 Patient 10 with horizontal class d2 defect. AeC. Virtual surgical planning at 3 planes. D. Preoperative frontal view. E. Postoperative CT.
Figure 6 Our revised design for maxillary reconstruction. A. horizontal class b defect. B. horizontal class c defect. C. horizontal class d1 defect. D. horizontal class d2 defect.
Virtual surgical planning for secondary accurate maxillary reconstruction
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Figure 7 Intraoperative application of guide template. A. The stereomodels included reconstructive model, mirror model, fibular osteotomy guide template, and neomaxilla repositioning guide template. B. The fibula was osteotomized using fibular osteotomy guide template. C. Neomaxilla was shaped using fibular repositioning guide template. D. Comparison of neomaxilla with reconstructive model.
reconstruct the orbital floor and the midface projection. The skin paddle of the fibular myoosseocutaneous flap was used to restore the palatal defect in all patients. After the neomaxilla was created, the anastomoses were performed between recipient and peroneal vessels.
Follow-up and postoperative aesthetic assessment The patients were examined to assess for bony union and aesthetics during the follow-up period. Aesthetic assessment was performed by the patients and surgeons using the following criteria: facial symmetry, concavity of the cheek and nasal alar, position of the globe and facial scars. The results were classified as ‘good’ (improved after the operation), ‘fair’ (unchanged after the operation) and ‘poor’ (worse after the operation).
Results Virtual surgical planning was replicated intra-operatively in all patients. The clinical data of secondary maxillary reconstruction are showed in Table 2. The fibulae were osteotomised into four segments in three patients with the horizontal class d2 defect and into three segments in eight patients with the horizontal class b w d1 defects, respectively. No vein grafts were needed in 11 patients.
Postoperative complications All primary anastomoses were successful except in one patient (Patient 5), where venous congestion occurred on
the second day postoperatively. The patient was taken back to the operating room for reanastomosis and survival of the flap was achieved. Therefore, the overall success rate for the 11 flaps was 100%. In another patient (Patient 8), exposure of the titanium mesh in the infraorbital area occurred at postoperative 4 months. The patient underwent additional surgery to remove the partially exposed mesh. No other complications were found in other patients.
Follow-up and postoperative aesthetic assessment The average follow-up period was 14.1 months (range, 4e26 months). Good bony unions and wound closure were observed in 11 patients by CT and panoramic radiograph during the follow-up period. Maximum incisal opening ranged from 3.0 to 4.0 cm. All patients tolerated a regular diet postoperatively. The postoperative midfacial appearance was good as evaluated by the surgeon and patient when compared to the preoperative midfacial appearance. Intelligible speech was also achieved in all 11 patients. In one patient (Patient 4), tumour recurrence at the mandibular ramus and temporal regions was detected at the 6-month visit. The patient underwent extra-cranial radical resection of the recurrent tumour. The reconstructed neomaxilla and titanium mesh was not removed and the new defect was restored with a pectoralis major myocutaneous flap. No other complications such as exposure of the titanium mesh or oronasal fistula have occurred. Oral rehabilitation with osseointegrated implants has been delayed because of the history of radiotherapy. At present, six patients are awaiting dental implantation.
900 Table 2
Y. Shen et al. The clinical data of secondary maxillary reconstruction in 11 patients.
Patient
Defect class
Secondary reconstruction
Length of fibula (cm)
No. of osteotomy
Skin paddle(cm)
1 2 3 4
IIIb IVd2 IIIb IIId2
FOF þ TM FOF FOF þ TM FOF þ TM
13 12 9 13
2 3 2 3
9 10 8 11
5 5 6 6
5 6 7 8 9 10 11
IIb IIIb IIc IIIb IIId1 IIId2 IIIb
FOF þ TM FOF þ TM FOF FOF þ TM FOF FOF FOF
9.5 12 9.5 9 12 13 10
2 2 2 2 2 3 2
7 6 7 7.5 7 9 11
6 6 5 6 7 6 3
Recipient vessels Facial artery and vein Facial artery and vein Facial artery and vein Superior thyroid artery and facial vein Facial artery and vein Facial artery and vein Temporal artery and vein Temporal artery and vein Temporal artery and vein Temporal artery and vein Temporal artery and vein
FOF: Fibula osteomyocutaneous flap, TM: Titanium mesh.
Discussion The goals of maxillary reconstruction are to restore the maxillary buttress and achieve optimal aesthetic appearance and to offer suitable conditions for oral rehabilitation with dentition.1 The use of maxillary prosthesis, local and regional pedicled flaps and free soft-tissue flap can only achieve these goals in limited maxillary defects. In more complex defects, these treatment options are no longer applicable. In such defects, the use of composite osteocutaneous free flaps, including the radial forearm osteocutaneous flap,11 the scapular system flaps,12,13 the iliac crest flap14 and fibula osteomyocutaneous flap1,2,15,16 is able to provide the replacement of the midfacial buttress and skeletal projection, minimise soft-tissue descent and improve the functional outcomes after dental rehabilitation.15,16 Abundant soft tissue and bone can be transferred with few limitations of vascular pedicle length, flap geometry and tissue orientation.17 In our team, we favour the fibular osteomyocutaneous flap for reconstruction of class II defects and the fibular osteomyocutaneous flap in combination with titanium mesh for reconstruction of class III defects, for both primary and secondary maxillary reconstruction. According to Cordeiro and Santamaria,18 the maxilla can be described as a geometric structure with six walls. The roof and floor of the maxilla are the horizontal buttresses, and the anterior, posterior, medial and lateral walls are the vertical buttresses. Among these buttresses, two horizontal (infraorbital rim and alveolar ridge) and one vertical (pterygomaxillary) buttresses of the maxilla are necessary to maintain function and facial proportions. In our design for maxillary reconstruction, the fibula is osteotomised into different segments to restore the alveolar ridge and the pterygomaxillary buttress. Titanium mesh can restore the infraorbital rim, the orbital floor and the anterior wall of the maxilla in the patient with a class III defect. In our previous patients before February 2009,1 the neomaxillary alveolar ridge was restored with one fibular segment for the horizontal class b and d1 defect. However, for the
horizontal class c defect and the horizontal class d2 defect, the neomaxillary alveolar ridge was restored with two fibular segments. Although the postoperative aesthetic and functional results after dental rehabilitation in our previous patients were acceptable, the neomaxillary alveolar arch was not completely consistent with the normal maxillary alveolar arch and there was some error in the spatial relationship between the neomaxilla and mandible. The difference between the straight neomaxillary alveolar ridge and normal curved alveolar ridge could result in the narrow midfacial width and did not provide ideal local bone stocks for dental implant placement. As such, using our revised planning protocol, these difficulties can be overcome by buttress reconstruction with fibular or fibular in combination with titanium mesh for reconstruction of the neomaxillary alveolar arch. With the development of computer software technology, computer-aided design software can be used not only to maximise the precision of bony osteotomies, which helps to recreate the shape of the mandibular or maxillary arch, but also to improve the overall efficiency of the reconstructive process.6 We have applied virtual surgical planning in accurate maxillary reconstruction and modified our previous design for reconstruction of the neomaxillary alveolar arch since June 2009. The postoperative aesthetic and functional results of our new patients are good. In our experience, secondary reconstruction is more difficult than primary reconstruction because sometimes there is not enough information in the local region for reference to do virtual planning. In such a situation, the mirror image of the contralateral unaffected maxilla and the curve of the mandibular arch and dentition can be used as the reference position for reconstruction. During our virtual planning for secondary maxillary reconstruction, the fibular image was superimposed on the mirror image of the contralateral maxilla to match the curve of the maxillary alveolar ridge and the pterygomaxillary buttress by osteotomising the digitised fibula. The sites of the osteotomies are usually performed at the regions of the canine and first molar to match the curve of
Virtual surgical planning for secondary accurate maxillary reconstruction the maxillary alveolar ridge. Therefore, the neomaxillary alveolar ridge is restored with two fibular segments for the horizontal class b and d1 defects and with three fibular segments for the horizontal class c defect. However, for the horizontal class d2 defect, the site of osteotomy at the contralateral alveolar ridge should be planned such that the shortest fibular segment is not shorter than 1.5 cm. In the horizontal class c and d defects, there is no mirror image in the premaxilla to aid in virtual planning. The neopremaxillary arch has to be shaped by the curve of the mandibular arch and dentition and further modified by its spatial relationship to the mandible so as to avoid an increased overbite and overjet at the bilateral canine region. Our design is different from that of Hanasono et al.9 In their article, using their design, a postoperative wider midface may result because the width of neomaxillary alveolar arch and the projection of the bilateral cheilion are increased by the increased overlay relationship between the neopremaxiila and mandible. More importantly, the interarch relationship should be ideal enough for oral rehabilitation with dental implants. Small inaccuracies in interarch spatial relationship can result in difficulty in achieving complete dental rehabilitation. In summary, we recommend that the horizontal class d defect in Brown’s revised defect classification of the maxilla and midface be divided into two sub-types according to whether it involved the contralateral canine or not. Special considerations in virtual surgical planning presented below are helpful when performing secondary accurate maxillary reconstruction with a vascularised fibular osteomyocutaneous flap. 1. For the horizontal class b defect, the fibular is osteotomised at the site of the canine using the mirror image of the contralateral alveolar ridge to match the maxillary alveolar arch. 2. For the horizontal class c defect, the fibula is osteotomised at the sites of the bilateral canines. This is further modified according to the curve of the mandibular arch and dentition and the spatial relationship to mandible because no mirror image is present for reference. 3. For the horizontal class d1 defect, the posterior neoalveolar ridge is shaped by the mirror image of the contralateral alveolar ridge; the premaxilla is restored from the ipsilateral canine to the contralateral residual alveolar ridge as in the horizontal class c defect. 4. For the horizontal class d2 defect, the ipsilateral neoalveolar ridge is restored as in the horizontal class b defect. The site of osteotomy at the contralateral alveolar ridge should be planned to ensure that the fibular segments are not shorter than 1.5 cm. 5. The inferior edge of the neoalveolar ridge in each horizontal class defect should be positioned about 0.5 cm cranial to the normal alveolar ridge to accommodate the skin paddle of the fibular osteomyocutaneous flap. 6. The virtual planning should be examined at three planes (coronal, sagittal and axial) to ensure that the optimal neomaxillary contour, intermaxillary distance and spatial relationship between neomaxilla and mandible are achieved.
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7. The neomaxilla repositioning guide template that is used to help surgeons replicate virtual planning intraoperatively must be arranged at the superior edge of the neoalveolar ridge to prevent from compression of the peroneal vessels.
Conflict of interest None.
Acknowledgement This work was supported by the Science and Technology Commission of Shanghai (08DZ2271100) and partially supported by the Program for Innovative Research Team of Shanghai Municipal Education Commission, and by the Research Grants (10DZ1951300) from the Science and Technology Commission of Shanghai Municipality.
References 1. Sun J, Shen Y, Li J, et al. Reconstruction of high maxillectomy defects with the fibula osteomyocutaneous flap in combination with titanium mesh or a zygomatic implant. Plast Reconstr Surg 2011;127:150. 2. Sun J, Shen Y, Weng YQ, et al. Lateral lip-splitting approach for total and subtotal maxillectomy. J Oral Maxillofac Surg 2009; 67:1197. 3. Eckardt A, Swennen GRJ. Virtual planning of composite mandibular reconstruction with free fibula bone graft. J Craniofac Surg 2005;16:1137. 4. Hallermann W, Olsen S, Bardyn T, et al. A new method for computer-aided operation planning for extensive mandibular reconstruction. Plast Reconstr Surg 2006;117:2431. 5. Cheng HT, Wu CI, Tseng CS, et al. The occlusion-adjusted prefabricated 3D mirror image templates by computer simulation: the image-guided navigation system application in difficult cases of head and neck reconstruction. Ann Plast Surg 2009;63:517. 6. Hirsch DL, Garfein ES, Christensen AM, et al. Use of computeraided design and computer-aided manufacturing to produce orthognathically ideal surgical outcomes: a paradigm shift in head and neck reconstruction. J Oral Maxillofac Surg 2009;67:2115. 7. Leiggener C, Messo A, Thor A, et al. A selective laser sintering guide for transferring a virtual plan to real time surgery in composite mandibular reconstruction with free fibula osseous flaps. Int J Oral Maxillofac Surg 2009;38:187. 8. Sharaf B, Levine JP, Hirsch DL, et al. Importance of computeraided design and manufacturing technology in the multidisciplinary approach to head and neck reconstruction. J Craniofac Surg 2010;21:1277. 9. Hanasono MM, Jacob RF, Luc Bidaut, et al. Midfacial reconstruction using virtual planning, rapid prototype modeling, and stereotactic navigation. Plast Reconstr Surg 2002;126:2010. 10. Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new classification. Lancet Oncol 2010;11:1001. 11. Cordeiro PG, Bacilious N, Schantz S, et al. The radial forearm osteocutaneous “sandwich” free flap for reconstruction of the bilateral subtotal maxillectomy defect. Ann Plast Surg 1998; 40:397.
902 12. Uglesic V, Virag M, Varga S, et al. Reconstruction following radical maxillectomy with flaps supplied by the subscapular artery. J Craniomaxillofac Surg 2000;28:153. 13. Clark JR, Vesely M, Gilbert R. Scapular angle osteomypgenous flap in postmaxillectomy reconstruction: defect, reconstruction, shoulder function and harvest technique. Head Neck 2008;30:10. 14. Brown JS, Jones DC, Summerwill A, et al. Vascularized iliac crest with internal oblique muscle for immediate reconstruction after maxillectomy. Br J Oral Maxillofac Surg 2002;40:183. 15. Yazar S, Cheng MH, Wei FC, et al. Osteomyocutaneous peroneal artery perforator flap for reconstruction of composite maxillary defects. Head Neck 2006;28:297.
Y. Shen et al. 16. Rodriguez ED, Bluebond-Langer R, Park JE, et al. Preservation of contour in periorbital and midfacial craniofacial microsurgery: reconstruction of the soft-tissue elements and skeletal buttresses. Plast Reconstr Surg 2008;121: 1738. 17. Triana RJ, Uglesic V, Virag M, et al. Microvascular free flap reconstructive options in patients with partial and total maxillectomy defects. Arch Facial Plast Surg 2000;2: 91. 18. Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 2000;105:2331.
Special considerations in virtual surgical planning for secondary accurate maxillary reconstruction with vascularised fibula osteomyocutaneous flap Yi Shen a, Jian Sun a,*, Jun Li a, Mei-mei Li b, Wei Huang c, Andrew Ow d a
Department of Oral and Maxillofacial Surgery, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, 639 Zhizaoju Road, Shanghai 200011, China b Materialise China Shanghai Office, Shanghai, China c Department of Oral and Craniofacial Implantology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China d Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore, Singapore Received 21 September 2011; accepted 24 December 2011
KEYWORDS Virtual surgical planning; Secondary maxillary reconstruction; Fibular osteomyocutaneous flap; Brown’s classification of maxilla and midface
Summary Background: This article describes our special considerations in virtual surgical planning for secondary maxillary reconstruction with vascularised fibular osteomyocutaneous flap and our revised surgical design for maxillary reconstruction. Methods: Eleven patients with different maxillary defects according to Brown’s revised classification underwent virtual surgical planning for secondary accurate reconstruction. For different horizontal class defects, the fibular was osteomised to match the maxillary alveolar arch by using the mirror image of the contralateral alveolar ridge or the curve of the mandibular arch and dentition. Results: Maxillary reconstruction was performed with the guidance of preoperative virtual planning and using fibular osteotomy and reposition guide templates to replicate the virtual planning intra-operatively. Virtual surgical planning was replicated intra-operatively in all patients. The fibulae were osteotomised into four segments in three patients with the horizontal class d2 defect and three segments in eight patients with the horizontal class bed1 defects, respectively. The overall success rate for 11 flaps was 100%. Good bony unions and wound closure were observed and intelligible speech was achieved in 11 patients. Maximum incisal opening ranged from 3.0 to 4.0 cm. All patients tolerated a regular diet postoperatively. Postoperative midfacial appearance was good in all patients. Conclusion: We recommend that the horizontal class d defect in Brown’s revised classification of maxilla and midface be divided into two sub-types according to whether it involves the contralateral canine or not. Special considerations in virtual surgical planning are helpful to perform accurate secondary maxillary reconstruction with a vascularised fibular
* Corresponding author. Tel.: þ86 21 23271699x5161. E-mail address: [email protected] (J. Sun). 1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.12.035
894
Y. Shen et al. osteomyocutaneous flap. ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Maxillary reconstruction is a major challenge for head and neck reconstructive surgeons. The aims of maxillary reconstruction are to restore the contour of the maxillary buttresses for optimal aesthetic appearance and to also provide suitable conditions for oral rehabilitation.1 Composite osteomyocutaneous free flaps may achieve these aims, especially for large maxillary defects. Since 2001, our team has performed maxillary reconstructions with a fibular osteomyocutaneous flap or a fibular osteomyocutaneous flap in combination with titanium mesh. The unilateral alveolar ridge of these patients was restored with one fibular segment based on a prefabricated occlusal template as reported in our previous studies.1,2 Although the postoperative aesthetic and functional results were acceptable, the reconstructed maxillary alveolar arch or neomaxilla was not completely consistent with the normal maxillary alveolar arch and the spatial relationship between the neomaxilla and the mandible was not ideal for dental implant rehabilitation. Recent advances in computer software technology have allowed surgeons to make virtual surgical planning in the computer preoperatively, and to perform real-time surgery intra-operatively.3e8 As a result, the accuracy of tumour resection and jaw reconstruction has improved with subsequent reduction in operative time. At present, virtual surgery is often performed in mandibular reconstruction, and it is seldom used in maxillary reconstruction. Hanasono et al.9 reported their results for midfacial reconstruction with a fibular osteomyocutaneous flap using virtual planning, rapid prototype modelling and stereotactic navigation. However, in their study, there was substantial overlap between the neopremaxilla and mandible, resulting in an increased postoperative width of the neomaxillary alveolar ridge and an increased projection of bilateral cheilions. Since June 2009, our team has used virtual surgical planning
Table 1
with the aim of achieving accurate and precise maxillary reconstruction. In our experience, some special considerations in virtual surgical planning should be made for secondary maxillary reconstruction because secondary reconstruction is more difficult than primary reconstruction. In this study, we present our virtual surgical planning in secondary maxillary reconstruction in detail and describe a revised design for the reconstruction of the maxillary alveolar arch.
Patients and methods Patients From June 2009 to July 2011, 20 patients underwent maxillary reconstruction with a fibular osteomyocutaneous flap using virtual surgical planning. Surgeries were performed by one surgical team. Among these 20 patients, 11 patients underwent secondary maxillary reconstruction. This group consisted of five males and six females with an average age of 43.7 years (range, 17e63 years). Primary diagnosis of these patients included malignant tumours (n Z 9), osteoradionecrosis (n Z 1) and severe trauma (n Z 1). Clinical data of these patients are shown in Table 1. According to Brown’s revised defect classification of maxilla and midface10 (Figure 1), the maxillary horizontal defects were divided into three classes: class b (n Z 6), class c (n Z 1) and class d (n Z 4), respectively.
Virtual surgical planning All patients underwent preoperative computed tomography (CT) scans of the craniofacial skeleton and lower extremities. These CT images were then converted into three-
The clinical data of primary lesions and treatment in 11 patients.
Patient
Gender/Age
Primary lesion
Maxillectomy
Primary reconstruction
Radiotherapy
1 2 3 4 5 6 7 8 9 10 11
Male/51 yr Female/53 Female/21 Male/43 yr Male/51 yr Female/17 Female/57 Female/30 Female/47 Male/43 yr Male/43 yr
SCC Severe trauma ACC SCC ACC chondrosarcoma SCC MFH ACC Osteosarcoma ORN
Total Total þ Subtotal Total Total þ Subtotal Subtotal Total Premaxillectomy Total Total þ Subtotal Total þ Subtotal Total
Prosthesis LDMF Prosthesis e e e e e TM TM RFF þ TM
þ e þ þ þ þ þ þ þ þ þ
yr yr
yr yr yr yr
SCC: Squamous cell carcinoma, ACC: Adenoid cystic carcinoma, MFH: Malignant fibrous histiocytoma, LDMF: Latissimus dorsi myocutaneous flap, TM: Titanium mesh, RFF: Radial forearm flap.
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Figure 1 Brown’s revised classification of maxillary and midfacial defect10 (with permission). Vertical classification: Iemaxillectomy not causing an oronasal fistula; IIenot involving the orbit; IIIeinvolving the orbital adnexae with orbital retention; IVewith orbital exenteration; Veorbitomaxillary defect; VIenasomaxillary defect. Horizontal classification: aepalatal defect only, not involving the dental alveolus; beless than or equal to 1/2 unilateral; celess than or equal to 1/2 bilateral or transverse anterior; degreater than 1/2 maxillectomy.
dimensional (3D) virtual models. Virtual surgical planning was performed according to the different class of maxillary defects using Surgicase 5.0 software (Materialise, Leuven, Belgium).
For horizontal class b defects (Figure 2), the 3D mirror image of the contralateral unaffected maxilla was used for reconstruction. Next, the ipsilateral 3D fibular image was superimposed on the mirror image of the contralateral
Figure 2 Patient 6 with horizontal class b defect. AeC. Virtual surgical planning at 3 planes. D. Preoperative frontal view. E. Frontal view at 4 months postoperatively. F. Postoperative CT.
896 maxilla. Based on the mirror image, maxillary reconstruction was planned by osteotomising the digitised fibula into three segments at the sites of the canine and first molar to match the curve of the maxillary alveolar ridge and pterygomaxillary buttress. The length of each fibular segment was not shorter than 1.5 cm so as to maintain the vascularity of each fibular segment. The shape of the neoalveolar ridge and neopterygomaxillary buttress was adjusted to fit the surrounding skeleton and to obtain an ideal spatial relationship to the mandible for future dental implant rehabilitation. For the horizontal class c defect (Figure 3), the mirror image of the residual maxilla was not useful because the defect was in the premaxilla. The neopremaxillary arch had to be shaped in relation to the curve of the mandibular arch and dentition. The digitised fibula was osteotomised into three segments at the sites of bilateral canines. The shape of the neoalveolar ridge was also adjusted in relation to the spatial relationship of the mandible. Care was taken to avoid an increased overbite and overjet at the bilateral canine area.
Y. Shen et al. For the horizontal class d defect, the 3D mirror image of the contralateral residual maxilla was applied to reconstruct the neopterygomaxillary buttress and posterior neoalveolar ridge. The neopremaxillary arch was shaped in relation to the curve of the mandibular arch and dentition like the horizontal class c defect. In our revised design, the horizontal class d defect was divided into two sub-types according to whether it involved the contralateral canine or not. For sub-type d1 (defect not involving the contralateral canine, Figure 4), one digitised fibular segment was used to restore the neopremaxilla from the ipsilateral canine to the contralateral residual alveolar ridge. The sites of the osteotomies of the digitised fibula were similar to that of the horizontal class b defect. For sub-type d2 (defect involving the contralateral canine, Figure 5), a third osteotomy of the fibular was performed at the contralateral region to restore the maxillary alveolar arch. Similarly, the length of each fibular segment was not shorter than 1.5 cm so as to maintain the vascularity of each fibular segment. Our revised planning protocol for reconstruction of the neomaxillary alveolar arch (Figure 6) is able to achieve
Figure 3 Patient 7 with horizontal class c defect. AeC. Virtual surgical planning at 3 planes. D. Preoperative frontal view. E. Frontal view at 10 months postoperatively. F. Postoperative CT.
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Figure 4 Patient 9 with horizontal class d1 defect. AeC. Virtual surgical planning at 3 planes. D. Preoperative frontal view. E. Frontal view at 7 months postoperatively. F. Postoperative CT.
a shape and contour that is consistent with a normal maxillary alveolar arch. In all cases, care should be taken to ensure that the inferior edge of the neoalveolar ridge in each defect be about 0.5 cm cranial to the normal alveolar ridge so as to accommodate the skin paddle of the fibular osteomyocutaneous flap. The virtual planning should be examined in all three planes (coronal, sagittal and axial) to ensure the optimal neomaxillary contour, intermaxillary distance and spatial relationship between the neomaxilla and mandible. Once surgeons and bioengineer approved the virtual surgical planning, the virtual fibular osteotomy and neomaxilla repositioning guide templates were added on by the bioengineer to help surgeons replicate the virtual planning intra-operatively. The repositioning guide template must be positioned at the superior edge of the neoalveolar ridge to prevent compression of the peroneal vessels. Upon confirmation of the final plan, the stereomodels including the reconstructive model, mirror model, fibular osteotomy guide template and neomaxilla repositioning guide template were produced (Figure 7).
Pre-bending of titanium miniplates and mesh Titanium miniplates were pre-bent on the reconstructive model. For five patients with vertical class III defect and
one patient with vertical class II defect and a thin infraorbital rim, a 0.6 mm thick titanium mesh was pre-bent on the mirror model to establish bilateral midfacial symmetry and support for the eye globe. Three patients with vertical class III defect had 1.0-mm thick titanium mesh implanted in the primary operation. Titanium mesh was not used in one patient with vertical class IV defect because the midface was well-supported by a latissimus dorsi myocutaneous flap that was performed after the primary operation. Titanium mesh was also not used in one patient with vertical class II and horizontal class c defect because the defect was in the premaxilla.
Surgical technique Previous midfacial scars were incised to expose the maxillary defect. Scars tissue was released, allowing correction of the elevated nasal alar and creating sufficient space to accommodate the grafted fibular osteomyocutaneous flap. For a vertical class III defect, the hypoglobus and enophthalmic eye globe should be readdressed. Coronoidectomy was performed in the patient with serious restriction of mouth opening. Maxillary reconstruction was performed using the fibular osteotomy and repositioning guide templates (Figure 7). When a titanium mesh was used, it was fixed to the fibular and the residual bony buttress to
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Figure 5 Patient 10 with horizontal class d2 defect. AeC. Virtual surgical planning at 3 planes. D. Preoperative frontal view. E. Postoperative CT.
Figure 6 Our revised design for maxillary reconstruction. A. horizontal class b defect. B. horizontal class c defect. C. horizontal class d1 defect. D. horizontal class d2 defect.
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Figure 7 Intraoperative application of guide template. A. The stereomodels included reconstructive model, mirror model, fibular osteotomy guide template, and neomaxilla repositioning guide template. B. The fibula was osteotomized using fibular osteotomy guide template. C. Neomaxilla was shaped using fibular repositioning guide template. D. Comparison of neomaxilla with reconstructive model.
reconstruct the orbital floor and the midface projection. The skin paddle of the fibular myoosseocutaneous flap was used to restore the palatal defect in all patients. After the neomaxilla was created, the anastomoses were performed between recipient and peroneal vessels.
Follow-up and postoperative aesthetic assessment The patients were examined to assess for bony union and aesthetics during the follow-up period. Aesthetic assessment was performed by the patients and surgeons using the following criteria: facial symmetry, concavity of the cheek and nasal alar, position of the globe and facial scars. The results were classified as ‘good’ (improved after the operation), ‘fair’ (unchanged after the operation) and ‘poor’ (worse after the operation).
Results Virtual surgical planning was replicated intra-operatively in all patients. The clinical data of secondary maxillary reconstruction are showed in Table 2. The fibulae were osteotomised into four segments in three patients with the horizontal class d2 defect and into three segments in eight patients with the horizontal class b w d1 defects, respectively. No vein grafts were needed in 11 patients.
Postoperative complications All primary anastomoses were successful except in one patient (Patient 5), where venous congestion occurred on
the second day postoperatively. The patient was taken back to the operating room for reanastomosis and survival of the flap was achieved. Therefore, the overall success rate for the 11 flaps was 100%. In another patient (Patient 8), exposure of the titanium mesh in the infraorbital area occurred at postoperative 4 months. The patient underwent additional surgery to remove the partially exposed mesh. No other complications were found in other patients.
Follow-up and postoperative aesthetic assessment The average follow-up period was 14.1 months (range, 4e26 months). Good bony unions and wound closure were observed in 11 patients by CT and panoramic radiograph during the follow-up period. Maximum incisal opening ranged from 3.0 to 4.0 cm. All patients tolerated a regular diet postoperatively. The postoperative midfacial appearance was good as evaluated by the surgeon and patient when compared to the preoperative midfacial appearance. Intelligible speech was also achieved in all 11 patients. In one patient (Patient 4), tumour recurrence at the mandibular ramus and temporal regions was detected at the 6-month visit. The patient underwent extra-cranial radical resection of the recurrent tumour. The reconstructed neomaxilla and titanium mesh was not removed and the new defect was restored with a pectoralis major myocutaneous flap. No other complications such as exposure of the titanium mesh or oronasal fistula have occurred. Oral rehabilitation with osseointegrated implants has been delayed because of the history of radiotherapy. At present, six patients are awaiting dental implantation.
900 Table 2
Y. Shen et al. The clinical data of secondary maxillary reconstruction in 11 patients.
Patient
Defect class
Secondary reconstruction
Length of fibula (cm)
No. of osteotomy
Skin paddle(cm)
1 2 3 4
IIIb IVd2 IIIb IIId2
FOF þ TM FOF FOF þ TM FOF þ TM
13 12 9 13
2 3 2 3
9 10 8 11
5 5 6 6
5 6 7 8 9 10 11
IIb IIIb IIc IIIb IIId1 IIId2 IIIb
FOF þ TM FOF þ TM FOF FOF þ TM FOF FOF FOF
9.5 12 9.5 9 12 13 10
2 2 2 2 2 3 2
7 6 7 7.5 7 9 11
6 6 5 6 7 6 3
Recipient vessels Facial artery and vein Facial artery and vein Facial artery and vein Superior thyroid artery and facial vein Facial artery and vein Facial artery and vein Temporal artery and vein Temporal artery and vein Temporal artery and vein Temporal artery and vein Temporal artery and vein
FOF: Fibula osteomyocutaneous flap, TM: Titanium mesh.
Discussion The goals of maxillary reconstruction are to restore the maxillary buttress and achieve optimal aesthetic appearance and to offer suitable conditions for oral rehabilitation with dentition.1 The use of maxillary prosthesis, local and regional pedicled flaps and free soft-tissue flap can only achieve these goals in limited maxillary defects. In more complex defects, these treatment options are no longer applicable. In such defects, the use of composite osteocutaneous free flaps, including the radial forearm osteocutaneous flap,11 the scapular system flaps,12,13 the iliac crest flap14 and fibula osteomyocutaneous flap1,2,15,16 is able to provide the replacement of the midfacial buttress and skeletal projection, minimise soft-tissue descent and improve the functional outcomes after dental rehabilitation.15,16 Abundant soft tissue and bone can be transferred with few limitations of vascular pedicle length, flap geometry and tissue orientation.17 In our team, we favour the fibular osteomyocutaneous flap for reconstruction of class II defects and the fibular osteomyocutaneous flap in combination with titanium mesh for reconstruction of class III defects, for both primary and secondary maxillary reconstruction. According to Cordeiro and Santamaria,18 the maxilla can be described as a geometric structure with six walls. The roof and floor of the maxilla are the horizontal buttresses, and the anterior, posterior, medial and lateral walls are the vertical buttresses. Among these buttresses, two horizontal (infraorbital rim and alveolar ridge) and one vertical (pterygomaxillary) buttresses of the maxilla are necessary to maintain function and facial proportions. In our design for maxillary reconstruction, the fibula is osteotomised into different segments to restore the alveolar ridge and the pterygomaxillary buttress. Titanium mesh can restore the infraorbital rim, the orbital floor and the anterior wall of the maxilla in the patient with a class III defect. In our previous patients before February 2009,1 the neomaxillary alveolar ridge was restored with one fibular segment for the horizontal class b and d1 defect. However, for the
horizontal class c defect and the horizontal class d2 defect, the neomaxillary alveolar ridge was restored with two fibular segments. Although the postoperative aesthetic and functional results after dental rehabilitation in our previous patients were acceptable, the neomaxillary alveolar arch was not completely consistent with the normal maxillary alveolar arch and there was some error in the spatial relationship between the neomaxilla and mandible. The difference between the straight neomaxillary alveolar ridge and normal curved alveolar ridge could result in the narrow midfacial width and did not provide ideal local bone stocks for dental implant placement. As such, using our revised planning protocol, these difficulties can be overcome by buttress reconstruction with fibular or fibular in combination with titanium mesh for reconstruction of the neomaxillary alveolar arch. With the development of computer software technology, computer-aided design software can be used not only to maximise the precision of bony osteotomies, which helps to recreate the shape of the mandibular or maxillary arch, but also to improve the overall efficiency of the reconstructive process.6 We have applied virtual surgical planning in accurate maxillary reconstruction and modified our previous design for reconstruction of the neomaxillary alveolar arch since June 2009. The postoperative aesthetic and functional results of our new patients are good. In our experience, secondary reconstruction is more difficult than primary reconstruction because sometimes there is not enough information in the local region for reference to do virtual planning. In such a situation, the mirror image of the contralateral unaffected maxilla and the curve of the mandibular arch and dentition can be used as the reference position for reconstruction. During our virtual planning for secondary maxillary reconstruction, the fibular image was superimposed on the mirror image of the contralateral maxilla to match the curve of the maxillary alveolar ridge and the pterygomaxillary buttress by osteotomising the digitised fibula. The sites of the osteotomies are usually performed at the regions of the canine and first molar to match the curve of
Virtual surgical planning for secondary accurate maxillary reconstruction the maxillary alveolar ridge. Therefore, the neomaxillary alveolar ridge is restored with two fibular segments for the horizontal class b and d1 defects and with three fibular segments for the horizontal class c defect. However, for the horizontal class d2 defect, the site of osteotomy at the contralateral alveolar ridge should be planned such that the shortest fibular segment is not shorter than 1.5 cm. In the horizontal class c and d defects, there is no mirror image in the premaxilla to aid in virtual planning. The neopremaxillary arch has to be shaped by the curve of the mandibular arch and dentition and further modified by its spatial relationship to the mandible so as to avoid an increased overbite and overjet at the bilateral canine region. Our design is different from that of Hanasono et al.9 In their article, using their design, a postoperative wider midface may result because the width of neomaxillary alveolar arch and the projection of the bilateral cheilion are increased by the increased overlay relationship between the neopremaxiila and mandible. More importantly, the interarch relationship should be ideal enough for oral rehabilitation with dental implants. Small inaccuracies in interarch spatial relationship can result in difficulty in achieving complete dental rehabilitation. In summary, we recommend that the horizontal class d defect in Brown’s revised defect classification of the maxilla and midface be divided into two sub-types according to whether it involved the contralateral canine or not. Special considerations in virtual surgical planning presented below are helpful when performing secondary accurate maxillary reconstruction with a vascularised fibular osteomyocutaneous flap. 1. For the horizontal class b defect, the fibular is osteotomised at the site of the canine using the mirror image of the contralateral alveolar ridge to match the maxillary alveolar arch. 2. For the horizontal class c defect, the fibula is osteotomised at the sites of the bilateral canines. This is further modified according to the curve of the mandibular arch and dentition and the spatial relationship to mandible because no mirror image is present for reference. 3. For the horizontal class d1 defect, the posterior neoalveolar ridge is shaped by the mirror image of the contralateral alveolar ridge; the premaxilla is restored from the ipsilateral canine to the contralateral residual alveolar ridge as in the horizontal class c defect. 4. For the horizontal class d2 defect, the ipsilateral neoalveolar ridge is restored as in the horizontal class b defect. The site of osteotomy at the contralateral alveolar ridge should be planned to ensure that the fibular segments are not shorter than 1.5 cm. 5. The inferior edge of the neoalveolar ridge in each horizontal class defect should be positioned about 0.5 cm cranial to the normal alveolar ridge to accommodate the skin paddle of the fibular osteomyocutaneous flap. 6. The virtual planning should be examined at three planes (coronal, sagittal and axial) to ensure that the optimal neomaxillary contour, intermaxillary distance and spatial relationship between neomaxilla and mandible are achieved.
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7. The neomaxilla repositioning guide template that is used to help surgeons replicate virtual planning intraoperatively must be arranged at the superior edge of the neoalveolar ridge to prevent from compression of the peroneal vessels.
Conflict of interest None.
Acknowledgement This work was supported by the Science and Technology Commission of Shanghai (08DZ2271100) and partially supported by the Program for Innovative Research Team of Shanghai Municipal Education Commission, and by the Research Grants (10DZ1951300) from the Science and Technology Commission of Shanghai Municipality.
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902 12. Uglesic V, Virag M, Varga S, et al. Reconstruction following radical maxillectomy with flaps supplied by the subscapular artery. J Craniomaxillofac Surg 2000;28:153. 13. Clark JR, Vesely M, Gilbert R. Scapular angle osteomypgenous flap in postmaxillectomy reconstruction: defect, reconstruction, shoulder function and harvest technique. Head Neck 2008;30:10. 14. Brown JS, Jones DC, Summerwill A, et al. Vascularized iliac crest with internal oblique muscle for immediate reconstruction after maxillectomy. Br J Oral Maxillofac Surg 2002;40:183. 15. Yazar S, Cheng MH, Wei FC, et al. Osteomyocutaneous peroneal artery perforator flap for reconstruction of composite maxillary defects. Head Neck 2006;28:297.
Y. Shen et al. 16. Rodriguez ED, Bluebond-Langer R, Park JE, et al. Preservation of contour in periorbital and midfacial craniofacial microsurgery: reconstruction of the soft-tissue elements and skeletal buttresses. Plast Reconstr Surg 2008;121: 1738. 17. Triana RJ, Uglesic V, Virag M, et al. Microvascular free flap reconstructive options in patients with partial and total maxillectomy defects. Arch Facial Plast Surg 2000;2: 91. 18. Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 2000;105:2331.