Primary Reconstruction of Extended Midface Defects

Introduction: Midface reconstruction after oncologic resection is a challenging and quickly evolving area in plastic surgery, often posing highly variable types of defects. Cordeiro et al.¹ have presented an algorithm to help classify and define the best reconstructive approach to different maxillectomy defects. Our goal was to verify the applicability of this algorithm to more extended resections, involving also the skull base and the mandible.

Methodology and Material: Over the past 2 years we have done 6 consecutive immediate reconstructions of maxillectomy defects Cordeiro’s type IIB (n = 1), IIIA (n = 2) and IIIB (n = 3) with free vertical rectus abdominis myocutaneous (VRAM) flaps bearing 2 or 3 independent skin islands. Oncological resections included anterior cranial fossa, partial middle cranial fossa, ethmoid bone, sphenoid bone and mandible. Calvarial bone grafts where used whenever orbital roof or floor reconstruction was necessary (n = 3).

Results: 6 free VRAM flaps were performed in 6 patients (1 male, 5 females). Average patient age was 63,3 years (range 39-70 years). Flap survival rate was 100%. 1 patient suffered a major systemic complication (stroke, full recovery) and 1 had a minor systemic complication (respiratory infection). 2 patients underwent revision surgery (1 bone graft osteomyelitis and 1 intracranial oncologic recurrence). All vascular anastomoses were made to the facial vessels (n = 6). Average hospitalization time was 22 days. 5 patients received post-operative radiotherapy. Functional results were globally good, none of the patients has diet restrictions and all present intelligible speech. The aesthetic outcomes were acceptable, with 40% of patients needing a second surgery for cosmetic improvements.

Conclusions: The free VRAM flap with independent skin islands provides a safe and effective reconstruction option for complex and extensive defects of the midface, allowing post-operative radiotherapy and ensuring good functional results. Even for more complex midface resections the Cordeiro et al. algorithm still holds its applicability.

References

Reference

1 Cordeiro PG, Chen CM. A 15-year review of midface reconstruction after total and subtotal maxillectomy: part I. Algorithm and outcomes. Plast Reconstr Surg 2012;129(1):124-136