A Brief Overview of Maxillary Reconstruction
06 May 2020 (online)
The midfacial region is a challenging area for the reconstructive surgeon. A good outcome depends on the ability of the plastic surgeon to consider both the functional and aesthetic demands of the patient. The defects are also extremely variable in nature depending on the etiology and amount of residual normal tissue. For example, cleft palate defects can be closed with local tissue with a low incidence of complications. However, gunshot wounds to the midface may lead to defects that require a face transplant to provide a reasonable outcome due to the massive amount of tissue loss. The entire reconstructive ladder may be needed to manage the spectrum of midfacial defects.
Standard flaps and grafts remain the primary reconstructive techniques. However, advanced surgical techniques including virtual surgical planning of osteocutaneous flaps have the potential to improve outcomes, although there is no substitute for an experienced microvascular surgeon. Other improvements in intraoperative and postoperative monitoring have contributed to the reduction in flap loss and better outcomes in this population of patients.
The functional rehabilitation of patients with large and small defects requires an excellent health care team. Functional outcomes improve with nurses, registered dieticians, speech therapists, and audiologists all working together to help these complex patients. Access to a prosthodontist is essential to provide the full spectrum of options, as some patients may be poor candidates for extensive reconstruction due to comorbidities. And last, but not least, it is vital to have appropriate psychosocial support, as many of the afflicted patients are in the disadvantaged segment of our population.
There have been an increasing number of well-trained surgeons from multiple specialties contributing to the advancement of maxillofacial care. There is considerable practice overlap between the plastic surgeons, oral and maxillofacial surgeons, and otolaryngologists. Some institutions have excellent interdisciplinary relationship, while other institutions have one specialty primarily manage the maxilla and skull base cases. Greater cooperation between specialties generally leads to improved patient care and a better working environment for providers.
In the past, obturator prosthesis was the best care these patients could hope to receive. Now the future may include composite tissue allografts or tissue engineering to eliminate donor-site morbidity completely. The future of maxillary and skull base surgery will certainly be exciting.