SURGICAL ONCOLOGY AND RECONSTRUCTION
Rec
and
Am
Challenges in the Reconstructionof Bilateral Maxillectomy Defects
eived
Recon
rita Un
*Assista
yAssocizAssistaxProfeskProfes{Profes
Shawn T. Joseph, MS, DNB,* Krishnakumar Thankappan, MS, DNB, MCh,yRahul Buggaveeti, MS,z Mohit Sharma, MS, MCh,x Jimmy Mathew, MS, MCh,k
and Subramania Iyer, MCh{
Purpose: Bilateral maxillectomy defects, if not adequately reconstructed, can result in grave estheticand functional problems. The purpose of this study was to investigate the outcome of reconstruction of
such defects.
Materials andMethods: This is a retrospective case series. The defects were analyzed for their compo-
nents and the flaps used for reconstruction. Outcomes for flap loss and functional indices, including oral
diet, speech, and dental rehabilitation, also were evaluated.
Results: Ten consecutive patients who underwent bilateral maxillectomy reconstruction received 14
flaps. Six patients had malignancies of the maxilla, and 4 patients had nonmalignant indications. Ten
bony free flaps were used. Four soft tissue flaps were used. The fibula free flap was the most common
flap used. Three patients had total flap loss. Seven patients were alive and available for functional evalua-
tion. Of these, 4 were taking an oral diet with altered consistency and 2 were on a regular diet. Speech wasintelligible in all patients. Only 2 patients opted for dental rehabilitation with removable dentures.
Conclusions: Reconstruction after bilateral maxillectomy is essential to prevent esthetic and functionalproblems. Bony reconstruction is ideal. The fibula bone free flap is commonly used. The complexity of
the defect makes reconstruction difficult and the initial success rate of free flaps is low. Secondary recon-
structions after the initial flap failures were successful. A satisfactory functional outcome can be achieved.
� 2015 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 73:349-356, 2015
Extensive defects of the maxilla result after surgical
resection of malignancies involving themaxillary sinus
and adjacent structures. Rarely, such defects also can
be a result of nonmalignant conditions or trauma.
Often, the defect can cross the midline to involve a
major part of the opposite maxilla or it can be a total
bilateral defect. Bilateral maxillectomy defects, if notadequately reconstructed, can result in grave esthetic
and functional problems. The purpose of this study
was to investigate the outcome of bilateral maxillary
reconstruction in a series of patients. The specific
aims of the study were to evaluate the components
of defect and the flaps used.
from the Department of Head and Neck Surgery, Plastic
structive Surgery, Amrita Institute of Medical Sciences,
iversity, Kochi, Kerala, India.
nt Professor.
ate Professor.
nt Professor.
sor.
sor.
sor and Head.
349
Materials and Methods
This is a retrospective descriptive review. The study
population consisted of 10 consecutive patients whounderwent bilateral maxillectomy reconstruction
over a period of 6 years, from January 2006 to
December 2012. To be included in the study, a patient
must have had a maxillectomy defect crossing the
midline. Malignant and nonmalignant cases were
included. The electronic medical records, including
clinical details, surgical details, and follow-up details,
were studied. Defects were analyzed for their compo-nents and the flaps used for reconstruction. Outcomes
Address correspondence and reprint requests to Prof
Thankappan: Department of Head and Neck Surgery, Amrita
Institute of Medical Sciences, Kochi, Kerala, India 682041; e-mail:
Received May 24 2014
Accepted August 30 2014
� 2015 American Association of Oral and Maxillofacial Surgeons
0278-2391/14/01408-6
http://dx.doi.org/10.1016/j.joms.2014.08.036
350 BILATERAL MAXILLECTOMY RECONSTRUCTION
for flap loss and functional indices, including diet,
speech, and dental rehabilitation, also were evaluated.
The complexities of bilateral maxillectomy defect
reconstruction are discussed. Institutional review
board approval was obtained for this review.
Results
Ten patients (5male and 5 female; mean age, 40.6 yr;
age range, 16 to 70 yr) received 14 flaps for reconstruc-
tion of bilateral maxillectomy defects during the study
period. Six patients had malignancies of the maxilla, 1
patient had recurrent pleomorphic adenoma of the
maxilla, 1 patient had post-traumatic necrosis of themaxilla involving the right and left sides, 1 patient
had resolved actinomycosis, and 1 patient was treated
for mucormycosis. The details of the defects are listed
in Table 1. Nine patients had palate and alveolus defects
in addition to other components, nasal bone support
was removed in 3 patients, 5 patients had defects
involving the unilateral orbital floor, and infratemporal
fossa clearance was performed in 3 patients. Accordingto the classification of maxillary defects by Brown and
Shaw,1 4 patients had Class IId defects (infrastructure
maxillectomy involving greater than half), 5 patients
had Class IIId defects (defects involving the orbital
floor, involving greater than half), and 1 patient (patient
10) had a defect involving the entire hard and soft
palate, but not the alveolus. This patient could not be
specifically categorized in any of the specified classes.Ten bony free flaps were used. This included 7 flaps
in primary cases and 3 flaps performed as salvage after
the failure of the first free flap. Four soft tissue flaps
were used in 3 patients. One radial forearm flap was
used to salvage a skin paddle loss in the fibula.
Tables 2 and 3 list the diagnoses of the 10 patients
and the flap characteristics.
Three patients had total flap loss (fibula free flap in2 patients and rectus abdominis free flap in 1 patient).
All these cases had orbital floor defects and attempts
Table 1. DETAILS OF DEFECT COMPONENTS IN 10 PATIENTS
Defect Component 1 2 3 4
Palate + + + +
Alveolus + + + +
Nasal bones + +
Orbital floor—unilateral + + +
ITF defect
Unilateral +
Bilateral + +
Brown class IId IIId IIId IIId
Abbreviation: ITF, infratemporal fossa.
Joseph et al. Bilateral Maxillectomy Reconstruction. J Oral Maxillofac Su
were made to reconstruct them. A separate segment
of fibula was used in 2 and a nonvascularized tenth
rib was used in addition to the rectus abdominis flap.
The rectus abdominis flap was salvaged with a fibula
free flap. The lost fibula flaps were salvaged with a
tensor-fascia-lata flap with iliac crest bone and a deep
circumflex iliac artery flap with iliac crest bone. One
patient with a fibula flap developed skin paddle necro-sis, which was salvaged with a adipose-fascial radial
forearm free flap.
The fibula free flap was the most common choice.
The skin paddle of the flap served as the palatal cover,
providing oronasal and oroantral separation. Osteo-
tomized segments (usually 2 or 3 osteotomies and 3
or 4 segments) formed the alveolus. The muscle com-
ponents of the flap filled the cavity to provide contour.This flap was plated and fixed to the zygoma on both
sides. Pre-molded reconstruction plates based on skull
models were used in 3 patients to shape the fibula.
Titanium miniplates were used in 5 patients and wires
were used in 1 patient. Anastomosis usually was to the
facial artery and common facial vein. Vein grafts were
used in 4 cases. A separate iliac crest bone placed on
top of the fibula to support the external nasal frame-work was used in 5 patients; otherwise the framework
would have collapsed. This reconstruction provided
the option for dental implants.
Of the 6 patients with malignancy, 1 died of recur-
rence, 1 was lost to follow-up, and 4 patients were
alive and free of disease (mean follow-up, 25 months).
Of patients with nonmalignancy, 7 were alive and
available for functional evaluation. Of these, 4 weretaking an oral diet with altered consistency and 2
were on a regular diet. Speech was intelligible in all
patients, as assessed subjectively by the clinician and
the patient’s relatives. Only 2 patients opted for dental
rehabilitation with removable dentures.
Figure 1 shows a patient with recurrent chondrosar-
coma and a history of maxillectomy with fibula recon-
struction (Fig 1A, B). Reconstruction was performed
5 6 7 8 9 10
+ + + + + +
+ + + + +
+
+ +
IIId IId IIId IId IId unspecified
rg 2015.
Table 2. DIAGNOSIS, FLAP USED, AND SALVAGE FLAP USED IN CASE OF FLAP FAILURE
Patient Diagnosis Flap Salvage Flap
1 sarcoma fibula
2 carcinoma fibula
3 sarcoma rectus + rib (flap failure) fibula
4 pleomorphic adenoma fibula (flap failure) TFL with iliac crest
5 sarcoma fibula (skin paddle failure) radial forearm
6 trauma with necrosis maxilla fibula
7 squamous cell carcinoma fibula with orbital mesh
8 actinomycosis fibula (flap failure) DCIA
9 mucormycosis anterolateral thigh
10 adenoid cystic carcinoma radial forearm
Abbreviations: DCIA, deep circumflex iliac artery; TFL, tensor-fascia-lata.
Joseph et al. Bilateral Maxillectomy Reconstruction. J Oral Maxillofac Surg 2015.
JOSEPH ET AL 351
using a rectus abdominis free flap (Fig 1C, D). A skin
paddle was used for the palatal defect. The musclemass was used to obliterate the maxillary ethmoid
defect. A tenth rib harvested with the flap with its peri-
osteal blood supply andwired to the zygomatic stumps
was used to form the maxillary arch. Figure 2 shows a
patient with squamous cell carcinoma of the left
maxilla involving the left orbital floor. He underwent
bilateral maxillectomy with removal of the entire infra-
structure and the orbital floor on the left side. The re-sulting defect (Brown Class IIID) was reconstructed
with a fibula free flap. A titaniummeshwas used to sup-
port the orbital floor. Figure 3 shows 3-dimensional
reconstructed computed tomograms of a patient with
bilateral maxillectomy defects reconstructed with a
free fibula flap.
Discussion
Surgical resection of malignancies involving the
maxillary sinus and adjacent structures, nonmalignant
Table 3. DETAILS OF FLAPS USED
Bony free
flap
free fibula 8 (7 primary +
1 salvage)
TFL with iliac crest 1 (salvage)
DCIA 1 (salvage)
Soft tissue
flap
free rectus abdominis 1
anterolateral thigh flap 1
radial forearm flap 2 (1 primary +
1 salvage)
Total 14
Abbreviations: DCIA, deep circumflex iliac artery; TFL,tensor-fascia-lata.
Joseph et al. Bilateral Maxillectomy Reconstruction. J Oral
Maxillofac Surg 2015.
conditions, or, rarely, trauma can result in large de-
fects. This study specifically investigated the defectsand outcomes of reconstructed bilateral maxillectomy
defects. The goals of reconstruction in a bilateral max-
illectomy defect include 1) adequate oronasal separa-
tion, 2) providing the alveolar arch, 3) preservation
of speech and mastication functions, and 4) structural
support to the midface, providing the facial height and
midfacial projection while maintaining the nasal
airway patency and providing support to the contentsof the orbit if there is loss of the same.
In a conventional unilateral maxillectomy, it can be
argued that reconstruction is not absolutely essential
and an obturator can provide adequate oronasal and
oroantral separation. However, in a case of bilateral
maxillectomy, this argument does not stand. Place-
ment of an obturator is nearly impossible, except
when one uses a long zygomatic implant. Such im-plants are not easily available and are technically diffi-
cult. The esthetic problems in a bilateral maxillectomy
defect are due to the loss of the central arch, leading to
collapse of the nose owing to lack of support of the
columella at the anterior nasal spine. If the orbital floor
is lost, enophthalmos and dystopia also can occur.
Functional problems include feeding and speech. If
the defect is not reconstructed, patients will requirelifelong feeding tube support.
Reconstruction of the lost components of the bilat-
eral maxillectomy defect is a challenge. Providing nasal
support and reconstructing the anterior alveolar arch
together with a single bone strut is difficult because
of the posterior position of the anterior nasal spine
in relation to the anterior alveolar arch. The nasal sup-
port, if lost, is provided by a bone strut, but placingit and covering it adequately with a thin soft tissue to
prevent exposure is difficult. Maintenance of the nasal
cavity also is difficult; because the usually used bone
flap, with a bulky soft tissue cover, will result in oblit-
eration of the cavity. Providing the orbital bone
FIGURE1. A,A patient with recurrent chondrosarcoma and a history of maxillectomywith fibula reconstruction. B, Intraoral view showing thetumor.C, Reconstructed outcome with a rectus abdominis free flap with rib, frontal view. D, Reconstructed outcome, intraoral view, showing thepalatal cover.
Joseph et al. Bilateral Maxillectomy Reconstruction. J Oral Maxillofac Surg 2015.
352 BILATERAL MAXILLECTOMY RECONSTRUCTION
support with the alveolus requires a separate piece of
bone, which is technically challenging. Lack of
adequate bone length, possible twisting and kinking
of the pedicle, and shortness of the pedicle are the
challenges.The fibula flap has been a flap of choice for recon-
struction of unilateral maxillectomy defects.2 The ad-
vantages of the fibula free flap in this clinical
situation include a long vascular pedicle; the provision
of bone, skin, and muscle tissue; relatively easy flap
harvesting; the possibility of a 2-team approach; and
a good recipient for the implant.3 A fibula osteocutane-
ous free flap performs the crucial function of
providing structural support to the midface. The
height of the fibula may not be sufficient for the alve-olus and nasal tip support. Providing support to the
external nasal framework while retaining the option
for a dental implant becomes difficult because of the
suboptimal fibular height. This view is shared by
Brown and Shaw1 who stated that, if there is loss of
FIGURE 2. A, A patient with squamous cell carcinoma of the maxilla extending to the orbital floor on the left side. Computed tomogram in thecoronal view shows the extent of tumor. B, Resected specimen. C, Reconstructed outcome, frontal view. D, Reconstructed outcome, intraoralview.
Joseph et al. Bilateral Maxillectomy Reconstruction. J Oral Maxillofac Surg 2015.
JOSEPH ET AL 353
alar support, bones of smaller dimension, such as the
radius and fibula, might not provide sufficient height
to reliably support the oronasal region. In the absence
of any single bone flap that can provide enough height
for alveolar reconstruction and for nasal framework
support, the authors believe the fibula remains the
best option. However, the authors have used an iliaccrest bone graft above the fibula in these cases to
support the external nasal framework and the fibula
to form the new alveolus.
Greater than expected flap loss (3 of 14; 21%) could
be explained by the complexity, extensiveness,
distance of the defect from the neck, and the short
pedicle of the available flaps. It is noteworthy that all
these patients with flap failures had additional orbital
floor defects. Moreover, it is remarkable that these
3 flap losses could be salvaged successfully with a
second free flap.
It is true that an ideal maxillary reconstructionwould be complete only with dental rehabilitation.
Only 2 patients in this series opted for dental rehabili-
tation. The primary aim of such reconstruction is to
allow oral feeding and to achieve near-normal speech
without the help of an obturator. This would be
FIGURE 3. Computed tomograms of a patient with a bilateral maxillectomy defect reconstructed with a fibula free flap. A, Anterior view.(Fig 3 continued on next page.)
Joseph et al. Bilateral Maxillectomy Reconstruction. J Oral Maxillofac Surg 2015.
354 BILATERAL MAXILLECTOMY RECONSTRUCTION
achieved by the flap reconstruction. Dental rehabilita-
tion, for the patient, could be a secondary consider-
ation after prolonged cancer treatment. Such
preferences and choices could be known only through
properly designed quality-of-life studies.
Reconstruction of large bilateral maxillectomy de-
fects have seldom been reported, which appears to
be due to the lack of enough cases. Futran et al,4 in
their series of midface reconstruction, described 8
cases of bilateral maxillectomy defects, whereas
FIGURE 3 (cont’d). B, Lateral view.
Joseph et al. Bilateral Maxillectomy Reconstruction. J Oral Maxillofac Surg 2015.
JOSEPH ET AL 355
some of the other large series of maxillectomy defect
reconstruction included even fewer of these defects.1
There also have been some isolated case reports on the
reconstruction of this defect using a fibula free flap
and a maxillofacial prosthesis, with good result.5-8
However, the defects and methods of reconstruction
have varied in these cases.
Thestudy is limitedbecauseof its retrospectivenature
and small sample. It is difficult to derive strong conclu-sions from this small study. However, the authors have
described the options in such complex reconstructive
situations and highlighted the difficulties.
Reconstruction after bilateral maxillectomy is essen-
tial to prevent esthetic and functional problems. Bony
356 BILATERAL MAXILLECTOMY RECONSTRUCTION
reconstruction is ideal. The fibula bone free flap is
commonly used. The complexity of the defect makes
the reconstruction difficult and the success rate of
the free flaps is initially low. Second reconstructions
after initial flap failures were successful. Satisfactory
functional outcomes were achieved. Very few patients
opted for dental rehabilitation.
References
1. Brown JS, Shaw RJ: Reconstruction of the maxilla and midface:Introducing a new classification. Lancet Oncol 11:1001, 2010
2. Peng X, Mao C, Yu GY, et al: Maxillary reconstruction with thefree fibula flap. Plast Reconstr Surg 115:1562, 2005
3. Futran ND, Haller JR: Considerations for free flap reconstructionof the hard palate. Arch Otolaryngol Head Neck Surg 125:665,1999
4. FutranND,Wadsworth JT, Villaret D, et al: Midface reconstructionwith the fibula free flap. Arch Otolaryngol Head Neck Surg 128:161, 2002
5. Nakayama B, Matsuura H, Ishihara O, et al: Functional reconstruc-tion of a bilateral maxillectomy defect using a fibula osteocutane-ous flap with osseointegrated implants. Plast Reconstr Surg 96:1201, 1995
6. Mukohyama H, Haraguchi M, Sumita YI, et al: Rehabilitation of abilateral maxillectomy patient with free fibula osteocutaneousflap. J Oral Rehabil 32:541, 2005
7. Anthony JP: Reconstruction of a complex midfacial defect withthe folded fibula free flap and osseointegrated implants. Ann PlastSurg 37:204, 1996
8. Barnouti L, Caminer D: Maxillary tumours and bilateral recon-struction of the maxilla. Aust N Z J Surg 76:267, 2006
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