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Midface Reconstruction
Introduction
Reconstruction of the midface, particularly of the maxilla, following tumor removal is a significant challenge because of its complex three-dimensional architecture and important role in facial esthetics and function. The goals of reconstruction include: (1) maintaining midfacial height, width, and projection; (2) creating a stable platform for mastication and dental restoration; (3) separating the oral cavity from the nasal cavity; (4) preserving a patent nasal airway; (5) supporting the soft tissues of the face, including the nose, lips, cheeks, and eyelids; and (5) restoring the bony orbit to avoid changes in orbital volume and globe position that may result in eye exposure or impaired vision, or provide stable wound closure for the exenterated orbit.
In the past, maxillary reconstruction mainly involved prosthetic obturation. This option results in immediate dental restoration without further surgery but, in larger defects, as well as in cases where radiation-associated tissue contracture occurs, instability, poor retention, and oronasal leakage of air, liquid, and food may occur. Furthermore, results of prosthetic obturation are disappointing or unacceptable in extensive midfacial defects, such as those that involve the orbital floor. The advent of microsurgery has permitted primary single-stage reconstruction of these complex facial defects, avoiding the use of a prosthesis as well as various combinations of local and regional flaps that have poorer esthetic and functional results and higher complication rates.
Reconstructive Approach
One of the biggest challenges associated with reconstructing the maxilla is that the defects created by oncologic resection are highly variable. Several classification systems have been proposed, each with its strengths and weaknesses. According to Archibald et al, the ideal maxillary treatment algorithm should “use a functional approach that defines the defect-related challenges, prioritizes the reconstructive goals, and identifies how and to what extent each of the microsurgical free flaps could meet these goals.” Therefore, rather than memorizing a specific classification system, it is more important to understand the critical structures that need to be addressed during the reconstruction and base the surgical approach on these needs. These structures include: the palate and alveolus, the orbital floor, and the orbital contents. , This chapter will examine each of these areas.
Reconstruction of the Palate and Alveolus
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