AAPS, American Association of Plastic Surgeons
AAPS, American Association of Plastic Surgeons
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AAPS 2007 Annual Meeting, May 19 - 22, 2007, The Coeur d'Alene Resort, Coeur d'Alene, Idaho.
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Reconstruction of Complex Maxillectomy and Midfacial Defects:
A Single Surgeon’s 15-year Experience with 100 Flaps

Peter G. Cordeiro, MD, FACS1, Constance M. Chen, MD, MPH2.
1Memorial Sloan-Kettering Cancer Center, New York, NY, USA, 2New York-Presbyterian Hospital, New York, NY, USA.

Purpose: Reconstruction of complex midfacial defects is best approached with a clear algorithm. Over time, the senior author has developed modifications to this algorithm for midface reconstruction to minimize complications and maximize outcomes. The objective of this study is to delineate specific refinements in technique and evaluate aesthetic and functional results.
Methods: Over a 15-year period (1992-2006), 100 flaps were performed by a single surgeon to reconstruct the following midfacial defects: type I, limited maxillectomy (n=20); type II, subtotal maxillectomy (n=16); type IIIa, total maxillectomy with preservation of the orbital contents (n=22); type IIIb, total maxillectomy with orbital exenteration (n=23); type IV, orbitomaxillectomy (n=19). Free flaps (74 rectus abdominis, 16 radial forearm, 3 gracilis, 1 latissimus dorsi) were used in 94 cases (94%), and pedicled flaps (5 temporalis, 1 pericranial) were used in 6 cases (6%). Table 1 lists reconstructive approaches.
Adjuvant chemotherapy was given to 30 patients (n=16, preop; n=10, postop; n=4, both preop and postop). Radiation therapy was administered to 74 patients (n=20, preop; n=45, postop; n=9, both preop and postop). Pathologic diagnoses included squamous cell carcinoma (n=49, 49%), osteogenic sarcoma (n=15, 16%), adenocarcinoma (n=8, 8%), adenoid cystic carcinoma (n=4, 4%), basal cell carcinoma (n=4, 4%), mucoepidermoid carcinoma (n=4, 4%), fibrous histiocytoma (n=4, 4%), spindle cell sarcoma (n=4, 4%), melanoma (n=3, 3%), verrucous papillary carcinoma (n=1, 1%), , leiomyosarcoma (n=1, 1%), chondrosarcoma (n=1, 1%), Ewing’s sarcoma (n=1, 1%), and undifferentiated carcinoma (n=1, 1%).
Results: A total of 100 flaps were performed in 96 patients (M=69, 72%; F=27, 28%); four patients underwent a second flap reconstruction due to recurrent disease (n=4, 4%). Average patient age was 49.2 years (range 13-81 years). Free-flap survival was 100%, with 1 partial flap loss (1%). There were 5 reexplorations (5.2%), due to 3 hematomas (3.1%) and 2 occluded anastomoses (2.1%). Five patients suffered systemic complications (5.2%), and 4 patients died within 30 days of hospitalization (4.2%). Average hospitalization time was 13.5 days (range 5-50 days). Average anesthesia time was 11.7 hours (range 5-18 hours). The majority of patients (>50%) returned to normal diet and speech. About one-half of patients had ectropion, which did not require treatment; less than 15% had mild dystopia, with no functional consequences. Major and minor complications are listed in Table 2.
Conclusions: Free-tissue transfer offers the most effective and reliable form of reconstruction for complex maxillectomy defects. Rectus abdominis and radial forearm flaps in combination with immediate bone grafting or as osteocutaneous flaps consistently provide the best aesthetic and functional results. Specific advancements in technique to reconstruct the orbital floor, eyelid and palate will be described to maximize functional outcome and aesthetic result.
Table 1. Type of Reconstruction

Maxillectomy Defect TypeTotalFree FlapLocal FlapBone Graft
Rectus Abdominis MyocutaneousRadial Forearm FasciocutaneousRadial Forearm OsteocutaneousGracilis MyocutaneousLatissimus Dorsi MyocutaneousTemporalisPericranialCranialIliacRibMandible

Table 2. Complications
TypeTotalMinor ComplicationsMajor Complications
NonePartial flap lossInfection/Wound healingHematoma/
SystemicDeathOccluded Anastomosis

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