21.3.1.2 Maxillectomy Without Orbital Exenteration

Reconstruction in patients who have undergone maxillectomy with preservation of the orbital contents but resection of the floor of the orbit can be particularly challenging. The orbital floor has to be reconstructed, and often the orbit and maxillary sinus area have to be irradiated after reconstruction, which limits the use of synthetic material to rebuild the orbital floor. In such cases, the best option may be autologous vascularized tissue flaps with bone grafts supplemented with titanium or other similar material to provide support. In many cases, despite all efforts, there may be ocular morbidity associated with removal of the orbital floor—e.g., there may be entrapment of the inferior soft tissues of the orbit, including the inferior rectus muscle.

Multiple approaches to reconstruction of the radical maxillectomy defect with preservation of the orbit have been described. These include prosthesis attached to the palate alone [2], soft tissue pedicled flaps [3], free flaps with secondary bone grafting [4, 5], vascularized osteocutaneous free flaps [5–9], and nonvascularized bone grafts in conjunction with a soft tissue free flap or pedicled muscle flap [1]. Cordeiro and Santamaria [10] describe a systematic approach for reconstruction of the complex maxillectomy and midfacial defect.

21.3.2 Types of Maxillary Defects and Strategies for Their Repair

21.3.2.1 Type I Defect

Type I defects result from limited maxillectomy, which includes resection of one or two walls of the maxilla, excluding the palate and occasionally the orbital rim. In most patients, the anterior wall is partially removed with either the medial wall

Fig. 21.3 Type I defect (limited maxillectomy). There is resection of anterior and medial walls of the maxilla (left). The resected area has skin, soft tissue, and bone creating a large surface area/low volume defect (center, left). The radial forearm fasciocutaneous flap provides multiple large surface areas with minimal volume (center, right). (Right) The radial forearm flap is shown in place with a skin island to resurface the anterior cheek and nasal lining. From Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 2000;80:2331–46. Reprinted with permission

Fig. 21.4 Type I defect (above, left) after partial resection of orbital floor, external skin, and medial and anterior walls of the maxilla in a 68-year-old woman with a recurrent desmoplastic melanoma of the right cheek. (Above, right) Post operative photograph demonstrating excellent facial contour and cosmesis. (Below) Two skin island radial forearm flap demonstrating large surface area and minimal volume. From Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 2000;80:2331–46. Reprinted with permission

or the orbital floor (Figs. 21.3 and 21.4). These defects have small volume and large surface area requirements. If critical segments of bone are missing, such as the orbital rim or the anterior floor of the orbit, nonvascularized bone grafts can be used. The radial forearm flap provides good external skin coverage and minimal

bulk with multiple skin islands that can be deepithelialized to improve contour, wrap around bone grafts, or supply nasal lining.

21.3.2.2 Type II Defects

Type II defects result from subtotal maxillectomy, which includes resection of the maxillary arch, palate, and anterior and lateral walls (lower five walls) with preservation of the orbital floor (Fig. 21.5). These defects usually have medium volume and large surface area requirements. The radial forearm flap, when folded over, provides ample skin to reline the palatal mucosal surface as well as the nasal floor. Another alternative is the “osteocutaneous sandwich flap” [16], which supplies a vascularized bony strut to support the upper lip and maintain anterior projection. The bone of this flap is also adequate for osteointegration. This “sandwich” provides a moderate amount of bulk and is usually sufficient for the volume requirements of reconstruction. The osteocutaneous sandwich flap is also an excellent solution for reconstruction after bilateral subtotal maxillectomy.

Fig. 21.5 Type II defects (subtotal maxillectomy). (Left) There is resection of five walls of the maxilla sparing the roof (orbital floor). The resected specimen palate/nasal floor lining and bone. (Center, left) The radial forearm “sandwich flap” provides moderate volume and large skin surface area with vascularized bone. (Center, right) The radial forearm “sandwich flap” in place (right) showing a vascularized bone strut to reconstruct the maxillary arch defect in between two skin islands that replace palatal and nasal lining. From Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 2000;80:2331–46. Reprinted with permission

21.3.2.3 Type III Defects

Type III defects result from total maxillectomy, which includes resection of all six walls of the maxilla, the floor of the orbit, and often the orbital contents [11]. When the orbital soft tissues are not involved with extension of cancer from the maxillary sinus, the orbital contents can often be preserved [12, 13]. This type of defect can be subdivided into type IIIa, in which the orbital contents are preserved (Fig. 21.6), and type IIIb, in which the orbital contents are exenterated (Fig. 21.7).

Fig. 21.6 Type IIIa defects. There is preservation of the orbit, but all six walls of the maxilla have been resected (above, left). The resected specimen demonstrates the orbital floor (roof of maxilla), vertical maxillary buttress, and palate creating a medium surface area/medium volume defect (center, left). Cranial or rib bone graft is used to reconstruct the floor of the orbit and is covered with a single island rectus abdominis myocutaneous free flap (center, right). The free flap is inset with the skin island used to close the roof of the palate, soft tissue to fill in the midfacial defect, and muscle to cover the bone graft. (Below) The patients that are not free-flap candidates can benefit from split calvarial bone grafts covered with temporalis muscle, transposed anteriorly. The zygomatic arch should be osteotomized temporarily to increase the excursion of the temporalis muscle. From Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 2000;80:2331–46. Reprinted with permission

Type IIIa defects are medium to large volume and surface area defects. The two functional requirements that need to be addressed are support of the orbital contents and reconstruction of the palate. Without exception, the orbital floor must be reconstructed. If this is not done, the orbital contents will sink into the cheek, creating orbital dystopia and diplopia. The orbital floor can be addressed with nonvascularized bone grafts. The bone graft must be sandwiched between a healthy flap below (rectus abdominis or temporalis) and the orbital contents above. The rectus abdominis flap, according to Cordeiro and Santamaria, provides the muscle coverage for bone grafts and also adequate subcutaneous fat that can be contoured for soft tissue fill (usually on a delayed basis) [10]. The temporalis flap covers bone effectively