Orbitomaxillary Reconstruction Using the Layered Fibula Osteocutaneous Flap FREE

Aesthetically pleasing and structurally sound maxillary reconstruction is extraordinarily challenging. The maxilla is a unique bone that provides height and width to the midface and contributes greatly to overall aesthetic facial contour. In addition, it provides support to the orbital contents and serves as a bony framework for maxillary dentition. Functionally, the maxilla also contributes to the oral phase of swallowing and speech articulation via palatal and alveolar arch integrity. Failure to account for each of these variables when composing an overall reconstructive strategy may result in significant quality of life issues.

Total palatomaxillary reconstruction presents surgeons with the difficult tasks of re-establishing a complex 3-dimensional form and providing vascular pedicle reach into the neck. The challenge of reconstruction increases with the amount of vertical and horizontal bone loss and rises to a different order of magnitude when orbital walls and/or floor are also absent.

Numerous techniques have been used to reconstruct maxillary defects. Over the last decade, contouring of various soft-tissue and bony free flaps including fibula, scapula, rectus abdominis, radial forearm, anterolateral thigh, and latissimus dorsi have gained popularity for maxillary reconstruction.¹ All of these free flaps have been noted for their advantages and disadvantages.² The scapular free flap has been the technique of choice for reconstructing total maxillectomy defects owing to its multiple skin paddle potential and ease of soft-tissue mobility around the bone.^3- 4 The fibula free flap has shown promise for reconstruction of lower palatal and alveolar defects with the advantage of allowing for osseointegrated dental implants but has been cited for having limited application for total maxillectomy defects including the orbital floor and greater than 50% of the palate and alveolar arch.⁵

This article describes a surgical technique using the fibula free flap for reconstruction of total maxillectomy and orbital defects, which provides both excellent aesthetic and functional results.

A retrospective review of cases performed at the Cleveland Clinic between 2005 and 2010 was performed. During this time, 7 patients with total maxillectomy defects (age range, 18-72 years) including greater than 50% of the palate, alveolar arch, and lower orbit (Brown 3a and 3b defects) were reconstructed using a layered fibula free-flap reconstruction technique.⁶ This retrospective study was approved by the institutional review board of the Cleveland Clinic.

All patients underwent total maxillary and inferior orbital reconstruction at the time of tumor resection. A layered fibula technique was applied using 3 to 5 bone segments. Simultaneous orbital reconstruction was performed in all patients using vascularized bone and vascularized fascia flap underlay. Titanium mesh was anchored to native bone and fibula and used for orbital floor and lower wall reconstruction in 5 patients. Vascular anastomosis to the ipsilateral facial artery and vein was performed in all cases without the use of vein grafts. Six patients underwent postoperative radiation therapy, and follow-up ranged from 6 to 71 months (mean, 30 months).

Demographic information including patient age, sex, pathologic subtype, Brown classification, adjuvant therapy, complications, current status, and follow-up time is listed in the Table. There were no partial or complete flap losses. All patients returned to soft (no remaining dentition) or regular diets within 6 weeks of reconstruction. Aesthetic facial reconstruction with excellent midface symmetry was accomplished in all patients. Regarding orbital reconstruction, 1 patient had aesthetically significant enophthalmos; no patients experienced orbital movement restriction or diplopia postoperatively.

Additional complications included ectropion requiring tarsal strip repair (3 patients), native cheek skin breakdown after radiation with plate exposure (1 patient), nasal obstruction requiring flap debulking (2 patients), trismus requiring secondary coronoidectomy (1 patient), midface/orbital contour distortion following facial trauma (1 patient), and postoperative visual impairment due to retinopathy (presumed ischemic) (1 patient). Two patients have undergone placement of osseointegrated implants, and 3 additional patients are in the planning stages of dental rehabilitation.

Length of postoperative hospital stay ranged from 7 to 11 days, with a mean of 8.42 days. The first 2 patients in our series underwent tracheotomy with decannulation prior to discharge. As comfort levels with this procedure have increased, all subsequent patients have been treated with nasal trumpets, which provided the 2-fold benefit of airway protection and stenting of the reconstructed nasal airway. As a result, no further patients have required tracheotomy.

A 63-year-old woman diagnosed as having a large adenoid cystic carcinoma of the left maxilla required resection of the entire orbital rim, anterior floor and lower medial wall, body of the maxilla, and greater than 50% of the hard palate and alveolar arch (Figure 1). The approach was via lateral rhinotomy with Weber-Ferguson extension sparing the skin-soft tissues of the face. After excision, bony reconstructive templates consisting of carved sterile tongue depressors were used to design fibula segments to provide a bony scaffold that would restore the height (lip commissure to inferior orbital rim) and width (anterior alveolar arch remnant to malar prominence) of the maxillary defect using facial symmetry as a guide.

A fibula free flap was harvested from the left leg with a moderately sized, long skin paddle (7-cm width by 18-cm length). Maximum length of the fibula bone was harvested sparing 6 cm proximally and distally to maintain joint stability. Next, sterile tongue depressors were used to plan the 5 fibula segments necessary to achieve 3-dimensional aesthetic contour of the midface as well as restore the orbital defects and alveolar arch (Figure 2).

Double closing osteotomies were then created in the fibula to achieve the desired facial contour and maximize bone-to-bone contact. These were then plated into the patient with distal bone at the upper lateral limit of reconstruction (Figure 3). Of note, 7 cm of pedicle without adherent bone exist between segments 3 and 4 to achieve optimal pedicle and bone segment geometry. The distal fibula skin paddle was used to provide lining and closure of the palate (Figure 4). Proximally, the skin paddle was de-epithelialized and used to obliterate the maxillary cavity. The peroneal artery of the fibula and vena comitante were anastomosed to the facial artery and vein.

At a follow-up visit 5 years after surgery and postoperative radiation therapy, this patient had normal articulation and was eating a regular diet. In addition, she had no diplopia and was happy regarding her aesthetic appearance (Figure 5).

An 18-year-old woman with osteosarcoma of the left maxilla underwent resection following preoperative chemotherapy and was left with a similar defect to case 1, including partial involvement of the lateral nasal wall and a large inferior orbital floor and rim defect (Figure 6).

A fibula free flap was harvested from the left leg similar to case 1. In this case, the fibula skin paddle was de-epithelialized partially to allow obliteration of the space previously occupied by the maxillary sinus and to provide a vascularized underlay for the orbital floor (Figure 7). The skin graft to repair the fibula harvest site defect was taken from the fibula skin paddle to avoid a thigh donor defect.

The osteotomy segments were designed to achieve maximal aesthetic contour while providing orbital rim support and lateral nasal wall and alveolar arch reconstruction. In addition, owing to the large orbital floor defect, the fibula served as a rigid structure on which to place firm titanium mesh posteriorly to recreate the orbital floor (Figure 8 and Figure 9).

Four years later this patient was disease free with normal speech articulation. Her intraoral reconstruction including her palate and alveolar arch was stable, and she had obtained osseointegrated implants for dental rehabilitation (Figure 10). A postoperative panoramic radiograph (panorex) at her most recent follow-up visit demonstrated preservation and union of bony structure with implants in position at the reconstituted anterior alveolar arch (Figure 11).

The maxilla represents a critical functional and aesthetic component of the midface. Historically, prostheses were the mainstay of reconstruction, followed more recently by free-tissue transfer.^1- 2 The fibula free flap provides a reliable platform for reconstruction of lower maxillary defects, but its utility for orbitozygomatic support has been questioned.⁷ Using 1 free flap for reconstruction of the orbitozygomatic buttress, hard palate, and anterior alveolar arch while providing a framework for dental implants is ideal. The technique described herein, using a layered osteocutaneous fibula free flap, accomplishes these goals while maintaining swallowing and speech functions and providing excellent aesthetic contour.

The fibula free flap has several advantages during maxillary reconstruction. First, harvesting of the fibula free flap can be accomplished simultaneously with cancer extirpation, thereby shortening operative time and facilitating a 2-team extirpation and reconstruction approach. In addition, patient positioning during the harvest does not compromise the ablative surgeon's efforts. Second, the fibula provides excellent bone stock and significant length of bone. This allows for creation of multiple independent segments, each designed to restore the complex contour of both orbital and maxillary defects, yet maintain vascular reach to neck vessels without the use of vein grafts. In addition, bony restoration of the anterior alveolar arch permits subsequent placement of secure osseointegrated dental implants.

Several key aspects of the method described are worth noting. The critical anchor points for the fibula in the technique described are the plating portions to the remnant zygoma (or zygomatic arch) and the remnant contralateral alveolar arch. These 2 rigid structures provide the bony foundation necessary to support the fibula free flap during maxillary reconstruction and provide for bone union to maintain long-term stability. Plating also spans the ascending process of the maxilla to the nasal bones when possible, but this buttress provides less support, given inherent limitations of nasal bone strength.

Notably, the nonanatomic lower bony reconstruction aims to provide sufficient anterior arch to support implants for stable prosthetic rehabilitation, and no attempt is made to reconstruct the posterior arch or articulate with the pterygomaxillary buttress for several reasons. First and most importantly, the pterygoid plates are included in the oncologic resection of the majority of cancer cases in our institution. Second, posterior displacement of the proximal bone segment would undermine facial contour correction and also require further pedicle reach and complicate already difficult pedicle geometry. Third, we believe that complete obliteration of the maxillary sinus and underlay of orbital floor construct with vascularized flap is a key to successful postoperative healing and minimization of long-term complications; articulation of the fibula segment posteriorly cannot be accomplished simultaneously. Lastly, we do not believe that the pterygomaxillary buttress provides reliable rigid fixation.

Although no reconstructions required vein grafts in this series, pedicle length and geometry are among the greatest challenges in this technique. If facial vessels are to be used for anastomosis, reconstruction begins with the upper lateral segment and proceeds lateral to medial superiorly then medial to lateral inferiorly as the pedicle passes in a subcutaneous tunnel into the neck. Communication with the extirpative surgeon is essential for maintenance of recipient vessels. In all of our cases, the facial artery and vein were used as donor and recipient vessels, either originating within the soft tissues of the cheek or just inferior to the body of the mandible. For the latter, a minimal access (3-cm incision) approach is effective in minimizing required pedicle reach when neck dissection is not performed. Special attention must be given to avoid kinking of pedicle vessels; removal of several centimeters of intersegmental bone may be necessary to allow folding of different fibula osteotomy segments for appropriate contouring.

Orbital reconstruction requires the provision of bone to restore aesthetic rim contour, to support the lower lid to minimize ectropion risk, and to act as an anchor point for mesh reconstruction of the remaining defect. The latter process does not attempt to recreate contour of absent orbital walls (if medial and/or lateral walls are included), but rather to restore orbital volume relationships to maintain globe position and function. Critically, vascularized tissue coverage of the orbital plate is provided with the proximal portions of the cutaneous paddle, and the underlying maxillary sinus volume defect is completely obliterated with this tissue, which then drapes inferiorly to restore palatal or gingivobuccal continuity. The medial aspect of this flap also mucosalizes to the restored lateral nasal wall.

Several adjunctive procedures may be necessary during the time of reconstruction or postoperatively including lower lid-tightening procedures to avoid or correct ectropion, dacryocystorhinostomy, and debulking or recontouring of the cheek soft-tissue envelope. Proximity of the lateral reconstruction to the coronoid process of the mandible may necessitate its removal to allow for full mandibular excursion.

As with all extensive facial reconstructions, aggressive soft-tissue suspension on closure is important to minimize ectropion risk and midface ptosis. However, given the extensive orbital reconstruction and aggressive volume correction during flap reconstruction, simultaneous lid-tightening procedures were avoided to minimize risk of exacerbation of orbital edema or compression. Typically, ectropion was either corrected as a postoperative office procedure under local anesthesia or at the same setting as oral flap debulking if this was required to optimize the milieu for dental implant placement.

Lastly, though the senior author (M.A.F) initially used synthetic models to plan reconstructive techniques for maxillary defects, subsequent cases have not used these models because the size of tumor extirpation defects can often be unpredictable and the utility of modeling did not justify the cost. Maintenance of facial symmetry while restoring critical bone loss and contour (orbital rim, midface, and alveolus) provides the guide for template creation.

In conclusion, the goals of complex maxillary reconstruction focus on maintenance of speech, swallowing, dentition, orbital support, and aesthetic contour. Accomplishing this requires adequate bone stock, flexibility of shape, a mobile cutaneous or fasciocutaneous paddle, and adequate pedicle reach. The technique using a layered fibula osteocutaneous free flap achieves these goals and should be considered an excellent option and potential method of choice for reconstructing large maxillary defects with or without orbital involvement.