3. Layout
Anatomy of Maxilla
Goals of Maxillary Reconstruction
Classification of Maxillectomy Defects
Planning and evaluation for reconstruction
Reconstruction options
Defect Specific Reconstruction
5. Goals of Maxillary Reconstruction
1. Obtain a healed wound.
2. Restore palatal competence and function.
3. Restore normal mastication and deglutition.
4. Support the eye.
5. Maintain a patent nasal airway.
6. Support and suspend facial soft tissues.
7. Restore the midfacial contour.
7. Classification
(Santamaria & Cordeiro or MSKCC)
Type I (Limited maxillectomy)
– One or two walls, preservation of
palate
Type II (Subtotal maxillectomy)
– Lower 5 walls, preservation of
orbital floor
8. Classification
(Santamaria & Cordeiro or MSKCC)
Type III (Total maxillectomy)
– Resection of all six walls
– Orbital preservation (IIIa)
– Exenteration of orbital
contents (IIIb)
17. Obturators
Advantages
– Shortens operative time
– Shortens post op hospital stay
– Better visualization for surveillance
– Helps in speech and swallowing
– Restores aesthetics
18. Obturators
Disadvantages
– Hypernasal speech
– Regurgitation of food and fluids into nasal cavity
– Difficulty maintaining hygiene
– Need for repeated adjustments
19. Staging of Obturators
Surgical Obturator
– Placed at surgery
– Restores palatal contour
– Retains surgical pack
– Reduces wound
contamination
– Removed in 10-14 days
(By Dr.Muslim Khan)
20. Staging of Obturators
Interim Obturator
– Used until healing completed
– Addresses both functional and aesthetic needs
Definitive Obturator
– Final prosthesis
– 6-12 months after surgery
– Problems corrected
24. Surgical Reconstruction
Local Flaps
Buccal Fat Pad Flap
– Rich vascular supply
– Commonly used for defects of
posterior maxilla and soft
palate
– Adequate for defects up to 4cm
– Epithelialized in about 2-3
weeks
25. Surgical Reconstruction
Local Flaps
Palatal Island Flap
– versatile and reliable local
flap
– greater palatine artery
– can be rotated 180 degree on
pedicle
– can cover up to 15cm defects
(By Dr.Muslim Khan)
26. Surgical Reconstruction
Local Flaps
Nasolabial Flap
– closure of oroantral fistulae and
defects of anterior floor of mouth
– facial and angular arteries
– up to 5cm width flap
– limited donor tissue, facial scarring
and second surgery (By Dr.Muslim Khan)
27. Surgical Reconstruction
Local Flaps
Tongue Flap
– closure of residual cleft and fistulae
of hard palate
– lingual artery
– donor site morbidity, limited arc of
rotation, and small size
(By Dr.Muslim Khan)
30. Surgical Reconstruction
Regional Flaps
Submental Flap
– fasciocutaneous or faciosubcutaneous
– submental branch of facial artery
– provides 7-15cm tissue
– reconstruction of anterior defects
– hidden donor site scar
31. Surgical Reconstruction
Regional Flaps
Temporoparietal-galea Flap
– Temporoparietal fascia and
subcutaneous
musculoaponeurotic
system(SMAS)
– superficial temporal artery
– used for less bulky
reconstruction such as coverage
of plates and bone
– thin, lack of hair, well
camouflaged donor site
32. Surgical Reconstruction
Regional Flaps
Temporalis Flap
– fan shaped
– deep temporal arteries and middle
temporal artery
– direct access through defect (high
maxillectomies)
– access via infratemporal fossa(low
maxillectomies)
(By Johan Fagan)
33. Surgical Reconstruction
Regional Flaps
Temporalis Flap
– outer table of temporal bone can be taken
– ease, proximity,hidden incision,reliable blood
supply
– potential facial nerve injury and temporal
hollowing
34. Surgical Reconstruction
Regional Flaps
Platysma Flap
– Myocutaneous
– submental and facial
arteries
– thin, pliable and easily
harvested
– less reliability (By Dr.Muslim Khan)
36. Surgical Reconstruction
Regional Flaps
Sternocleidomastoid Flap
– myocutaneous or myo-osseus
– occipital, superior thyroid and supra scapular
arteries
– proximity to defect site, lack of requirement for
another incision
37. Surgical Reconstruction
Regional Flaps
Trapezius Flap
– Myocutaneous
– may be used as composite flap with a portion of
clavicle or scapula
– transverse cervical artery, occipital, posterior
intercostal and dorsal scapular arteries
– adequate volume of well vascularized tissue
40. Surgical Reconstruction
Microvascular Free Flaps
Radial Forearm Free Flap
– faciocutaneous or
osteofasciocutaneous
– radial artery
– up to 16cm of vascularized bone
segment
– long pedicle and reliable
– good size vessels
– fracture of remaining radius
( by Brian Dickson M.D)
41. Surgical Reconstruction
Microvascular Free Flaps
Rectus Adominus Flap
– Large skin surface
– Large volume of soft tissue
– Can be divided into 2-3 flaps
– Upto 18-20cm pedicle length
– Best for type 3 and 4 defects
42. Surgical Reconstruction
Microvascular Free Flaps
Fibula Osteo-cutaneous Flap
– peroneal artery and vein
– provides greatest length of
available bone
– usual pedicle length about 6-7cm
– provides sufficient bone for implant
placement
43. Surgical Reconstruction
Microvascular Free Flaps
Scapular Osteo-myocutaneous Flap
– circumflex scapular artery
– pedicle length up to 20cm
– average thickness of bone about 3cm
– sufficient for implant placement
– inferior quality bone
– can be oriented vertically as well as horizontally
44. Surgical Reconstruction
Microvascular Free Flaps
Vascularized Iliac Crest
– most successful
– deep circumflex iliac artery(DCIA)
– accompanying internal oblique
muscle provides excellent soft
tissue
– less donor site morbidity
46. Surgical Reconstruction
Avascularized Bone Grafts
Requirements Of Ideal Bone Grafts
– Stability
– Potential for graft integration
– Available in large quantities
– Moldable
No such ideal graft is available
47. Surgical Reconstruction
Avascularized Bone Grafts
Commonly used bone grafts
– Calvarial bone graft
– Iliac crest bone graft
– Rib graft
– Fibula bone graft
– Scapula bone graft
49. Surgical reconstruction
Titanium Mesh
Alternative in patients where bone
grafts are not available or disallowed
Can also be used in combination
with bone grafts or hydroxyapatite
cement
Biocompatible
Readily available
No donor site morbidity
52. Defect Specific Reconstruction
Palate and Alveolar Arch Defects
(Brown class1)
– greater functional than aesthetic
consequence
– may be allowed to heal by secondary
intention
– palatal island flap best suited
53. Defect Specific Reconstruction
Inferior Maxillectomy (Brown
Class 2,MSKCC Type II)
– Obturators
– Temporalis flap with or without
calvarial bone
– Fasciocutaneous Radial Forearm
Flap
– Osteocutaneous Radial Forearm
Flap
– Fibula Osteocutaneous Flap
– Scapula Osteocutaneous Flap
– Vasculariced iliac crest
54. Defect Specific Reconstruction
Bilateral Inferior Maxillectomy
– only orbital supporting bone and zygomatic arch
remain
– Scapular osteocutaneous free flap and
osseointegrated implants(min 4)
– Prosthesis
55. Defect Specific Reconstruction
Total Maxillectomy with Orbital
Preservation (Brown class 3,
MSKCC Type IIIa)
– reconstructive challenge
– Obturator
– Temporalis muscle flap
– Vascularized Osteocutaneous
free flaps are best
– followed by implants and
prosthesis
56. Defect Specific Reconstruction
Total Maxillectomy with Orbital
Exenteration (Brown Class 4,
MSKCC Type IIIb)
– Prosthesis
– prosthesis with myocutaneous
flap e.g. rectus abdominus
– iliac crest myo-osseous flap
– Scapular osteocutaneous free
flap
– dental implants
57. Defect Specific Reconstruction
Orbitomaxillctomy (MSKCC
Type IV)
– simpler to reconstruct
– no horizontal bone must be
reconstructed
– myocutaneous rectus
abdominus suitable to fill the
defect
