Type 3b Extended Maxillectomy

The extended maxillectomy defect is a large-volume defect that includes the orbital contents and/or cheek skin. Aside from the usual requirements of soft tissue and bone after a subtotal maxillectomy, there is a need to cover (or obliterate) the eye socket and to reconstruct the often-extensive cheek defect. The inferior orbital rim is often also removed when the cheek skin is involved.

Patients undergoing maxillectomy with orbital exenteration are candidates for a bone-containing free flap. Only the scapular flap and iliac crest flap possess sufficient soft tissue bulk to close these defects effectively while providing adequate bone substrate for osseointegration. Multiple paddles can be created to close the nasal, palatal, and socket defects independently while completely obliterating the maxilla. The thickness of the flaps can be significant and, although fine for socket obliteration, this excessive bulk will cause nasal obstruction and a large roof-of-mouth mass. The iliac crest flap is a good solution since it provides adequate bone stock for both the neoalveolus and orbital rim, and the internal oblique muscle can be draped over the bone intraorally to provide a relatively thin covering (21). The skin component may be used for obliteration of the socket.

Extended maxillectomy with cheek skin excision (but not orbital exenteration) may be reconstructed with a bone-containing free flap to provide a substrate into which osseointegrated implants are placed for denture retention. Any of the common osseous free flaps are capable of closing this defect. For example, an osteocutaneous scapular flap can be used with the bone secured across the neoalveolus with a straight miniplate (Fig. 29). The skin components are used to cover the lateral nasal wall, cheek, and hard palatal defects. Unfortunately, the osseous free flaps do not have skin components that are a good match in terms of color and texture with natural cheek skin. Patients undergoing maxillectomy, orbital exenteration, and excision of overlying cheek skin are also candidates for a bone-containing free flap. Of the bone-containing free flaps, only the subscapular system and iliac crest osteo-myocutaneous flaps possess sufficient tissue volume and plasticity to reconstruct this

Figure 30 Tripartite myocutaneous rectus flap to reconstruct a complex three-dimensional extended maxillectomy defect.

extensive defect. The drawbacks to using the scapular flap include the need to turn the patient for flap harvest and the problems previously mentioned regarding excess bulk. In fact, the excessive bulk and small bone stock in the oral cavity often impede the placement of osseointegrated implants unless multiple shaping and debulking procedures are performed. The prognosis for these patients is poor and they may not desire or have sufficient survival time to complete the multiple revision procedures necessary for full oral rehabilitation. Palliation in these patients is of utmost concern. For this reason, a more expeditious method with lower potential donor site morbidity is chosen. The flap most often used in this circumstance is the myocuta-neous rectus abdominis free flap. It can be fashioned into a tripartite soft tissue flap that is folded to provide skin cover for the lateral nasal wall, hemipalate, cheek, and orbit while obliterating the antrum and socket (Fig. 30). This type of reconstruction is applicable to patients with extensive cheek resections with or without orbital exen-terations (Figs. 31, 32).

Figure 31 Patient with extended maxillectomy defect associated with a large cheek resection and orbital exenteration. Large tripartite rectus myocutaneous flap being sutured into place (C, cheek surface; N, nasal surface; P, palate surface).
Figure 32 Another patient with a similar defect to that shown in Figure 31: without orbital exenteration but with extension onto the upper lip (a). This patient was also reconstructed with a tripartite rectus flap (b).
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