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Midface Reconstruction With the Fibula Free Flap
Neal D. Futran, MD, DMD;
Jeffrey Trad Wadsworth, MD;
Douglas Villaret, MD;
D. Gregory Farwell, MD
Arch Otolaryngol Head Neck Surg. 2002;128:161-166.
ABSTRACT
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Objective To evaluate the use, indications, and outcomes of the fibula osteocutaneous
free flap when reconstructing the midface.
Design Retrospective review of a case series.
Setting Tertiary referral center.
Patients We evaluated all patients requiring midface reconstruction after tumor
resection between January 1, 1994, and January 1, 2000. Twenty-seven individuals
who lacked sufficient retentive surfaces and/or teeth to support a conventional
prosthesis were offered vascularized bony reconstruction.
Interventions All patients underwent fibular osteocutaneous free flap reconstruction
of the midface: 16 primarily, 11 secondarily.
Main Outcome Measures Success of free tissue transfer, perioperative complications, oral diet,
speech, type of dental reconstruction, and cosmesis.
Results Twenty-six of 27 flaps survived. Four patients had wound complications
managed successfully with local wound care. Fourteen patients achieved a regular
diet and 13 patients maintain a soft diet. Eighteen patients had osseointegrated
implants placed, and 14 patients used an implant-borne prosthesis. Cosmetic
results were judged to be excellent in 14 patients; good in 8; fair in 4;
and poor in 1.
Conclusions Use of the fibula osteocutaneous free flap to reconstruct the midface
is highly reliable and our flap of choice for lower maxillary defects requiring
bony reconstruction. However, when orbitozygomatic support is the primary
objective, the utility of this flap is limited. Because of the complexity
of this procedure, the choice of midface reconstruction technique should be
individualized for each patient.
INTRODUCTION
MIDFACIAL DEFECTS arising from tumor extirpation or trauma may involve
any portion of the central area of the face, including the palate, cheek,
maxilla, orbit, and/or nose. Also, loss of these key structures has significant
functional and cosmetic consequences. These may include the creation of large
oronasal and oromaxillary fistulae, loss of significant tooth-bearing segments,
loss of lip, cheek, and eye support, and loss of midface projection. In addition,
oral alimentation and speech may be impaired.
The goals of reconstructing these defects include (1) consistently obtaining
a healed wound; (2) restoring palatal competence and function (separation
of the oral and sinonasal cavity); (3) supporting the orbit or filling in
the orbital cavity in cases of exenteration; (4) obliterating a maxillary
defect; (5) restoring facial contours; and (6) recreating a functional dentition.1 Obturation with maxillary prostheses has been the
traditional method of rehabilitation for these patients. However, over the
past 10 years, microvascular free tissue transfer techniques have greatly
expanded the surgeon's ability to reconstruct this challenging area with a
variety of composite tissues. Microvascular free tissue reconstruction allows
for the transfer of adequate amounts of soft tissue and/or bone in a single-stage
procedure without the limitations of pedicle length or flap geometry. Although
many authors advocate soft tissue reconstruction of these defects,2-8
functional dental rehabilitation cannot be achieved in all cases. When there
is significant loss of tooth-bearing segments, reconstruction of the defect
with vascularized bone is necessary to provide a suitable substrate for osseointegrated
implants and a subsequent dental prosthesis.
The fibula osteocutaneous free flap has enjoyed wide success in reconstructing
the mandible,9-10 but few data
are available on using this flap in reconstructing midface defects. We present
a series of patients who underwent fibula free flap reconstruction of the
midface and evaluate the success and functional outcomes of this technique.
PATIENTS AND METHODS
PATIENT POPULATION AND ASSESSMENT TOOLS
A retrospective review was done on patients who underwent microvascular
free flap reconstruction of the midface from January 1, 1994, to January 1,
2000. All 62 patients requiring maxillary resection and/or reconstruction
were evaluated preoperatively by the surgical team and maxillofacial prosthodontist.
Eleven patients underwent primary maxillofacial prosthetic reconstructions;
17 underwent soft tissue free flap reconstruction with or without cranial
bone; 3 patients received scapular flaps; 4 with small anterior maxillary
defects underwent radial forearm osteocutaneous free flap reconstruction.
In those patients without sufficient retentive surfaces and/or teeth
to support a conventional prosthesis, fibula osteocutaneous free flap reconstruction
was offered. Twenty-seven patients in this category underwent fibula osteocutaneous
free flap reconstruction. Preoperative plaster models were made of the maxillary
and mandibular arches. The patients were evaluated for length of primary flap
ischemia, perioperative complications, and adequate wound healing. Follow-up
ranged from 6 months to 6 years (mean, 26 months). The patients were evaluated
postoperatively for type of diet (comparison of preoperative to postoperative
diet), speech intelligibility, cosmesis, and dental restoration. Cosmesis
was judged individually by the patient, significant other (when applicable),
and physician on a scale of 1 to 10. The results were averaged for a final
score, and ratings were applied as follows: 1.0 to 3.0 indicated poor results;
3.1 to 6, fair; 6.1 to 8, good; and 8.1 to 10, excellent.
SURGICAL TECHNIQUE
Figure 1 shows a preoperative
facial view and panoramic radiograph of a representative patient. The fibula
flap was harvested in the standard fashion as described by Hidalgo.9 All bony buttresses available for contact with the
fibula flap in the midface were exposed (Figure 2A). The upper neck vessels were isolated, and frequently
the submandibular gland was removed for access. A subcutaneous tunnel was
made over the mandible into the maxillary defect to a width of 2 finger breadths
to allow the vascular pedicle to easily pass through. The flap was then transferred
to the recipient site. The leg wound was closed primarily in 23 cases. Four
patients required skin grafting to avoid tightness of the closure.
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Figure 1. A, A 55-year-old man 14 years
after surgery and radiation therapy for maxillary alveolar carcinoma. Cosmesis
score, 5.7 (mean scores for the patient, his significant other, and his physician,
5, 6, and 6, respectively). B, Panoramic radiograph of maxillary defect.
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Figure 2. A, All bony buttresses available
for contact with the fibula flap in the midface were exposed. B, Osteotomies
are made to shape the fibula into the maxillary alveolar shape.
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Osteotomies were then made in the fibula bone to recreate the missing
tooth-bearing segment (Figure 2B).
The maxillary model was used as a guide for placement of the osteotomies.
In those cases where zygomatic reconstruction was necessary, an additional
osteotomy was made to recreate the buttress and abut the bone to the residual
zygoma. The osteotomies were made distally to proximally so that any excess
proximal bone could be discarded, thus increasing the pedicle length. The
pedicle was transferred through the subcutaneous tunnel into the neck, and
1.3-mm titanium miniplates (Synthes Maxillofacial, Paoli, Pa) were used to
fix the fibula to the residual bony buttresses (Figure 3A). A minimum of 4 plates were placed to achieve maximum
stability. If the vascular pedicle was noted not to be long enough to reach
fully to the neck vessels, vein grafts were added to the peroneal vessels
on a back table prior to final bony fixation. The flap was then fixed to the
maxilla.
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Figure 3. A, Fibula fixed to residual zygoma
and maxillary buttress with 1.3-mm titanium plates. B, Soft tissue flap inset.
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The soft tissue was contoured and then sutured in place to seal the
palate and fill in soft tissue contours (Figure 3B). If the orbital floor has been resected, fascial or Alloderm
(LifeCell Corp, Branchburg, NJ) slings were placed to support the orbit. Once
this was completed, the microvascular anastomoses were performed, and final
wound assessment and closure were done. Osseointegrated implants were placed
3 to 6 months after this initial procedure (Figure 4 ). They were uncovered after 3 to 4 months, and the maxillary
prosthesis was completed (Figure 5).
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Figure 4. A, Osseointegrated implants in
place 5 months after primary procedure. B, Panoramic radiograph after implant
placement.
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Figure 5. One-year postoperative result.
Postoperative cosmesis score, 8.7 (mean scores for the patient, his significant
other, and his physician, 8, 9, and 9, respectively).
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RESULTS
Twenty-seven patients underwent fibula osteocutaneous free flap reconstruction
of maxillary defects. Sixteen were done primarily at the time of tumor extirpation.
Eleven were performed secondarily. The tabulation below lists the patient
characteristics:
All patients were missing at least 50% of the maxillary tooth-bearing
segment. Seven patients also had loss of the zygoma and infraorbital rim and
floor. The primary flap ischemia time ranged from 2 to 5 hours (mean,
3 hours 45 minutes). All flaps were noted to be viable at the completion of
the surgical procedure. Nine patients required vein grafts to lengthen the
vascular pedicle.
The following tabulation lists the perioperative complications:
There was 1 patient with total flap failure. This patient was noted
to have arterial insufficiency 24 hours after the procedure. Reexploration
in the neck revealed patency in both the arterial and venous anastomoses;
however, the flap was clearly not viable. This patient had vein grafts placed
during the primary procedure, and it was ultimately noted that the patient
had occlusion at the anastomosis between the peroneal artery and vein graft.
This anastamosis was buried under the cheek, and attempts at salvage were
unsuccessful. This patient went on to have reconstruction with a maxillary
obturator.
Two patients developed venous occlusion within 36 hours of procedure
completion. A hematoma was evacuated in 1 patient resulting in resolution
of the venous occlusion. The second patient had kinking of the vein. This
was realigned, and the flap was salvaged successfully. Four patients developed
partial wound dehiscence in the early postoperative period, and these all
resolved within 21 days with local wound care. One patient underwent additional
soft tissue reconstruction with a rectus abdominus free flap to improve soft
tissue contour in the infraorbital and zygomatic area. Three patients developed
lower lid ectropion and required secondary local procedures for correction.
The following tabulation summarizes functional rehabilitation results:
All osseointegrated implants were placed secondarily. Eleven patients
can eat all food consistencies, similar to their preoperative diet. Three
patients actually improved from a preoperative soft diet to a postoperative
regular diet. Of the 13 patients who tolerated a soft diet, 8 ate all food
consistencies preoperatively, while 5 had maintained a soft diet. Although
formal speech evaluations tions were not performed, all patients were intelligible
on the telephone. In those patients who had inferior maxillary defects with
preservation of most of the zygomatic prominence, cosmesis was judged to be
excellent. In those patients with loss of most of the zygomatic prominence
and/or infraorbital rim and floor, cosmesis was noted to be fair, mainly owing
to flattening in this area. In the patient who ultimately required a maxillary
obturator, cosmesis was judged to be poor.
COMMENT
Maxillary defects resulting from tumor extirpation or trauma represent
a challenging dilemma for reconstructive surgeons. The choice of reconstruction
depends on the extent and anatomic locations of bony and soft tissue loss,
which varies from patient to patient. Common reconstructive goals, however,
include consistently obtaining a healed wound, sealing the palate and separating
the oral and sinonasal cavities, obliterating the defect, supporting the orbit,
and restoring facial contours.1 Restoration
of functional maxillary dentition can optimize speech, swallowing, and cosmesis.11-13
No single reconstructive technique has been described to achieve all
of these goals. Though traditionally these defects were obturated by a maxillary
prosthesis,14-15 recent advances
in microvascular free tissue transfer allow the potential for single-stage
autologous tissue maxillary reconstruction.1-3,5-6,16
Initially, soft tissue flaps provided adequate bulk and a long vascular
pedicle to reach recipient vessels in the neck. Shestak et al4-5
found the latissimus dorsi free flap to be very versatile. In all patients
reported, the palates were sealed and aesthetic recontouring of the face and
cheek soft tissues was achieved. The rectus abdominus flap demonstrates similar
attributes and postoperative results.6-8
These soft tissue reconstructions, however, do not address the maxillary bony
skeleton, particularly the orbit, zygoma, and alveolus.
The scapula osteocutaneous free flap offers the potential to address
these needs.17-20
This flap is advantageous because the soft tissue component can be rotated
around the bone stock with greater freedom than with other composite flaps.
It is particularly useful in defects when both the orbital floor/zygoma and
palate must be reconstructed. If the angular branch of the thoracodorsal vessel
is included in the flap harvest, both the tip and lateral border of the scapula
can be harvested.
When appropriate osteotomies are made, the palate and infraorbital regions
can be restored.21 Uglesic et al22
have described an osteomyocutaneous free flap based on the subscapular system
of flaps for reconstruction of the total maxillectomy defect with orbital
exenteration. This type of flap has good bone stock that can be used for the
infraorbital area and palate, a muscle component (latissimus dorsi) for cavity
obliteration, and a skin component fulfilling soft tissue deficits of the
face, cheek, and palate. The scapula, however, may not always be suitable
for placement of osseointegrated implants.23-24
Further disadvantages include inability to harvest the flap simultaneously
with the extirpative procedure; difficulty in orienting the bone to provide
orbit, zygoma, and alveolar reconstruction; and the relatively short pedicle
length.
When only the soft tissue of the palate is reconstructed, conventional
dentures provide functional dentition if adequate teeth and/or retentive surfaces
are available to provide stability.13 In many
cases, soft tissue reconstruction alone results in a flatter surface of the
maxillary arch than in the native condition. Blunted neoalveolar contours
are created, and loss of depth occurs in the gingivosulcus and palatal arch.
This results in a "trampoline-like" surface so that the reconstructed maxilla
functions poorly to retain the denture. Osseointegrated implants can provide
superior retentive areas to allow the achievement of a functional dentition.13, 25
The fibula osteocutaneous free flap has provided these attributes in
reconstruction in the oromandibular complex.9-10
Multiple case reports have described the use of this flap to reconstruct a
variety of maxillary defects.1, 11-12,26-33
These reports describe the ease with which the flap can be harvested and the
excellent bone stock and soft pliable skin paddle that can be used for either
intraoral or cutaneous reconstruction. In addition, the vascular pedicle may
be lengthened to avoid the need for vein grafts by removing the excess proximal
bone.
In the largest series, Foster et al12
used the fibula free flap in 5 patients. It was principally used when the
amount of bone loss exceeded the hemipalate, but it could also be contoured
to additionally reconstruct the orbital rim. Our experience has shown this
flap to be extremely versatile as well. The principal determination in the
choice of this flap was the extent of the palatal defect. After consultation
with the maxillofacial prosthodontist, if the residual palate and/or dentition
was insufficient to support a conventional prosthesis, the fibula was selected
so that osseointegrated implants could be placed. In the 20 of 27 patients
whose defects were limited to the inferior maxilla, excellent results were
obtained for speech, swallowing, and cosmesis. The bone provided bulk and
skeletal support, while the soft tissue was easily rotated to resurface the
palate and lower malar areas when necessary.
We also found, however, that as the need for reconstruction of the zygomatic
complex, infraorbital rim, and floor increased, this flap was limited in its
ability to restore the entire maxillary form. The technical difficulties increased
as well. It is difficult to osteotomize and orient the bone to both restore
the palate and fill the infraorbital area. Even with the harvest of additional
soleus to provide soft tissue bulk, there is somewhat limited rotation of
the skin paddle to resurface the palate as well as provide zygomatic and infraorbital
contour. This resulted in cheek flattening and ectropion in 4 of the 7 patients
with this type of defect.
Secondary lower lid procedures were necessary in 3 patients owing to
persistent ectropion. These patients did, however, have the same excellent
speech and swallowing function as those with more inferior defects. Five of
these 7 patients required vein grafts for the pedicle to reach the neck recipient
vessels. The 1 flap failure was due to kinking of the peroneal artery and
anastomosis with the vein graft caused by acute angulation at the level of
the zygoma. This anastomosis was buried under the subcutaneous tunnel and
could not be salvaged.
To provide maximum bone to reconstruct these maxillary defects, the
iliac crest myo-osseous flap provides an excellent source of tissue. Brown34 and Brown et al35
presented 3 cases of reconstruction using this flap and had favorable functional
results. The disadvantages of using this flap and the maxilla are its potentially
excessive bulk, limited soft tissue mobility in relationship to the bone,
and short pedicle length. Freije et al36 advocated
the use of dual free flaps to reconstruct the face. Although success has been
reported in a small series of patients, the advantages of 2 separate free
flaps have not been demonstrated. Despite the increased complexity and amount
of time involved in this procedure, it has not proven more beneficial than
the use of a properly designed single free flap, which provides excellent
bone stock and pliable soft tissue.
Most recently, Cordeiro et al2 and Cordeiro
and Santamaria3 have elegantly described the
use of soft tissue free flaps with nonvascularized (rib, calvarium) and vascularized
(radius) bone to reconstruct a variety of maxillary defects. In these series,
particular attention was paid to osseous reconstruction of the orbit and zygoma,
and excellent cosmetic results were achieved. The palate, however, was sealed
with soft tissue only, although 43 of 46 patients tolerated an unrestricted
or soft diet. Thirty-nine of 46 patients had nearly normal or normal speech,
while 6 more had intelligible speech. Only 15 of 46 had a useable prosthesis,
but the authors stated that this was not considered a requisite to assist
chewing function.
Our experience has shown that the ability to recreate a functional dentition
led to improved swallowing and cosmesis in all cases. In those patients who
have yet to receive a maxillary prosthesis, attainment of a soft diet was
the rule, and limited data suggest lack of upper teeth leaves some patients
self-conscious about their appearance.
It is clear from the literature and our series that no single flap or
technique is sufficient to reconstruct complex maxillary defects in all cases.
The fibula osteocutaneous free flap has excellent utility for primarily alveolar
and palatal defects and when the need for implant-borne prostheses is paramount.
When orbitozygomatic support is the primary objective, the utility of the
fibula free flap is limited, and other techniques described may be more appropriate.
Future directions in maxillary reconstruction will be to combine these techniques
in each individual defect to achieve the optimum result for the patient. The
complexity of the techniques should always be matched to the desired goals
of the patient as well as the needs of the defect.
AUTHOR INFORMATION
Accepted for publication September 4, 2001.
Presented at the Fifth International Conference on Head and Neck Cancer,
San Francisco, Calif, August 1, 2000.
Corresponding author: Neal D. Futran, MD, DMD, University of Washington
School of Medicine, Department of Otolaryngology–Head and Neck Surgery,
Box 356515, Seattle, WA 98195-6515 (e-mail: nfutran{at}u.washington.edu).
From the Departments of Otolaryngology–Head and Neck Surgery
at the University of Washington School of Medicine, Seattle (Drs Futran, Wadsworth,
and Farwell), and at the University of Florida, Gainesville (Dr Villaret).
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