The Layered Fibula Osteocutaneous Flap Sets New Standard For Advanced Maxillary Cancers

By Michael A. Fritz, MD

Surgical defects created during total palatomaxillectomy for tumor resection present surgeons with one of their most daunting challenges in facial reconstruction. The maxillary bone provides height and width to the midface and contributes greatly to the overall aesthetic facial contour. From a functional aspect, the maxilla provides support to the orbital contents, serves as a bony framework for dentition and 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 can result in significant quality-of-life issues.

Total palatomaxillary reconstruction poses difficult tasks in terms of re-establishing a complex three-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 arguably it rises to a different order of magnitude when the orbital walls and/or floor are also absent.

Previous Techniques Have Come Up Short

Numerous techniques have been employed to reconstruct maxillary defects. Over the past decade, contouring of various soft-tissue and bony free flaps — including fibula, scapula, iliac crest, rectus abdominus, radial forearm, anterolateral thigh and latissimus dorsi flaps — has been endorsed for maxillary reconstruction. However, no technique has consistently addressed all aesthetic and functional deficits following total maxillectomy, particularly when a large component of the orbit is involved.

The fibula free flap has been advocated for reconstruction of lower palatal and alveolar defects with the advantage of allowing for osseointegrated dental implants. It has been cited, however, for having limited application for total maxillectomy defects, including those in the orbital floor, the alveolar arch and more than half of the palate.

A Novel Technique for Orbitomaxillary Reconstruction

Using a layered fibula free-flap design, we have developed a technique that addresses both form and function in total maxillary and orbital reconstruction. By modifying the fibula to address orbitozygomatic defects superiorly and palatal-alveolar absence inferiorly, we have adapted the fibula flap to (1) replace midface and orbital contour and (2) provide a platform for dental rehabilitation.

This method of reconstructing large additional defects of the orbital walls and floor allows us to preserve normal eye appearance and function. Further adaptation of our recently published technique1 has allowed us to reconstruct defects that have included up to three of the four orbital walls.

The layered fibula technique employs three to five bone segments with double-closing osteotomies to establish normal curvature of the orbital rim, zygoma and alveolar arch. The distal bone segment articulates with the remnant of the zygoma superolaterally, and the bony reconstruction sweeps medially to the nasomaxillary buttress and then falls inferomedially to connect to the medial remnant of the alveolar arch. The construct then sweeps inferolaterally toward the first segment and the inferior aspect of the zygoma. The bone segments are stabilized with titanium reconstruction plates (Figure 1).

Figure 1. Diagram depicting the layered fibula construct in place to repair an extensive orbitomaxillary defect. This demonstrates the nonanatomic orientation of titanium mesh and the complete obliteration of the cavity with vascularized tissue from the free flap

Simultaneous orbital reconstruction is performed using titanium mesh anchored to native bone (i.e., the remaining orbit and skull base) and fibula and is utilized for orbital floor and wall reconstruction. The orbital mesh construct is secured in a nonanatomic fashion to restore periorbital volume loss from resection; this prevents postoperative enophthalmos. Importantly, the vascularized soft-tissue component of the fibula flap completely obliterates the maxillary sinus and surrounds the mesh to prevent movement or exposure over time. The cutaneous paddle replaces the palatal defect. Vascular anastomosis to the ipsilateral facial or angular vessels is performed.

Surgical Outcomes

We have used this reconstructive technique in 12 patients, with follow-up ranging from nine months to seven years (outcomes of the first seven cases are detailed and illustrated in our previous publication1). Eight patients underwent postoperative radiation therapy. There were no partial or complete flap losses. Patients with no dentition began a soft diet within six weeks of reconstruction, while the rest returned to their regular diets. Aesthetic facial reconstruction with midface symmetry and unrestricted eye function was accomplished in all patients, as demonstrated by the photos in the case study sidebar and in Figure 2.

Figure 2. Photos showing the surgical defect and post-reconstruction outcome with dental prosthesis in place at two years after treatment of adenoid cystic carcinoma. This patient had undergone a right total maxillectomy and resection of the lower three orbital walls as well as postoperative radiation therapy.

Case Study

A 55-year-old woman underwent resection of a right maxillary adenocarcinoma. Her defect included the entire medial orbital wall, rim and floor and the inferior aspect of the lateral wall. Orbital reconstruction was accomplished with titanium mesh anchored to the skull base and the remaining orbit; the mesh was articulated with the layered fibula at the rebuilt orbital rim. Follow up one year after radiation therapy demonstrated good eye position and midface symmetry.

Dr. Fritz (fritzm1@ccf.org) is a specialist in facial plastic and reconstructive surgery in the Head & Neck Institute.