KEY POINTS
- Midface reconstruction after tumour removal is a highly complex task.
This requires careful planning and as such techniques have continued
to evolve with time.
- Trainees should be aware of the options previously practised, as this
can still serve as a lifeboat when the gold standard is not possible.
- Reconstruction requires bone and soft tissue considerations, always
consider donor tissues and pedicle carefully and where to find
recipient vessels.
- Obturators and locorgeional flaps provide a poor solution. We consider
their use is best reserved for salvage and revisional cases, or when
patients comorbidities necessitate expedient surgery.
- Tissue engineering and 3D scaffolds/printing is an exciting prospect
to reduce donor morbidity and should be welcomed to provide patients
with a bespoke reconstruction.
Background
Today, microvascular surgery is an essential facet in the treatment
of head and neck defects from any cause. The functional morbidity,
aesthetic implications and impact on quality of life are universally
appreciated. Prosthetic devices and obturators are not well-tolerated by
patients and fall short in assisting with speech or mastication,
especially in the presence of an oronasal/antral communication.
Prior to addressing this clinical need in midface reconstruction, the
emphasis was largely placed on mandibular reconstruction and its
associated soft tissue defects1. There are several
reasons for this. The mandible in essence is largely a pillar, whereas
the anatomical features of the midface are highly complex with vital
neighboring structures creating its borders. The maxilla forms the
anterior aspect of the midface but bridges the floor of the orbit and
separates both oral and nasal cavities whilst housing the superior
dental arch. Indeed, prosthetic restoration (obturator) first described
in the 16th century by Ambroise
Paré2, arguably provide satisfactory results for Brown
class I and II defects3. Moreover, compared with
mandibular reconstruction, the technical challenges posed by midface
reconstruction include the consideration of a longer pedicle for
anastomosis to vessels within the neck. Vein grafts have been used and
increase the risk of microvascular failure4.
The ideal microvascular flap for the midface relies on a stable bony
construct providing adequate bone stock for dental implantation. Soft
tissue flaps should aim to restore facial contour whilst
compartmentalizing the oral and nasal cavities. We aim to discuss the
evolution of midface microvascular reconstruction in our reconstructive
head and neck service over three decades that largely mirrors that of
clinical practice worldwide.