Discussion
Anatomically, the maxilla possesses a vital role. It forms the orbital
floor, superior dental arch, separates the oronasal cavity and
contributes to midface projection. Its proximity to multiple neighboring
structures means maxillectomy lends itself to a host of functional
impairments, including speech and visual disturbance and impaired
swallowing. Unsurprisingly, in addition to the cosmetic implications
with loss in midface projection, this has a significant impact on
quality of life with psychological sequelae17.
Obturators provide a poor solution to tackle these issues and
locoregional flaps often require staged procedures which correspondingly
leave visible donor scars in the head and neck and in such cases leave a
paucity of options available. We consider their use is best reserved for
salvage and revisional cases, or when patients comorbidities necessitate
expedient surgery to mitigate prolonged operative times.
In this paper we have presented our experiences in the evolution of
three microsurgical modalities for midface reconstruction over three
decades (Table. 2) . The aim was to discuss and outline the range
and often controversial debate about which techniques and approach
deliver the desired patient outcomes. Indeed, we acknowledge these are
the views of a single centre but does highlight, especially for trainee
surgeons the progressive management of such complex cases and the
historical basis behind a shift in practice for midface reconstruction.
It also highlights how residents should be open minded about innovation,
and to be aware of emerging technologies. Better still would be for the
next generation of reconstructive surgeons to collaborate and develop
new techniques in their respective field of work.
We are often asked by our residents what is the future of midface
reconstruction? In our opinion 3D planning, rapid prototyping and
intraoperative navigation will be the golden standard in the near
future, especially given the plethora of uses for 3D printing, which has
now reached the point of ‘in-house’ printing. Using tissue engineering
departments have 3D printed bioresorbable scaffolds bespoke to the
patient for this particular purpose in maxillectomy but the outcomes are
yet to be clearly identified18. For the meantime,
microvascular flap reconstructions will remain the mainstay of
management as soft tissue cover is needed and tissue engineering does
not have an answer for this at the current time19-21.
We found that the main advantages of utilizing 3D planning for free
fibula reconstruction are that we can plan the resection and
reconstruction much more precisely and as a result, we have achieved
more predictable outcomes (Table. 3) . This addition of this
technology to the reconstructive armamentarium has enabled us to provide
stable soft tissue support and the ability to accurately place implants
for mastication. Preoperative planning (within a week) in concert with a
simultaneous two team surgical approach, we have considerably reduced
operative time. We have not experienced any major complications using
this reconstructive approach. However, one limitation is that the
maximum follow-up for this cohort of patients is five years in seven
patients. We intend on providing a more definitive answer as we recruit
more patients with a longer follow up with more subjective and objective
measures with regards to outcomes.
In conclusion, the ultimate paradigm shift in midface reconstruction
will arise from tissue engineering, sparing the morbidity and any
complications from harvest of autologous tissues using ‘in house 3D
printing technology’. Tissue engineering represents a promising prospect
for the future wherein biological scaffolds and growth factors are
combined with autologous cells to engineer a composite tissue construct
that integrates with the recipient. The end goal should be to have an
incorporated construct that has sensibility, durability and remains
viable long-term. The translation of laboratory engineered constructs,
bespoke for the individual most likely utilizing 3D printing is very
appealing yet still remains at the experimental phases in the basic
science literature. Importantly, microvascular reconstruction is still
likely to play an adjunctive role to vascularize or supplement
biocompatibility with further research required to deliver a solution at
human scale22.
Conflict of interest: None