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