KEY POINTS
  1. Midface reconstruction after tumour removal is a highly complex task. This requires careful planning and as such techniques have continued to evolve with time.
  2. Trainees should be aware of the options previously practised, as this can still serve as a lifeboat when the gold standard is not possible.
  3. Reconstruction requires bone and soft tissue considerations, always consider donor tissues and pedicle carefully and where to find recipient vessels.
  4. 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.
  5. 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.