Most maxillectomy defects can be managed conventionally without the use of free flaps. A split-thickness skin graft and palatal obturator are adequate to maintain coverage and contour of the midface; functionally restore mastication, speech, and swallowing; and allow for detection of recurrent tumor. However, when not enough palate remains to support a prosthesis, autologous tissue is needed for reconstruction. In these patients, we prefer the use of the pedicled temporalis flap for reconstructing total palatal defects. The advantages of the temporalis include immediate restoration of oral-nasal separation and fast healing; however, the flap does not permit placement of dentures or an obturator and thus limits dental rehabilitation. We have not found swallowing to be significantly affected in these patients. Indications for free flaps in this area include full-thickness defects of the midface, which require complex three-dimensional volume and multi-surface coverage requirements. Although a pedicled flap such as the pectoralis myocutaneous (PMC) may be used in the midface, it is limited in its superior extent and arc of rotation by its pedicle. The combined effect of the pedicle and weight of the PMC can place tension at the suture line, resulting in dehiscence. The large muscle bulk can cross functional areas interfering with mastication, speech, and swallowing. For these reasons, we do not favor the use of pedi-cled flaps in the midface unless the patient is not a candidate for free-flap reconstruction.

Many different flaps, including the radial forearm, rectus abdominis, scapular, and latissimus dorsi, can be used with multiple skin paddles designed to reconstruct the palate and external skin defect.29 We prefer the subscapular system for reconstruction, as it provides multiple flaps that can be tailored independently and inset in a three-dimensional manner. The ribs or lateral edge of the scapula provide vascularized bone.30 The thicker edge of the scapula is an ideal buttress for the infraorbital rim, zygomaticomaxillary buttress, and alveolar ridge; the thin portion is useful for the orbital floor or orbit.29 For obliterating the paranasal sinus cavity, we prefer the latissimus dorsi or serra-tus anterior muscles, which can be harvested with other components of the subscapular system with a common vascular pedicle. These muscle flaps can then be rolled to provide multiple skin paddles for lining the intraoral and external skin defects and to provide adequate contour to the midface.

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