An Algorithm for Maxillectomy Defect Reconstruction

The Laryngoscope

Lippincott-Raven Publishers, Philadelphia © 1998 The American Laryngological, Rhinological and Otological Society, Inc.

An Algorithm for Maxillectomy Defect Reconstruction
Steven P. Davison, DDS, MD; David A. Sherris, MD; N. Bradly Meland, MD

A maxillectomy defect creates a communication from oral cavity to nasal cavity that may extend to the orbit. Functional deglutition and speech problems with a significant soft tissue deficit ensue. This paper defines the reconstruction options for the spectrum of inferior partial maxillectomy defects to midface­ orbital exonerations. Treatment protocols from maxil­lectomy patients treated in January 1991 to February 1996 at a major tertiary care institution were re- viewed (n = 108). An ascension of care from dental ob­ turator, nonvascularized graft, local flap, regional flap, and free tissue grafts (n = 28) is described. These data and experience were organized to provide a treatment algorithm to assist in presurgical planning for maxillectomy reconstruction.

INTRODUCTION

Maxillary sinus tumors have minimal early symptomatology. They therefore present late with advanced stage and size. This can leave a large anatomical defect that invades surrounding anatomical boundaries including the oral cavity, nasal cavity, orbital cavity, soft tissues of the face, and anterior skull base. To minimize the speech, deg­lutition, and physiological problems associated with a maxillectomy defect, preoperative consideration must also be given to rehabilitation. In the past, surgical recon­struction of a palatal defect has been contraindicated, as it does not allow close observation of the tumor site at fol­low-up physical examination. The use of a palatal obturator has been used for accessibility to evaluate the maxil­lectomy defect, the most common site of recurrence failures. 2 Surgical obturation or reconstruction has been advocated for small lesions with minimal potential recur­rence 3 , 4 or defects with extensive sino-orbital or skull base involvement. Local and regional flaps that include modi­fied cheek flaps, deltopectoral flaps, and temporalis

Presented at the Meeting of the Western Section of the American Laryngological, Rhinological and Otological Society, Inc., Tucson, Arizona, January 1993.

From the Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota (s.e.n., D.A.S.) and the Department of Plastic Surgery, Mayo Clinic, Scottsdale, Arizona (N.B.M.).

Send Reprint Requests to David A. Sherris, MD, Mayo Clinic, De­partment of Otorhinolaryngology, 200 First Street SW, Rochester, MN 55905, U.S.A.

Laryngoscope 108: February 1998

muscle flaps have been used. 5 - 7 The success of free tissue transfer flaps intracranially has pioneered the use of the radial forearm flap, 8 , 9 iliac bone graft,'°," scapular free flaps, 12 and fibula flap. 13 Particular attention has been paid to more extensive sino-orbital defects that involve ex-posed skull base, nasal, and oral cavities. For these defects, success has been achieved with rectus abdominis, 14 latis­simus dorsi, 15 and a variety of other free tissue transfers.

The debate regarding the relative merits of pros­thetic versus surgical maxillectomy obturation contin­ues. 17 This paper reviews a large series of maxillectomy patients and presents a potential treatment algorithm for the management of maxillectomy defects. We discuss the advantages, disadvantages, and risks of alternative treat­ment selections.

METHODS

The study was a retrospective review of maxillectomy pa ­ tients treated at a major tertiary care medical center. A chart re - view based on computer-coded diagnosis of maxillectomy patients treated between January 1990 and September 1996 was under - taken. An initial sample of 287 patient charts was reviewed. Se ­ lections for final analysis and comparison were those with surgi ­cal violation of the maxillary sinus cavity. This eliminated a number of patients with marginal resection of the maxillary alve ­olus. A large subgroup of 77 patients who had violation of the maxillary sinus cavity as part of a medial maxillectomy for in­ tranasal tumors or anterior skull base tumors had reconstruction limited to split-thickness skin grafts or coverage of exposed dura. The final inclusion group of 108 was analyzed. The patient s ' med ­ ical records were evaluated for the following criteria: age, sex, pri ­ mary pathology, surgical treatment, size or type of maxillectomy defect, and involvement of the orbit or associated soft tissues. The use of split-thickness skin grafts, local regional, or free flap tissue transfer was documented, as was the use of an obturator pros - thesis. Medical records were reviewed for subjective evaluation of deglutition, speech, and satisfaction of cosmetics. The mean fol ­low-up time, complications, and incidence of recurrent were noted.

RESULTS

From a primary computer-coded diagnosis of maxil­lectomy, 108 of 287 patients were found to have maxillec­tomy defects other than medial maxillectomies. The most common primary pathological diagnosis was squamous cell carcinoma (56 of 108 patients). The second most fre­quent pathological diagnosis was minor salivary gland tumor (20 patients) (Table I). The mean age of the patients was 58 years. The male-to-female ratio was 61:47. The in­cidence of maxillectomy type is documented in Table II, as is the association with soft tissue deficits including orbital exenteration. A wide distribution of reconstruction op­tions was used in 103 of 108 patients (Table III). The ma­jority of patients who had maxillectomies with limited as­sociated soft tissue deficits received a prosthetic obturator (n = 54) after a split-thickness skin graft (n = 32). Local flaps were limited to reconstruction of partial, inferior, or premaxilla defects, which numbered eight. Half of these patients also used a prosthesis. Regional flaps including temporalis and medial forehead myocutaneous flaps were used predominantly in patients with superior maxillec­tomies or those involving orbital exenteration (n = 11). Free flaps were used in patients with extensive sino-or­bital defects, significant soft tissue deficits, or bilateral maxillectomy defects (n = 28). All split-thickness skin grafts and flap reconstructions were primary. The mean follow-up period was 21 months, with 39 patients (36%) experiencing disease recurrence. Free flaps were utilized in patients with more advanced disease and larger soft tissue defects. This is reflected in a recurrence rate of 18 of 28 patients versus 21 of 80 in the non-free flap group. Ten patients in each group were dead of disease (mean, 11 months for the free flap group and 19 months for the non-free flap group). Documentation of subjective patient sat­isfaction with deglutition, speech, and cosmetics was in-complete. However, when this information was available, 70% of the patients with prosthetic obturators described their speech, deglutition, and periorbital cosmetics as fair to good. Twenty percent reported leakage around the ob­turator bulb and 10% could not tolerate their prosthesis. The total number of complications was 24. The majority of complication patients (n = 17) had free flap reconstruc­tion. Complications included excess tissue bulk in three patients, hematomas in four patients, infection/fistuliza­tion in four patients, and flap death in six patients. How-ever, four patients successfully wore a prosthesis. The bulk of extensive soft tissue reconstruction precluded the use of a final prosthesis in three of the patients.

DISCUSSION

TABLE I. Incidence of a Pathological Process in the Maxillectomy Group. Pathology Patients (n) Squamous cell carcinoma 56 Minor salivary gland tumor 20 Sarcoma 13 Basal cell carcinoma 7 Other 12 Total 108

The maxillectomy defect creates a significant reha­bilitative issue, as it creates speech, deglutition, cosmetic, and possible orbital problems. Microvascular surgical techniques have revolutionized surgical reconstruction but have not eliminated the need for prosthetic rehabilitation. Surgical reconstruction should meet the objectives outlined by Hoopes and Edgerton: 1. consistently obtain a healing wound, 2. restore palatal competence and func­tion, 3. support the orbit or fill the orbital cavity in exen­teration, 4. obliterate the maxillectomy defect, and 5. re-store facial contour. This patient review emphasizes that the majority of the patients in this series underwent suc­cessful prosthetic rehabilitation with fair to good speech, deglutition, and cosmetic results. The obvious disadvan­tage of an obturator is that it remains a prosthesis with inherent problems of leakage, cleaning, and constant pros­thetic refinement. Patients with poor manual dexterity or visual impairments may have considerable difficulty with manipulating a prosthesis.

Problems also exist with surgical reconstruction, pri­marily related to tissue bulk and wound complications. Although Konno et al. 6 recommended a delayed deltopec­toral flap reconstruction of extended total maxillectomy defects, this approach was not utilized in the series of pa­tients predominantly because of the bulky pedicle and two-stage procedure. Flaps, regional or free, can droop into the oral cavity, compromise tongue movement, and preclude any esthetic dental restoration, particularly of anterior teeth. Soft tissue flaps without bony substructure do not provide the ideal support for a prosthesis. Certain free flap grafts including the iliac bone graft and scapu­lar free flaps 12 provide bony support but, again, may have excessive bulk. Excessive bulk has also compromised ipsi­lateral nasal competency. 14 Surgical reconstruction of the maxillectomy defect adds additional operating time, cost, and patient complications and also requires highly spe­cialized surgical techniques. 14.17 As with any treatment modality, patient selection is crucial. From this large se­ries of 108 patients, the majority of the patients (n = 54) did well with an obturator prosthesis, particularly if pre-prosthetic surgical planning was maximized.

TABLE II.
Distribution of Maxillectomy Defects.

Maxillectomy Patients (n)
Alveolectomies
Medial maxillectomy Lateral rhinotomy Skull base
Suprastructure
With orbit
Without orbit
Infrastructure
Anterior
Posterior
Inferior
Complete
Unilateral
Bilateral
Orbit exenteration Midface defect
Skin/cheek defect Total
Davison et al.: Maxillectomy Defect Reconstruction

Fig. 1. Residual palate improves the stability of the prosthesis by moving the fulcrum from midline to a more favorable position.

Fig. 2. The scar band formed at the skin graft-mucosal junction can benefit lateral retention and improve prosthesis success.

The following recommendations have been made to maximize maxillectomy technique for prosthetic obtura­tor restoration.

• A maxillectomy technique that leaves the greatest amount of residual hard palate without compromising tumor control should be used (Fig. 1).
• A tooth adjacent to the defect is important as an abut­ment for a prosthesis. The alveolar bone supporting this tooth should be preserved with resection placed through the socket of an extracted tooth.
• A split-thickness skin graft provides a tissue surface that accepts pressure and has more friction resis­tance. 2,21 The scar band that forms at the junction of the residual buccal mucosa and skin graft assists in reten­tion of the obturator at the defect site (Fig. 2). In this patient group, 32 of the patients were reconstructed with split-thickness skin graft.

TABLE III.
Reconstruction Type With Corresponding Defect.

Reconstruction	No.	Defect	No.
Obturator	62	Inferior	17
No tissue	22	Posterior	14
STSG	32	Complete	29
Local flap	3	Anterior	3
Regional flap	1	Posterior	1
Free flap	4	Extended	4
Local flap	8
Tongue	1	Inferior	1
Buccinator	3	Interior/anterior	12
Nasolabial	2	Anterior	2
Forehead	1	Anterior	1
Iliac bone	1	Anterior	1
Regional flap	11	Superstructure	7
Temporalis	8	Inferior	1
Pectoralis	3	Posterior/tonsil	3
Free vascularized flap Rectus abdominus	32 20	Extended maxillectomy with soft tissue defect	28
Radial forearm	6
Parascapular	2
Fibular	2
Latissimus dorsi	1

No reconstruction (n = 5).

STSG = split-thickness skin graft.

The removal of the inferior turbinate reduced the possi­bility of interference with an obturator bulb (Fig. 2). 22

• When nondisease palatal mucosa is available after the bony maxillary resection, it could be reflected over the medial margin of the resected palate for tissue coverage. This approach is preferable to granulation or skin graft­ing of the soft tissue deficit. 18 , 19
• When half or more of the soft palate requires resection in an anterior/posterior dimension, it may be better to remove the residual adynamic soft palate. 18 , 20 , 22

This review reconfirmed that certain surgical defects benefit from flap reconstruction. Very small openings in the maxillary sinus, particularly ones associated with the maxillary tuberosity, are predisposed to the development and extrusion of polypoid mucosa from the maxillary si­nus. This complication is exacerbated by the irritation of a palatal prosthesis. The utilization of buccal, alveolar, or palatal rotation flaps with or without bone grafting may be a better reconstructive option. 3 The temporalis regional flap is particularly useful in the reconstruction of posterior and superior partial maxillectomy defects associated with orbital floor resections. In this review, free flap reconstruc­tion was utilized for maxillectomy defects with substantial associated sino-orbital or soft tissue deficits. Defects with cranial exposure, soft tissue cheek defects, or extensive midface basosquamous tumors benefited from surgical re-construction. The indications, management, and complica­tions of this series were previously described by Olsen and Meland 14 in an isolated review of 16 extensive sino-orbital defects. Olsen and Meland found the rectus abdominis flap to be of significant benefit in reconstruction of extended sino-orbital defects. This more extensive review found the radial forearm and scapula flaps to be successful alterna­tives. Brown in his recent description of free iliac bone crest transfer states that it provides bony support to the maxillectomy defect. Bony grafts must be carefully placed to provide support for implants or a prosthesis. In this re-view, two bony grafts were placed too anterior and were unsuitable for reconstruction.

CONCLUSION

The necessity for both prosthetic and surgical recon­ struction of maxillectomy defect continues. The majority of maxillectomy defects can be ideally reconstructed with an uncomplicated prosthetic obturator, facilitating easy surgi­cal follow-up. However, careful preprosthetic surgical plan­ning with a team approach between surgeon and prostho­ dontist is ideal. Very minimal surgical defects benefit from surgical reconstruction and the elimination of a potentially irritating prosthesis. On the other end of the spectrum, maxillectomy defects with extended soft tissue deficits and/or orbital exenteration benefit from a combined surgi­cal and/or prosthetic approach. The refinement of micro-surgical techniques with free vascularized bone may pro-vide an ideal answer in providing surgical reconstruction that could support an implant-borne prosthesis. This is at the case of increased time, expense, and complication rate. A suggested treatment algorithm to assist in reconstruc­tion decision making is provided in Figure 3.

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