Osseous Maxillary Reconstruction with Immediate Dental Implant Placement: An Optimized Workflow for the Oncologic Patient.

INTRODUCTION: Maxillary reconstruction is a complex undertaking characterized by a 3-dimensional surgical site with deficiencies in multiple tissue types. Prior to virtual surgical planning(VSP), bony reconstruction was inaccurate and inefficient, thus reconstructions defaulted to soft tissue flaps or obturators. The current study describes an efficient and accurate approach to bony maxillary reconstruction with immediate dental implant placement(IDIP). METHODS: A reconstructive workflow was developed for osseous reconstruction to improve functional and aesthetic outcomes. Critical aspects include VSP, 3-D printed plates and IDIP. Review of a prospectively maintained database identified patients who underwent osseous maxillary reconstruction with a fibula flap and immediate dental implants from 2017-2022, with a focus on oncologic characteristics and reconstructive outcomes. RESULTS: During the study, 20 patients underwent maxillary reconstruction with VSP and IDIP. One dental implant out of 55 failed to osseointegrate and no flaps were lost. Three patients suffered partial loss of the fibula skin island; one required palatal closure with a radial forearm flap, and two were managed with outpatient debridement. Fifteen patients achieved either an interim or final retained dental prosthesis. All prostheses achieved acceptable aesthetic results without the instability associated with non-bone borne devices(e.g.dentures/obturators). No patients experienced delays in oncologic treatment. CONCLUSIONS: VSP technology has enabled surgeons to replace like with like to achieve better outcomes with acceptable morbidity for maxillary defects. IDIP provides all patients an opportunity for a fixed prosthesis even though not all complete the process. This maxillary reconstruction workflow can be safely accomplished in oncologic patients with promising and effective early results.

Standardized templates for shaping the fibula free flap in mandible reconstruction.

Conversion of the straight fibula bone flap into the parabolic mandible shape can be performed using customized acrylic templates made from a 1:1 mandible computed tomography scan and lateral cephalogram. The premise of the current study is to objectively quantify the variability in a series of acrylic templates used for mandible reconstruction to assess the feasibility of creating a standardized template.In this study acrylic templates of 48 consecutive adult dentate patients who underwent fibula flap mandible reconstruction from 1994 to 1999 were evaluated. Osteotomy angles for the mandibular angle, midbody and parasymphysis, and length of each bony segment were determined using a metric ruler and protractor. Values were reported as means ± standard deviation.The mean mandibular angle measured 122.6 ± 6.4 degrees, while the midbody and parasymphysis angles were 153 ± 4.5 degrees and 130 ± 4.2 degrees, respectively. Mean bone segment lengths were: ramus 64.5 ± 9.8 mm, distal body 47.6 ± 4.2 mm, mesial body 40.6 ± 3.2 mm, and symphysis 18.5 ± 2.2 mm.It was concluded that the evaluation of patient acrylic templates used in a series of mandible reconstructions demonstrates osteotomy angles vary minimally (3-5%). Bone segment lengths vary from 10 to 15%, suggesting heterogeneity in mandible size. A standard template can be used to shape the fibula in most mandible reconstructions eliminating the need for routine preoperative imaging or costly fabricated computer-aided design/computer-aided manufacturing cutting guides.

Making the Case for Virtual Surgical Planning: Bilateral Sequential Fibula Flaps with Immediate Dental Implants for Maxillectomy.

SUMMARY: Oncologic maxillectomy defects requiring bony reconstruction are among the most challenging head and neck cases because of the complex three-dimensional geometry of the midface. Virtual surgical planning technology is advantageous in these cases because it provides superior positional precision and accuracy compared with traditional techniques and facilitates prosthodontic rehabilitation. Maxillary cancer recurrence after an initial fibula flap reconstruction presents a unique challenge. The authors report the first two cases of sequential fibula flaps after second or recurrent cancer of the maxilla. Virtual surgical planning facilitated resection with adequate tumor margins, optimized anatomic positioning of the fibula construct with three-dimensional printed plates, and enabled immediate functional dental implant placement.

Long-term Growth, Functional, and Aesthetic Outcomes after Fibula Free Flap Reconstruction for Mandibulectomy Performed in Children.

Background: The long-term outcome of mandible reconstruction when performed in children has not been well documented. Methods: This is a retrospective case series of patients who underwent immediate oncologic mandible reconstruction with a fibula free flap at younger than 18 years of age over a 20-year period, by a single surgeon, who had long-term follow-up. Results: A total of 10 patients met inclusion criteria. Patient age ranged from 3 years and 8 months to 17 years and 9 months (mean 11 years). The etiology was malignant tumors in seven patients and benign locally aggressive tumors in three patients. All fibula flaps survived. All donor sites were closed primarily. The mean follow-up duration was 10 years and 5 months (range 3-20 years). The mean patient age at follow-up was 21 years and 10 months (range 8 years and 9 months to 30 years and 9 months). All patients achieved a regular diet and normal speech. Final occlusion was normal in seven of 10 patients. The aesthetic outcome, as evaluated by clinical examination, was a symmetric mandible in eight patients (in the other two the aesthetic asymmetry and malocclusion was minor and did not require operative intervention). Dental implants were ultimately placed in three patients. Leg function was normal in eight patients. Achilles lengthening and tendon transfer was required in one patient, and one patient developed ankle pain associated with running. Conclusion: Mandible reconstruction in children with the fibula free flap provides excellent aesthetic and functional outcomes that are durable over time.

Incidence of benign and malignant peri-implant fluid collections and masses on magnetic resonance imaging in women with silicone implants.

BACKGROUND: To assess the incidence of benign and malignant peri-implant fluid collections and/or masses on magnetic resonance imaging (MRI) in women with silicone implants who are being screened for silent implant rupture. METHODS: The institutional review board approved this HIPAA-compliant retrospective study and waived informed consent. Women who underwent silicone implant oncoplastic and/or cosmetic surgery and postoperative implant-protocol MRI from 2000 to 2014 were included. Peri-implant fluid collections and/or masses were measured volumetrically. A benign peri-implant fluid collection and/or mass was pathologically proven or defined as showing 2 years of imaging and/or clinical stability. A malignant peri-implant fluid collection was pathologically proven. Incidence of peri-implant fluid collections and/or masses and positive predictive value (PPV) were calculated on a per-patient level using proportions and exact 95% confidence intervals (CIs). Fisher's exact test was used in the analysis to test statistical significance pre-defined as P-value < 0.05. RESULTS: A total of 1070 women with silicone implants were included (mean age, 50.7 years; range, 40.4-53.8). Median time between reconstructive surgery and first MRI was 88.9 months (range, 0.8-1363.3). Eighteen women (1.7%) had a peri-implant fluid collection and/or mass: 15/18 (83.3%) had adequate follow-up; and only 1/15 was malignant implant associated anaplastic large cell lymphoma, with a PPV of 6.7% (95% CI: 0.003-0.0005). The median peri-implant fluid collection size was 89 mL (range, 18-450 mL). CONCLUSION: Peri-implant fluid collections and/or masses identified at silicone implant protocol breast MR imaging are rarely seen 24 months after reconstructive surgery. Image-guided fine-needle aspiration with flow cytometry may be warranted to evaluate for implant-associated lymphoma.

The vertically oriented free myocutaneous gracilis flap in head and neck reconstruction.

Oncologic resections in the head and neck can result in a variety of complex defects. Many free tissue transfers have been described for soft-tissue reconstruction in this area. The pedicled, vertical gracilis myocutaneous flap has been well described for use in the perineum, but is rarely used as a free tissue transfer because of previously documented unreliability of the skin island. The objective of this study was thus to review a single author's experience with reconstruction of complex head and neck defects using the vertically oriented free myocutaneous gracilis flap. A retrospective review of all head and neck reconstructions at a major cancer center from 2003-2006 was performed. Demographic, oncologic and reconstructive data were retrieved from a prospectively maintained clinical database. Ten patients (mean age, 57 years; range, 33-84 years) with complex defects of the head and neck were reconstructed using a gracilis myocutaneous flap with a vertically oriented skin paddle. Seven patients had a malignant skin tumor; 3 patients had a parotid gland tumor. Mean surface area requirements were 88.6 cm. Composite resections were common and included skin, facial nerve, mandibular and/or temporal bone, partial glossectomy, parotidectomy, and/or orbital exenteration. Six patients had a history of prior irradiation; 6 patients received postoperative radiotherapy. Mean follow-up was 8 months (range, 2-20 months). Total flap survival was 100%. There were no partial flap losses. Primary wound healing occurred in all cases. The vertically oriented free myocutaneous gracilis flap is a reliable option for reconstruction of moderate volume and surface area defects in the head and neck. It represents an underutilized flap that should be more commonly considered for soft-tissue reconstruction of complex defects in the head and neck.

A 20-Year Experience with 202 Segmental Mandibulectomy Defects: A Defect Classification System, Algorithm for Flap Selection, and Surgical Outcomes.

BACKGROUND: This study establishes a novel and broadly applicable defect classification system and flap selection algorithm for segmental mandibulectomy defects that emphasize the importance of the soft-tissue deficit, in addition to that of the bony defect. METHODS: Between 1992 and 2011, 202 patients with mandibulectomy defects underwent immediate reconstruction performed by a single surgeon. Details of the bony and soft-tissue defects, recommendations for the most appropriate reconstruction for each clinical scenario, and surgical outcomes are presented. RESULTS: A total of 211 flaps were performed in 202 patients. Forty-one (19 percent) were nonosseous only, and 170 (81 percent) were osseous-containing. The majority of osseous flaps were fibula osseous or osteocutaneous flaps (91 percent), and the majority of nonosseous flaps were vertical rectus abdominis myocutaneous flaps (68 percent). Flap selection was influenced by the number of soft-tissue zones resected; defects of one soft-tissue zone or less were predominantly reconstructed with an osseous flap, whereas defects that involved four or more zones underwent reconstruction with only a soft-tissue flap in 55 percent of cases. CONCLUSIONS: The algorithm for reconstruction of the mandibulectomy defect must include both nonosseous and osseous flaps based on defect size, location, and number of soft-tissue zones involved. As the extent of the soft-tissue defect increases, nonosseous flaps are preferred because of greater reliability of the skin island. The surgical outcomes associated with this algorithm are similar to or better than what is published in the literature. This series represents the largest reported single-surgeon experience with mandibulectomy defect reconstruction.

Microvascular reconstruction of the skull base: a clinical approach to surgical defect classification and flap selection.

Skull-base tumor resection and reconstruction produce a major physiologic and anatomic impact on the patient. At our institution, the use of vascularized, free-tissue transfer has replaced pedicled flaps as the preferred modality for reconstructing complex cranial base defects involving resection of dura, brain, or multiple major structures adjacent to skull base, including the orbit, palate, mandible, skin, and other structures. The goals of reconstruction are to: (1) support the brain and orbit; (2) separate the CNS from the aerodigestive tract; (3) provide lining for the nasal cavity; (4) re-establish the nasal and oropharyngeal cavities; (5) provide volume to decrease dead space; and (6) restore the three-dimensional appearance of the face and head with bone and soft tissues. Surgical management requires a multidisciplinary effort with collaborating neurosurgical, head and neck, and plastic surgical teams. Successful reconstruction of skull base defects is predicated upon a careful appreciation of the specific region. Defects may be classified based on their anatomic location and loss of volume, support, and skin cover. Free flaps provide reliable, well-vascularized soft tissue to seal the dura, obliterate dead space, cover exposed cranial bone, and provide cutaneous coverage for skin or mucosa.

Natrelle 410 Extra-Full Projection Silicone Breast Implants: 2-Year Results from Two Prospective Studies.

BACKGROUND: The safety and effectiveness of the Natrelle Style 410 highly cohesive silicone gel breast implant (Allergan, Inc., Irvine, Calif.) in full or moderate height and projection have been shown in a 10-year study. Extra-full projection implants may be an appropriate option for some women undergoing breast reconstruction. METHODS: A total of 2795 women received at least one Natrelle 410 extra-full projection implant (X-style) for breast reconstruction in two similarly designed, prospective, multicenter studies. Data collected for 2 years after implantation in these studies were pooled to evaluate complication rates and subject and physician satisfaction. RESULTS: Most subjects (76.0 percent) underwent bilateral reconstruction; a total of 4912 devices were implanted. Complication rates at 2 years were low. The most common complications were asymmetry (4.8 percent) and capsular contracture (3.3 percent). The cumulative risk of reoperation was 21.6 percent by subject and 16.6 percent by device; the most common reasons for reoperation were scarring (n = 97), asymmetry (n = 89), implant malposition (n = 78), and infection (n = 71). Subject and physician satisfaction rates exceeded 90 percent. At 2 years, 97 percent of physicians reported that the shape of the breast reflected the shape of the implant, and that the breast implant had maintained its original position. CONCLUSIONS: The safety profile of the Natrelle 410 extra-full projection implant mirrors that of its moderate projection and full projection counterparts. Both physicians and subjects were highly satisfied with the implants 2 years after surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A 15-year review of midface reconstruction after total and subtotal maxillectomy: part I. Algorithm and outcomes.

BACKGROUND: Reconstruction of complex midfacial defects is best approached with a clear algorithm. The goals of reconstruction are functional and aesthetic. METHODS: Over a 15-year period (1992 to 2006), a single surgeon (P.G.C.) performed 100 flaps to reconstruct the following midfacial defects: type I, limited maxillectomy (n = 20); type IIA, subtotal maxillectomy with resection of less than 50 percent of the palate (n = 8); type IIB, subtotal maxillectomy with resection of greater than 50 percent of the palate (n = 8); type IIIA, total maxillectomy with preservation of the orbital contents (n = 22); type IIIB, total maxillectomy with orbital exenteration (n = 23); and type IV, orbitomaxillectomy (n = 19). Free flaps were used in 94 cases (94 percent), and pedicled flaps were used in six (6 percent). RESULTS: One hundred flaps were performed in 96 patients (69 males, 72 percent; 27 females, 28 percent); four patients underwent a second flap reconstruction due to recurrent disease (n = 4, 4 percent). Average patient age was 49.2 years (range, 13 to 81 years). Free-flap survival was 100 percent, with one partial flap loss (1 percent). Five patients suffered systemic complications (5.2 percent), and four died within 30 days of hospitalization (4.2 percent). Over 50 percent of patients returned to normal diet and speech. Almost 60 percent were judged to have an excellent aesthetic result. CONCLUSIONS: Free-tissue transfer offers the most effective and reliable form of reconstruction for complex maxillectomy defects. Rectus abdominis and radial forearm free flaps in combination with immediate bone grafting or as osteocutaneous flaps consistently provide the best functional and aesthetic results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A 15-year review of midface reconstruction after total and subtotal maxillectomy: part II. Technical modifications to maximize aesthetic and functional outcomes.

BACKGROUND: Midface reconstruction of oncologic defects is one of the most challenging problems in plastic surgery. Over time, the senior author (P.G.C.) has developed modifications in his technique for oncologic midface reconstruction to minimize complications and maximize outcomes. METHODS: Over a 15-year period (1992 to 2006), 100 flaps for midface oncologic reconstruction were performed at Memorial Sloan-Kettering Cancer Center. The first 50 flaps were performed from 1992 to 2000, and the second 50 flaps were performed from 2001 to 2006. Over time, technical improvements were made in the following areas: palate, dental implants and prosthesis, orbital floor, eyelid, nasal sidewall, lips, cranial base and dura, and pedicle anastomosis. Using a prospectively maintained database, the authors compared the functional and aesthetic outcomes of the first 50 flaps and the second 50 flaps. RESULTS: Improvements in palatal reconstruction increased the proportion of patients who achieved normal speech from 38.9 percent in the first half of the series (1992 to 2000) to 50 percent in the second half of the series (2001 to 2006). The percentage of patients who were able to tolerate an unrestricted diet increased from 44.4 to 52 percent. The use of new methods to reconstruct the orbital floor also lowered the ectropion rate from 71.4 to 47.6 percent. The percentage of patients whose aesthetic results were judged as "excellent" increased from 12 to 58.6 percent. CONCLUSIONS: Over the last 15 years, the senior author has refined methods of midface reconstruction that have improved functional and aesthetic outcomes. These technical advancements have made it possible to obtain better and more consistent results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Microvascular reconstruction of oncologic defects of the midface.

Reconstruction of a midfacial defect can represent a formidable challenge for the reconstructive surgeon. Attesting to both the variety and the complexity of midfacial defects, numerous different classification schemes have been proposed, and are reviewed in this article. The approach to reconstruction can be simplified, however, by classifying maxillectomy defects into four types. Understanding the complex three-dimensional anatomy of the maxilla and its relationship to contiguous structures is the first step in approaching reconstruction of the midface. Achieving basic functional and aesthetic goals of maxillary reconstruction can be achieved using free flap reconstruction with good reliability and predictability in the majority of patients. A specific approach to each defect type is outlined.

Indications and outcomes for mandibular reconstruction using sequential bilateral fibula flaps.

BACKGROUND: A subset of patients with recurrent or second intraoral tumors undergo both primary and secondary mandibular reconstruction using bilateral fibula flaps. The objective of this report is to describe indications and outcomes for these patients. METHODS: A retrospective analysis of a prospectively collected database was performed. Charts were reviewed to identify demographics, operative features, and functional outcomes. RESULTS: Ten patients underwent mandibular reconstruction with a second fibula flap for recurrent or second oral tumors. Time between flaps averaged 20 months. Bone gap size measured 8 cm after both resections. Eighty percent of secondary resections included the mandibular arch, in contrast to 20 percent of primary resections (p=0.070). Compared with primary resections, secondary soft-tissue defects were larger and more frequently included composite tissues. There were low complication rates and no flap failures after both reconstructions. Functional evaluation showed a greater dependency on supplemental enteral nutrition after the second resection (p=0.033). Five patients died at a median of 12.5 months after the second resection and the remaining patients have survived for a median of 18.6 months. CONCLUSIONS: The principal indication for second fibula flaps in mandibular reconstruction is central segment defects where rigid support is required to prevent sequelae of the Andy Gump deformity. For lateral resections, the large soft-tissue deficits of secondary extirpation may be better served by reconstruction with soft-tissue flaps. Second osseous free flaps can be performed safely, but with a significant decline in postoperative oropharyngeal function. Goals of surgery and quality of life need to be addressed before ablation of recurrent or second oral tumors is performed.

Acellular human dermis implantation in 153 immediate two-stage tissue expander breast reconstructions: determining the incidence and significant predictors of complications.

BACKGROUND: Little information exists on the incidence of complications after acellular human dermis implantation in two-stage tissue expander breast reconstruction. The purpose of this study was to evaluate the incidence of postoperative adverse events and identify significant predictors of complications in acellular human dermis tissue expander breast reconstruction. METHODS: This study accrued all patients from January of 2004 through April of 2008 undergoing two-stage immediate tissue expander breast reconstruction using acellular human dermis. A total of 153 expanders were placed. Complications were assessed. Univariate and multivariate logistic regression modeling was performed. Comparison of complication rates using the traditional (non-acellular human dermis) technique from concurrent (2004 to 2008) and consecutive time periods (2001 to 2003) for 2910 and 1170 expanders, respectively, is provided. RESULTS: A total of 153 expanders were implanted in 96 women: 39 unilateral and 57 bilateral. Eleven (7.2 percent) were removed due to infection (n = 5, 3.3 percent), exposure (n = 4, 2.6 percent), or patient preference (n = 2, 1.3 percent). Other complications included cellulitis (3.9 percent), seroma (7.2 percent), hematoma (2.0 percent), mastectomy flap necrosis (4.6 percent), and leak/failed expansion (0.0 percent); 92.8 percent were successfully expanded and exchanged for a permanent implant. Eleven seromas (7.2 percent) were identified; nine underwent aspiration. None of these resulted in infection or reconstructive failure. Univariate analysis revealed age, body mass index, axillary dissection, and postoperative chemotherapy to be associated with reconstructive failure (p < 0.05). Multivariate analysis revealed that age, body mass index, and axillary dissection are independent risk factors for developing complications (p < 0.05). CONCLUSION: Acellular human dermis is a useful adjunct for intraoperative pocket development in immediate tissue expander reconstruction but can result in an increased risk of complications, in particular, seroma and reconstructive failure.

Patient satisfaction with postmastectomy breast reconstruction: a comparison of saline and silicone implants.

BACKGROUND: At a time when the safety and effectiveness of breast implants remains under close scrutiny, it is important to provide reliable and valid evidence regarding patient outcomes. In the setting of postmastectomy reconstruction, patient satisfaction and quality of life may be the most significant outcome variables when evaluating surgical success. The objective of the current study was to identify predictors of patient satisfaction with breast appearance, including implant type, in a large sample of women who underwent breast reconstruction surgery using implants. METHODS: A multicenter, cross-sectional study design was used. A total of 672 women who had completed postmastectomy, implant-based reconstruction at 1 of 3 centers in North America were asked to complete the BREAST-Q (Reconstruction Module). Multivariate linear regression modeling was performed. RESULTS: Completed questionnaire data were available for 482 of the 672 patients. In 176 women, silicone implants were placed and in 306, saline implants were used. The multivariate model confirmed that patients' satisfaction with their breasts was significantly higher in patients with silicone implants (P = .016). The receipt of postmastectomy radiotherapy was found to have a significant, negative effect on breast satisfaction (P<.000) in both silicone and saline implant recipients. In addition, for women who received either silicone or saline implants, satisfaction diminished over time (P = .017). CONCLUSIONS: In the setting of postmastectomy reconstruction, patients who received silicone breast implants reported significantly higher satisfaction with the results of reconstruction than those who received saline implants. This information can be used to optimize shared medical decision-making by providing patients with realistic postoperative expectations.

Reconstruction of extensive composite posterolateral mandibular defects using nonosseous free tissue transfer.

BACKGROUND: The management of composite oromandibular defects involving the posterolateral mandible and surrounding soft tissue remains a reconstructive challenge. Although bony reconstitution restores continuity of the mandible, osteocutaneous flaps sometimes do not provide adequate soft-tissue coverage of these postablative defects. The purpose of this study was to evaluate the use of soft-tissue flaps for extensive posterolateral oromandibular defects. METHODS: Consecutive patients who underwent reconstruction of composite oromandibular defects following posterolateral mandibulectomy between 1992 and 2006 were identified. Patient data were obtained from a prospectively maintained clinical database. Medical records were reviewed to characterize the extent of all postablative soft-tissue defects. Soft-tissue resection zones were defined as those involving the external cheek skin and/or lips, intraoral lining, tongue, retromolar trigone, palate, pharynx, and/or esophagus. RESULTS: In total, 76 patients were identified as having extensive posterolateral oromandibular defects reconstructed with soft-tissue flaps alone. In 62 percent of patients who underwent nonosseous free-tissue transfer, the oromandibular defect involved two or more soft-tissue zones. The most common flap used was the vertical rectus myocutaneous flap (n = 68). At the time of discharge, 54 percent of patients were on an oral diet. Sixty percent of patients had intelligible speech. Overall aesthetic outcome was good in 49 percent, fair in 21 percent, and poor in 30 percent of patients. CONCLUSIONS: Extensive composite defects of the posterolateral mandibular can be repaired effectively using soft-tissue flaps alone. When reconstructing a defect involving (1) the posterolateral mandible, overlying soft-tissues, and external skin and/or (2) the posterolateral mandible and two or more adjacent soft-tissue zones, the use of a soft-tissue flap alone can maximize success.

Frontiers in free flap reconstruction in the head and neck.

This chapter describes the state of the art in head and neck free flap reconstruction and will stress some of its major deficits. It will also discuss some of the most promising frontiers in reconstruction, including tissue engineering and composite allotransplantation. The true frontiers of reconstruction need to be refined at the cellular level where tissue engineered from the individual cells and manipulation of the patient's immune system will potentially allow allotransplantation without affecting rates of cancer cure.

Go for the jugular: a 10-year experience with end-to-side anastomosis to the internal jugular vein in 320 head and neck free flaps.

Preferential use of end-to-side anastomosis to the internal jugular vein in head and neck reconstruction offers distinct advantages and has consistently yielded excellent outcomes. Presented is a series of 320 consecutive cases by a single surgeon at 1 institution over 10 years. The most common flaps employed were the rectus (33%), forearm (28%), and fibula (21%) flaps. The most common defects were the mandible +/- floor of mouth (27%), pharyngoesophagus (25%), and tongue or cheek (17% each). Minor wound-healing problems, infection, and hematoma were noted in 5% or less. Partial flap loss was seen in 2%. Total flap loss and arterial or venous thrombosis occurred in less than 1% of patients. The size, constant anatomy, patency, and possibility for multiple anastomoses make use of the internal jugular vein very advantageous. Kinking is not observed when the neck is rotated, and high patency rates can be expected.

Reconstruction of maxillectomy and midfacial defects with free tissue transfer.

The maxillary bones are part of the midfacial skeleton and are closely related to the eyeglobe, nasal airway, and oral cavity. Together with the overlying soft tissues, the two maxillae are responsible to a large extent for facial contour. Maxillectomy defects become more complex when critical structures such as the orbit, globe, and cranial base are resected, and reconstruction with distant tissues become essential. In this article, we describe a classification system and algorithm for reconstruction of these complex defects using various pedicled and free flaps. Most defects that involve resection of the maxilla and adjacent soft tissues may be classified into one of the following four types: Type I defects, Limited maxillectomy; Type II defects, Subtotal maxillectomy; Type III defects, Total maxillectomy; and Type IV defects, Orbitomaxillectomy. Using this classification, reconstruction of maxillectomy and midfacial defects may be approached considering the relationship between volume and surface area requirements, that is, addressing the bony defect first, followed by assessment of the associated soft tissue, skin, palate, and cheek-lining deficits. In our experience, most complex maxillectomy defects are best reconstructed using free tissue transfer. The rectus abdominis and radial forearm free flap in combination with immediate bone grafting or as an osteocutaneous flap reliably provide the best aesthetic and functional results. A temporalis muscle pedicled flap is used for reconstruction of maxillectomy defects only in those patients who are not candidates for a microsurgical procedure.