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Discussion: A Comprehensive Algorithm for Oncologic Maxillary Reconstruction

T is a retrospective review of the cumulative experience of at least 15 surgeons who performed maxillary reconstruction at a major cancer center over a 10-year period. The objective of the article was to devise an algorithm for reconstruction of these defects. The authors describe 13 defects and assign one or two possible free flap choices for reconstruction. As with all algorithms for reconstruction, the extent of the defect determines the choice of flap. In the midface, the structures that are most essential for function and aesthetics include the floor of the orbit, the palate and palatal arch, the lips, and oral sphincter. If the orbit is resected, requirements of the defect are dictated by cranial base/brain exposure and potential other critical resected structures such as eyelids. The classification system that we have described condenses the 13 defects described by Hanasono et al. into six types that encompass most midfacial defects created by oncologic resections.1,2 The M. D. Anderson experience is that of multiple surgeons, and the diversity of flap selection is likely attributable to the fact that each surgeon has a specific comfort level with certain flaps. Reconstructing the floor of the orbit is essential, and although we favor bone grafts, a metal prosthetic (or allograft) could also be used. We originally described this type of reconstruction in combination with a soft-tissue flap, that is dictated by the extent of soft-tissue and palatal involvement.3 The algorithm proposed by Hanasono et al. does not clearly delineate the flap selection process for closure of the palate. In some cases, a muscle flap alone is used. The anterolateral thigh flap provides enough skin for palatal closure, but the pedicle length can be deficient. Our bias is to always close the palate with a skin island because this provides the patient with the ability to speak and eat without use of an obturator and this primarily determines the choice of free flaps. The rectus abdominis myocutaneous flap provides both volume and skin to reline the palate and also an excellent pedicle that can extend to the neck and is our most common flap of choice. For larger defects, this flap also provides skin for external coverage and nasal lining. This important aspect of flap selection should always be addressed clearly. Any maxillary defect that includes the anterior arch or a significant amount of hard palate resection should ideally be reconstructed with a bony free flap. It is our bias not just to provide bony reconstruction and palate closure, but to reline the nasal floor as well. We have described use of the radial forearm osteocutaneous sandwich flap for this purpose because it provides the vascularized bone necessary for the reconstruction of the palatal arch and also enough skin to resurface the nasal/palatal surfaces.4 The fibula is a much larger flap and, except in the thinnest patients, is too bulky to provide skin for palatal/ nasal lining. It is certainly the best option for osseointegration but may compromise the reconstruction with regard to resurfacing palate, nose, and external skin. One of the critical contributions to function in the midface is the oral sphincter. We have described reconstructing the oral sphincter in combination with free flaps and feel that sphincteric closure is essential, even when aesthetics are compromised.5 Thus, the choice of free flap in this scenario may also be dictated by priorities such as maintenance of oral competence. The algorithm proposed by Hanasono et al. and the figures provided do not address concomitant reconstruction of the lip. We have described some of the aesthetic and technical refinements that address reconstruction of the palate, the lips, the nasal cavity, the orbit, and eyelids, all of which are equally important when establishing an algorithm for midfacial reconstruction.5 Thus, the algorithm for flap se-