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Microsurgical Reconstruction of PosttraumaticHigh-Energy Maxillary Defects: Establishingthe Effectiveness of Early Reconstruction

Eduardo D. Rodriguez,M.D., D.D.S.

Mark Martin, M.D., D.M.D.Rachel Bluebond-Langner,

M.D.Marwan Khalifeh, M.D.

Navin Singh, M.D.Paul N. Manson, M.D.

Baltimore, Md.

Background: Posttraumatic, high-energy defects of the midface can be chal-lenging to reconstruct because they involve extensive composite tissue loss andresult in significant permanent functional and cosmetic deformity. These in-juries require replacement of the bony framework, external soft tissue, andintraoral mucosa. Local skin flaps and nonvascularized bone grafts have beenused for reconstruction, but bony resorption and the associated soft-tissuecollapse limit long-term viability. The authors present a classification of max-illary defects following high-energy trauma and a treatment algorithm usingvascularized bone flaps.Methods: Fourteen patients with significant maxillary loss from high-energytrauma underwent reconstruction with composite vascularized bone flaps. Eightpatients had fibula flaps and six had iliac crest flaps. There were five women andnine men, with a mean age of 36.3 years (range, 21 to 48 years) and a meanfollow-up of 18 months (range, 5 to 54 months).Results: Thirteen of the 14 flaps survived. Nine patients had additional pro-cedures. Nine patients had oronasal fistulas and eight were dependent ongastrostomy tubes preoperatively. All patients were able to feed orally withoutnasal regurgitation postoperatively. All patients achieved stable restoration ofthe midfacial architecture.Conclusions: The classification scheme presented centers on the missingmaxillary subunits. The reconstructive algorithm is based on the type ofdefect, tissue requirement, and donor tissues necessary to restore facialprojection and prosthodontic rehabilitation. Iliac crest and fibula bone freeflaps are ideal for restoring a variety of traumatic maxillary defects. Theauthors advocate early reconstructive intervention using vascularized boneflaps to achieve superior functional and cosmetic outcomes. (Plast. Reconstr.Surg. 120 (Suppl. 2): 103S, 2007.)

The majority of high-energy maxillary defectsare composite, involving the skin, skeleton,and mucosa. Successful reconstruction re-

stores facial projection and lays the foundation forendosseous dental rehabilitation by replacing the

buttresses, resurfacing the external and internalsoft-tissue lining, eliminating oronasal fistulas,and restoring the alveolus. Strict adherence tothese principles limits unfavorable outcomes, in-cluding gross deformity, poor facial projection,incoherent speech, and oral incompetence.

The history of maxillary reconstruction closelyparallels advances made in the field of plastic sur-gery. Prosthetic obturation is one of the earliest

From the Division of Plastic, Reconstructive, and Maxillo-facial Surgery, R Adams Cowley Shock Trauma Center/University of Maryland School of Medicine, and the JohnsHopkins University School of Medicine.Received for publication May 5, 2006; accepted September28, 2006.Presented in part at the 85th Annual Meeting of the Amer-ican Association of Plastic Surgeons, in Hilton Head, SouthCarolina, May 6 through 9, 2006.Copyright ©2007 by the American Society of Plastic Surgeons

DOI: 10.1097/01.prs.0000260728.60178.de

Disclosure: None of the authors has a financialinterest in any of the products, devices, or drugsmentioned in this article.

www.PRSJournal.com 103S

reconstructive tools and is still used today.1 Localflaps including cervical, forehead, temporalis, anddistant tubed flaps combined with interposed non-vascularized autologous bone grafts (i.e., rib, cra-nium, and ilium)2 allow restoration of the skeletonand soft-tissue envelope.3–5 This technique, how-ever, is plagued by gradual bone graft resorptionand thus creates the need for additional reconstruc-tion (Fig. 1). The introduction of free tissue transfertechniques in the 1970s—specifically, composite vas-cularized bone flaps—addressed this problem andprovided a more enduring solution for compositemaxillary defects. In addition, vascularized boneflaps provide a sound foundation for the final com-ponent of maxillary rehabilitation, the osseointe-grated implant.6 There is extensive literature onmaxillary reconstruction using vascularized boneflaps following tumor extirpation; however, thereare few reports on the use of composite freetissue transfer for high-energy posttraumaticmaxillary defects, and there are no current clas-sification schemes or treatment algorithms fortraumatic maxillary defects.

PATIENTS AND METHODSWe reviewed 14 patients who underwent max-

illary reconstruction with either a fibula or an iliaccrest flap following high-energy traumatic injuriesat the R Adams Cowley Shock Trauma Centerfrom April of 2001 to October of 2005. Data in-cluding age, sex, mechanism of injury, type of

defect, types of procedures, diet, speech, and out-come were collected (Table 1). Five patients werewomen and nine patients were men, with an av-erage age of 36.3 years (range, 21 to 48 years). Sixpatients had iliac crest flaps and eight had fibulaflaps. The recipient vessels were the facial arteryand vein in 11 patients, the superficial temporalartery in two patients, and the superior thyroidartery and facial vein in one patient. Four patientsunderwent immediate reconstruction of the max-illary defect (class I) after the initial injury, and theremaining 10 patients underwent secondary re-construction of their defects (four class I, fourclass II, and two class III). Two of the patients hadbilateral maxillary defects (class III) and the re-maining 12 patients sustained unilateral injuries(eight class I and four class II). Average follow-upwas 18 months (range, 5 to 54 months).

ClassificationThe choice of osseous flap for maxillary re-

construction depends on tissue and pedicle lengthrequirement and the donor tissues available. Awell-designed fibula or iliac crest flap is ideal. Aclassification of maxillary defects has been devisedthat focuses on the essential maxillary functionalsubunits that require replacement and is pur-posely related to the selection of either the fibulaor iliac crest free flaps for reconstruction (Figs. 2and 3). When the maxilla is missing, the inferiororbital rim and contiguous malar prominence

Fig. 1. Ten years before presentation, the patient’s maxilla was reconstructed with a nonvascularized ribgraft. The bone has resorbed, resulting in hard- and soft-tissue collapse.

Plastic and Reconstructive Surgery • December Supplement 2, 2007

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Tab

le1

.P

atie

nt

Sum

mar

y

Pat

ient

Sex

Age

(yr)

Inju

ryD

ate

Tim

ing

ofR

econ

stru

ctio

nM

OI

Loc

atio

nof

Max

illar

yD

efec

t

Typ

eof

Max

illar

yD

efec

tP

EG

Fist

ula

Seco

ndP

roce

dure

Den

tal

Impl

ants

DO

SFl

apT

ype

Loc

atio

nR

ecip

ient

Ves

sels

1M

339/

19/1

998

Del

ayed

Lan

dm

ine

Lef

tII

b(�

)N

oN

o4/

25/2

001

Fibu

laL

eft

Supe

rior

thyr

oid

arte

ry,

faci

alve

in2

M22

5/12

/200

0D

elay

edG

SWR

igh

tII

a(–)

Yes

Yes

1.U

lnar

flap

2.A

LT

8/11

/200

3Fi

bula

Rig

ht

Faci

alar

tery

,fa

cial

vein

3M

268/

27/2

003

Imm

edia

teG

SWR

igh

tIa

(�)

Yes

Yes

Oss

eous

con

tour

8/29

/200

3Il

iac

Rig

ht

Faci

alar

tery

,fa

cial

vein

4F

449/

10/2

001

Del

ayed

GSW

Bila

tera

lII

Ia(�

)Ye

sYe

s1.

Oss

eous

con

tour

Yes

9/22

/200

3Il

iac

Rig

ht

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alar

tery

,E

Jve

in2.

Nos

e5

F41

9/1/

1998

Del

ayed

MV

CR

igh

tIa

(�)

Yes

Yes

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eous

con

tour

Yes

10/6

/200

3Il

iac

Rig

ht

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alar

tery

,fa

cial

vein

6M

445/

31/2

004

Imm

edia

teG

SWR

igh

tIa

(�)

Yes

Yes

6/11

/200

4Il

iac

Rig

ht

Supe

rfic

ial

tem

pora

lar

tery

and

vein

7M

2919

97D

elay

edM

VC

Rig

ht

Ia(�

)N

oN

oD

istr

acti

on7/

26/2

004

Fibu

laL

eft

Faci

alar

tery

,fa

cial

vein

8M

218/

17/2

004

Imm

edia

teG

SWL

eft

Ia(�

)N

oN

o8/

27/2

004

Fibu

laL

eft

Faci

alar

tery

,fa

cial

vein

9M

476/

21/2

004

Del

ayed

MV

CL

eft

Ia(�

)Ye

sYe

sSo

ft-ti

ssue

debu

lk10

/15/

2004

Ilia

cL

eft

Faci

alar

tery

,fa

cial

vein

10F

4819

92D

elay

edM

VC

Bila

tera

lII

a(�

)Ye

sYe

s1.

Dis

trac

t2.

Oss

eous

con

tour

Yes

10/1

8/20

04Fi

bula

Lef

tFa

cial

arte

ry,

faci

alve

in

11F

3912

/21/

2004

Imm

edia

teG

SWL

eft

Ib(�

)Ye

sYe

sSo

ft-ti

ssue

debu

lk1/

3/20

05Il

iac

Lef

tSu

perf

icia

lte

mpo

ral

arte

ryan

dve

in12

M42

1/1/

1997

Del

ayed

Can

cer/

MV

CR

igh

tII

Ib(�

)N

oYe

sA

LT

3/7/

2005

Fibu

laL

eft

Faci

alar

tery

,fa

cial

vein

13M

3819

83D

elay

edG

SWA

nte

rior

Ia(�

)N

oN

o5/

23/2

005

Fibu

laA

nte

rior

Faci

alar

tery

,fa

cial

vein

14F

5819

83D

elay

edG

SWR

igh

tII

b(�

)N

oN

o5/

31/2

005

Fibu

laR

igh

tFa

cial

arte

ry,

EJ

vein

MO

I,m

ech

anis

mof

inju

ry;P

EG

,per

cuta

neo

usen

dosc

opic

gast

rost

omy;

DO

S,da

teof

surg

ery;

GSW

,gun

shot

wou

nd;

MV

C,m

otor

veh

icle

cras

h;A

LT

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late

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mal

e.

Volume 120, Number 7 Suppl. 2 • Microsurgical Maxilla Reconstruction

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must also be replaced for several reasons. First,autogenous bone is necessary for eventual stabi-lization of the orbital floor defect. Second, in caseswhere both the nasomaxillary and zygomatico-maxillary buttresses are damaged or absent, thenewly reconstructed rim will provide a site of fix-ation for the neoalveolus. Third, the malar prom-inence defines the width and projection of themidface and is essential for optimal aesthetic out-comes.

An ascending order of reconstructive com-plexity is therefore outlined in which a type I de-fect has a unilateral dentoalveolar defect, a type IIdefect is missing the inferior orbital rim in addi-tion to the ipsilateral maxilla, a type III defectinvolves bilateral maxillary dentoalveolar loss, anda type IV defect involves bilateral maxillary den-toalveolar loss and at least one orbital rim. Thepresence or absence of facial skin is denoted by theletters a and b, respectively. A modifier is includedin the classification that indicates the presence(�) or absence (–) of a posterior point of fixation(pterygomaxillary buttress) that affects the choiceand complexity of fixation. Mucosal lining defectsare intentionally not included in the classificationbecause they are assumed to be present in essen-tially all cases. The presence or absence of theglobe is not included in the algorithm because wefeel that optimal restoration of the periorbitalarea, whether provided by soft-tissue reconstruc-tion or prosthetic replacement, requires recon-

struction of normal facial dimensions and a cir-cumferential orbital rim.

This algorithm is different from prior algo-rithms because it is based on functional and aes-thetic structures rather than patterns of defectsfollowing tumor ablation. This algorithm advo-cates vascularized composite tissue with either fib-ula or iliac crest flaps for all reconstructions. Theseflaps are tailored based on the missing subunits—alveolus, orbital rim, and/or malar prominence.

Operative TechniqueIt is difficult to complete reconstruction in a

single stage in patients with acute high-energytraumatic injuries because the effects of tissuecrush, ischemia, and cavitation may not be imme-diately obvious.7 These patients require early skel-etal and soft-tissue stabilization followed by serialdebridements of nonviable tissue before pursuingmicrosurgical reconstruction. When embarkingon microsurgical reconstruction, either the fibulaor the iliac crest flap (deep circumflex iliac artery)can be harvested, depending on the type of bonydefect, pedicle length required, and donor sitesavailable.

Extensive preoperative planning is critical toachieve intraoperative success. To determine theoperative plan, facial anthropometrics are as-sessed, including facial thirds, facial fifths, facialand dental midlines, and upper and lower incisor

Fig. 2. Algorithm of free flap choice for posttraumatic maxillary defects.


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show at rest and while smiling. Precise analysis ofdimensions can be obtained using current clinicalphotographs, preinjury clinical photographs, den-tal impressions, and three-dimensional computed

tomography. If maxillofacial osteotomies are to beperformed, bite registration, facebow transfer,and lateral and posteroanterior cephalograms arehelpful in guiding the position of the skeletal pil-

Fig. 3. Illustrationsofreconstructeddefects.(Above)ClassIdefectreconstructionwitheitherafibulaoriliaccrestflap.(Center)Class II defect reconstruction with a fibula flap. (Below) Class III defect reconstruction with either a fibula or iliac flap.


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lars and occlusion. The relationship of the maxillato the mandible in centric occlusion should be re-corded and mounted on an articulator. Dental mod-els and a three-dimensional computed tomographicscan provide information regarding dimensions ofthe soft- and hard-tissue defects, location of fistulas,and deficient alveolar dimensions.

Preoperative assessment of the donor vessels(i.e., superficial temporal, facial, and external ca-rotid vessels) may be performed clinically by ob-servation and palpation, paying close attention tolacerations, incisions, contusions, hematomas,edema, and scarring. Potential tissue donor re-gions must also be evaluated. Preoperative lowerextremity angiography is not routinely indicatedbefore harvesting a fibula flap.8

We prefer to dissect the donor vessels first,followed by exploration of the defect, and finallyfree flap harvest. This allows precise determina-tion of the types and quantity of tissue and thepedicle length required. If external skin coverageis not required, the maxillary defect may be ex-posed by means of an intraoral approach, avoidingfacial degloving incisions. Defining the defect canbe demanding in the patient presenting for sec-ondary reconstruction, given dense scar tissue, de-bris, and obscured tissue planes. After preciselydefining the composite tissue requirements andthe location of the recipient vessels, a second teammay proceed with final flap design and flap har-vest. It is at this time that corrective maxillofacialosteotomies and fixation may be executed simul-taneously during flap harvest. A coronoidectomyis routinely performed to prevent flap interfer-ence and pedicle obstruction during mandibularexcursion.

When embarking on microsurgical recon-struction, the fibula osteoseptocutaneous flap isideal for bilateral maxillary defects, given its longpedicle length. Although the iliac crest flap hasbeen used for bilateral defects, it is best suited forunilateral defects requiring a shorter pediclelength. The fibula flap may be harvested with agenerous skin paddle for both internal and exter-nal lining. In the case of the iliac crest flap, a skinpaddle is less ideal, given its moderate thickness.Instead, a portion of the internal oblique muscleis incorporated for intraoral lining. A 2.0-mm ti-tanium miniplate template is contoured preopera-tively based on dental models of remaining dentoal-veolus and three-dimensional stereolithographicmodels of the facial skeleton. It is sterilized andused intraoperatively to design flap dimensionsand facilitate flap inset (Fig. 4). This method min-imizes warm ischemia time by guiding the location

of osteotomies and allows for in situ semirigidstabilization. The pterygoid plates serve as the pos-terior stops for the neomaxilla. This method en-sures a proper interarch relationship between themaxilla and mandible for eventual dental reha-bilitation. Ostectomies are routinely limited to theregion of the canine because it serves as the pivotpoint for the dentoalveolus. Watertight, layeredrepair of tissue planes is crucial to avoid fistulaformation, flap dehiscence, and infection.

RESULTSThirteen of the 14 free flaps (92.8 percent)

were successful. The one flap failure was the resultof a hematoma that compressed the pedicle. Thir-teen patients achieved stable restoration of themidfacial architecture. Globe position in all pa-tients was not affected by the maxillary reconstruc-tion; however, three patients who presented fordelayed reconstruction had existing ectropion oftheir lower eyelids. Four of the patients underwentimmediate reconstruction (within 13 days of the

Fig. 4. A 2.0-mm template is used to facilitate a bilateral maxil-lary reconstruction.


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initial injury) and 10 patients underwent delayedreconstruction (between 4 months and 22 yearsafter the initial injury). All patients who under-went delayed reconstruction had prior attempts atreconstruction using local, distant, or free myo-fascial flaps combined with nonvascularized bonegrafts. Collapse of the bony architecture and dis-figuring soft-tissue contracture prompted second-ary reconstruction in all of these patients. Nine of

the 14 patients had oronasal fistulas preopera-tively that were obliterated with either the skinpaddle of the free fibula or the internal obliquemuscle of the deep circumflex iliac artery flapwithout recurrences. Preoperatively, eight pa-tients were dependent on gastrostomy tube feedsfor nutrition because of large oronasal fistulas.Postoperatively, all patients were able to feedorally without nasal regurgitation and able to

Fig. 5. The patient in case 5. (Above) Preoperative photograph and computed tomographic scan depict-ingrightmaxillarytypeIa(�)defect. (Below)Postoperativephotographandthree-dimensionalcomputedtomographic scan 12 months after right maxillary reconstruction with an iliac crest free flap.


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maintain adequate caloric intake, allowing re-moval of gastrostomy tubes. Three of the patientshad successful dental rehabilitation with os-seointegrated implants. Nine patients had addi-tional procedures following maxillary reconstruc-tion: two patients underwent additional free tissuetransfers for soft-tissue cheek augmentation, twounderwent soft-tissue debulking, two underwentdistraction and stabilization of the neomaxilla,and three underwent osseous contouring of theneomaxilla following removal of hardware.

CASE REPORTSType Ia(�)

The patient in case 5 is a 41-year-old woman who sustainedsignificant craniofacial injuries from a high-velocity motor ve-hicle collision. She presented to us following multiple opera-tions for repair of the right maxilla and eventual placement ofendosteal dental implants. A vascularized iliac crest with inter-nal oblique muscle flap was used to restore the maxilla andeliminate the oronasal fistula (Fig. 5).

Type Ib(�)The patient in case 11 is a 39-year-old woman who sus-

tained a shotgun wound to the left face and arm. Aftermultiple washouts, there was 9 � 5-cm, full-thickness, soft-tissue defect and a 6 � 3-cm maxillary defect. The maxilla wasmobile from the left lateral incisor to the pterygoid plate,with loss of maxillary wall from the alveolus to the orbital rim.She underwent immediate reconstruction (13 days after ini-tial injury) with a free iliac osteocutaneous flap to the leftmaxilla and cheek. The intraoral mucosa was resurfaced withinternal oblique muscle, the skin paddle was used to restorethe external envelope, and vascularized iliac bone was usedto restore the missing maxilla (Fig. 6).

Type IIa(–)The patient in case 2 is a 22-year-old man who sustained

injuries to the craniofacial region from a self-inflicted submen-tal gunshot wound. The patient was acutely managed at anoutside hospital and eventually referred to our center for sec-ondary management of his deformities. He was missing his righteye, maxilla, and palate, with an associated large oronasal fis-tula. Despite previous efforts to correct the malocclusion witha left Le Fort I maxillary osteotomy, the remaining portion ofthe left maxilla was poorly aligned, with associated malocclu-sion. He underwent maxillary and mandibular osteotomies tocorrect the malocclusion, removal of orbital hardware, andreconstruction of the left maxillary defect with a free fibulaosteoseptocutaneous flap (Fig. 7).

Type IIb(�)The patient in case 12 is a 42-year-old man who initially

underwent multiple reconstructive procedures for a right max-illary defect following tumor ablation at an outside hospital. Hewas subsequently managed at our unit following right midfacialinjuries sustained from a motor vehicle collision. On presen-tation he had severe ectropion with an orbital floor defect anda maxillary defect extending from the central incisor to thepterygoid plate. A free fibula osteoseptocutaneous was har-vested to reconstruct the orbital rim (5 cm of bone) and themaxilla (8 cm of bone). The skin paddle measuring 15 � 3 cmwas used for intraoral and extraoral lining (Fig. 8).

Type IIIa(�)The patient in case 4 is a 40-year-old woman who sustained

a self-inflicted submental midline gunshot wound. She hadbilateral naso-orbito-ethmoid, maxillary, and mandibular frac-tures. Initial reconstruction included stabilization of the skel-etal injuries followed by palatal obturation. The patient hadsignificant difficulty with deglutition and was dependent on agastrostomy tube to maintain nutrition. She also complained ofobturator discomfort and hypernasal speech. A vascularizediliac crest with internal oblique muscle flap was used to recon-struct the maxilla and eliminate the oronasal fistula. She sub-sequently underwent nasal reconstruction with a calvarial bonegraft and a paramedian forehead flap (Fig. 9).

DISCUSSIONThe goals of maxillary reconstruction include9–11

obturation of the underlying defect and repair oforonasal fistulas, support of the horizontal andvertical facial buttresses, restoration of speech anddeglutition by establishing palatal competence,and support for implant or tissue-borne dentalprosthesis. Although there are six walls to the max-illa, these goals may be met by restoring the su-perior, anterior, and inferior walls. The superiorwall is required for orbital support; the inferiorwall is required for prosthodontic restoration,which will accommodate occlusal forces duringmastication; and the anterior wall determinescheek projection and thus makes a significant con-tribution to sagittal facial dimension.

For high-energy wounds of the midface, weadvocate aggressive debridement followed by earlyreconstruction with either plating, local flaps, ormicrosurgical tissue transfer. Earlier reconstruc-tion (within 2 weeks), before scar contracture,facilitates dissection of anatomical planes, allow-ing more precise alignment of skeletal structuresand maintenance of soft-tissue envelope volumeduring the acute phase of wound healing12 (Fig.10). In our experience, delayed reconstructionsare less accurate and more time consuming. Thedefect must be recreated, scar tissue removed, andmultiple osteotomies made to realign the dis-torted skeleton and reexpand the soft-tissue en-velope, ultimately producing suboptimal results(Fig. 11). Case 2 clearly demonstrates the effectsof soft-tissue contracture on the remaining leftmaxilla (Fig. 7, left). There is palatal rotation of themaxillary dentition because of lack of a stable con-tralateral skeletal buttress. The need for early re-construction becomes more critical in more severeinjuries (types II through IV) because there isgreater bone loss and potentially more soft-tissueloss. Although the perceived cosmetic result maybe comparable in immediate and delayed recon-struction, the operative time and complexity is


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greater in delayed reconstruction, thereby increas-ing the potential morbidity.

The combination of pedicled flaps with inter-posed nonvascular bone grafts was considered thestandard treatment in the management of acutehigh-energy midfacial injuries.2,12 Unfortunately,the long-term durability of this method is unreli-able because the bone grafts undergo partial orsubtotal resorption and require future augmenta-tion with additional bone.12 Nonvascularized bonegrafts remain an excellent option for the manage-ment of small bone defects surrounded by well-vascularized soft tissue.9 Extensive maxillarytrauma, such as injuries produced by high-energyballistic weapons, is associated with deficient vas-cularized soft tissue and extensive bone loss and isthus not amenable to a nonvascularized bonegraft.2,13 Free omental, muscle, or fasciocutaneousflaps wrapped around nonvascularized bone wereoriginally advocated because of their ability toobliterate dead space and provide vascularizedcoverage of nonvascularized bone.14 In our hands,this technique has also been plagued by partial orsubtotal resorption and thus we advocate compos-ite vascularized bone flaps for such severe high-energy injuries (Fig. 12).

Microvascular free tissue transfer techniquesare preferred over pedicled flaps in contemporaryhead and neck reconstruction.15 The four majorsources of vascularized bone routinely used for

craniofacial reconstruction include the fibula, il-ium, radius, and scapula. Each source of bone hasits own set of inherent advantages and limitations.With respect to dental rehabilitation with os-seointegrated implants, the final goal in maxillaryreconstruction, the fibula and iliac crest reliablyprovide adequate bone width and height whencompared with the scapula and radius.16

The fibula can be harvested as an osteosepto-cutaneous flap with a large, reliable skin paddle.It has a predictably long vascular pedicle and min-imal donor-site morbidity and allows a two-teamapproach. Up to 26 cm of long straight bone maybe harvested, and multiple osteotomies can beperformed without embarrassing the vascular sup-ply, allowing the fibula to be accurately shaped tomatch any contour defect.17 A portion of flexorhallucis longus or soleus muscle may be includedwith the flap to obliterate dead space. In addition,the fibula provides excellent bone stock to supportosseointegrated implants and is the only bone flapthat allows bicortical purchase during implantplacement.16 Approximation of the posterior com-partment musculature appears to preserve powerof great toe flexion. All these features make thefibula flap a versatile and reliable option in max-illary reconstruction.

The iliac crest free flap was popularized byUrken et al. for mandibular reconstruction18

and subsequently used by Brown et al. for max-

Fig. 6. The patient in case 11. (Left) Right maxillary type Ib(�) defect from a gunshot wound. (Right)Immediate reconstruction with a free iliac crest musculocutaneous flap. There is no contracture ofthe soft-tissue envelope.


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illary reconstruction, achieving excellent orofa-cial rehabilitation.11,19 Ample height for osseointe-grated implants, cheek projection, and orbitalreconstruction can be obtained by harvesting thisflap well into the pelvis.16 The orientation of theiliac flap is versatile and allows it to fill both highand low defects. The internal oblique muscle isused to line the nasal and oral cavity. Over 2 to 3weeks, the muscle contracts and epithelializes,precluding the need for later debulking as in skinpaddle–based flaps.19,20 Two potential disadvan-tages of the iliac crest flap involve the thick sub-

cutaneous layer associated with Western popula-tions and its short pedicle of 4 to 5 cm, making itproblematic in cases where the facial vein andartery are inadequate.11,19 Donor-site morbidity iscomparable in both flaps.21 When selecting a do-nor site, we consider first concomitant injuriesthat may limit available tissue, need for dentalrehabilitation, pedicle length, and finally the di-mensions of the bone defect.

When combined with osseointegrated im-plants, free flaps offer the patient a degree of oralrehabilitation previously unavailable. The ulti-

Fig. 7. The patient in case 2. (Left) Preoperative clinical photograph and three-dimensional com-puted tomographic scan of a left type IIa(–) maxillary defect. (Right) Clinical photograph and three-dimensional computed tomographic scan 24 months after simultaneous reconstruction with a freefibula osteoseptocutaneous flap and maxillary/mandibular osteotomies.


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mate functional goal of maxillary reconstruction isto restore speech, deglutition, and appearance.Restoration of speech requires obliteration of fis-tulas to avoid air escape and nasal regurgitation.Both soft-tissue flaps and obturators have beenused, but each has its own disadvantage. Soft-tissueflaps do not provide a foundation that will toleratethe forces of mastication. Obturators require rou-

tine insertion and removal, which can be uncom-fortable and inconvenient, particularly on raw tis-sue surfaces. Endosteal implants transfer the loadto an implant-borne prosthesis, reducing prob-lems of ulceration and discomfort. Preplacementof the dental implants into the flap during a first-stage operation, followed by flap transfer at 4 to 6weeks, may shorten total rehabilitation time and

Fig. 8. The patient in case 12. (Above) Clinical photograph and preoperative three-dimensional com-puted tomographic scan demonstrating a right type IIb(�) defect. (Below) Clinical photograph andpostoperative three-dimensional computed tomographic scan 6 months after reconstruction with asingle free fibula osteoseptocutaneous flap.


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Fig. 9. The patient in case 4. (Above, left) Clinical photograph obtained immediatelyafter reconstruction of soft tissue only. (Above, right) Three months after injury, there is


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provide a dentally determined flap inset.13 Thefibula and iliac crest are superior to the scapulaand radius when planning for dental implants.16

Although there is significant debate about place-ment of bone flaps for oncologic head and neck

defects given that many patients require radiationtherapy, the trauma patient tends to be young,otherwise healthy, and with a long life expectancy.Therefore, we aim for total oral rehabilitation,which includes placement of osseointegrated im-plants. Although implants are often not coveredby insurance initially, we have been successful inobtaining insurance coverage for patients withposttraumatic injuries, after much persistence.

The classification and algorithm presented fa-cilitates evaluation and reconstruction of severetraumatic maxillary defects. Close attention isgiven to the skeletal pillars of the midface. Initial

total midface collapse because of lack of midface skeletal support.(Center) Preoperative clinical photograph and three-dimensionalcomputed tomographic scan of a type IIIa(�) maxillary defect. (Be-low) Postoperative clinical photograph and three-dimensionalcomputed tomographic scan at 1 year after free iliac crest with aninternal oblique muscle flap.

Fig. 10. The patient in case 3. (Left) Preoperative clinical photograph and three-dimensional computedtomographic scan of a right type Ia(�) maxillary defect caused by a gunshot wound. (Right) Postoperativeclinical photograph and three-dimensional computed tomographic scan 1 year after immediate recon-struction with a free iliac bone flap. There was no contracture of the soft-tissue envelope.


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procedures focus on stabilization of the facial skel-eton, correction of malocclusion, and eliminationof fistulas. We prefer composite hard-tissue re-

placement at the initial stage of maxillary recon-struction. This allows ideal shaping of the arch forplacement of endosteal dental implants.

Many patients will undergo revisions or sec-ondary procedures. Achieving an optimal result is

Fig. 11. Clinical photograph and three-dimensional computed tomographic scan depicting a lefttype IIa(�) maxillary defect with involution and contracture of the soft-tissue envelope resulting invertical dystopia and loss of facial projection.

Fig. 12. One-year postoperative clinical photograph of a re-construction with nonvascularized rib graft wrapped in a freerectus flap.

Fig. 13. The patient in case 12. Postoperative clinical photographof soft-tissue augmentation of the malar prominence with an an-terolateral thigh flap.


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critical in trauma patients, as they are generallyyoung, without comorbidities, and have long lifeexpectancies. The goal of the first phase of recon-struction is to restore the skeletal construct anddeliver adequate or abundant soft-tissue bulk thatcan be contoured or rearranged at a later date. Inthe second phase, the bone and soft tissue arecontoured, and the position of the eyelids and thenose are addressed. We have found that type IIand presumably type IV deformities often requireadditional soft-tissue augmentation in the perior-bital and malar region as demonstrated in two ofour cases (Fig. 13).

Complex maxillary reconstruction requirescareful preoperative planning to ensure predict-able results. Variables to consider when planningthe operation include initial date of injury, mech-anism of injury (high or low energy), other organsystems involved, nutritional status, and previousoperative interventions,22 all of which will affectdonor-site selection. Free tissue transfer for treat-ment of high-energy facial trauma is reserved forsevere cases with significant bone and soft-tissueloss. At our institution, this algorithm is applicableto a fraction of patients with severe facial injuries(approximately 0.1 percent). Although these casesare rare, proper initial treatment is critical. In ourexperience, tremendous amounts of time and ef-fort have been spent correcting inadequate re-constructions that collapsed over time.

SUMMARYEarly aggressive operative intervention with

vascularized bone flaps is recommended to avoidtissue contraction, scarring, bone malalignment,and bone resorption. A two-team approach inwhich one team explores the defect, dissects therecipient vessels, realigns the skeletal pillars, andcorrects malocclusion with osteotomies while thesecond team harvests the flap is ideal. Althoughsoft-tissue flaps obliterate dead space, they do notsupport the structural pillars crucial for facial pro-jection and permanent dental rehabilitation. Theauthors’ experience indicates that early interven-tion with a vascularized bone flap is ideal for per-manent restoration of the maxilla and midface.The algorithm presented defines the range oftraumatic defects and offers a systematic approachto complex reconstruction.

Eduardo D. Rodriguez, M.D., D.D.S.Plastic, Reconstructive and Maxillofacial Surgery

R Adams Cowley Shock Trauma Center22 South Greene Street

Baltimore, Md. [email protected]

REFERENCES1. Genden, E. M., Okay, D., Stepp, M. T., et al. Comparison of

functional and quality-of-life outcomes in patients with andwithout palatomaxillary reconstruction: A preliminary re-port. Arch. Otolaryngol. Head Neck Surg. 129: 775, 2003.

2. Gruss, J. S., Antonyshyn, O., and Phillips, J. H. Early definitivebone and soft-tissue reconstruction of major gunshot woundsof the face. Plast. Reconstr. Surg. 87: 436, 1991.

3. Edgerton, M. T., Jr., and Zovickian, A. Reconstruction ofmajor defects of the palate. Plast. Reconstr. Surg. 17: 105, 1956.

4. Miller, T. A. The Tagliacozzi flap as a method of nasal andpalatal reconstruction. Plast. Reconstr. Surg. 76: 870, 1985.

5. Campbell, H. Reconstruction of the left maxilla. Plast. Re-constr. Surg. 3: 66, 1948.

6. Branemark, P. I. Osseointegration and its experimental back-ground. J. Prosthet. Dent. 50: 399, 1983.

7. Bartlett, C. S. Clinical update: Gunshot wound ballistics. Clin.Orthop. 408: 28, 2003.

8. Lutz, B. S., Wei, F. C., Ng, S. H., et al. Routine donor legangiography before vascularized free fibula transplantationis not necessary: A prospective study in 120 clinical cases.Plast. Reconstr. Surg. 103: 121, 1999.

9. Muzaffar, A. R., Adams, W. P., Jr., Hartog, J. M., et al. Max-illary reconstruction: Functional and aesthetic consider-ations. Plast. Reconstr. Surg. 104: 2172, 1999.

10. Davison, S. P., Sherris, D. A., and Meland, N. B. An algorithmfor maxillectomy defect reconstruction. Laryngoscope 108:215, 1998.

11. Brown, J. S. Deep circumflex iliac artery free flap with in-ternal oblique muscle as a new method of immediate recon-struction of maxillectomy defect. Head Neck 18: 412, 1996.

12. Robertson, B. C., and Manson, P. N. High-energy ballisticand avulsive injuries: A management protocol for the nextmillennium. Surg. Clin. North Am 79: 1489, 1999.

13. Rohner, D., Jaquiery, C., Kunz, C., et al. Maxillofacial recon-struction with prefabricated osseous free flaps: A 3-year ex-perience with 24 patients. Plast. Reconstr. Surg. 112: 748, 2003.

14. Suominen, E., and Tukiainen, E. Close-range shotgun andrifle injuries to the face. Clin. Plast. Surg. 28: 323, 2001.

15. Genden, E. M., Higgins, K., and Urken, M. L. The role ofpedicled flaps in a microvascular world. Semin. Plast. Surg. 17:275, 2003.

16. Frodel, J. L., Jr., Funk, G. F., Capper, D. T., et al. Osseointe-grated implants: A comparative study of bone thickness in fourvascularized bone flaps. Plast. Reconstr. Surg. 92: 449, 1993.

17. Yim, K. K., and Wei, F. C. Fibula osteoseptocutaneous freeflap in maxillary reconstruction. Microsurgery 15: 353, 1994.

18. Urken, M. L., Buchbinder, D., Costantino, P. D., et al. Oro-mandibular reconstruction using microvascular compositeflaps: Report of 210 cases. Arch. Otolaryngol. Head Neck Surg.124: 46, 1998.

19. Brown, J. S., Jones, D. C., Summerwill, A., et al. Vascularizediliac crest with internal oblique muscle for immediate re-construction after maxillectomy. Br. J. Oral Maxillofac. Surg.40: 183, 2002.

20. Kakibuchi, M., Fujikawa, M., Hosokawa, K., et al. Functionalreconstruction of maxilla with free latissimus dorsi-scapularosteomusculocutaneous flap. Plast. Reconstr. Surg. 109: 1238,2002.

21. Rogers, S. N., Lakshmiah, S. R., Narayan, B., et al. A com-parison of the long-term morbidity following deep circum-flex iliac and fibula free flaps for reconstruction followinghead and neck cancer. Plast. Reconstr. Surg. 112: 1517, 2003.

22. Dolin, J., Scalea, T., Mannor, L., et al. The management ofgunshot wounds to the face. J. Trauma 33: 508, 1992.


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