moreno et al-2010-head & neck

ORIGINAL ARTICLE

MICROVASCULAR FREE FLAP RECONSTRUCTION VERSUSPALATAL OBTURATION FOR MAXILLECTOMY DEFECTS

Mauricio A. Moreno, MD,1,2 Roman J. Skoracki, MD,1 Ehab Y. Hanna, MD,2

Matthew M. Hanasono, MD1

1Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center,Houston, Texas. E-mail: [email protected] of Head and Neck Surgery, The University of Texas M. D. Anderson CancerCenter, Houston, Texas

Accepted 3 August 2009Published online 9 November 2009 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hed.21264

Abstract: Background. Palatal obturators and microvascu-

lar free flaps are both used to treat patients with maxillectomy

defects, however, the optimal technique remains controversial.

Methods. A retrospective analysis of 113 patients under-

going maxillectomy for cancer was performed. Seventy-three

patients received an obturator and 40 patients were recon-

structed with a free flap.

Results. Speech intelligibility and postoperative diet were

comparable between the obturator and free flap groups,

except in cases of extensive (>50%) palatal defects, where

free flap reconstruction was superior in both aspects (p ¼ .019

and p ¼ .043, respectively). The average time for presenting

with a local recurrence in advanced cancer involving the pal-

ate was comparable in both groups (p ¼ .33).

Conclusion. Moderate-sized maxillectomy defects involving

the palate can be successfully treated with either an obturator

or free flap reconstruction. Extensive defects have a better

functional outcome with free flaps. Evidence does not suggest

that free flap reconstructions delay diagnosis of local

recurrences. VVC 2009 Wiley Periodicals, Inc. Head Neck 32:

860–868, 2010

Keywords: head and neck cancer; microvascular free flap;

maxillectomies; obturator; prosthesis

The maxilla is the pivotal structure of the mid-face, separating the oral, antral, and orbital cav-ities, and providing support to the globes, lowereyelids, cheeks, lips, and nose. In addition, themaxillae play a critical role in speech, swallow-ing, and mastication. Consequently, reconstruc-tion of maxillectomy defects is 1 of the mostdifficult challenges faced by the head and neckreconstructive surgeon. Maxillectomy defectsare typically treated by prosthetic obturation orautologous tissue reconstruction. Each tech-nique has its advantages and disadvantages,and the best approach is a subject of debate.1–3

Traditionally, rehabilitation with a palatalobturator has been the most common approachfor treating maxillectomy defects. The advan-tages of this technique include a shorter opera-tive time, shorter postoperative hospital stay, andcomplete visualization of the maxillectomy cavity,which simplifies oncologic surveillance.4 Unfortu-nately, there are also numerous disadvantages

Correspondence to: M. M. Hanasono

This work was presented at the American Society for ReconstructiveMicrosurgery Annual Meeting, Maui, HI, January 10–13, 2009.

VVC 2009 Wiley Periodicals, Inc.

860 Reconstruction of Maxillectomy Defects HEAD & NECK—DOI 10.1002/hed July 2010

associated with obturators, including the poten-tial for hypernasal speech, regurgitation of foodsand liquids into the nasal cavity, difficulty inmaintaining hygiene of the maxillectomy cavity,and the need for repeated prosthesis adjustmentsdue to progressive changes in the size and shapeof the palatal defect, especially in patients whoreceive radiation therapy.5 Larger defects areharder to obturate as the prosthesis may beoverly heavy and difficult or impossible to retain,particularly in partially or totally edentulouspatients.6,7

A variety of local and regional flaps havebeen used to reconstruct maxillary defects withvariable success.8–10 Unfortunately, all thesetechniques have been limited by a paucity ofavailable tissue, restricted reach of the vascularpedicle, and the frequent need for staged proce-dures to achieve an optimal result. Maxillaryreconstruction changed radically with theadvent of microvascular free tissue transfer,which provides abundant tissue for reconstruc-tion, the freedom to orient, shape, and inset theflap as required for the specific defect, and theability for reconstruction to be performed as asingle-stage procedure.11 Additionally, transferof vascularized bone provides the option of den-tal restoration via implantation of osseointe-grated implants, even in irradiated tissues.7 Forsome massive midface–skull base lesions, theresection is only possible if the defect can imme-diately be reconstructed with free tissue trans-fer, such as when there is exposure of criticalneurovascular structures, for example. In addi-tion, there are some defects that are not amena-ble to rehabilitation with prosthesis unless someform of free tissue transfer reconstruction isperformed.

Disadvantages of free flaps include longersurgical and recovery times with increasedpotential for complications compared with pros-thetic obturation. Another concern is the possi-bility that obliteration of the maxillectomydefect by the free flap may delay the diagnosisof a local recurrence. To date, the few studiescomparing obturators to free flap reconstruc-tions of maxillectomy defects have not been ableto demonstrate a difference in functional out-comes that would favor 1 method over the other,nor have they been able to identify subsets ofpatients that might benefit from 1 approach orthe other.2,3 One reason is that maxillectomiesare relatively uncommon procedures whencompared with other head and neck oncologic

surgeries, making it difficult to build a largepersonal or institutional experience with thistype of reconstruction.12 The objectives of thepresent study were to compare outcomes of pros-thetic obturators and microvascular reconstruc-tion of maxillectomy defects with regard to: (1)speech and swallowing function, (2) rate of com-plications, and (3) cancer surveillance for localrecurrence.

MATERIALS AND METHODS

Institutional review board approval to conduct aretrospective review of reconstruction and reha-bilitation after maxillectomy was obtained. Asearch of a prospectively collected database wasperformed to identify 201 patients who under-went a maxillectomy at The University of TexasM. D. Anderson Cancer Center between Janu-ary 1, 2000, and December 31, 2006. Inclusioncriteria for patients to be included in this studywere: (1) a maxillectomy performed at our insti-tution; (2) at least 1 preoperative and 1 postop-erative head and neck CT or MRI scan; (3) aminimum of 6 months of postoperative follow-uptime; and (4) a speech and swallowing evalua-tion by a speech pathologist in the postoperativeperiod. Exclusion criteria were: (1) defects thatproduced no communication between the oraland sinonasal cavities such as medial maxillec-tomies, suprastructure maxillectomies, and lim-ited tuberosity resections; (2) reconstruction ofthe defect by grafts, local flaps, or any meansother than free tissue transfer or a palatal obtu-rator; and (3) absent or incomplete chart docu-mentation. A total of 113 patients met thesecriteria and were included in the study.

Information retrieved included demographicdata, cancer status at presentation (primary vsrecurrent), histopathology, status of maxillaryand mandibular dentition, margin status, use ofadjuvant chemotherapy or radiation therapy,and complications. The surgical defect was clas-sified in the vertical and horizontal (palatal)planes according to the classifications systemsdescribed by Okay et al6 and Brown et al,13

respectively (Figure 1 and Figure 2). Forpatients who underwent free flap reconstruc-tion, the information obtained included: type offlap, osseointegrated implant placement, andtechnique for orbital floor reconstruction, ifperformed.

Reconstruction of Maxillectomy Defects HEAD & NECK—DOI 10.1002/hed July 2010 861

As a standard practice in our institution, allpatients who received a palatal obturator wereassessed preoperatively by the dental team toobtain dental impressions. Upon completion ofthe ablation, a temporary obturator made ofTrusoft (Bosworth Dental, Skokie, IL) wasplaced intraoperatively and kept in place forapproximately 1 week. This was subsequentlyexchanged for a definitive obturator in the

dental clinic, which was then adjusted on an as-needed basis.

Patients were evaluated postoperatively byexperienced speech pathologists for speech intel-ligibility defined as the percentage of wordsunderstandable to an unfamiliar listener. Thisinformation was combined into a 5-pointdescriptive scale described by Matsui et al14: (1)excellent, all speech is understood or patient

FIGURE 2. Classification of maxillectomy defects based on the vertical extent of resection originally described by Brown et al.13

Reprinted with permission from Elsevier.

FIGURE 1. Classification of maxillectomy defects based on the extent of palatal resection originally described by Okay et al.6 Type Ia:

Hard palate but no tooth-bearing maxillary alveolus. Type Ib: Premaxilla or any portion of maxillary alveolus posterior to canines. Type

II: Any portion of hard palate and tooth-bearing alveolus and only one canine. Transverse palatectomy defects that involve less than

50% of the palate. Type III: Tooth-bearing maxillary alveolus including both canines. Transverse palatectomy defects than involve more

than 50% of the palate. Reprinted with permission from Elsevier.


has intelligibility above 80%; (2) good, requiresoccasional repetition, 65% to 75% intelligibility;(3) fair, can be understood when conversationalcontent is already known, 45% to 60% intelligi-bility; (4) poor, difficult to understand, requiresfrequent repetition, 30% to 40% intelligibility,and (5) dismal, extremely difficult to understandor less than 25% intelligibility. The postopera-tive diet was also recorded by the speech pathol-ogist. When patients had multiple speechpathology visits, the best-documented speechand oral diet were considered for the study.

Statistical analysis was performed using theSPSS Statistics version 17.0 software (SPSSIncorporated, Chicago, IL). Proportional datawere compared using the chi-square test orFisher’s exact test as appropriate and continu-ous data were compared using the t test. Allanalyses were 2-tailed, and p values less than.05 were considered statistically significant. Thep values less than .0001 are reported as such;otherwise, actual p values are shown.

RESULTS

There were 63 men and 50 women in the serieswith a median age of 54 years (range, 9–88years). Twenty-five patients presented withrecurrent or residual disease while 88 were pre-viously untreated. All patients were treatedwith curative intent. The mean follow-up timewas 27.3 months (range, 7–63 months) and the5-year overall survival for the series was 61.9%.The histologic diagnoses included squamous cellcarcinoma in 43 patients (38%), sarcoma in 22patients (19.4%), adenoid cystic carcinoma in 20patients (17.7%), benign tumors in 10 patients(8.9%), melanoma in 6 patients (5.3%), adeno-carcinoma in 4 patients (3.5%), verrucoid squa-mous cell carcinoma in 2 patients (1.7%),ameloblastic carcinoma in 1 patient (0.8%), car-cinoma expleomorphic in 1 patient (0.8%), aciniccell carcinoma in 1 patient (0.8%), mucoepider-moid carcinoma in 1 patient (0.8%), adnexal car-cinoma in 1 patient (0.8%), and papillarytransitional carcinoma in 1 patient (0.8%).

Sixty-one patients had complete maxillarydentition while 68 had complete mandibulardentition at the time of presentation. Eighty-onepatients underwent radiation therapy, including12 patients who received preoperative radiationand 69 patients who received postoperativeradiation. The total radiation dose ranged from

28 to 70 Gray (Gy) with an average of 58.8 Gy;55 patients received a dose of 60 Gy or higher.Thirty-six patients received chemotherapy,which was used as induction therapy in 18patients and adjuvant chemotherapy in18 patients. Surgical margins were positive in11 patients, close (less than 1 mm) in 6 patients,and negative in the remaining 96 patients.

Seventy-three patients were rehabilitatedwith a palatal obturator and 40 patients werereconstructed with a free flap. There were nostatistically significant differences in age, sex,use of chemotherapy, use of radiation therapy,or preoperative dentition between these 2groups (Table 1). Differences in surgical timeand hospital stay were significant. In the obtu-rator group, the device was fitted to the remain-ing teeth in 53 patients, the palatal defect in 17patients, and osseointegrated in 3 patients. Ofthe 40 patients in the free flap group, 19(47.5%) had complete maxillary dentition, 14(35%) had partial maxillary dentition, and 7(17.5%) were edentulous before surgery. Uponcompletion of the reconstruction, 9 patients(22.5%) remained with functional dentition. Anobturator was fitted in 27 of the 31 remainingpatients; this was implant-borne in 9 cases,implant-retained in 5 cases, and tissue-borne in13 cases. In 4 cases, the obturator could not befitted due to bulky soft tissue reconstruction ofextensive defects and/or an inability to performimplant placement.

Table 2 shows the free flaps utilized forreconstruction and their respective outcome. Of3 patients that underwent surgical re-explora-tion for vascular compromise, 1 was successfullysalvaged and 2 had complete flap loss. In 1 ofthese cases, a rectus abdominis myocutaneousfree flap was subsequently replaced by ananterolateral thigh free flap without furthercomplications. In the other case, the patient

Table 1. Comparison of obturator and free flap groups.

Obturator Free flap p value

Median age 57.1 (16–88) 50.8 (9–88) .0660

Sex, M/F 36/37 26/14 .1684

Radiation, Y/N 50/23 31/9 .3848

Average surgical

time, min 252.9 668.6 <.0001Average hospital

stay, d 3.4 9.7 <.0001Recurrent or

residual, Y/N 9/64 16/24 .0016


declined another surgery and was rehabilitatedwith a palatal obturator. A partial flap lossinvolving less than 10% of the cutaneous paddlewas observed in 2 fibula osteocutaneous freeflaps, both of which healed without further sur-gery. One patient who underwent reconstructionwith an anterolateral thigh flap was re-exploredfor venous congestion and developed delayed fatnecrosis. This patient did require surgical de-bridement but no additional reconstructive pro-cedures. Other postoperative complications,summarized in Table 3, were more frequent inthe free flap group (p ¼ .007). There were noperioperative deaths in this series.

There were 59 (52.2%) type II defects, 32(28.3%) type III defects, and 22 (19.4%) type IVdefects based on their vertical extension (Brownet al13 classification). Since the absence of anoroantral communication was part of the exclu-sion criteria, there were no patients with a type Idefect in this study. Classification of the defect inthe horizontal (palatal) plane (Okay et al6 classi-

fication) yielded 2 patients (1.8%) with a type IAdefect, 33 patients (29.2%) with a type IB defect,51 patients (45.1%) with a type II defect, and 27patients (23.8%) with a type III defect. Recon-struction of the orbital floor with titanium meshwas performed in 5 patients as an associated pro-cedure to free flap reconstruction. A comparisonof patients treated with obturators and free flapsdemonstrated significantly different distributionsof vertical and horizontal defects (p < .0001 andp ¼ .004, respectively), with free flaps more fre-quently used to address more extensive defects inboth the vertical and horizontal planes (Table 4and Table 5).

Some degree of functional speech was pre-served in all patients, regardless of the defectextent. The extent of the defect in the horizontal(palatal) plane was found to adversely affectspeech and swallowing in a statistically signifi-cant fashion (Table 6). The vertical extent of thedefect did not significantly affect speech andswallowing outcomes (p ¼ .66 and p ¼ .07 forspeech and swallowing, respectively). Whencomparing the functional outcome between theobturator and free flap groups, no statisticallysignificant difference was found if the data werenot stratified (Table 7). When outcomes werestratified by defect size (Table 8), a statisticallysignificant advantage favoring the free flapgroup in patients with a type III palatal defectwas identified. The charts of the 10 patients inthe obturator group with poor swallowing

Table 3. Postoperative complications.

Complication

Free

flap, n % Obturator, n %

Delayed nasocutaneous

fistula

5 12.5 3 4.2

Bleeding/hematoma 2 5 3 4.2

Cellulitis/abscess 2 5 1 1.4

Pneumonia 2 5 1 1.4

Delirium 2 5 1 1.4

CSF leak 2 5 0 0.00

Urinary retention 1 2.5 1 1.4

Acute renal failure 1 2.5 0 0.00

Bowel obstruction 1 2.5 0 0.00

Urinary tract infection 1 2.5 1 1.4

Total 19 47.5 11 15.0

Abbreviation: CSF, cerebrospinal fluid.p ¼ .007.

Table 4. Classification of the defect in the vertical plane

(Brown et al).13

Obturator Free flap

Vertical extension n % n %

Type II 49 67.1 10 25

Type III 21 28.8 11 27.5

Type IV 3 4.1 19 47.5

Total 73 100 40 100

p < .0001.

Table 5. Classification of the defect in the horizontal plane

(Okay et al).6

Obturator Free flap

Horizontal extension n % n %

Type Ia/Ib 28 38.4 7 17.5

Type II 35 47.9 16 40

Type III 10 13.7 17 42.5

Total 73 100 40 100

p ¼ .004.

Table 2. Free flaps used and flap outcome.

Free flap n Flap outcome

Anterolateral thigh 11 1 venous congestion

w/o flap loss

Osteocutaneous fibula 11 1 TL, 2 PL (<10%

cutaneous paddle)

Rectus abdominis 10 1 TL

Osteocutaneous fibula þ ALT 3 All viable

Radial forearm free flap 2 All viable

Lateral arm 1 Viable

Serratus composite 1 Viable

Free rectus þ skin graft 1 Viable

Abbreviations: TL, total loss; PL, partial loss; ALT, anterolateral thigh.


outcomes (nothing prescribed orally [NPO]/liq-uid diet) were reviewed. Six of these patientshad extensive (type III) horizontal defects, 2patients had multiple unsuccessful revisions ofthe device, 1 patient presented with severe tris-mus, and 1 patient had a cerebrovascular eventwith severe aspiration. There were no differen-ces in the use of external beam radiation orchemotherapy in this group when comparedwith the rest of the series (p ¼ .66 and p ¼ .32,respectively). In the same fashion, there wereno identifiable additional defects, such as pha-ryngeal or soft palate resection that couldexplain their worse functional outcome.

To determine whether free flap reconstruc-tion hampers oncologic surveillance, we ana-

lyzed 11 patients primarily treated for a T4squamous cell carcinoma of the maxillary gin-giva/hard palate that developed local recurrence.This histology and stage was chosen because ofthe high prevalence in the series and compara-ble number of patients reconstructed with freeflaps and palatal obturation. The average timeto diagnose the local recurrence was 7.6 monthsfor the free flap group and 13 months for the ob-turator group; this difference was not statisti-cally significant (p ¼ .33). Additionally, thecharts of all patients who had a local recurrencewere analyzed to document if the diagnosis wasfirst made by physical examination or routineimaging. We found that the diagnosis was mostfrequently made by physical examination inboth the free flap and obturator groups (Table9), and no significant difference was foundbetween the groups (p ¼ .694).

DISCUSSION

Most studies comparing functional outcomes ofprosthetic rehabilitation and microvascular freeflap reconstruction after maxillectomy have notshown significant differences between thesetechniques.2,3 One of the problems with evaluat-ing these techniques is the lack of a universallyaccepted nomenclature for maxillectomy defects,which vary greatly in their size and extent.15,16

In the present study, we decided to compare pal-atal obturation to free flap reconstruction using

Table 6. Functional results stratified by type of horizontal

defect.

Type Ia/Ib Type II Type III

n % n % n %

Diet*

Unrestricted 23 65.7 31 60.8 8 29.6

Soft 12 34.3 14 27.5 11 40.7

Liquid 0 – 4 7.8 6 22.2

NPO 0 – 2 3.9 2 7.4

35 100 51 100 27 100

Speech†

Excellent 22 62.9 23 45.1 8 29.6

Good 13 37.1 18 35.3 10 37

Average 0 – 9 17.6 6 22.2

Poor 0 – 1 2 3 11.1

35 100 51 100 27 100

*p ¼ .003 (combining 2 lower categories).†p ¼ .007 (combining 2 lower categories).

Table 7. Functional results for the obturator and free flap

groups, all patients.

Obturator Free flap

n % n %

Diet*

Unrestricted 40 54.8 22 55

Soft 23 31.5 14 35

Liquid 8 11 2 5

NPO 2 2.7 2 5

73 100 40 100

Speech†

Excellent 34 46.6 19 47.5

Good 25 34.2 16 40

Average 12 16.4 3 7.5

Poor 2 2.7 2 5

73 100 40 100

Abbreviation: NPO, nothing prescribed orally.*p ¼ .68.†p ¼ .54.

Table 8. Summary of p values comparing free flaps versus

obturator, stratified by defect extension.

Diet, p value Speech, p value

Horizontal classification

Type Ia/Ib .99 .99

Type II .9276 .4285

Type III .0425 .019

Vertical classification

Type II .2906 .3138

Type III .3567 .5438

Type IV N/A N/A

Abbreviation: N/A, not applicable.

Table 9. Method used for diagnosis of local recurrence.

Clinical Images

Free flap 9 4

Obturator 8 6

p ¼ .694.


2 systems that are based on expected functionaloutcomes. Our goal was not only to comparethese 2 techniques, but also to identify subsetsof patients who might benefit more from 1 tech-nique over the other.

The extent of the maxillectomy defect in thehorizontal plane (ie, the palatal component) wasclassified according to the system described byOkay et al.6 This classification system not onlyconsiders the extent of the palatal defect butalso utilizes biomechanic concepts to predict theability of successful obturator retention and,therefore, the likelihood of successful prostheticrehabilitation. In the present study, we foundthat this system was highly correlated to post-operative speech and swallowing outcomes andis, therefore, a valuable tool to evaluate the suc-cess of obturation and free flap reconstruction.In contrast, the extension of the defect in thevertical plane according to the classification sys-tem described by Brown et al13 did not correlatewith functional outcome. This probably indicatesthat once the palatal surface and alveolar archhave been adequately restored, the continuity ofthe maxillary superstructure has a limited effecton speech and swallowing, although they mayhave an effect on cosmesis or orbital support.This was acknowledged by Brown et al,13 whoalso proposed a subclassification based on thepalatal defect. We opted to use the horizontalclassification proposed by Okay et al6 because ittakes into account the ability to stabilize andretain an obturator.

When the extent of the horizontal componentof the defect (Okay et al6 classification) was con-sidered, a significant difference favoring freeflap reconstruction in patients with a type IIIdefect was observed. This was confirmed byreviewing the charts of patients with poor func-tional outcome in the obturator group. In thesecases, no identifiable factors other than theextensive nature of the defect appeared as plau-sible explanations for this observation in themajority of these patients. These results implythat patients with a resection of the hard palategreater than 50% of the total area, or of the an-terior palate, in which both canines are includedin the resection, should undergo reconstructionwith a free flap whenever feasible, while smallerdefects could be addressed equally well by eithera palatal obturator or a free flap. Free flapsprobably give better functional results in exten-sive or anterior defects because obturators can-not be adequately stabilized by the remaining

alveolus or teeth. The majority of patients whounderwent a free flap reconstruction for thistype of defect had bony restoration of the palatalarch with a fibula flap, resulting in a stableocclusal plane.

Larger maxillary defects often preclude theuse of a conventional denture for dental restora-tion, particularly in edentulous patients. Insome cases, a denture-obturator can make useof the maxillary defect to improve retention.However, in very large defects, such an obtura-tor can be overly heavy, may require multiplemagnet-retained parts, and the retention maybe unstable. For large defects, our current strat-egy is to perform bony reconstruction followedby dental restoration using implant-retainedprostheses whenever possible. The reconstruc-tive plan in these cases obviously requires closecooperation and pretreatment planning with aprosthodontist and with the patient.

The complication rate was higher in thefree flap group than in the obturator group(Table 3). This was not entirely unexpected asfree flap procedures are longer and were gen-erally used for more extensive defects in boththe vertical and horizontal plane. Interestingly,a nasocutaneous fistula along the Weber-Ferguson incision was the most common surgi-cal complication in both groups. Six of the 8patients who developed a nasocutaneous fistulareceived full-dose radiation, which emphasizesthe role of this treatment in the developmentof this complication.

One of the major concerns about free flapreconstruction after maxillectomy for cancer isthe risk of delaying the diagnosis of a localrecurrence. To date, there are no studies in theliterature documenting any delay in the detec-tion of recurrent tumors in patients undergoingfree flap reconstruction after maxillectomy, butthis is still an area of debate.17 To address thisquestion, we compared the average time for pre-sentation of local recurrence in a group ofpatients matched for cancer stage and histologyand found no statistically significant differencesbetween the free flap group and the obturatorgroup. Also, we found that the diagnosis ofrecurrence was more frequently made by physi-cal examination in both groups. This contrastswith results from other series in which CT andMRI scan techniques were shown to identifylocal recurrences earlier than physical examina-tion alone.18 Overall, our findings support thehypothesis that free flaps are an oncologically


sound option for addressing the maxillectomydefect in patients with cancer.

Despite the fact that palatal obturation pro-vides good functional results in reconstructionof small to medium-sized palatal defects, thereare other limitations that are inherent to pros-thetic rehabilitation. These include difficultieswith keeping the maxillectomy cavity clean, res-idue buildup on the obturator even with vigilantcleaning, the inability to eat or communicateeffectively without the device, and the need forrepeated readjustment of the obturator as thesize and shape of the palatal defect changesover time, which may negatively affect thepatient’s quality of life. In a recent series, Gen-den et al19 demonstrated that free flap recon-struction improves the patient’s quality of lifeover prosthetic rehabilitation even in patientswith small to medium-sized defects. Thus, inpatients who are good candidates for microvas-cular reconstruction based on their medicalstatus and overall prognosis, free flap recon-struction may be preferable even when thedefect size is modest.

Multiple microvascular free flaps have beendescribed for maxillary reconstruction, includingthe iliac crest,20 fibula,7 radial forearm,21

anterolateral thigh,22 rectus abdominis myocu-taneous,23,24 and scapula12,17 free flaps. Each ofthese alternatives has its own advantages anddisadvantages in maxillary reconstruction. Anevaluation of the various free flap types used inmaxillary reconstruction is beyond the scope ofthis study. Ultimately, the decision of which flapto use is dependent on the extent and location ofthe defect, potential for dental restoration, anddonor site availability, as well as the surgeon’spersonal preference.

CONCLUSIONS

The size and extent of the palatal defect bestpredicts the speech and swallowing outcome ofpatients undergoing maxillectomy. While func-tional results are comparable in small tomedium-sized palatal defects, reconstructionwith free flaps provides better speech and swal-lowing results than palatal obturation in exten-sive or anterior defects. Microvascular freeflaps, in our experience, were associated with a95% success rate without significant long-termcomplications. In addition, we found no differ-ence in the rate of detecting local recurrences

that would favor either free flap reconstructionor palatal obturation. Based on the results ofthis study, microvascular free flap reconstruc-tion should be strongly considered in patientsundergoing maxillectomy, particularly when thedefect is large or anterior. Less extensivedefects can be rehabilitated successfully witheither an obturator or reconstructed with freetissue transfer, although free flap reconstruc-tion eliminates problems with prosthetic reten-tion, maxillectomy cavity hygiene, and theneed for repeated obturator adjustment toprevent oral-nasal escape.

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moreno et al-2010-head & neck

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