Background
Maxillectomy is the gold standard for management of resectable disease involving the maxilla and mid-face. However, it presents unique challenges both for tumour ablation and reconstruction.
Reconstruction of the midface is challenging given the anatomical complexity of the region and the need to restore function and aesthetics while ensuring en bloc resection, with the aim of achieving clear margins. Options include local tissue flaps, prosthetic obturation, the use of osseointegrated implants, as well as soft tissue and composite free tissue transfer.
Herein, we describe 28 consecutive Maxillectomy cases performed for the management of malignant disease during a 2-year period.
Methods
This is a retrospective review of all maxillectomies performed for the management of malignant disease in the Maxillofacial Surgery Department at St James Hospital during a 2-year period. Variables recorded include: age, sex, pathology, tumour resection margins, Brown class of maxillectomy defect, method of reconstruction, surgical complications and length of follow-up. Patients with benign disease were excluded.
Results
Twenty-eight patients (16 males, 12 females) met the inclusion criteria. A further 5 maxillectomies were performed for benign disease, and so not included in this study. The mean age at presentation was 56-years (range, 7 to 81 years). Twenty patients had a squamous cell carcinoma (of which 70% were a pT4); 4 had a salivary gland tumour; and 1 each of malignant melanoma, secretory cell carcinoma, and clear cell carcinoma.
Regarding defect classification: 63% had a Brown Class II; 33% a Class I, and 3% a Class III.
Twenty-eight percent (n=8) were reconstructed with a soft tissue free flap alone; 28% (n=8) with a local flap with/without a healing plate; 25% (n=7) were reconstructed with a Zygomatic Implant Perforator (ZIP) Flap; 14% (n=4) with an obturator; and one with a zygomatic implant retained prosthesis. Regarding complications; there were no acute returns to theatre; 1 patient required a return to theatre 2 weeks post op for management of wound dehiscence. There was no neuro-surgical involvement in any case. There were no flap failures. Twenty-four (86%) patients had clear margins, while the remainder had margins between 2-4mm. There were no involved margins. For patients receiving a ZIP flap, the mean time to prosthesis (teeth) placement was 17 days post-surgery.
Conclusion
This study describes the safe management of 28 patients with malignant maxillary/mid-face disease from an ablative and reconstruction view-point. There has been a shift in the reconstruction of this group of patients, with the successful use of Zygomatic Implants either alone or in combination with free tissue transfer (free flap).
Tamer Darwazeh1, M Ryan1, Edward Cotter2, Conor Bowe1, John Edward O’Connell1
1 Department of Oral & Maxillofacial Surgery, St James’s Hospital, Dublin
2 Hermitage Medical Clinic, Dublin