Challenges in midface reconstruction.

Defects of the midface and maxilla are often the most challenging problems faced by the reconstructive surgeon. Resections that involve critical structures of the face such as the nose, eyelids, and lips in conjunction with the maxilla can be particularly difficult to reconstruct. The algorithm for reconstruction of these defects is usually based on the extent of maxilla that is resected. A classification system for maxillectomy defects is the most useful way to approach these reconstructions. A vast majority of extensive defects involving the maxilla and midface require free flap reconstructions. The type of flap selected is based on the extent of skin, soft tissue, and bone that is resected. Smaller volume defects with large skin surface requirements are best reconstructed with the radial forearm fasciocutaneous or osteocutaneous flaps. Larger soft-tissue volume and skin surface can be provided by the rectus abdominus myocutaneous flap. Critical structures such as lips, eyelids, and nose should be reconstructed separately, using local flaps if at all possible. The free tissue transfer should ideally not be incorporated into these structures. Most patients with even the largest resections can be restored to fairly good function by following this algorithm. Semin. Surg. Oncol. 19:218-225, 2000.