Maxillary reconstruction: the role of the fibula free flap

Abstract

Reconstruction of the maxilla is a difficult task to perform consistently with good results. Multiple procedures are often required to achieve a result that is almost always less than ideal. Numerous reconstructive options are available; however, no single option has yet emerged as the staple for management of this defect. With the development and refinement of microvascular technique, free-tissue transfer has leaped to the forefront of the quest for advancement in maxillofacial reconstruction. A variety of free flaps have been described, either alone or in combination with other techniques, with the aim of improving reconstructive outcomes. A consensus, however, has yet to be reached with respect to specific flap selection; and still today, there are those who would favour obturation in some, if not the majority, of situations. While obturation does has its advantages, it is this author's opinion that it should no longer be regarded as a preferred method of reconstruction; and should be reserved for those cases where other more definitive options, i.e. free tissue transfer, are deemed inappropriate. In this paper we review the anatomy of the maxilla, the classification of maxillary defects, the principles of maxillary reconstruction and the various reconstructive options available for each class of defect. We then focus on the free fibula flap, as it is the free fibular flap that we find most versatile in reconstruction of the maxillectomy defect. A description of our surgical approach is presented and is supplemented by a series of illustrative cases.