BackgroundCurrent indications of maxillary reconstruction with scapular tip free flap are palatoalveolar defects associated with zygomaticomaxillary buttress and/or orbital floor defects. The scapular tip free flap can be placed either horizontally or vertically. Horizontal placement usually allows ideal palatal conformation preventing oronasal communication but has been argued to compromise orbital support and projection of the midface, while vertical placement is advocated for midface support but may be insufficient for complete closure of the palate. The present work focuses on the horizontal placing of scapular tip free flap to allow complete palate reconstruction and fistulae prevention while still obtaining optimal midface projection and orbital support. Material and methodsWe share our experience of twenty-one case complex maxillary reconstructions with this flap, in which the horizontally placed scapular tip component replaced the palate, a muscular flap component was included for midface volume restoration and an alloplastic implant utilized for supporting the orbital content when needed. Observation and resultsNone of our patients presented palatal fistulas or alterations in the orbital support. ConclusionA multi-level approach is proposed according to the maxillectomy defect. Our experience supports the horizontal insetting of the scapular tip free flap to allow palatal fistulae prevention while still obtaining an optimal midface projection and orbital floor support.