To describe the authors' experience in the reconstruction of patients after total maxillectomy with preservation of orbital contents for maxillary tumors using titanium mesh and autogenous fascia lata, where no setting for free flap reconstruction is available.
Patients and Methods
Twelve consecutive patients with paranasal sinus tumors underwent total maxillectomy without orbital exenterations and primary reconstruction. The defects were reconstructed by titanium mesh in combination with autogenous fascia lata in the orbital floor performed by 1 surgical team. Titanium mesh (0.2 mm thick) was contoured and fixed to reconstruct the orbital floor and obtain midface projection. Fascia lata was used to cover the titanium mesh along the orbital floor to prevent fat entrapment in the mesh holes.
The most common pathology was squamous cell carcinoma (50%). Patients' mean age was 45.66 years (33 to 74 yr). The mean follow-up period was 35.2 months (30 to 49 months). During follow-up, no infection or foreign body reaction was encountered. Extrusion of titanium mesh occurred in 4 patients who underwent postoperative radiotherapy. Two cases of mild diplopia at extreme gaze occurred early during the postoperative period that resolved after a few months.
Placing fascia lata between the titanium mesh surface of the orbital implant and the orbital contents was successful in preventing long-term diplopia or dystopia. Nevertheless, exposure of the titanium implant through the skin surface represented a complication of this technique in 25% of patients. Further studies are required with head-to-head comparisons of artificial materials and free flaps for reconstruction of maxillectomy defects.
Maxillary and orbital reconstruction is a major challenge for head and neck reconstructive surgeons. Because maxillectomy is an uncommon operation, evidence is limited regarding the best reconstructive procedure. Although the selection of the method depends on the extent of the bony and soft tissue defect, there is no clear optimal method of obturation, reconstruction, and rehabilitation.
Titanium mesh is a very suitable reconstructive material that allows precise anatomic reconstruction, but subsequent extrusion and complications have always been problematic. This report describes the authors' experience in the reconstruction of 12 patients who underwent total maxillectomy with preservation of orbital contents for maxillary tumors by titanium mesh and autogenous fascia lata.
Patients and Methods
From August 2009 to December 2010, at the Imam Khomeini Hospital, an affiliated hospital of the Tehran University of Medical Sciences (Tehran, Iran), 12 consecutive patients with paranasal sinus tumors underwent total maxillectomy without orbital exenterations (Class III) and primary reconstruction. The cases that required orbital exenteration were excluded. This study was approved by the Imam Khomeini Hospital institutional review board and all participants signed an informed consent agreement. The defects were reconstructed by titanium mesh in combination with autogenous fascia lata in the orbital floor performed by 1 surgical team. Eleven patients received postoperative radiotherapy (range, 30 to 66 Gy).
All surgeries and reconstructions were performed by 1 team. A total maxillectomy (including orbital floor resection with preservation of the orbital contents) was carried out in all patients. A Weber-Ferguson incision with subciliary extension was made. An upper cheek flap was raised with the lower eyelid portion elevated off the orbicularis oculi muscle. The flap was raised 1 cm lateral to the lateral canthus. The orbicularis oculi and the orbit periosteum were dissected off the inferior orbital rim and elevation was carried back near the orbital apex. The cheek skin and the contralateral palate were preserved. After performing the maxillectomy, the cheek flap was covered with a split-thickness skin graft. Titanium mesh (0.2 mm thick) was contoured and fixed to the remaining structures (zygoma, hard palate, alveolar ridge, and nasal bone) to reconstruct the orbital floor and obtain midface projection ( Figs 1, 2 ).
Fascia lata was harvested from the ipsilateral lower extremity through a longitudinal incision, approximately 3 to 5 cm long, along the lateral thigh, the center of which lies over the junction of the upper and middle thirds of the upper leg. The graft was used to cover the titanium mesh along the orbital floor to prevent fat entrapment in the mesh holes ( Fig 3 ).