The Omega-Shaped Fibula Osteocutaneous Free Flap for Reconstruction of Extensive Midfacial Defects

Sir: Restoration of the complex three-dimensional form of the midface with bone and soft-tissue flaps that do not inherently resemble the shape of the native maxillae makes reconstruction of extensive palatomaxillary defects extremely challenging. Our goal was to describe a technique for midfacial reconstruction using the fibula osteocutaneous free flap that best recreates the original form and function of the maxillary bones. The leg ipsilateral to the recipient blood vessels is selected for fibula osteocutaneous free flap harvest so that the skin paddle can be used to reconstruct the palate. Bilateral defects are reconstructed with a fibula shaped to resemble the Greek letter omega (Ω) in the transverse plane (Fig. 1). Unilateral defects are reconstructed with a fibula shaped to resemble half or a portion of an omega. Oriented transversely, the omega-shaped fibula restores the width and projection of the midface. The lateral surface of the fibula bone, which averages 14 to 17 mm in width, restores the vertical height of the maxilla.1 The skin paddle is inset at the level of the resected alveolus, rather than at the level of the dentition, to provide room for an implant-retained dental prosthesis.Fig. 1.: A fibula osteocutaneous free flap shaped using closing wedge osteotomies to resemble the Greek letter omega to restore a bilateral maxillectomy defect before (left) and after (right) flap inset using rigid fixation with a titanium locking reconstruction plate.We performed 20 reconstructions for palatomaxillary defects between 2005 and 2008, including 16 bilateral and four unilateral defects (Fig. 2). Ten reconstructions were performed immediately after maxillectomy and 10 reconstructions were delayed. Operative times averaged 12.7 ± 2.3 hours. Intensive care unit stays averaged 3.0 ± 1.7 days and hospital stays averaged 10.7 ± 3.0 days. Complications included two recipient-site hematomas, one recipient-site infection, one palatal dehiscence, one plate exposure, and one donor-site partial skin graft loss. All patients demonstrated 100 percent speech intelligibility, and only one patient had hypernasal speech. Postoperatively, 10 patients consume a regular diet and 10 patients consume a soft diet (preoperatively, 11 patients consumed a regular diet, eight patients consumed a soft diet, and one patient was feeding tube dependent). Eight patients have undergone dental restoration with osseointegrated implants and can tolerate a regular diet. Five additional patients are awaiting implant placement.Fig. 2.: Anterior (above, left) and lateral (above, right) postoperative photographs of a 28-year-old woman with a left maxillary osteosarcoma 18 months after left total maxillectomy and reconstruction with a half-omega–shaped fibula osteocutaneous free flap. Osseointegrated implants were used to retain a prosthesis for dental restoration (below).For extensive palatomaxillary defects, obturator rehabilitation may not be an option because of overly heavy prostheses with poor retention, particularly in edentulous patients.2,3 Microvascular free flaps have largely replaced local and regional flaps, which are limited by their small size, short pedicle length, and frequent need for staging of procedures.4 Although a number of free flaps have been suggested,4,5 a standard reconstructive technique has not emerged, partially because none of these flaps resembles the complex shape of the maxillae in their native form. Our technique for shaping the fibula osteocutaneous free flap mimics the configuration of the midface, restoring midfacial height, width, and projection; prevents palatal incompetence; and can accommodate osseointegrated implants for dental restoration. We recommend this reconstructive technique for all patients with extensive unilateral or bilateral maxillectomy defects, as consistently good aesthetic and functional results can be achieved with minimal morbidity in appropriate surgical candidates. Matthew M. Hanasono, M.D. Roman J. Skoracki, M.D. Department of Plastic Surgery University of Texas M. D. Anderson Cancer Center Houston, Texas DISCLOSURES The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this article. No funding was received for the work presented in this article.