Principles of midface free tissue transfer: A defect-based approach

Free flap reconstruction has become the standard of care for complex midfacial defects. Each reconstruction requires a highly individualized, defect-driven approach with special consideration to restoration of midface buttresses, orbital and skull base support, oronasal separation, and dental rehabilitation. The subscapular system of flaps is a workhorse of midface reconstruction and can meet the demands of virtually any defect as it allows for precise reconstruction of multiple buttresses with significant soft tissue availability. The fibula flap provides a reliable option for bony reconstruction, particularly when dental rehabilitation is desired. Adequate flap volume should be prioritized to support critical neurovascular structures and withstand radiation therapy. Pedicle management can be challenging due to the distance of flap inset from the neck vasculature and may require the use of small-caliber distant vessels, grafting, or flow-through techniques. Virtual surgical planning (VSP) allows for conceptualization of complex midfacial defects and facilitates reconstructive planning with the use of cutting guides, osteotomies, and customized hardware.