Reconstruction de l'étage moyen de la face par transplants libres

Study aim

Midface is situated between the occlusal plane and the transverse midorbital plane. The aim of midface reconstruction is to restore the bony and soft tissue contour of the face, to obtain a rigid support for the velum, to allow oronasal separation, and to allow support for the orbit and obliteration of the maxillary sinus in order to restore the main functions: respiration, speech, deglutition, mastication, olfaction, vision.

Patients and methods

Between 1988 and 1997, 65 patients with defects to the midface in relation with cancer (n=60), gunshot (n=3), or congenital malformation (n=2), underwent reconstruction with one or more transplants: forearm (n=21), latissimus dorsi (n=23), scapula (n=12), composed subscapula (n=10), and fibula (n=4). Fortyseven of the patients were men and 18 were women. The mean age was 56 years (12–90 years). In patients with cancer, tumoral resection was immediately followed by midface reconstruction in the last 43 cases. Free flaps were selected for reconstruction of each part of the mid-face: cheek, nose, orbit floor, maxillary and palate.

Results

One post-operative death occurred (1.5%). The morbidity rate (18.7%) included necrosis of the free flaps in four cases. Average resumption of oral intake was ten days. The mean time to discharge was 17 days. Aesthetic and functional results were rated good or excellent in 53 patients. After one year, 52 patients were alive. Oral intake was normal in 48 patients, and mixed in four. Speech was excellent or good in 49 patients. From amongst the patients, 80% were able to find a job.

Conclusion

Free flaps with micro surgery provides an optimal, functional, morphological and aesthetic outcome. Patients with advanced cancer of the midface are best managed through a multidisciplinary team approach. Microsurgical reconstruction represents the technical state of the art in case of extensive and complex midface defect.