Accepted 13 March 2008 Published online 18 July 2008 in Wiley InterScience ( DOI: /hed.20874

Transcription

1 ORIGINAL ARTICLE ZYGOMATICOMAXILLARY BUTTRESS RECONSTRUCTION OF MIDFACE DEFECTS WITH THE OSTEOCUTANEOUS RADIAL FOREARM FREE FLAP Patricio Andrades, MD, Eben L. Rosenthal, MD, William R. Carroll, MD, Christopher F. Baranano, MD, Glenn E. Peters, MD Division of Otolaryngology Head and Neck Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama. Accepted 13 March 2008 Published online 18 July 2008 in Wiley InterScience ( DOI: /hed Abstract: Background. The purpose of this study was to evaluate morbidity, functional, and aesthetic outcomes in midface zygomaticomaxillary buttress reconstruction using the osteocutaneous radial forearm free flap (OCRFFF). Methods. A retrospective review of 24 consecutive patients that underwent midface reconstruction using the OCRFFF was performed. All patients had variable extension of maxillectomy defects that requires restoration of the zygmatico-maxillary buttress. After harvest, the OCRFFF was fixed transversely with miniplates connecting the remaining zygoma to the anterior maxilla. The orbital support was given by titanium mesh when needed that was fixed to the radial forearm bone anteriorly and placed on the remaining orbital floor posteriorly. The skin paddle was used for intraoral lining, external skin coverage, or both. The main outcome measures were flap success, donor-site morbidity, orbital, and oral complications. Facial contour, speech understandability, swallowing, oronasal separation, and socialization were also analyzed. Results. There were 6 women and 18 men, with an average age of 66 years old (range, 34 87). The resulting defects after maxillectomy were (according to the Cordeiro classification; Disa et al, Ann Plast Surg 2001;47: ; Santamaria and Cordeiro, J Surg Oncol 2006;94: ): type I (8.3%), type II (33.3%), type III (45.8%), and type IV (12.5%). There were no flap losses. Donor-site complications included partial loss of the split thickness skin graft (25%) and 1 radial bone fracture. The Correspondence to: E. L. Rosenthal VC 2008 Wiley Periodicals, Inc. most significant recipient-site complications were severe ectropion (24%), dystopia (8%), and oronasal fistula (12%). All the complications occurred in patients with defects that required orbital floor reconstruction and/or cheek skin coverage. The average follow-up was 11.5 months, and over 80% of the patients had adequate swallowing, speech, and reincorporation to normal daily activities. Conclusions. The OCRFFF is an excellent alternative for midface reconstruction of the zygomaticomaxillary buttress. Complications were more common in patients who underwent resection of the orbital rim and floor (type III and IV defects) or external cheek skin. VC 2008 Wiley Periodicals, Inc. Head Neck 30: , 2008 Keywords: midface; reconstruction; microsurgery; osteocutaneous radial forearm free flap; zygomaticomaxillary buttress Midface defects after ablative tumor surgery or trauma usually involve skin, mucosal lining, facial skeleton, and intervening soft tissue. 1 Reconstruction of these lesions is complex and challenging because of the 3-dimensional architecture of the midface serves functional and aesthetic roles. The maxilla provides support to muscles that are critical for facial expression, mastication, speech, and deglutition. In addition, midface bones and soft tissue are responsible to a large extent for Midface Reconstruction with the Osteocutaneous RFFF HEAD & NECK DOI /hed October

2 facial contour. 2 Based on these considerations, the final goals for midface reconstruction should ideally be (1) to give support to the orbital content and avoid changes in globe position, orbital volume, and eyelid functions; (2) to maintain oronasal separation to preserve a platform for mastication, speech quality, and dental rehabilitation; (3) and to recreate an adequate and symmetric facial contour with the other side of the face. Many techniques have been described to achieve these goals. In the past, prosthetic obturation was the only reconstruction option allowing immediate dental restoration without further surgery but with problems such as instability, poor retention, and oronasal insufficiency. The advent of microsurgery has permitted primary, singlestage reconstruction of these complex facial defects, avoiding the use of various combinations of local and regional flaps that have poorer aesthetic and functional results. 1,3 Because maxillectomy is an uncommon operation, a single unit experience is small, and evidence is limited regarding the best reconstructive procedure. 4 Although the selection method depends on the extent of the bony and soft tissue defect, there is no clear or generally accepted recommendation. As a result, the controversy remains as to the method of obturation, reconstruction, and rehabilitation. The osteocutaneous radial forearm flap (OCRFFF) has been extensively and successfully used in head and neck reconstruction. It is a reliable flap, easy to harvest, with a thin bone and a versatile skin paddle. These dynamic qualities make it an ideal alternative for complex midface reconstruction. The purpose of this study was to evaluate morbidity, functional, and aesthetic outcomes in midface zygomaticomaxillary buttress reconstruction using the osteocutaneous radial forearm free flap. PATIENTS AND METHODS Patients. This study is a case series of 24 consecutive patients treated at the University Hospital, Division of Otolaryngology, Head and Neck Surgery at the University of Alabama in Birmingham between 2001 and All the patients underwent OCRFFF midface reconstruction of the zigomaticomaxillary buttress after variable oncologic resections of the maxilla and surrounding structures. Patients were divided in 4 groups depending on the postmaxillectomy defect as described by Cordeiro et al 5 : type I, limited maxillectomy or central defects without infraorbital rim or dental arcade/palate compromise (n 5 2, 8.3%); type II, subtotal infrastructural maxillectomy or lower defects including the dental arcade/palate but sparing the infraorbital rim (n 5 8, 33.3%); type III, total maxillectomy including dental arcade/ palate and orbital rim, with or without preservation of the orbital content (n 5 11, 45.8%); and type IV suprastructural orbitomaxillectomy or upper resections including orbital rim and/or content but sparing the dental arcade and palate (n 5 3, 12.5%). In this study, there were 6 women and 18 men. The mean 6 standard error of the mean (SEM) age was years (range, years). A total of 18 patients (75%) had at least 1 comorbidity and 16 (66.7%) used tobacco. The most common indication for surgery was squamous cell carcinoma (n 5 17, 70.8%), sarcoma (n 5 4, 16.7%), melanoma (n 5 2, 8.3%), and trauma (n 5 1, 4.2%). Almost all the tumors were advanced stage or recurrences, and 19 patients (79.2%) required preoperative or postoperative radiation therapy. Follow-up varied between 1 and 48 months (mean 6 SEM, months), and the overall survival was 71% during the 6-year study (Table 1). Surgical Technique. OCRFFF harvest was performed as previously described. 6,7 We use the keel-shape modification of the radial bone osteotomies as described by Weinzweig et al. 8 The donor radial bone was prophylactically plated along the volar surface with 10 to 12 holes, 2.4-mm reconstruction locking plate. 9 Plating was performed by the reconstruction team, and no allograft bone material was used. Subsequently, the plate is covered with muscle, and a split thickness skin graft is applied. The arm is placed in volar splint for 5 days, with a Xeroform bolster over the skin graft site, and good capillary refill is checked in the thumb and forefingers. The flap is transferred to the recipient site and inset into the defect. The radial bone is fixed transversely with 2.0 miniplates, connecting the remaining zygoma with the anterior maxilla. The orientation of the radial bone varied to some extent depending on the type of defect. In type III lesions, the bone was oriented transversely as described, but in type I lesions, the bone was oriented more vertical, and in type II and IV lesions, it was more horizontal. The principle was to always try to reconstruct the zygomaticomaxillary buttress of the midface (anterior wall of the 1296 Midface Reconstruction with the Osteocutaneous RFFF HEAD & NECK DOI /hed October 2008

3 Table 1. General, oncologic and follow-up characteristics of the study population. Patient Patient, sex/age Comorbidities/ smoking Tumor type Tumor stage Radiation Defect type* Skin/oral resurfacing Donor-site complication Recipient-site complication Follow-up, mo Survival 1 M/57 Yes/Yes SCC T4N2 Postop I Oral No No 1 Alive 2 M/65 Yes/No SCC Rec. Postop I Skin and oral No No 48 Dead 3 M/68 Yes/Yes SCC T4N0 No II Skin and oral No No 1 Dead 4 M/67 Yes/No Sarcoma Rec. Postop II Skin and oral No Ectropion 49 Dead 5 F/74 Yes/Yes SCC T3N0 No II Oral No No 15 Alive 6 M/65 No/Yes SCC T4N1 Postop II Oral No No 15 Alive 7 M/49 No/No SCC Rec. Preop II Oral No No 3 Alive 8 F/81 Yes/Yes SCC T2N0 No II Oral No No 6 Alive 9 M/45 No/Yes Sarcoma Rec. Preop II Oral STSG take No 2 Alive 10 M/57 No/Yes SCC T4N0 Postop II Skin and oral No Fistula 2 Alive 11 M/86 Yes/No SCC T3N2 Preop III Skin and oral No Wound dehiscence 2 Dead 12 F/48 No/Yes SCC T4N3 Postop III Oral No No 1 Dead 13 M/69 No/No SCC T3N0 Postop III Oral No Ectropion, fistula 37 Alive 14 F/79 Yes/Yes SCC T4N2 Postop III Oral STSG take Hematoma 27 Alive 15 M/65 Yes/Yes Melanoma Rec. Preop III Oral No Ectropion 3 Alive 16 M/54 Yes/Yes Sarcoma Rec. Preop III Oral STSG take No 9 Dead 17 M/79 Yes/Yes Melanoma T2N0 No III Oral No Fistula 3 Dead 18 F/85 Yes/No SCC Rec. Postop III Skin and oral No Ectropion, Dystopia 15 Alive 19 M/80 Yes/No SCC T3N2 Postop III Oral STSG take No 3 Alive 20 M/76 Yes/Yes SCC T4NO Postop III Skin and oral STSG take No 1 Alive 21 M/56 Yes/No SCC T4N3 Postop III Oral STSG take No 1 Dead 22 F/64 Yes/Yes SCC T4N0 Postop IV Skin and oral Radial fracture No 2 Alive 23 M/34 Yes/Yes Trauma NA NA IV Skin No Ectropion 20 Alive 24 M/81 Yes/Yes Sarcoma T4N1 Postop IV Skin and oral No Ectropion, Dystopia 9 Alive Abbreviations: M, male; F, female; SCC, squamous cell carcinoma; STSG, split thickness skin graft; NA, no available information. *Type of defect according to Cordeiro et al s classification (see text, for detail). Midface Reconstruction with the Osteocutaneous RFFF HEAD & NECK DOI /hed October

4 FIGURE 1. (A) and (B) IIIa midface defect after total maxillectomy with resection of the infraorbital rim and floor, but sparing the orbital contents. (C) Reconstruction of the zigomaticomaxillary buttress using the radial bone. (D) Restoration of the orbital floor using a titanium mesh anchored to the radial bone and remnant orbital walls. (E) Inset of the skin paddle for external skin coverage and intraoral lining, leaving an intermediate area for de-epithialization. (F) Closure of the cheek flap by layers. (G) Basal view of the palatal and cheek coverage. (H) Final immediate postoperative result. maxilla). In some cases with resection of the malar bone, a radial bone osteotomy was required to improve the malar projection for appropriate restoration of facial contour. The skin paddle was used for intraoral lining, external skin coverage, or both by de-epitheliazing variable parts of the flap. No skin islands were used, and the flap was de-epitheliazed in the middle, leaving 2 areas of skin separated by dermis, 1 for the palate lining and the other for the cheek. The radial bone was covered by the flap soft-tissue paddle anteriorly to protect from exposure and to improve cheek projection and form, even if no skin resurfacing was required. In type III and IV defects, a 1.3 titanium mesh was used to reconstruct the orbital floor and rim. After adequate medial and lateral canthal support, the titanium mesh was placed on the lateral and posterior orbital wall remnant, and curved to recreate the medial orbital wall. The titanium mesh was then secured to the lateral orbital rim remnant and to the radial forearm bone anteriorly (Figure 1). Vascular anastomoses were performed under the microscope using standard techniques. A continuous 8 0 nonabsorbable suture was used for the arterial anastomoses, and a coupler device was applied for the venous anastomoses. The most frequently used recipient artery was the facial artery (80%), followed by the carotid (12%), the occipital (4%), and the superior thyroid (4%). For the vein, a lateral stump of the internal jugular vein (facial or superior thyroid) was always used. Internal Doppler for the artery and vein were placed for vascular monitoring. The mean 6 SEM flap time (from flap elevation to complete inset and wound closure) was hours (range, hours). The mean 6 SEM hospital stay was days (range, 3 24 days). Outcome Measures. The primary outcome variables measured were flap success, donor, and recipient-site morbidity. Facial contour, aesthetic results, ability to eat solid foods, oronasal separation, speech understandability, and socialization outside home were also studied. The aesthetic results were assessed by a modified deformity scale described by Funk et al, 10 where the patient was assigned 1 of the following scores: 4, no deformity; 3, minimal deformity; 2, moderate deformity; and 1, severe deformity. Speech understand Midface Reconstruction with the Osteocutaneous RFFF HEAD & NECK DOI /hed October 2008

5 Table 2. Aesthetic and functional results for all the patients and by categories. No. (%) Recipient-site complications Ectropion Oronasal fistula Diet score Speech score Aesthetic score Socialization score Total 10 (42) 6 (25) 3 (13) Defect type I (n 5 2) 0 (0) 0 (0) 0 (0) Defect type II (n 5 8) 2 (25) 1 (13) 1 (13) Defect type III (n 5 11) 6 (55) 3 (27) 2 (18) Defect type IV (n 5 3) 2 (67) 2 (67) 0 (0) p value* Oral lining only (n 5 14) 4 (29) 1 (7) 2 (14) Skin and oral lining (n 5 10) 6 (60) 4 (40) 1 (10) p value** Orbital floor intact (n 5 10) 2 (20) 1 (10) 1 (10) Orbital floor removed (n 5 14) 8 (57) 5 (36) 2 (14) p value** > No radiation (n 5 4) 1 (25) 0 (0) 1 (25) Radiation (n 5 19) 8 (42) 5 (26) 2 (11) p value** *Only Group II vs. III complications were compared using Fisher test. Scores were compared using Kruskal-Wallis test. **Complications were compared using Fisher test and scores using Kruskal-Wallis test. ability was evaluated using a modified scale described by List et al 11 : 4, always understandable; 3, usually understandable but with frequent repetition or face-to-face contact required; 2, difficult to understand even with face-to-face contact; and 1, never understandable with written communication necessary. Swallowing and oronasal separation were indirectly appraised by the type of diet: 4, regular diet without restrictions; 3, pureed, moist, or soft diet; 2, liquid diet; and 1, no oral and tube-dependant intake. Finally, socialization outside the home was categorized as: 4, frequent; 3, occasional; 2, rarely; and 1, never. Statistics. Continuous and ordinal variables are described as mean and SEM, and nominal variables are described as percentages. Fisher test was used for categorical variables. For continuous and ordinal variables, Student s t test was used for simple comparisons and Kruskall-Wallis tests for multiple comparisons. For statistical significance, an a error of 0.05 was considered, and all confidence intervals are described at 95%. RESULTS There were no flap failures in our series of 24 cases. A total of 7 patients (29.2%) developed donor-site complications: 6 patients (25%) had between 10% and 30% of skin graft loss that healed by secondary intention with standard wound care; and 1 patient (4.2%) had a radial bone fracture that was managed successfully by splint immobilization for 4 weeks and physical therapy. There were no clinically apparent signs of hand-grip weakness or decreased flexion-extension in the operated forearms. In addition, plate exposure through the skin graft did not occur, and no patient needed a reoperation for donor-site problems. Recipient-site complications occurred in 10 patients (42%). Only 2 cases had early complications: 1 patient developed an acute postoperative hematoma that required surgical drainage, and the other patient developed a wound dehiscence with bone and pedicle exposure due to a local and systemic recurrence and died 65 days after surgery. The remaining 8 patients developed late complications: 2 patients (8.3%) were seen with dystopia and diplopia that were corrected by orbital floor adjustments; 6 cases (25%) had a severe ectropion that required lateral canthopexy; and 3 (12.5%) had an oronasal fistula that was closed effectively by local tissue advancements. No osteomyelitis or osteoradionecrosis was observed in this study after follow-up. The functional and aesthetic outcomes may be seen in Table 2 and in a case presented in Figure 2. The mean 6 SEM aesthetic contour score of the entire population was Fifteen patients (62.5%) had no or minimal deformity, 5 patients (20.8%) had a moderate deformity, and 4 patients (16.7%) had a severe deformity. All the postoperative moderate to severe deformities were caused Midface Reconstruction with the Osteocutaneous RFFF HEAD & NECK DOI /hed October

6 FIGURE 2. Preoperative and postoperative frontal, oblique and basal view of a 76-year-old patient that underwent a right midface zygomaticomaxillary buttress reconstruction of a IIIa defect. A mild ectropion, no dystopia, lowered right oral commeasure due to secondary facial paralysis but with an overall adequate result may be observed. by surgical recipient-site complications that required reoperation for correction and repair with adequate results. Most patients were able to tolerate a soft or a regular diet, and the mean 6 SEM diet score for all patients was Although no patient underwent dental rehabilitation, only 2 persisted in a liquid oral diet and needed gastrostomy tube assistance. A total of 21 patients (87.5%) had good speech understandability (scores 4 or 3), with a mean 6 SEM speech score of Three patients developed understandability problems due to secondary facial paralysis (1 case) and oronasal fistulas (2 cases) that were successfully corrected after secondary surgery. Patients socialize outside their homes either frequently (29.2%), occasionally (45.8%), or rarely (25%). The most important reason for low socialization was advanced age, cancer recurrence, and medical problems. Recipient-site complications were more frequently observed in patients with type III IV defects than I II defects (p <.05). Also, type II defects demonstrated a significantly better aesthetic score than the rest of the groups. The use of the flap skin paddle for intraoral and external skin resurfacing showed statistically poorer deformity and socialization scores. Lower overall complication and ectropion rates were observed in the group that did not require external skin coverage, but without statistical differences. On the other hand, removal of the orbital floor is a risk factor for developing donor-site morbidity (p 5.047; OR 5 6.0; 95% CI ) and had a significant impact on the aesthetic outcome. Preoperative or postoperative radiation therapy negatively affected the cosmetic results but was demonstrated to have no influence on oronasal fistula formation (Table 2). DISCUSSION The osteocutaneous flaps that have been described for the reconstruction of complex midface defects have been the scapula, iliac crest, fibula, and radial forearm. Among them, the OCRFFF is 1 of the most suitable for midface 1300 Midface Reconstruction with the Osteocutaneous RFFF HEAD & NECK DOI /hed October 2008

7 defects, because it provides a thin, reliable, and pliable soft tissue/skin paddle that may undergo sensate reconstruction. It is easy to harvest flap with a separate 2-team approach, and it also has a long vascular pedicle that can be anastomosed to any vessel in the ipsilateral neck. Unfortunately, there has been a relative paucity of literature on maxillofacial reconstructions with this flap. 7,12 15 Some case reports or small series have been published without a clear definition of the defect or actual role of the OCRFFF in midface reconstruction. Although our study is not a large series, we tried to apply the same flap and principles to lesions with increasing size and complexity, so we can establish in which patients the OCRFFF would give the best functional and aesthetic result. For this purpose, we decided to work with the Cordeiro and Santamaria postmaxillectomy defects classification 2,5 because of its order and simplicity when compared with others. 16 The morbidity of the OCRFFF donor site is an important factor when considering this flap. The most important complications are pathologic radial bone fracture, decreased grip and pinch strength, decreased sensation in the dorsum of the hand, cosmetic issues, and wound-healing problems with tendon exposure. In this study, 25% of the cases had mild to moderate loss of the split thickness skin graft that was resolved with conservative therapy, and 1 patient (4.2%) was seen with a radial bone fracture. It has been demonstrated that the osteotomized radius has less resistance to torsion and bending when compared with the normal and to the osteotomized and plated radius. 17 This is the reason why prophylactic plating of the radial bone after harvesting is considered the standard method of radial donor-site closure today. 7,12 Also, the use of keel shape osteotomies on the donor radius bone further reduced the incidence of donor radius fractures. 7,8,12,18 Although we followed these recommendations, 1 case in our series had a donor radial bone fracture in an elderly patient with osteoporosis where 40% to 50% of the bone thickness was harvest. However, this 4.2% fracture incidence is favorable compared with the old series with up to 25% of this complication, it is central to highlight the importance of harvesting no more than 30% to 40% of bone thickness in cases with thin or osteoporotic radius and to use and apply correctly the appropriate hardware. Recipient-site complications occur in 42% of our cases, demonstrating the challenging and complex process of midface reconstruction. Most of these complications were related to orbital and intraoral problems that determined medium to good aesthetic and functional results. The most important factors that influenced the occurrence of these problems were the maxillectomy defect, the resection of the infraorbital rim and floor, the use of the skin paddle for cheek skin resurfacing, and preoperative or postoperative radiation. Type II defects, with preservation of the infraorbital rim, requiring intraoral lining only and without radiation therapy showed the best results when the zygomaticomaxillary buttress was reconstructed with the OCRFFF. The type of defect after maxillectomy depends on the cancer type, stage, and localization. Type I or central defects usually involve parts of the nose, as in 2 cases of our series. The OCRFFF in these types of patients may be used to reconstruct the external and/or internal lining, with the bone use more vertically to recreate the medial maxillary buttress. 2 The cosmetic results are going to depend more on the restoration of the central facial subunit rather than the maxilla, because there is no orbital or alveolar/palatal compromise. Type II or infrastructural defects had the best aesthetic and functional results in this series. The orbital floor is not involved, and the OCRFFF may be used to reconstruct the anterior maxillary wall as described in this study, or the superior alveolar ridge as described by Villeret and Futran. 12 In these cases, oral rehabilitation may be achieved with tissue-borne or implant-retained dental prosthesis, but not with implant-borne prosthesis. 19 However, mostly, because of their limited insurance coverage, financial burden, short life expectancy, and preservation of the dentition on the unaffected side, none of our patients was able to obtain dental prostheses. In type III and IV defects, in which the infraorbital rim and floor are excised, poorer results were observed with a higher incidence of dystopia and ectropion using the OCRFFF. The transverse orientation of the radial bone allows an adequate cheek contour but does not support the eye and eyelid adequately. Although it may be beneficial for postoperative oncologic surveillance, the scar contraction of soft tissue over an empty sinus accentuates the problem. One way to solve this problem is to use a more horizontal radial bone to reconstruct the orbital rim with an obturator prosthesis for palate and oral restoration as described by Chepeha et al. 15 Muscle flaps with nonvascularized bone grafts 2 or myo-osseous flaps (like the ileac crest with internal oblique muscle 4,20,21 ) may be a Midface Reconstruction with the Osteocutaneous RFFF HEAD & NECK DOI /hed October

8 better option for these patients, because they provide more soft tissue and bone for orbital support. Reconstruction of the 2 horizontal and 3 vertical buttresses of the maxilla is crucial, because they are responsible for midfacial contour and vertical facial height. 22 After restoring the maxillary bone deficit, the soft tissue involved must be assessed and repaired. Critical functional structures such as the palate, oral commissure, nasal airway, and eyelids need to be treated appropriately. In this study, whenever external skin coverage was required, there was a tendency to have more recipient-site complications, ectropion, and oronasal fistula, resulting in a statistically significant worst deformity and socialization score when compared with patients who required intraoral lining only. On the other hand, the formation of an oronasal fistula was not influenced by the type of defect, resurfacing requirements, or radiation therapy. Despite these problems, the overall functional results in the studied population were acceptable and comparable to other studies. CONCLUSIONS Midface reconstruction is still a challenging and complex problem. There is an ongoing controversy about the best reconstructive technique. In this study, by applying the same technique to a variety of defects, we were able to establish the real role of the OCRFFF in the restoration the zygomaticomaxillary buttress of midfacial defects. The best candidate for this technique would be a patient with a type II defect that respects where the infraorbital rim and floor are preserved. In addition, patients that require external skin coverage tend to have more complications and poorer aesthetic results. REFERENCES 1. Disa JJ, Liew S, Cordeiro PG. Soft-tissue reconstruction of the face using the folded/multiple skin island radial forearm free flap. Ann Plast Surg 2001;47: Santamaria E, Cordeiro PG. Reconstruction of maxillectomy and midfacial defects with free tissue transfer. J Surg Oncol 2006;94: Rosenthal E, Carroll W, Dobbs M, Scott Magnuson J, Wax M, Peters G. Simplifying head and neck microvascular reconstruction. Head Neck 2004;26: Brown JS, Jones DC, Summerwill A, et al. Vascularized iliac crest with internal oblique muscle for immediate reconstruction after maxillectomy. Br J Oral Maxillofac Surg 2002;40: Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 2000;105: , discussion Urken ML. Radial forearm flap. In: Urken ML, Cheney ML, Sullivan MJ, Biller HF, editors. Atlas of regional and free flaps for head and neck reconstruction. New York: Raven; pp Kim JH, Rosenthal EL, Ellis T, Wax MK. Radial forearm osteocutaneous free flap in maxillofacial and oromandibular reconstructions. Laryngoscope 2005;115: Weinzweig N, Jones NF, Shestak KC, Moon HK, Davies BW. Oromandibular reconstruction using a keel-shaped modification of the radial forearm osteocutaneous flap. Ann Plast Surg 1994;33: , discussion Nuñez VA, Pike J, Avery C. Prophylactic plating of the donor site of osteocutanous radial forearm flaps. Br J Oral Maxillofac Surg 1997;37: Funk GF, Laurenzo JF, Valentino J, McCulloch TM, Frodel JL, Hoffman HT. Free-tissue transfer reconstruction of midfacial and cranio-orbito-facial defects. Arch Otolaryngol Head Neck Surg 1995;121: List MA, Ritter-Sterr C, Lansky SB. A performance status scale for head and neck cancer patients. Cancer 1990;66: Villaret DB, Futran NA. The indications and outcomes in the use of osteocutaneous radial forearm free flap. Head Neck 2003;25: Cordeiro PG, Bacilious N, Schantz S, Spiro R. The radial forearm osteocutaneous sandwich free flap for reconstruction of the bilateral subtotal maxillectomy defect. Ann Plast Surg 1998;40: Cordeiro PG, Santamaria E, Kraus DH, Strong EW, Shah JP. Reconstruction of total maxillectomy defects with preservation of the orbital contents. Plast Reconstr Surg 1998;102: , discussion Chepeha DB, Moyer JS, Bradford CR, Prince ME, Marentette L, Teknos TN. Osseocutaneous radial forearm free tissue transfer for repair of complex midfacial defects. Arch Otolaryngol Head Neck Surg 2005;131: Brown JS, Rogers SN, McNally DN, Boyle M. A modified classification for the maxillectomy defect. Head Neck 2000;22: Bowers KW, Edmonds JL, Girod DA, Jayaraman G, Chua CP, Toby EB. Osteocutaneous radial forearm free flaps. The necessity of internal fixation of the donor-site defect to prevent pathological fracture. J Bone Joint Surg Am 2000;82: Bardsley AF, Soutar DS, Elliot D, Batchelor AG. Reducing morbidity in the radial forearm flap donor site. Plast Reconstr Surg 1990;86: , discussion Funk GF, Arcuri MR, Frodel JL Jr. Functional dental rehabilitation of massive palatomaxillary defects: cases requiring free tissue transfer and osseointegrated implants. Head Neck 1998;20: Maranzano M, Atzei A. The versatility of vascularized iliac crest with internal oblique muscle flap for composite upper maxillary reconstruction. Microsurgery 2007; 27: Genden EM, Wallace D, Buchbinder D, Okay D, Urken ML. Iliac crest internal oblique osteomusculocutaneous free flap reconstruction of the postablative palatomaxillary defect. Arch Otolaryngol Head Neck Surg 2001;127: Manson PN, Clark N, Robertson B, et al. Subunit principles in midface fractures: the importance of sagittal buttresses, soft-tissue reductions, and sequencing treatment of segmental fractures. Plast Reconstr Surg 1999;103: ; quiz Midface Reconstruction with the Osteocutaneous RFFF HEAD & NECK DOI /hed October 2008