Evolution of midface microvascular reconstruction: three decades of experience from a single institution

Midface reconstruction poses a complex set of challenges for reconstructive surgeons. The optimal midface reconstruction must possess a durable underlying bone construct capable of integrating dental implants. Facial contour is restored by the overlying microvascular soft tissue reconstruction with reestablishment of the oral cavity. A plethora of microvascular flaps used in clinical practice have been described including those harvested from the iliac crest, scapula, fibula, forearm and back (latissimus dorsi). The objective was to share our experiences with each of these treatment options that have continued to evolve over time for the benefit of patients.

Our institution has over three decades of experience in reconstructing complex midface defects and this article summarizes midface reconstruction from an evolutionary perspective (for type II, III and IV defect; Browns classification, Supplementary Table I). We broadly divide this into (i) flaps supplied by the subscapular system (ii) autologous reconstruction with titanium mesh and (iii) fibula microvascular flaps using 3D planning.

The advantages and disadvantages for each approach are discussed (Supplementary Table II).

In the future, it is expected that 3D planning coupled with rapid prototyping, intraoperative navigation and CT imaging will become standard procedural practice.