Systematic review of autologous midface reconstruction methods: subtotal maxillary defects

Subtotal midfacial defects, commonly resulting from oncological resection, pose a rare but complex reconstructive challenge. Loss of the palate and dentoalveolar complex severely impairs speech, swallowing, mastication, and the facial contour, while imposing a substantial psychosocial burden. Despite surgical advances, standardized reconstructive strategies remain lacking, partly due to anatomical complexity and inconsistent terminology. This systematic review forms part of a broader series analysing autologous reconstruction for specific midfacial defect types, aiming to identify commonly used flap-based methods per classification. The present study focused on subtotal defects classified as A2H2-H5 according to the Mommaerts classification. A comprehensive search of PubMed, Embase, and Wiley Library (through January 2026) identified 27 eligible clinical studies with patient-level data. Methodological quality was assessed using the MINORS tool, with scores indicating generally low quality (range 4-12 out of 16). Pedicled regional flaps were not frequently reported for A2 defects; reconstruction relied on free flaps. Small osteocutaneous flaps and, in selected cases, soft tissue-only flaps were used for unilateral defects (A2H2-H3), typically in staged or medically compromised settings. Bilateral defects (A2H4-H5) consistently required vascularized bone flaps to restore skeletal projection and support dental rehabilitation. Functional outcomes were associated with defect size. Patient-reported outcomes were rarely documented but suggested overall satisfaction. Due to study heterogeneity and limited quality, a formal statistical analysis was not feasible. In conclusion, subtotal midfacial reconstruction must be tailored to the horizontal extent, with vascularized bone flaps essential in bilateral cases. Functional rehabilitation and long-term prosthodontic planning remain critical needs.