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Reconstruction of Midface and Orbital WallDefects After Maxillectomy and Orbital

Content Preservation With Titanium Meshand Fascia Lata: 3-Year Follow-Up

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*Assista

ck Surg

yProfeszAssistack Surg

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Addres

nt of O

Maziar Motiee-Langroudi, MD,* Iraj Harirchi, MD,y Amin Amali, MD,zand Mehrdad Jafari, MDx

Purpose: To describe the authors’ experience in the reconstruction of patients after total maxillectomywith preservation of orbital contents for maxillary tumors using titanium mesh and autogenous fascia lata,

where no setting for free flap reconstruction is available.

Patients and Methods: Twelve consecutive patients with paranasal sinus tumors underwent total

maxillectomy without orbital exenterations and primary reconstruction. The defects were reconstructed

by titanium mesh in combination with autogenous fascia lata in the orbital floor performed by 1 surgical

team. Titanium mesh (0.2 mm thick) was contoured and fixed to reconstruct the orbital floor and obtain

midface projection. Fascia lata was used to cover the titanium mesh along the orbital floor to prevent fat

entrapment in the mesh holes.

Results: The most common pathology was squamous cell carcinoma (50%). Patients’ mean age was

45.66 years (33 to 74 yr). The mean follow-up period was 35.2 months (30 to 49 months). During

follow-up, no infection or foreign body reaction was encountered. Extrusion of titanium mesh occurred

in 4 patients who underwent postoperative radiotherapy. Two cases of mild diplopia at extreme gazeoccurred early during the postoperative period that resolved after a few months.

Conclusion: Placing fascia lata between the titanium mesh surface of the orbital implant and the orbital

contents was successful in preventing long-term diplopia or dystopia. Nevertheless, exposure of the tita-nium implant through the skin surface represented a complication of this technique in 25% of patients.

Further studies are required with head-to-head comparisons of artificial materials and free flaps for recon-

struction of maxillectomy defects.

� 2015 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 73:2447.e1-2447.e5, 2015

Maxillary and orbital reconstruction is a major

challenge for head and neck reconstructive surgeons.

Because maxillectomy is an uncommon operation,evidence is limited regarding the best reconstructive

procedure.1 Although the selection of the method

depends on the extent of the bony and soft tissue

from the Imam Khomeini Medical Complex, Tehran

of Medical Sciences, Tehran, Iran.

nt Professor, Department of Otolaryngology–Head and

ery, Otolaryngology Research Center.

sor, Department of Oncologic Surgery, Cancer Institute.

nt Professor, Department of Otolaryngology–Head and

ery, Otolaryngology Research Center.

nt Professor, Department of Otolaryngology–Head and

ery, Otolaryngology Research Center.

s correspondence and reprint requests to Dr Jafari: Depart-

tolaryngology–Head and Neck Surgery, Otolaryngology

2447.e

defect, there is no clear optimal method of obturation,

reconstruction, and rehabilitation.2

Titanium mesh is a very suitable reconstructivematerial that allows precise anatomic reconstruction,

but subsequent extrusion and complications have

always been problematic. This report describes the

Research Center, Imam Khomeini Medical Complex, Tehran Univer-

sity of Medical Sciences, Bagherkhan Street, Tehran, Iran

1419733141; e-mail: Mehrdadj82@yahoo.com

Received March 17 2015

Accepted August 11 2015

� 2015 American Association of Oral and Maxillofacial Surgeons

0278-2391/15/01178-7

http://dx.doi.org/10.1016/j.joms.2015.08.011

1

2447.e2 TITANIUM MESH WITH FASCIA LATA IN RECONSTRUCTION

authors’ experience in the reconstruction of 12

patients who underwent total maxillectomywith pres-

ervation of orbital contents for maxillary tumors by

titanium mesh and autogenous fascia lata.

Patients and Methods

PATIENTS

From August 2009 to December 2010, at the Imam

Khomeini Hospital, an affiliated hospital of the

Tehran University of Medical Sciences (Tehran, Iran),

12 consecutive patients with paranasal sinus tumors

underwent total maxillectomy without orbital exen-

terations (Class III) and primary reconstruction. The

cases that required orbital exenteration wereexcluded. This study was approved by the Imam

Khomeini Hospital institutional review board and all

participants signed an informed consent agreement.

The defects were reconstructed by titanium mesh in

combination with autogenous fascia lata in the orbital

floor performed by 1 surgical team. Eleven patients

received postoperative radiotherapy (range, 30

to 66 Gy).

SURGICAL TECHNIQUES

All surgeries and reconstructions were performed

by 1 team. A total maxillectomy (including orbital

floor resection with preservation of the

orbital contents) was carried out in all patients.

FIGURE 1. Reconstruction of the maxilla and orbital floor with

Motiee-Langroudi et al. Titanium Mesh With Fascia Lata in Reconstruct

AWeber-Ferguson incision with subciliary extension

was made. An upper cheek flap was raised with the

lower eyelid portion elevated off the orbicularis

oculi muscle. The flap was raised 1 cm lateral to

the lateral canthus. The orbicularis oculi and the

orbit periosteum were dissected off the inferior

orbital rim and elevation was carried back near the

orbital apex. The cheek skin and the contralateralpalate were preserved. After performing the maxil-

lectomy, the cheek flap was covered with a split-

thickness skin graft. Titanium mesh (0.2 mm thick)

was contoured and fixed to the remaining structures

(zygoma, hard palate, alveolar ridge, and nasal bone)

to reconstruct the orbital floor and obtain midface

projection (Figs 1, 2).

Fascia lata was harvested from the ipsilateral lowerextremity through a longitudinal incision, approxi-

mately 3 to 5 cm long, along the lateral thigh, the

center of which lies over the junction of the upper

and middle thirds of the upper leg. The graft was

used to cover the titanium mesh along the orbital

floor to prevent fat entrapment in the mesh holes

(Fig 3).

FOLLOW-UP

During follow-up, the cases were reviewed for the

presence of complications (diplopia, epiphora, enoph-

thalmos or proptosis, infection, or extrusion of

titanium mesh).

titanium mesh (asterisk) covered with fascia lata (arrow).

ion . J Oral Maxillofac Surg 2015.

FIGURE2. Three-dimensional computed tomogram of a patient 6 weeks after total maxillectomy and reconstructionwith titaniummesh (arrow)and fascia lata.

Motiee-Langroudi et al. Titanium Mesh With Fascia Lata in Reconstruction . J Oral Maxillofac Surg 2015.

MOTIEE-LANGROUDI ET AL 2447.e3

Results

Twelve patients with stage T3 to T4 paranasal sinus

tumors (mean age, 45.66 yr; range, 33 to 74 yr) were

enrolled in this study. The most common pathology

was squamous cell carcinoma (50%). The mean

follow-up period was 35.2 months (30 to 49 months).

During follow-up, no infection or foreign body reac-tion was encountered (Table 1). Extrusion of titanium

mesh occurred in 4 patientswho underwent postoper-

ative radiotherapy (Fig 4). Tumor recurrence was

detected in 2 extrusion cases. Two cases of mild

diplopia at extreme gaze occurred early during the

postoperative period that resolved after a few months.

There were 3 cases of ectropion, 2 of which required

surgical management. Good cosmetic results for

midface reconstruction were obtained.

Discussion

In this study, titanium mesh and fascia lata were

used for reconstruction of Class III defects ofthe maxilla and orbital walls. A vascularized osteocuta-

neous free flap is believed to be the ideal material for

reconstructing defects of the maxilla or mandible after

radical cancer surgery in many studies.3-9 However,

FIGURE 3. Prefabricated titaniummesh at the orbital floor coveredwith fascia lata.

Motiee-Langroudi et al. TitaniumMesh With Fascia Lata in Recon-

struction . J Oral Maxillofac Surg 2015.

2447.e4 TITANIUM MESH WITH FASCIA LATA IN RECONSTRUCTION

reconstruction using these flaps is more complicated

than using artificial material, especially in orbital

reconstruction, and morbidity at the donor site

cannot be avoided. Furthermore, there are many

Table 1. DEMOGRAPHICS, PATHOLOGIC INFORMATION, AN

Case Gender

Age

(yr) Pathology Tumor Stage C

1 Female 33 Synovial sarcoma T3 Epiphor

2 Male 27 ACC T3 Tum

3 Male 63 SCC T4 Epip

4 Male 59 SCC T4 Tem

5 Male 74 BCC T4 Epiphor

6 Male 54 SCC T3

7 Male 35 DFP T4

8 Male 23 Ameloblastoma —

9 Female 45 SCC T3

10 Male 67 SCC T3 Tumor r

11 Male 31 Osteosarcoma T3

12 Male 37 SCC T4 Tem

Abbreviations: BCC, basal cell carcinoma; DFP, dermatofibrosis pr

Motiee-Langroudi et al. Titanium Mesh With Fascia Lata in Reconstruct

surgical centers around the world that still do not

have the expertise or adequate funding to establish

the setting required for free flap reconstruction of

head and neck defects.

Different materials for orbital support after total

maxillectomy have been described since the 1960s.

Artificial materials, especially titanium, have been

used to support orbital contents after total maxillec-tomy.10-13 Although as a thin mesh it is considered an

ideal implant for facial skeletal reconstruction, there

is a potential risk of infection and exposure because

it is a foreign body. Sun et al14 used titanium mesh

and a radial forearm flap for palatomaxillary recon-

struction, but not the orbital walls, and obtained

good cosmetic results. Extrusion of implants occurred

in 3 of 19 patients. In the present study, titaniummeshimplants were exposed after radiotherapy in 4 cases.

The rate of infection also is low in patients who

undergo reconstruction with titanium mesh. Dep-

prich et al15 found fewer pathologic micro-organisms

on titanium-based obturators compared with

polymer-based obturators for oral rehabilitation of pa-

tients after maxillectomy. None of the present patients

developed infection during the postoperative period.The titanium mesh was not removed; thus, the dehis-

cence was reconstructed using locoregional flaps.

No extrusion was detected afterward.

This study showed that placing fascia lata between

the superior aspect of the titanium mesh surface of

the orbital implant and the orbital contents can be suc-

cessful in preventing long-term diplopia or dystopia.

Nevertheless, exposure of the titanium mesh throughthe anterior skin represented a complication of this

technique in 25% of patients. The authors suggest

that reconstruction of combined maxillectomy and

D COMPLICATION RECORDS OF STUDY PATIENTS

omplications Extrusion

Extrusion

Occurrence

(mo)

Follow-Up

(mo)

a, tumor recurrence + 17 33

or recurrence � 49

hora, ectropion + 8 39

porary diplopia � 31

a, tumor recurrence + 11 37

Ectropion � 30

— � 34

— + 27 30

Epiphora � 36

ecurrence, ectropion � 39

— � 31

porary diplopia � 34

otuberans; SCC, squamous cell carcinoma.

ion . J Oral Maxillofac Surg 2015.

FIGURE 4. Extrusion of titanium mesh after maxillectomy andpostoperative radiotherapy.

Motiee-Langroudi et al. TitaniumMesh With Fascia Lata in Recon-

struction . J Oral Maxillofac Surg 2015.

MOTIEE-LANGROUDI ET AL 2447.e5

orbital floor defects with titanium mesh covered by

fascia lata might be an option to consider. Further

studies are required with head-to-head comparison of

allografts, alloplasts, and free flaps for reconstruction

of maxillectomy defects that also involve the

orbital floor.

References

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2. Andrades P, Militsakh O, Hanasono MM, et al: Current strategiesin reconstruction of maxillectomy defects. Arch OtolaryngolHead Neck Surg 137:806, 2011

3. Triana RJ Jr, Uglesic V, Virag M, et al: Microvascular free flapreconstructive options in patients with partial and total maxil-lectomy defects. Arch Facial Plast Surg 2:91, 2000

4. Futran ND, Wadsworth JT, Villaret D, et al: Midface reconstruc-tion with fibula free flap. Arch Otolaryngol Head Neck Surg128:161, 2002

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