Purpose: High-energy maxillary injuries result in composite tissue loss, functional compromise and cosmetic deformity. Tissue flaps with non-vascularized bone grafts have been the mainstay. However, bony resorption and soft tissue contraction limit long-term success. Previous investigators have described microvascular maxillary reconstruction following tumor resection but few have applied these prinicples to trauma. This study classifies patterns of maxillary injury and defines a microvascular treatment algorithm.
Methods: This is a retrospective review (1998-2005) of 66 patients admitted to R Adams Cowley Shock Trauma Center with high-energy maxillary injuries. CT scans were reviewed and defects classified according to missing maxillary subunits (see algorithm).
Results: Type I defects were predominant (n = 38) followed by Type II (n = 16), III (n = 9), and IV (n = 3). Injuries prior to July 2003 were treated with prosthetic obturation or tissue flaps and non-vascularized bone grafts. Since July 2003 our institution has undergone a paradigm shift; 14 patients with maxillary loss underwent reconstruction with vascularized bone flaps (8 fibula flaps and 6 iliac crest flaps). Flap survival rate was 93% and average follow-up time was 17 months.
Conclusion: Patterns of high-energy maxillary injury have not changed in the past 7 years, however there has been a distinct change in the treatment algorithm. The authors advocate early reconstruction with vascularized bone flaps to achieve superior functional and cosmetic outcomes.