Title: Bilateral reconstruction of the midface (Le Fort I/II) with microvascularized fibular flap: A proposed new technique
Abstract:
Introduction: Many surgical techniques emerge primarily when there are failures in prevention programs for oral cancer and other pathologies affecting the maxillofacial complex. In these cases, resections of facial tumors involving the maxilla and mandible frequently result in significant functional and aesthetic sequelae, affecting speech, chewing, swallowing, and the self-esteem of patients. In our service, we have observed the referral of patients with advanced disease staging, frequently associated with aggressive tumor biology and complex anatomical location. Each procedure represents a challenge for the multidisciplinary team, especially when the anatomical defects exceed the possibilities of simple local repairs. In this context, the surgeon's experience becomes fundamental, stimulating the development and improvement of new reconstructive techniques. Reconstructions with microvascularized fibula flaps have been part of our institution's routine since 1995, which motivates us to constantly seek surgical alternatives that provide greater comfort and better results for patients. Our focus is on restoring function, aesthetics, and facial expression. Each patient represents a unique challenge in the pursuit of promoting quality of life and facilitating their social reintegration.
Objective: To present a maxillary reconstruction technique (Le Fort I and II types) using a U-shaped microvascularized fibular flap (RMF-FFU).
Method: The technique is indicated for patients who require reconstruction of maxillary defects classified as Le Fort I/II, resulting from tumor resection, necrosis, or trauma. The fibular osteotomy is performed in three segments. The first and third segments are intended for the reconstruction of the left and right superior alveolar crests, also contributing to the structural reinforcement of the maxilla. The intermediate segment is used to reconstruct the anterosuperior region of the maxilla, giving the flap a U-shaped configuration. To stabilize the bone segments, miniplates and screws of the 2.0 system are used, promoting fixation between the segments and their anchoring to the zygomatic complex in the posterior region. In a second surgical procedure, approximately three months after the first surgery, bone grafting from the iliac crest is performed, forming two pillars in the canine fossa, connected to the fibular segment and the anterior zygomatic complex.
Case Report: A 20-year-old white female patient with a history of a nautical accident involving a jet ski, which resulted in bilateral horizontal maxillary avulsion, classified as Le Fort type I/II. The patient sought specialized care for late reconstruction of the maxillary defects. The reconstruction was planned and performed using the RMF-FFU technique. The procedure proceeded without vascular complications and presented satisfactory stability between the bone segments. After five years of follow-up, favorable clinical evolution was observed, with the possibility of dental implant placement and prosthetic rehabilitation. Facial aesthetics and masticatory and phonatory functions were adequately restored.
Conclusion: The described procedure, using the microvascularized fibula flap reconstruction technique in a U shape, demonstrated satisfactory results from both an aesthetic and functional point of view, overcoming the technical challenges frequently encountered in the reconstruction of the midface region. It is believed that the RMF-FFU technique can significantly contribute to the treatment of patients who are victims of facial tumors or trauma and require restoration of the anatomy of the maxilla and the bilateral zygomatic complex. In addition to favoring bone formation and enabling prosthetic rehabilitation, this approach contributes to the recovery of speech and facial expression, promoting improved quality of life and facilitating the social reintegration of patients.
