Reconstruction of Midface and Orbital Wall Defects After Maxillectomy and Orbital Content Preservation With Titanium Mesh and Fascia Lata: 3-Year Follow-Up Maziar Motiee-Langroudi, MD, * Iraj Harirchi, MD,y Amin Amali, MD,z and Mehrdad Jafari, MDx Purpose: To describe the authors’ experience in the reconstruction of patients after total maxillectomy with 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 gaze occurred 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. Ó 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 defect, there is no clear optimal method of obturation, reconstruction, and rehabilitation. 2 Titanium mesh is a very suitable reconstructive material that allows precise anatomic reconstruction, but subsequent extrusion and complications have always been problematic. This report describes the Received from the Imam Khomeini Medical Complex, Tehran University of Medical Sciences, Tehran, Iran. *Assistant Professor, Department of Otolaryngology–Head and Neck Surgery, Otolaryngology Research Center. yProfessor, Department of Oncologic Surgery, Cancer Institute. zAssistant Professor, Department of Otolaryngology–Head and Neck Surgery, Otolaryngology Research Center. xAssistant Professor, Department of Otolaryngology–Head and Neck Surgery, Otolaryngology Research Center. Address correspondence and reprint requests to Dr Jafari: Depart- ment of Otolaryngology–Head and Neck Surgery, Otolaryngology Research Center, Imam Khomeini Medical Complex, Tehran Univer- sity of Medical Sciences, Bagherkhan Street, Tehran, Iran 1419733141; e-mail: [email protected]Received March 17 2015 Accepted August 11 2015 Ó 2015 American Association of Oral and Maxillofacial Surgeons 0278-2391/15/01178-7 http://dx.doi.org/10.1016/j.joms.2015.08.011 2447.e1
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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
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
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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