Treating defects of the midface often involves few of its elements including the palate, cheek, maxilla, orbit and the nose. The reconstruction goals are to provide volume and support for the maxilla and orbit, restore facial contour and coverage, and restore palatal and nasal airway passages competence. Composite soft-tissue or osseo-cutaneous flaps were used addressing these goals with vascularized osseous flaps recommended for a significant teeth-bearing segment holding a low volume defect. Large volume defects are better reconstructed with composite soft-tissue flaps including bone grafts but may compromise obturator adjustment and nasal airway.

In the period of October 2001 – June 2003, we have treated 12 patients with 14 composite soft-tissue free flaps and one composite osseo-cutaneous fibula flap for various midface defects. Eight of these patients had their palate reconstructed with composite myocutaneous rectus abdominis and latissimus dorsi flaps. Iliac bone grafts were used to provide support and contour as necessary. The palate and nasal airway were stented with an obturator and nasopharingeal airway for six weeks. One patient underwent delayed second reconstruction by composite fibula flap and one patient had a second flap after flap failure. All patients were able to use permanent dental obturator with a stable support. Nasal airway remained patent after the removal of the stent. Good facial contour was achieved except for one patient where the flap volume was limited. All patients were satisfied with the results.

Maxillary reconstruction with or without exenteration by free soft tissue transfer can provide both function and esthetics if planned properly. Accessory bone grafting or titanium mesh should be used for large maxillary and orbital defects.