title: Microsurgical reconstruction of the maxilla: Algorithm and concepts.
abstract: BACKGROUND
  The main purpose of this article is to highlight free tissue transfers as the first-choice method for three-dimensional (3D) maxillary reconstruction, particularly in providing enough bone for palate and maxillary arch reconstruction and consequently an implant-retained prosthesis. To achieve this, the myosseous free iliac crest was selected whenever possible as the first choice inside the reconstructive algorithm and free flap armamentarium. A new maxillectomy classification and algorithm reconstruction are proposed. Technical modifications and improvements accomplished over time are discussed, considering palate, dental implants and prosthesis, nasal sidewall, cranial base and dura, as well as recipient vessels. We present functional and aesthetic outcomes of the senior author's past 24-year experience (H. C.) with complex midface reconstructions.
  
  
  METHODS
  The authors report and analyse a 24-year experience with 57 midface defects in 54 patients (30 males and 24 females). A total of 57 maxillary defects - classified as Class I (limited maxillectomy) = 12, Class II (subtotal maxillectomy) = 15, Class III (total maxillectomy) = 19 and Class IV (orbitomaxillectomy) = 11 - were analysed regarding sex, age, tumour recurrence, free flap, reconstruction and necrosis. In addition, functional outcomes were evaluated regarding diet, speech, globe position and vision, while aesthetic outcomes were evaluated by patient and surgeon scores.
  
  
  RESULTS
  A total of 52 free flaps were performed in 47 patients; three patients were operated upon twice; and two other patients needed two sequentially linked flow-through flaps. The free flap survival was 96% with two total flap losses (4%). The other seven patients were fitted with a soft tissue-retained obturator prosthesis.
  
  
  CONCLUSIONS
  Microsurgical vascularised osteomyocutaneous free flaps are actually the gold standard for reconstruction of complex defects following maxillectomy. This algorithm is based on the anatomofunctional defect of the maxilla and it facilitates flap selection, which is a must.
authors.affiliation: Plastic Reconstructive Craniomaxillofacial and Microsurgical Unit, Centro Hospitalar de Gaia, I.C.B.A.S. - Faculty of Medicine - Oporto University, Rua Conceição Fernandes, s/n, 4434-502 Gaia, Portugal. Electronic address: plasticagaia@gmail.com.
authors.forename: Horácio
authors.initials: H
authors.lastname: Costa
authors.affiliation: Plastic Reconstructive Craniomaxillofacial and Microsurgical Unit, Centro Hospitalar de Gaia, I.C.B.A.S. - Faculty of Medicine - Oporto University, Rua Conceição Fernandes, s/n, 4434-502 Gaia, Portugal.
authors.forename: Horácio
authors.initials: H
authors.lastname: Zenha
authors.affiliation: Plastic Reconstructive Craniomaxillofacial and Microsurgical Unit, Centro Hospitalar de Gaia, I.C.B.A.S. - Faculty of Medicine - Oporto University, Rua Conceição Fernandes, s/n, 4434-502 Gaia, Portugal.
authors.forename: Hugo
authors.initials: H
authors.lastname: Sequeira
authors.affiliation: Plastic Reconstructive Craniomaxillofacial and Microsurgical Unit, Centro Hospitalar de Gaia, I.C.B.A.S. - Faculty of Medicine - Oporto University, Rua Conceição Fernandes, s/n, 4434-502 Gaia, Portugal.
authors.forename: Gustavo
authors.initials: G
authors.lastname: Coelho
authors.affiliation: Plastic Reconstructive Craniomaxillofacial and Microsurgical Unit, Centro Hospitalar de Gaia, I.C.B.A.S. - Faculty of Medicine - Oporto University, Rua Conceição Fernandes, s/n, 4434-502 Gaia, Portugal.
authors.forename: Nuno
authors.initials: N
authors.lastname: Gomes
authors.affiliation: Plastic Reconstructive Craniomaxillofacial and Microsurgical Unit, Centro Hospitalar de Gaia, I.C.B.A.S. - Faculty of Medicine - Oporto University, Rua Conceição Fernandes, s/n, 4434-502 Gaia, Portugal.
authors.forename: Cristina
authors.initials: C
authors.lastname: Pinto
authors.affiliation: Plastic Reconstructive Craniomaxillofacial and Microsurgical Unit, Centro Hospitalar de Gaia, I.C.B.A.S. - Faculty of Medicine - Oporto University, Rua Conceição Fernandes, s/n, 4434-502 Gaia, Portugal.
authors.forename: João
authors.initials: J
authors.lastname: Martins
authors.affiliation: Plastic Reconstructive Craniomaxillofacial and Microsurgical Unit, Centro Hospitalar de Gaia, I.C.B.A.S. - Faculty of Medicine - Oporto University, Rua Conceição Fernandes, s/n, 4434-502 Gaia, Portugal.
authors.forename: Diana
authors.initials: D
authors.lastname: Santos
authors.affiliation: Plastic Reconstructive Craniomaxillofacial and Microsurgical Unit, Centro Hospitalar de Gaia, I.C.B.A.S. - Faculty of Medicine - Oporto University, Rua Conceição Fernandes, s/n, 4434-502 Gaia, Portugal.
authors.forename: Carolina
authors.initials: C
authors.lastname: Andresen
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000714:Anastomosis, Surgical / Q000379:methods; D002648:Child; D003803:Dentigerous Cyst / Q000601:surgery; D004954:Esthetics; D005145:Face / Q000601:surgery*; D005260:Female; D018214:Fibroma, Ossifying / Q000601:surgery; D058752:Free Tissue Flaps / Q000637:transplantation*; D006085:Graft Survival; D006801:Humans; D008297:Male; D008437:Maxilla / Q000601:surgery*; D008441:Maxillary Neoplasms / Q000601:surgery; D008875:Middle Aged; D009669:Nose Neoplasms / Q000601:surgery; D019647:Oral Surgical Procedures / Q000379:methods; D010019:Osteomyelitis / Q000601:surgery; D010157:Palatal Neoplasms / Q000601:surgery; D010159:Palate / Q000601:surgery; D019651:Plastic Surgery Procedures / Q000379:methods*; D012086:Reoperation; D016896:Treatment Outcome
keywords: Bone-growing centre; Intraoral microvascular anastomosis; Maxilla reconstruction; Reconstructive algorithm; Sequentially linked flow-through flaps