Microsurgical reconstruction in midface defects based on defect morphology and size – Reconstruction techniques, complications, and outcomes

PURPOSE: This study´s aim was to analyse clinical outcomes of microvascular reconstructions performed for malignancy-caused midface defects of varying sizes at our department. METHODS: This retrospective study included 98 patients (38 women; 60 men; age range 16-94 years) who underwent microvascular reconstruction for a malignancy-related midface defect between April 2017 and August 2022. RESULTS: Bony (fibula, scapula) and soft tissue (radial forearm, anterolateral thigh) flap techniques were used depending on defect size. Most defects requiring coverage were classified as class II (n = 70, 71.4%; 18 (25.7%) bony vs. 52 (74.3%) soft tissue) or class IV (n = 16, 16.3%; 4 (25.0%) bony vs. 12 (75.0%) soft tissue) according to Brown and Shaw. The proportion of other horizontal defect classes was significantly lower (n = 12, 12.2%; all soft tissue). Unilateral defects were present in 81 cases (82.7%; 15 (18.5%) bony vs. 66 (81.5%) soft tissue), while bilateral defects were observed in 17 cases (17.3%; 7 (42.2%) bony vs. 10 (57.8%) soft tissue). Postoperative complications were observed in 57 cases (58.2%), predominantly comprising minor issues such as bleeding or wound healing disorders. Major complications, including the need for transplant revisions, occurred in 9 cases (9.2%), with early transplant loss in three instances. No significant correlation was found between transplant loss and defect classification (p = 0.73) or transplant type (p = 0.07). However, bony flaps demonstrated a higher tendency towards flap loss compared to soft tissue flaps (18.2% vs 4.0%). Dental rehabilitation using dental implants was performed in only 18.2% of all patients who received bony reconstruction. CONCLUSION: The complication rate associated with microvascular reconstructions was relatively high. Most complications were minor and could be managed therapeutically. Major complications, such as flap failure, remained relatively uncommon. Neither defect size nor transplant type used demonstrated a significant impact, though bony transplants showed a higher tendency towards flap loss. Despite the observed complication rate, free flaps continue to represent a reliable treatment option for patients with midfacial defects. In cases where bony reconstruction is not strictly necessary, dental rehabilitation using patient-specific preprosthetic implants may offer a viable alternative to bone grafts.