Reconstructive Surgery

Maxillofacial Reconstructive Surgery

Fortunately, only a few individuals will ever require the need for maxillofacial reconstructive surgery. More often than not, the term relates to the surgical correction of a sizeable acquired defect of the maxillofacial region. As one might imagine, over the course of a lifetime an individual may experience any number of events that can produce a defect of their physical being in the head and neck region. This misfortune may come from something as simple as a fall resulting in a blow to the facial region to as complicated as oral cancer that requires one to have a portion of their facial skeleton removed. When the facial bones are damaged it is sometimes necessary to rebuild them or “reconstruct” them to return the individual to normal function and appearance. Untreated conditions of this kind can be very disabling and may often result in low self esteem and depression if the circumstances are dire enough. A team approach to manage these conditions is often required.

Who Is A Candidate For Reconstructive Surgery?

woman with head wrapped in bandage

While nearly all patients who have experienced a loss of their facial structure are candidates for reconstructive surgery, the variables are numerous when defining a timeline for such surgery or predicting an outcome. As mentioned above, the reconstruction can range from simple to complex depending on the anatomical region requiring treatment and the magnitude of the loss. Furthermore, the etiology of the defect can often play a role in mandating what course of action is the best to take. A patient who has been in a serious accident and has lost sizeable soft and hard tissue mass may require several stages of surgery to add back what a misfortune has taken away in seconds. These patients often require a surgical stage or multiple stages of surgery that will simply restore lost soft tissue before a hard tissue infrastructure can be attempted with grafted bone, reconstruction plates and/or alloplastic materials.

Patients who have lost facial structure from cancer will often require radiation after their initial ablative surgery. Recovery from the effects of radiation can require an extended period of time in many cases and sometimes involve exposure to hyperbaric oxygen before grafted bone and a complete reconstruction has a chance for long term survival.

Infection is another source of bone loss and catastrophic structural damage to the facial skeleton. Resolution of the infection and the associated soft tissue destruction must be achieved before reconstruction can be attempted in these cases. In conclusion, it will be the responsibility of your surgeon to develop a comprehensive treatment plan that lays out a timeline and sequence to address your particular condition.

How Does Reconstructive Surgery Differ From Orthognathic Surgery?

While orthognathic surgery can be considered a form of reconstructive surgery, more often than not the two take on different meanings. More simply stated, orthognathic surgery usually involves a realignment of the existing jaw structure while reconstructive surgery usually connotes the rebuilding or replacement of missing jaw structure. As mentioned above, the patient requiring reconstruction will often need the actual replacement of hard and soft tissue parts that are missing. Mitered cuts for realignment or a surgeon’s sleight of hand seldom suffice to fix the problem completely as is normally the case with orthognathic surgery. Please refer to our section on “orthognathic surgery” for a more detailed explanation of this commonplace treatment modality.

Some Generalities About 'Maxillofacial Reconstructive Surgery'

Reconstructive surgery is primarily aimed at restoring the patient to normal function and an acceptable if not pleasing appearance. Numerous modalities are used during the treatment planning phase, surgical phase and post-surgical period to fully accomplish a comprehensive reconstruction. The facial skeleton is extraordinarily complex when compared to other parts of the human skeleton. The skull, when taken by itself, is comprised of twenty-eight individual bones. When these bones have been broken or are rendered as separate pieces, the challenge to reassemble them is sometimes rivaled only by “all the kings’ horses and all the kings’ men putting “humpty dumpty” back together again.” More simply stated, we often use all the tricks in our bag when operating on a reconstructive case.

As previously mentioned, the nature of the patient’s injury will normally dictate the terms of a maxillofacial reconstruction:

The Cancer Patient

Surgery to eradicate oral and/or head and neck cancer typically requires the removal of soft tissues and often the removal of hard tissues of the facial skeleton. The ablative stage of this patient’s treatment is generally accomplished by a team of surgeons including a head and neck oncological surgeon and a maxillofacial surgeon. The head and neck surgeon has received extensive training on the staging and removal of head and neck malignancies. They are generally masters at eradicating the gross physical presence of disease while leaving vital anatomical structures for the patient’s future function, survival and well being. By the same token, the maxillofacial surgeon’s expertise is to engineer the reconstruction of hard tissues so that the patient can return to a normal function and appearance. Once the hard tissues have been removed, they must be replaced as quickly as possible to optimize future function. On the day of the patient’s ablative surgery, it is likely that only temporary measures can be taken to maintain the space and provide support that was initially afforded by bony structures. This is generally done with the use of reconstruction plates and is aimed at getting the patient to the other side of his/her disease while preparing him/her for a more definitive reconstruction down the road. As mentioned above, this patient also may be required to undergo radiation following surgery. In these cases, they may be asked to undergo several “dives” of “hyperbaric oxygen” before reconstruction is attempted. Treatment with hyperbaric oxygen prepares the patient’s soft tissues that have been damaged by radiation to be more receptive to future grafting with live bone. Failure to take this situation into account can result in a failure of bone grafting to survive and an untoward outcome from reconstruction.

The final reconstruction following cancer resection can be delayed for several months after the initial ablative surgery and it is important that the individual remain patient. The maxillofacial surgeon realizes how anxious the patient is to restore function and aesthetics to their life. However, this patient’s best opportunity for success is rendered during their first attempt at reconstruction. Rushing to surgery that is not well planned can have disastrous consequences. In addition, subsequent reconstruction attempts in the face of a previous failure are fraught with increasing amounts of risk and less predictable results.

Patients with Benign Oral Pathology

A patient may present to the oral and maxillofacial surgeon with oral pathology that is actually very benign but is a considerable structural problem. There is a very complex embryological history to the facial region that is responsible for numerous and unusual forms of benign and malignant lesions of this region. The fact that teeth are present in this region alone adds to the complexity of the range of pathology that can present itself. Fortunately, most lesions are benign and will not be the source of the patient’s ultimate demise. However, some of these lesions can be very aggressive and occupy large areas of space within the facial bones. This can make removal difficult without subsequent primary or secondary structural replacement. Unlike the cancer patient, however, it is not uncommon for these lesions to be treated in a single event after biopsy has confirmed a benign diagnosis. It is also possible in some cases to use banked bone, reconstruction plates and/or dental implants with local measures to get the job done. In the case of benign tumors of the facial bones, it is the job of your maxillofacial surgeon to engineer the best route to balancing an eradication of the disease with preserving and restoring normal structure and function. Your surgeon will present you with an architectural plan to treat your condition once he has a firm diagnosis.

Trauma Patients

While trauma patients can present with many of the same issues as the cancer patient (massive soft and hard tissue loss), more often than not, most of the parts are still available for the surgeon to use in the process of rebuilding their facial form and restoring normal function. A scrambled mess, yes; but totally missing, not usually. Furthermore, these patients are not recovering from radiation therapy. As you may have guessed, the trauma patient is truly the “humpty dumpty” for our specialty. For a more detailed account of the specific care of the “trauma patient” you should not hesitate to visit our section dedicated to this commonly acquired condition.

In summary, “maxillofacial reconstruction” often presents the maxillofacial surgeon with some of his most challenging problems. Numerous variables must be considered when treating this patient, ranging from supporting their psychological health to engineering a lasting structural fix that re-establishes the individual’s function and appearance.