The radial forearm osteocutaneous "sandwich" free flap for reconstruction of the bilateral subtotal maxillectomy defect.

Complex resections of the maxilla produce a three-dimensional defect that can be difficult to reconstruct using autogenous tissue without utilizing a free tissue transfer. The osteocutaneous flaps that have been described for reconstruction of this area have been the scapula, iliac crest, and fibula, which are often hampered by their bulkiness and less than ideal intraoral lining. The bilateral subtotal maxillectomy defect is particularly difficult to reconstruct because it requires restoration of the bony framework of the midface as well as the restoration of the palatal and nasal lining. We present a new technique for reconstruction of this type of defect using the osteocutaneous radial forearm free flap. Two patients with bilateral subtotal maxillectomy defects, in whom the entire hard palate and maxillary arch were resected, underwent primary reconstruction. The bone from the osteocutaneous flap was osteotomized and contoured to recreate the maxillary arch. The large skin island was folded around the bone, as in a sandwich, and used to replace the palatal and nasal lining. This sandwiched osteocutaneous flap allowed for secure fitting of a dental prosthesis and the future possibility of osteointegrated implants. Long-term stability of the bone without retrusion was achieved with an excellent functional and aesthetic outcome. The radial forearm osteocutaneous free flap is ideal for the reconstruction of the maxillary infrastructure in that (1) it provides bone and thin, pliable skin in the correct proportions; (2) the described "sandwich" technique restores an excellent functional and aesthetic state; and (3) dental rehabilitation can be further improved by using either a prosthesis or osteointegrated implants.