Horizontal versus vertical scapular free flap reconstructions in total maxillectomies without orbital exenteration-A systematic review and clinical case series.

Background: The scapular free flap is a recognized reconstructive option for total maxillectomies, however, its optimal orientation and position in reconstructions without orbital exenteration is undetermined. The following study aimed to evaluate horizontal and vertical scapular reconstructions of the orbito-palato-maxillary complex by means of a systematic review of the literature and in a clinical case series. Methods: A systematic review was performed, including articles from Pubmed, Medline, Embase and Cochrane databases. In parallel, a retrospective review of consecutive clinical cases treated between 2016 and 2022 at a tertiary care center in Sweden was performed. Data was collected on scapular flap orientation and positioning, use of adjunctive orbital floor support (vascularized or alloplastic), soft tissue configuration, and postoperative complications related to ocular and palato-maxillary outcomes. Results: Eleven studies comprising 44 patients met inclusion criteria. Vertically orientated scapulas (26 patients) were most common and demonstrated fewer complications than horizontally orientated scapulas (p = 0.04), particularly when excluding alloplastic material by using an osteotomized fragment to reconstruct the orbital floor (13 patients) (p = ≤0.001). Adopting a hybrid approach, combining vascularized bone with alloplastic material for enhanced orbital floor support, did not eliminate ocular or infective complications in a clinical case series. Conclusion: No universally optimal technique exists for reconstructing the total maxillectomy without orbital exenteration, however, the vertically orientated scapula with an osteotomized fragment for orbital floor reconstruction has the potential to offer a "single flap" solution. The indications for alloplastic adjuncts for orbital floor support remain undetermined.