Chapter 89 - Part D: Reconstruction vs Second Intention: When Fixing the Defect Makes Things Worse

In this BoardsCast episode, we continue Tobias Chapter 89 - Mandibulectomy and Maxillectomy by exploring one of the most counterintuitive truths in maxillofacial surgery:
Sometimes, the worst thing you can do is “fix” the defect.

After mandibulectomy or maxillectomy, reconstruction may seem like the right choice — but in many cases, reconstruction creates more complications than it prevents. Between tension, necrosis, infection, occlusal mismatch, airway compromise, and mechanical failure, repairing the defect can turn a stable patient into a failing one.

This episode explains when to reconstruct, when not to, and how to decide — exactly what the boards expect you to understand.

You’ll learn:

• Why reconstruction can worsen biomechanics, occlusion, or airway function
• When second intention healing provides a superior biologic outcome
• Flap choices: axial, local, regional, and when each fails
• The mechanical traps of tension, dead space, and unstable load transfer
• Why maxilla vs mandible defects heal differently
• High-risk situations where reconstruction predictably fails
• Board-relevant case patterns involving partial vs segmental jaw defects

This episode teaches you to stop thinking “fill the hole” and start thinking “optimize function and healing.”

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Listen On:
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Chapters

• 0:00 Introduction: The Instinct to Close
• 1:00 New Mental Model: Second Intention as a Primary Choice
• 2:30 The Biology of Open Healing: Why the mouth excels at self-repair
• 4:15 The Tension Trap: Why sutures often act as cheese-wires
• 6:00 Drainage Mandate: Preventing the "Enzymatic Swamp" of trapped saliva
• 8:15 Reconstruction Disasters: When the flap becomes a functional obstacle
• 10:45 The Golden Rule: If it can't move without tension, leave it open
• 13:30 Managing Owner Expectations: Selling the "open" look
• 15:50 Final Thought: Quality of life over cosmetic primary closure