Reconstruction of maxillectomy defects using deep circumflex iliac artery-based composite free flap

Reconstruction of maxillectomy defects using deep circumflexiliac artery–based composite free flapAmresh S. Baliarsing, MS, MCh,a Vinay V. Kumar, MDS,b Neelima A. Malik, MDS,c andDilip Kumar B., MDS,d Mumbai, IndiaB. Y. L. NAIR HOSPITAL AND T. N. MEDICAL COLLEGE, SWAMI DEVI DYAL HOSPITAL AND DENTALCOLLEGE, AND NAIR HOSPITAL DENTAL COLLEGE

Reconstruction of maxillectomy defects is a challenging endeavor, and various methods have been describedto rehabilitate these defects, out of which composite free tissue transfer has an established role in reconstruction of themaxillary defects. The deep circumflex iliac artery (DCIA) flap has distinct advantages regarding the volume and lengthof the bone in reconstruction. The contour of the iliac bone is similar to the maxilla and provides good esthetic result.Good volume of bone allows placement of osseointegrated implant for dental rehabilitation. We present 8 cases ofmaxilla reconstruction using DCIA flap (3 osteocutaneous and 5 osseous flaps) for benign and malignant pathologiesof the maxilla. DCIA flap is difficult to harvest, has variable anatomy, and needs meticulous planning for

The maxilla is a vital structure of the face, both esthet-ically and functionally. It fundamentally forms a sup-port for the maxillary teeth, transmitting masticatoryforces, provides a vertical support for the orbit and itscontents, separates the oral and nasal cavities, andendows attachment to muscles of facial expression. Thefacial soft tissues swathe around the maxilla and asso-ciated bony framework, forming the unique facial char-acteristic of every individual.1

Tumors afflicting the maxilla and the maxillary sinuscan bring about devastating effects on the patient’sesthetics and functional well-being. These tumors arenot always confined to the boundaries of the maxilla;therefore, adjacent tissues, such as the hard and softpalate, adjacent soft tissues, and orbital contents, mayhave to be sacrificed as well. Inefficient mastication,inarticulate speech leading to hindered communication,impaired nutrition and deglutition, salivary drooling,uncontrollable nasal leakage of fluids, diplopia, ectro-pion, difficulty in maintenance of oral hygiene, severepsychologic damage, and social unacceptability are

aProfessor and Head, Department of Plastic and Reconstructive Sur-gery, B. Y. L. Nair Hospital and T. N. Medical College.bSenior Lecturer, Department of Oral and Maxillofacial Surgery,Swami Devi Dyal Hospital and Dental College.cFormer Dean, Professor and Head, Department of Oral and Maxil-lofacial Surgery, Nair Hospital Dental College.dSenior Lecturer, Department of Oral and Maxillofacial Surgery, NairHospital Dental College.Received for publication Aug 8, 2009; returned for revision Sep 24,2009; accepted for publication Oct 21, 2009.1079-2104/$ - see front matter© 2010 Published by Mosby, Inc.

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some of the handicaps faced by these patients, in addi-tion to esthetic facial disfigurement.2

Ideal reconstruction of maxillectomy defects re-quires the presence of a healed wound, separation oforal and nasal cavities, suspension and support of dy-namic facial soft tissues including avoidance of ectro-pion, restoration of midfacial contour, restoration ofmaxillary buttresses, restoration of functional dentition,mastication, and deglutition, and maintenance of a patentnasal airway.3

Reconstruction of maxillectomy defects, owing to itscomplex anatomy, is one of the most challenging areasof reconstructive surgery. Traditionally, these defectshave been rehabilitated by a prosthetic obturator andare still considered by a majority of centers to be thegold standard.4 A variety of local, pedicled, and freesoft tissue flaps either alone or in combination withalloplastic materials such as meshes, nonvascularizedbone, and implants have also been used. None of thesemethods provides an ideal solution to the reconstructionand rehabilitation of extensive maxillectomy defects.5

Vascularized bone grafts provide a good bony founda-tion for esthetic midface projection as well as for func-tional dental retention by implants.6 The aim of thepresent study was to evaluate the results of 8 cases oflarge maxillectomy defects reconstructed by free deepcircumflex iliac artery (DCIA)–based iliac crest–inter-nal oblique composite free flap.

PATIENTS AND METHODSThis study consisted of 8 consecutive patients who

had undergone reconstruction of tumors of the maxilla

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our institution in 6 cases, whereas in 2 patients it hadbeen done in another institution.

We considered the Brown et al.7 classification sys-tem of maxillectomy defects to classify the patients inour study (Table I).

The flap harvesting technique was as described byUrken et al. (1989)8 using the superolateral approach(Fig. 1). Four flaps were harvested with the iliac crestand internal oblique, and 4 flaps were harvested alongwith an overlying skin paddle. All flaps were harvestedfrom the ipsilateral side.

The graft was placed in the prepared defect sitevertically, with the iliac crest forming the maxillaryanterior neoridge (Fig. 2). The pedicle was entering thereconstructed site posteriorly and laterally. The pedi-cle was passed through a subcutaneous tunnel madein the cheek which traversed from the posterior aspectof the maxillary defect to a submandibular incision foranastomosis to the facial vessels. In all of the cases, theanastomosis was done to the ipsilateral facial vessels,except in 1 case where a subcutaneous tunnel was madethrough the upper lip and anastomosis done to thecontralateral facial vessels. The internal oblique musclewas sutured to the cut edge of the remaining palatalmucosa as well as the lateral nasal wall. The bone graftwas fixed to the native maxilla and the zygomatic archby bone plates. The donor site was closed meticulouslyin layers. Suction drains were placed in donor andrecipient sites.

Postoperative monitoring consisted of hourly moni-toring for the first 24 hours using conventional clinicalmonitoring methods and a handheld Doppler followedby 2-hourly monitoring for the next 48 hours by thesame methods and a single photon emission computer-ized tomography scan on the 15th day after surgery.

RESULTSEight patients underwent maxillectomy procedure

Table I. Classification of maxillary defects by Brownet al.7

Component Class/type Description

Vertical 1 Maxillectomy without an oroantral fistula2 Low maxillectomy (not including orbital

floor or contents)3 High maxillectomy (involving orbital

contents)4 Radical maxillectomy (includes orbital

exenteration)Horizontal a Unilateral alveolar maxillectomy

b Bilateral alveolar maxillectomyc Total alveolar maxillary resection

followed by reconstruction with a vascularized DCIA-

based composite flap (Table II; Figs. 3 and 4). Therewere 7 female and 1 male patient, with a mean age of21.375 years (range 8-60 years). Six of them were �18years of age.

Three patients had a malignant pathology (2 cases ofmucoepidermoid carcinoma and 1 squamous cell car-cinoma), and 5 patients had a benign but locally ag-gressive pathology (3 cases of ossifying fibroma, 1 caseof desmoplastic fibromatosis, and 1 aneurysmal bonecyst). None of the patients with malignant tumors hadnodal metastasis. Two of the patients had an immediateprimary reconstruction, whereas the others were recon-structed secondarily.

Two patients had undergone radiation, and the re-constructive procedure was taken up 4 months later inone of these patients. The other patient had the resec-tion and radiation carried out in another institute andpresented to our institute for reconstruction 3 yearsafter surgery and radiation.

Four of the defects were of Brown class III type a,with half of the hard palate as well as floor of the orbitexcised along with the anterolateral and medial walls ofthe maxilla. The other 4 patients had Brown class IItype a defect, with less than half of the hard palateremoved, the infraorbital floor and rims being intact.

Two of the patients required an intermediate veingraft. The saphenous vein was used for one of thesepatients, and an aberrant artery was used as intermedi-ate vessel graft in the other. The anastomosis was donewith the facial artery and vein in all of the patients.

One flap loss occurred. This patient was given atemporary obturator until further surgical managementof the defect. It was not necessary to return any patientto the operation theater for salvaging a flap. One patienthad a hematoma and the facial sutures had to be re-opened for evacuation and drainage. One patient hadnecrosis of the skin paddle, which had to be removedunder general anesthesia. Although at the time of place-ment all flaps seemed to be of a larger size comparedwith the defect, the muscle mass shrunk well enough toavoid a second surgical procedure in all but 1 of thepatients. A secondary debulking procedure with ves-tibuloplasty was carried out for that patient under gen-eral anesthesia.

The donor site in all the cases healed uneventfully.There were no donor site dehiscence noted, and therewas no hernia formation. Only 1 patient complained ofanesthesia of the lateral cutaneous nerve of thigh, al-though all patients exhibited varying degrees of anes-thesia/parasthesia. All patients had abnormal gait oncethey were walking in the immediate postoperative pe-riod, but all returned to normal gait within a month after

and incorporation of the required amount of external oblique muscle;bottom right, flap in recipient site.

the pedicle during harvesting and in the defect.

OOOOEe10 Baliarsing et al. March 2010

All patients (except the single unfortunate case offlap failure) were rehabilitated with a conventional re-movable upper partial denture (Table II). One patienthad to undergo total dental extraction, and a temporarycomplete denture was provided. The other patientswere given conventional removable partial dentures.Cosmesis was considered excellent in 5 patients andgood in 1.

DISCUSSIONThe ideal approach for reconstruction of maxillec-

tomy defects differs from that of any other defects ofthe body. The reconstructive procedures should providea sound bony base to transmit the occlusal forces,create multiple mucosal surfaces that separate func-tional units, bring about support for the orbit, andcontribute to the sagittal, transverse, and vertical di-mensions of the midface in bringing about optimalfacial projection and esthetics.1,3,5

Various methods have been used for the reconstruc-tion and rehabilitation of maxillectomy defects. Pros-thetic obturators are the most commonly used methodfor the rehabilitation of these patients, because it is asimple method which can be widely employed andrehabilitates the patient with reasonable functional and

d after incision through skin, fascia, internal oblique muscle,bottom left, flap dissected out, showing various components;

Fig. 1. Top left, The outline of the flap; top right, iliac crest expose

Fig. 2. Line diagram showing the orientation of the flap and

OOOOEVolume 109, Number 3 Baliarsing et al. e11

the essential characteristics of living tissue and maycontribute to certain problems, such as leakage betweenoral and nasal cavities, adjacent tissue trauma in irra-

Table II. Summary of the main data and functional reNo. Age Gender D H/o RT Class* T.Recon PA Typ

1 16 F DF N 2a 2 mos M2 18 F JOF N 2a 14 yrs M3 8 M ABC N 3a Primary M4 15 F MEC Y 3a 5 mos O

5 28 F MEC N 2a Primary O6 60 F SCC Y 2a 3 yrs O7 11 F JOF N 3a 2 mos O8 15 F JOF N 3a Primary O

D, Diagnosis; H/o RT, history of radiotherapy; T.Recon PA, timing ofemale; M, male; DF, desmoplastic fibromatosis; JOF, juvenile ossifySCC, squamous cell carcinoma; N, no; Y, yes; MO, myo-osseous; OMremovable partial denture; DO, dental obturator; CD, complete dentu*Brown et al. classification system (Table I).

Fig. 3. Patient no. 1, diagnosed with desmoplastic fibroma ocenter, preoperative intraoral photograph, revealing palatal eof lesion. Bottom left, Postreconstructive facial appearance;radiograph showing the bone graft in place.

diated patients, discomfort in wearing a rigid appliance

in a mobile area, and difficulty in maintenance of goodoral hygiene, causing malodor. In patients with poormanual dexterity, visual impairment, or trismus, it may

tation of the complete group of patients (n � 8)Diet Speech DR Cosmesis Complications

UR IOP RPD Excellent NilUR IOP RPD Good Mild dehiscenceUR IOP RPD Excellent NilUR IOP RPD Excellent Hematoma

Skin paddle necrosisUR IOP DO N.A. Flap lossUR IOP CD Excellent LCNTAUR IOP RPD Excellent NilUR IOP RPD Under evaluation Nil

structive surgery after ablative surgery; DR, dental rehabilitation; F,ma; ABC, aneurysmal bone cyst; MEC, mucoepidermoid carcinoma;myo-cutaneous; UR, unrestricted; IOP, intelligible over phone; RPD,not applicable; LCNTA, lateral cutaneous nerve of thigh anesthesia.

ight maxilla. Top left, Preoperative patient appearance; topon; top right, preoperative MRI image, revealing the extentm center, postoperative intraoral ridge form; bottom right,

habilie of flap

OOOMC

MCMCMCMC

f reconing fibroS, osseore; NA,

f the rxpansibotto

be difficult for them to insert a large prosthesis.9

OOOOEe12 Baliarsing et al. March 2010

Numerous pedicled and free soft tissue flaps havebeen used to restore a maxillectomy defect.10-14 Theymay be considered to be a method of separating the oralcavity from the sinus. They do not provide restorationof the maxillary alveolus and therefore create a flatplane which often sags down into the oral cavity, oblit-erating the vestibular depth. It is extremely difficult toobtain a border seal, and the remaining bony ridgecan not be used to stabilize and retain the obturator.The resultant anatomy may provide poor support,retention, and stability for the denture. It may bereserved for those patients who retain an adequatedentition for mastication with only a palatal defectfor coverage.15

The use of a bone-containing composite flap formaxilla reconstruction has many advantages of provid-ing a stable alveolar ridge for the dentition, soft tissuelining for the oral and nasal side of the defect, supportfor the orbit, and a base for check projection.16,17

Although scapula18 and fibula19 free flaps may be used,

Fig. 4. Patient no. 4, diagnosed with mucoepidemoid carcinocenter, preoperative intraoral photograph, revealing palatal exof lesion. Bottom left, Postreconstructive facial appearance,3-dimensional CT showing the bone graft in place.

in our experience the DCIA20 is the most apt.

In the present series of cases, none of the defectsrequired reconstruction of the facial skin. The iliaccrest component has a natural curvature which mim-ics that of the maxillary alveolar ridge. It has suffi-cient amount of bone which can provide the depthrequired to support the orbital contents and sufficientmass for providing an esthetic cheek prominence. Itprovides an ideal medium to place osseointegrated den-tal implants. The internal oblique muscle seems to bebulky immediately after reconstruction, but shrinksconsiderably onto the bone to offer a realistic replace-ment for the lining of the oral and nasal cavities. Thesequalities can not be matched by other donor sites.

This flap had a few shortcomings. There was 1 caseof flap loss, which was attributed to aberrant DCIAanatomy, where there was a duplication of the DCIA.During surgery, 1 of the 2 supplying vessels wasclamped and the blood flow to the flap was apparentlyfound to be sufficient. This artery was thought to be thedominant artery. The clamped artery was ligated at its

right maxilla. Top left, Preoperative patient appearance; topn; top right, preoperative CT scan image, revealing the extentm center, postoperative intraoral ridge form; bottom right,

ma ofpansiobotto

base and sectioned and used as an intermediate vessel

OOOOEVolume 109, Number 3 Baliarsing et al. e13

graft. Although the handheld Doppler signals were pos-itive at the recipient site, the graft failed to perfuseadequately and clinical signs of flap failure were ap-parent from the second day after surgery.

A disadvantage of this flap is that it has a shorterpedicle length. Although the pedicle was of sufficientlength for most of our patients, in 2 of them we requireda vein graft. In one of the patients, the anastomosis wasdone to the contralateral facial vessels, thus the need foradditional length.

Another disadvantage is that it is time consumingand requires a longer time of dissection compared withother commonly carried out free flaps. Though abdom-inal herniation is cited as a complication, we have notcome across this in our 8 patients in spite of not usinga mesh for closure.

The esthetic results achieved were excellent in 5 outof 8 patients. One patient at the time of writing wasrecently reconstructed and is therefore awaiting judge-ment on cosmesis. The other patient whose estheticresults were not considered to be excellent, had pre-sented with a defect for 15 years during her growingperiod. As a result, she had a severe occlusal cant andhypoplasia of one side of face. This patient wouldrequire a secondary corrective surgery. All of the pa-tients were rehabilitated by a conventional denture, andrehabilitation with osseointegrated implant–supporteddenture was being considered.

Owing to all of the characteristic advantages of theDCIA flap, its use has been the first reconstructive choicein the management of maxillectomy defect in our institu-tion. This is in accordance with earlier authors who havereported its use in maxillectomy defects.20-24

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Mr. Amresh S. BaliarsingPlastic and Reconstructive SurgeryB. Y .L. Nair Charitable Hospital and T. N. Medical CollegeDr. A. L. Nair RoadMumbai Central, MumbaiMumbai, MaharashtraIndia