Reconstruction of the Maxilla with Loss of the Orbital Floor and Orbital Preservation: A Case for the Iliac Crest with Internal Oblique

ABSTRACT

Although many techniques have been described to reconstruct the midface and the maxilla, there remains little agreement on the most effective methods when the orbit itself is preserved but there is loss of the maxilla, orbital floor, and often the medial wall. If the principle of replacing form and function is to be preserved, then a complex three-dimensional bony shape is required, which can support the orbital floor and provide a functioning dentition through an implant-retained prosthesis. At the same time, the oral fistula must be closed and a nasal lining provided. The iliac crest with internal oblique provides a bone structure that can be shaped for the defect and can easily articulate with the malar remnant, the nasal bones, and the upper alveolus. The internal oblique muscle effectively closes the oral fistula and lines the nasal cavity and becomes epithelialized resulting in a natural appearance. This article describes the principles of use of the iliac crest with internal oblique in the reconstruction of this defect and compares this technique with the many other methods reported in the literature. The article is mainly descriptive as there are few comparative studies comparing reconstructive techniques for a similar defect.

KEYWORDS

Maxilla - reconstruction - iliac crest

REFERENCES

• 1 Brown J S, Rogers S N, McNally D N, Boyle M. A modified classification for the maxillectomy defect.  Head Neck. 2000;  22 17-26
• 2 Coleman III J J, Coleman J J. Microvascular approach to function and appearance of large orbital maxillary defects.  Am J Surg. 1989;  158 337-341
• 3 Futran N D, Futran N D. Primary reconstruction of the maxilla following maxillectomy with or without sacrifice of the orbit.  J Oral Maxillofac Surg. 2005;  63 1765-1769
• 4 Genden E M, Okay D, Stepp M T et al.. Comparison of functional and quality-of-life outcomes in patients with and without palatomaxillary reconstruction: a preliminary report.  Arch Otolaryngol Head Neck Surg. 2003;  129 775-780
• 5 Rogers S N, Lowe D, McNally D et al.. Health-related quality of life after maxillectomy: a comparison between prosthetic obturation and free flap.  J Oral Maxillofac Surg. 2003;  61 174-181
• 6 Askar I, Oktay M F, Kilinc N, Askar I, Oktay M F, Kilinc N. Use of radial forearm free flap with palmaris longus tendon in reconstruction of total maxillectomy with sparing of orbital contents.  J Craniofac Surg. 2003;  14 220-227
• 7 Bianchi B, Bertolini F, Ferrari S et al.. The rectus abdominis myocutaneous flap combined with vascularized costal cartilages for orbito-malar facial reconstruction.  J Oral Maxillofac Surg. 2005;  63 1026-1029
• 8 Brennan P A, Pratt C, Brown J S. Reconstruction of the total maxillectomy defect using a pedicled coronoid flap and deep circumflex iliac artery flap.  Bri J Oral Maxillofac Surg. 2008;  46 423-426
• 9 Brown J S, Jones D C, Summerwill A et al.. Vascularized iliac crest with internal oblique muscle for immediate reconstruction after maxillectomy.  Br J Oral Maxillofac Surg. 2002;  40 183-190
• 10 Chang D W, Langstein H N. Use of the free fibula flap for restoration of orbital support and midfacial projection following maxillectomy.  J Reconstr Microsurg. 2003;  19 147-152
• 11 Chepeha D B, Moyer J S, Bradford C R et al.. Osseocutaneous radial forearm free tissue transfer for repair of complex midfacial defects.  Arch Otolaryngol Head Neck Surg. 2005;  131 513-517
• 12 Cordeiro P G, Santamaria E, Kraus D H, Strong E W, Shah J P. Reconstruction of total maxillectomy defects with preservation of the orbital contents.  Plast Reconstr Surg. 1998;  102 1874-1884
• 13 Davison S P, Boehmler J H, Ganz J C et al.. Vascularized rib for facial reconstruction.  Plast Reconstr Surg. 2004;  114 15-20
• 14 Granick M S, Ramasastry S S, Newton E D et al.. Reconstruction of complex maxillectomy defects with the scapula free flap.  Head Neck. 1990;  12 377-385
• 15 Hashikawa K, Tahara S, Ishida H et al.. Simple reconstruction with titanium mesh and radial forearm flap after globe-sparing total maxillectomy: a 5-year follow-up study.  Plast Reconstr Surg. 2006;  117 963-967
• 16 Lee H B, Hong J P, Kim K T, Chung Y K, Tark K C, Bong J P. Orbital floor and infraorbital rim reconstruction after total maxillectomy using a vascularized calvarial bone flap.  Plast Reconstr Surg. 1999;  104 646-653
• 17 McLoughlin P M, Gilhooly M, Phillips J G. Reconstruction of the infraorbital margin with a composite microvascular free flap.  Br J Oral Maxillofac Surg. 1993;  31 227-229
• 18 Muneuchi G, Miyabe K, Hoshikawa H et al.. Postoperative complications and long-term prognosis of microsurgical reconstruction after total maxillectomy.  Microsurgery. 2006;  26 171-176
• 19 Nakayama B, Matsuura H, Hasegawa Y, Ishihara O, Hasegawa H, Torii S. New reconstruction for total maxillectomy defect with a fibula osteocutaneous free flap.  Br J Plast Surg. 1994;  47 247-249
• 20 Nakayama B, Hasegawa Y, Hyodo I et al.. Reconstruction using a three-dimensional orbitozygomatic skeletal model of titanium mesh plate and soft-tissue free flap transfer following total maxillectomy.  Plast Reconstr Surg. 2004;  114 631-639
• 21 Peng X, Mao C, Yu G Y et al.. Maxillary reconstruction with the free fibula flap.  Plast Reconstr Surg. 2005;  115 1562-1569
• 22 Pryor S G, Moore E J, Kasperbauer J L et al.. Coronoid-temporalis pedicled rotation flap for orbital floor reconstruction of the total maxillectomy defect.  Laryngoscope. 2004;  114 2051-2055
• 23 Sakuraba M, Kimata Y, Ota Y et al.. Simple maxillary reconstruction using free tissue transfer and prostheses.  Plast Reconstr Surg. 2003;  111 594-598
• 24 Schmelzeisen R, Schliephake H. Interdisciplinary microvascular reconstruction of maxillary, midfacial and skull base defects.  J Craniomaxillofac Surg. 1998;  26 1-10
• 25 Schusterman M A, Reece G P, Miller M J. Osseous free flaps for orbit and midface reconstruction.  Am J Surg. 1993;  166 341-345
• 26 Shestak K C, Schusterman M A, Jones N F, Johnson J T. Immediate microvascular reconstruction of combined palatal and midfacial defects using soft tissue only.  Microsurgery. 1988;  9 128-131
• 27 Smolka W, Iizuka T, Smolka W, Iizuka T. Surgical reconstruction of maxilla and midface: clinical outcome and factors relating to postoperative complications.  J Craniomaxillofac Surg. 2005;  33 1-7
• 28 Triana Jr R J, Uglesic V, Virag M et al.. Microvascular free flap reconstructive options in patients with partial and total maxillectomy defects.  Arch Facial Plast Surg. 2000;  2 91-101
• 29 Yamamoto Y, Kawashima K, Sugihara T et al.. Surgical management of maxillectomy defects based on the concept of buttress reconstruction.  Head Neck. 2004;  26 247-256
• 30 Coleman J J. Reconstruction of the midface with vascularized bone and soft tissue.  Semin Plast Surg. 2003;  17 291-303
• 31 Brown J S. Deep circumflex iliac artery free flap with internal oblique muscle as a new method of immediate reconstruction of maxillectomy defect.  Head Neck. 1996;  18 412-421
• 32 Haughey B H, Fredrickson J M, Lerrick A J et al.. Fibular and iliac crest osteomuscular free flap reconstruction of the oral cavity.  Laryngoscope. 1994;  104(11 Pt 1) 1305-1313
• 33 Shpitzer T, Neligan P C, Gullane P J et al.. The free iliac crest and fibula flaps in vascularized oromandibular reconstruction: comparison and long-term evaluation.  Head Neck. 1999;  21 639-647
• 34 Rogers S N, Lakshmiah S R, Narayan B et al.. A comparison of the long-term morbidity following deep circumflex iliac and fibula free flaps for reconstruction following head and neck cancer.  Plast Reconstr Surg. 2003;  112 1517-1525
• 35 Brown J S, Thomas S, Chakrabati A et al.. Patient preference in placement of the donor site scar in head and neck cancer.  Plast Reconstr Surg. 2008;  122 20e-22e