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A modified technique for reconstruction of a total maxillary defect
ARTICLE IN PRESS
YBJOM-4624; No. of Pages 3
Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Short communication
A modified technique for reconstruction of a total maxillary defect Miao Yu, Xing-jun Qin ∗∗ , Chen-ping Zhang, Li-qun Xu ∗ Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People’s Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China Accepted 15 September 2015
Abstract Total maxillary defects with orbital retention (Brown class 2b) are a challenge to reconstructive surgeons because of the variety of anatomical structures involved. Traditional techniques to reconstruct the orbital floor, zygoma, and maxilla using only a vascularised fibular flap are complicated, as the osteotomy and orientation of bone are difficult. Reconstruction of the orbital floor with titanium mesh may also cause palpable discomfort and increase the risk of secondary infection. We describe a modified technique using a vascularised fibular flap, together with a coronoid temporalis pedicle flap, which we used in two patients in whom we achieved satisfactory aesthetic and functional results. Our technique provides adequate tissue for infraorbital skin defects, provides pedicles of sufficient length, and requires only one fibular osteotomy. To our knowledge this is the first report of this technique. © 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Total maxillary defect; Reconstruction; Coronoid temporalis pedicle flap; Fibula flap
Introduction Total maxillary defects with orbital retention (Brown class 2b1 ) have posed formidable challenges to restore and reconstruct the anatomical structures involved. Even though many techniques have been described, there are still shortcomings including adequate length of pedicle and infraorbital skin reconstruction.
∗ Corresponding author. Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, No.639 Zhi Zao Ju Road, Shanghai, 200011, China. Tel.: +86 15801907187; fax: +86 21 63136856. ∗∗ Co-corresponding author. Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China. E-mail addresses: [email protected] (X.-j. Qin), [email protected] (L.-q. Xu).
We therefore present a modified technique to reconstruct the orbital floor with a coronoid temporalis pedicle flap and the infraorbital skin, alveolar bone, and internal nasal and oral lining, with a vascularised fibular flap. Our technique simplifies the operation, shortens the operating time, reduces the likelihood of postoperative infection, ensures adequate length of the pedicle, and reconstructs the infraorbital skin defect. We have used this technique in two cases with successful outcomes. Case report A 63-year-old man with squamous cell carcinoma of the right maxillary sinus had had a right total maxillectomy and reconstruction with titanium mesh 2 years previously (Fig. 1). Subsequently, he was given postoperative radiotherapy that led to exposure of the titanium mesh (Fig. 2). After we had excluded the possibility of recurrence, we made a preoperative Surgicase 5.0 (Materialise, Belgium)
http://dx.doi.org/10.1016/j.bjoms.2015.09.015 0266-4356/© 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Yu M, et al. A modified technique for reconstruction of a total maxillary defect. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.09.015
YBJOM-4624; No. of Pages 3
2
ARTICLE IN PRESS M. Yu et al. / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
oral lining and the infraorbital skin. Finally, the peroneal vessels were anastomosed to the facial vessels through incisions in the submandibular creases. One month postoperatively the patient was free of disease and had satisfactory aesthetic results. His mouth opening was 4.0 cm, speech and swallowing were normal, and he had no additional complications such as diplopia, ectropion, exophthalmos, or necrosis of the flap. Postoperative computed tomographic scans showed normal morphology of the orbit and ossification of the transplanted bone grafts. We could see no bony resorption (Figs. 2 and 3). Unfortunately, the patient refused to complete oral rehabilitation with a dental implant or removable prosthesis for economic reasons.
Discussion
Fig. 1. Three-dimensional reconstruction before operation.
design to reconstruct the alveolar bone with a 2-stage fibular flap (32.5 x 27.4 mm) from the opposite side, and the orbital floor with a coronoid process flap (3.5 x 1.5 cm). Subsequently, the coronoid temporalis pedicle flap was fashioned as described by Curioni et al.,2 to support the orbital contents. The osteocutaneous fibular flap was raised to the same level as the Hidalgo flap3 to reconstruct the alveolar bone. The skin of the fibular flap is used to reconstruct the nasal mucosa, the
Currently, autologous grafting is the gold standard for reconstruction, and the vascularised fibular flap and the iliac flap are the best materials for total maxillary reconstruction with dental implant.4 However, the iliac flap (with or without a coronoid temporalis pedicle flap)5 has the risk of inadequate length 6,7 and it is not able to reconstruct the infraorbital skin defect. The fibula flap needs two or more osteotomies8 and orientation of the skin island is challenging.1 In our technique the orbital floor is reconstructed with a temporalis coronoid flap and fibula is used to reconstruct the alveolar bone with only a single osteotomy, which simplifies the operation considerably. Unlike with iliac crest, we can reconstruct the infraorbital skin defect with this technique. At the same
Fig. 2. Before operation (left) and 1 month postoperatively (right) (published with the patient’s consent).
Please cite this article in press as: Yu M, et al. A modified technique for reconstruction of a total maxillary defect. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.09.015
YBJOM-4624; No. of Pages 3
ARTICLE IN PRESS M. Yu et al. / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
3
In summary, the reconstruction of a total maxillary defect with a vascularised fibular flap combined with a coronoid temporalis pedicle flap is simple and effective, and gives excellent clinical results.
Conflict of Interest We have no conflict of interest.
Ethics statement/confirmation of patient’s permission The patient has given permission for his photographs to be used in this paper.
References
Fig. 3. Three-dimensional reconstruction after operation.
time it can retain sufficient length for the vascular anastomosis without vein grafting, as the pedicle is not required to go through the orbital floor and nasal lining. By reconstructing the orbital floor with a coronoid temporalis pedicle flap, the titanium mesh implant is not required, which obviates the risk of extrusion or exposure, minimises the risk of infection,7 and reduces the impact of postoperative irradiation. The donor and recipient sites are within the same operative field, which eliminates additional trauma. The coronoid process closely matches the contour and dimensions of the orbital floor, which makes the appearance more symmetrical.9
1. Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new classification. Lancet Oncol 2010;11:1001–8. 2. Curioni C, Toscano P, Fioretti C, et al. Reconstruction of the orbital floor with the muscle-bone flap (temporal muscle with coronoid process). J Maxillofac Surg 1983;11:263–8. 3. Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg 1989;84:71–9. 4. Brown JS, Jones DC, Summerwill A, et al. Vascularized iliac crest with internal oblique muscle for immediate reconstruction after maxillectomy. Br J Oral Maxillofac Surg 2002;40:183–90. 5. Brennan PA, Pratt C, Brown JS. Reconstruction of the total maxillectomy defect using a pedicled coronoid flap and deep circumflex iliac artery free flap. Br J Oral Maxillofac Surg 2008;46:423–4. 6. Neligan PC. Head and neck reconstruction. Plast Reconstr Surg 2013;131:e260–9. 7. Sun J, Shen Y, Li J, et al. Reconstruction of high maxillectomy defects with the fibula osteomyocutaneous flap in combination with titanium mesh or a zygomatic implant. Plast Reconstr Surg 2011;127:150–60. 8. Shipchandler TZ, Waters HH, Knott PD, et al. Orbitomaxillary reconstruction using the layered fibula osteocutaneous flap. Arch Facial Plast Surg 2012;14:110–5. 9. Mintz SM, Ettinger A, Schmakel T, et al. Contralateral coronoid process bone grafts for orbital floor reconstruction: an anatomic and clinical study. J Oral Maxillofac Surg 1998;56:1140–5.
Please cite this article in press as: Yu M, et al. A modified technique for reconstruction of a total maxillary defect. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.09.015
YBJOM-4624; No. of Pages 3
Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Short communication
A modified technique for reconstruction of a total maxillary defect Miao Yu, Xing-jun Qin ∗∗ , Chen-ping Zhang, Li-qun Xu ∗ Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People’s Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China Accepted 15 September 2015
Abstract Total maxillary defects with orbital retention (Brown class 2b) are a challenge to reconstructive surgeons because of the variety of anatomical structures involved. Traditional techniques to reconstruct the orbital floor, zygoma, and maxilla using only a vascularised fibular flap are complicated, as the osteotomy and orientation of bone are difficult. Reconstruction of the orbital floor with titanium mesh may also cause palpable discomfort and increase the risk of secondary infection. We describe a modified technique using a vascularised fibular flap, together with a coronoid temporalis pedicle flap, which we used in two patients in whom we achieved satisfactory aesthetic and functional results. Our technique provides adequate tissue for infraorbital skin defects, provides pedicles of sufficient length, and requires only one fibular osteotomy. To our knowledge this is the first report of this technique. © 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Total maxillary defect; Reconstruction; Coronoid temporalis pedicle flap; Fibula flap
Introduction Total maxillary defects with orbital retention (Brown class 2b1 ) have posed formidable challenges to restore and reconstruct the anatomical structures involved. Even though many techniques have been described, there are still shortcomings including adequate length of pedicle and infraorbital skin reconstruction.
∗ Corresponding author. Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, No.639 Zhi Zao Ju Road, Shanghai, 200011, China. Tel.: +86 15801907187; fax: +86 21 63136856. ∗∗ Co-corresponding author. Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China. E-mail addresses: [email protected] (X.-j. Qin), [email protected] (L.-q. Xu).
We therefore present a modified technique to reconstruct the orbital floor with a coronoid temporalis pedicle flap and the infraorbital skin, alveolar bone, and internal nasal and oral lining, with a vascularised fibular flap. Our technique simplifies the operation, shortens the operating time, reduces the likelihood of postoperative infection, ensures adequate length of the pedicle, and reconstructs the infraorbital skin defect. We have used this technique in two cases with successful outcomes. Case report A 63-year-old man with squamous cell carcinoma of the right maxillary sinus had had a right total maxillectomy and reconstruction with titanium mesh 2 years previously (Fig. 1). Subsequently, he was given postoperative radiotherapy that led to exposure of the titanium mesh (Fig. 2). After we had excluded the possibility of recurrence, we made a preoperative Surgicase 5.0 (Materialise, Belgium)
http://dx.doi.org/10.1016/j.bjoms.2015.09.015 0266-4356/© 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Yu M, et al. A modified technique for reconstruction of a total maxillary defect. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.09.015
YBJOM-4624; No. of Pages 3
2
ARTICLE IN PRESS M. Yu et al. / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
oral lining and the infraorbital skin. Finally, the peroneal vessels were anastomosed to the facial vessels through incisions in the submandibular creases. One month postoperatively the patient was free of disease and had satisfactory aesthetic results. His mouth opening was 4.0 cm, speech and swallowing were normal, and he had no additional complications such as diplopia, ectropion, exophthalmos, or necrosis of the flap. Postoperative computed tomographic scans showed normal morphology of the orbit and ossification of the transplanted bone grafts. We could see no bony resorption (Figs. 2 and 3). Unfortunately, the patient refused to complete oral rehabilitation with a dental implant or removable prosthesis for economic reasons.
Discussion
Fig. 1. Three-dimensional reconstruction before operation.
design to reconstruct the alveolar bone with a 2-stage fibular flap (32.5 x 27.4 mm) from the opposite side, and the orbital floor with a coronoid process flap (3.5 x 1.5 cm). Subsequently, the coronoid temporalis pedicle flap was fashioned as described by Curioni et al.,2 to support the orbital contents. The osteocutaneous fibular flap was raised to the same level as the Hidalgo flap3 to reconstruct the alveolar bone. The skin of the fibular flap is used to reconstruct the nasal mucosa, the
Currently, autologous grafting is the gold standard for reconstruction, and the vascularised fibular flap and the iliac flap are the best materials for total maxillary reconstruction with dental implant.4 However, the iliac flap (with or without a coronoid temporalis pedicle flap)5 has the risk of inadequate length 6,7 and it is not able to reconstruct the infraorbital skin defect. The fibula flap needs two or more osteotomies8 and orientation of the skin island is challenging.1 In our technique the orbital floor is reconstructed with a temporalis coronoid flap and fibula is used to reconstruct the alveolar bone with only a single osteotomy, which simplifies the operation considerably. Unlike with iliac crest, we can reconstruct the infraorbital skin defect with this technique. At the same
Fig. 2. Before operation (left) and 1 month postoperatively (right) (published with the patient’s consent).
Please cite this article in press as: Yu M, et al. A modified technique for reconstruction of a total maxillary defect. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.09.015
YBJOM-4624; No. of Pages 3
ARTICLE IN PRESS M. Yu et al. / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
3
In summary, the reconstruction of a total maxillary defect with a vascularised fibular flap combined with a coronoid temporalis pedicle flap is simple and effective, and gives excellent clinical results.
Conflict of Interest We have no conflict of interest.
Ethics statement/confirmation of patient’s permission The patient has given permission for his photographs to be used in this paper.
References
Fig. 3. Three-dimensional reconstruction after operation.
time it can retain sufficient length for the vascular anastomosis without vein grafting, as the pedicle is not required to go through the orbital floor and nasal lining. By reconstructing the orbital floor with a coronoid temporalis pedicle flap, the titanium mesh implant is not required, which obviates the risk of extrusion or exposure, minimises the risk of infection,7 and reduces the impact of postoperative irradiation. The donor and recipient sites are within the same operative field, which eliminates additional trauma. The coronoid process closely matches the contour and dimensions of the orbital floor, which makes the appearance more symmetrical.9
1. Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new classification. Lancet Oncol 2010;11:1001–8. 2. Curioni C, Toscano P, Fioretti C, et al. Reconstruction of the orbital floor with the muscle-bone flap (temporal muscle with coronoid process). J Maxillofac Surg 1983;11:263–8. 3. Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg 1989;84:71–9. 4. Brown JS, Jones DC, Summerwill A, et al. Vascularized iliac crest with internal oblique muscle for immediate reconstruction after maxillectomy. Br J Oral Maxillofac Surg 2002;40:183–90. 5. Brennan PA, Pratt C, Brown JS. Reconstruction of the total maxillectomy defect using a pedicled coronoid flap and deep circumflex iliac artery free flap. Br J Oral Maxillofac Surg 2008;46:423–4. 6. Neligan PC. Head and neck reconstruction. Plast Reconstr Surg 2013;131:e260–9. 7. Sun J, Shen Y, Li J, et al. Reconstruction of high maxillectomy defects with the fibula osteomyocutaneous flap in combination with titanium mesh or a zygomatic implant. Plast Reconstr Surg 2011;127:150–60. 8. Shipchandler TZ, Waters HH, Knott PD, et al. Orbitomaxillary reconstruction using the layered fibula osteocutaneous flap. Arch Facial Plast Surg 2012;14:110–5. 9. Mintz SM, Ettinger A, Schmakel T, et al. Contralateral coronoid process bone grafts for orbital floor reconstruction: an anatomic and clinical study. J Oral Maxillofac Surg 1998;56:1140–5.
Please cite this article in press as: Yu M, et al. A modified technique for reconstruction of a total maxillary defect. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2015.09.015