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Reconstruction of maxillary defects with serratus anterior muscle and angle of the scapula
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British Journal of Oral and Maxillofacial Surgery 49 (2011) 53–57
Reconstruction of maxillary defects with serratus anterior muscle and angle of the scapula V. Ilankovan ∗ , P. Ramchandani, S. Walji, R. Anand Poole Hospital, Longfleet Road, Poole, Dorset BH15 2JB, UK Accepted 28 October 2009 Available online 26 March 2010
Abstract Large maxillary defects ideally require reconstruction with a free flap. Varied classifications have been reported to describe maxillary/orbital defects. We describe our experience of free flaps in large maxillary defects using composite tissue of serratus anterior muscle and the angle of the scapula. Eleven patients (6 men and 5 women, age range 42–69 years) were studied retrospectively and the outcome was recorded. We conclude that the composite flap is versatile enough to reconstruct maxillary defects of various sizes. © 2010 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons. Keywords: Maxillectomy; Scapula flap; Composite tissue
Introduction Different techniques have been described for reconstruction and rehabilitation of maxillary/orbital defects,1 including obturators, alloplastic implants, pedicled flaps, free flaps, or a combination. As in any protocol for treatment of the head and neck, it is impossible to compare different methods and come to an agreed algorithm. The maxillary/orbital defects are reconstructed surgically with pedicled and free flaps, and it is increasingly accepted among head and neck reconstructive surgeons that large maxillary/orbital defects are better repaired with a free flap than any other way.2 The argument that the maxillary defect should be kept patent for detection of recurrence lost its battle a long time ago.3 Obturators are therefore reserved for patients who are not able to withstand major surgery, or where reconstruction has failed. There are published classifications that describe the degree of maxillary/orbital defects.1,3–5 The proponents for classifi∗
Corresponding author. Tel.: +44 01202 442576; fax: +44 01202 448005. E-mail addresses: [email protected], [email protected] (V. Ilankovan).
cation argue that the defect should be described in a unified fashion so that the outcome of different units can be compared in a rational way. Classifications have also tried to guide the type of tissue required for the repair, but so far nobody has put the benefit of this classification to the test for knowledge, information, and comparison of outcome. The various maxillectomy defects result in loss of hard and soft palate and alveolar bone, the buttress that gives stability to the midface, maxillary sinus, lateral wall of the nose, orbital floor, and sometimes the orbital contents and overlying skin. The ideal requirement for reconstruction of these defects should consist of bone of suitable dimensions; enough soft tissue bulk; and mobility between the tissues of the composite flap. It should also be able to provide stability to the midface and a denture-bearing surface. Maxillectomy defects create a three-dimensional aesthetic problem, mainly the loss of anteroposterior, vertical, and transverse dimensions. The functional disabilities as a result of the resection are creation of an oronasal fistula, velopharyngeal incompetence, and difficulty in nasal breathing. We think that the defects should be planned before resection, assessed after resection, and a reconstructive technique should be chosen that restores the three-dimensional aesthetics and lost functions. A donor site that filled all these
0266-4356/$ – see front matter © 2010 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
doi:10.1016/j.bjoms.2009.10.034
54
V. Ilankovan et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) 53–57
Fig. 1. Patient positioned laterally with the composite tissue harvested from the right scapula marked.
Fig. 2. The anterior border of the latissimus dorsi muscle and branch of serratus anterior identified and marked with an arrow.
requirements should be considered as the ideal reconstructive tool. We use a serratus anterior muscle with an angle of the scapula as a composite flap to reconstruct various large maxillary defects, and here report our experience with aesthetics and function.
A skin incision is made from the midpoint of the axilla to the midpoint between the anterior superior iliac spine and the posterior superior iliac spine. Sharp dissection allows the anterior border of the latissimus dorsi muscle to be identified (Fig. 2). The areolar fatty tissue is dissected and branches to the serratus anterior muscles are identified (Fig. 3). The required volume of serratus anterior muscle is harvested. The thoracodorsal system is identified by proximal dissection from the branches to the serratus anterior. The angular artery is identified and is followed to the angle of the scapula. Dissection deep to the latissimus dorsi releases the medial supraspinatus attachments to the scapula to mobilise the angle of the scapula. The desired shape of the scapular bone is cut with a combination of saw and drill. Once the segment is completely mobilised, the thoracodorsal system is traced to the axilla. The harvested flap will have a serratus anterior section with its blood supply, angle of the scapula with its blood supply, and a long thoracodorsal pedicle (Figs. 4 and 5). If a portion of the latissimus dorsi and the overlying skin is required, it is mobilised as a separate pedicle of the composite flap. The mean length of the pedicle was 12 cm (range 8–14 cms). The facial artery and facial vein were the main recipient vessels. The flap was
Patients and methods Only those patients who required reconstruction of maxillary defects with free flaps were included in the study. Eleven patients, 6 men and 5 women, age range 42–69 years, were studied retrospectively. Their diagnoses were squamous cell carcinoma (n = 5), adenocarcinoma (n = 3), and adenoid cystic carcinoma, angiosarcoma, and ameloblastoma (n = 1 each), and all the patients required composite free tissue transfer. Clinical and personal details are shown in Table 1. Surgical technique The patient is placed in the lateral decubitus position with the arm extended and rotated forwards (Fig. 1). Table 1 Details of patients. Case
Age (years)
Diagnosis
Classification4
Outcome
1 2 3 4 5 6 7 8 9 10 11
61 55 61 54 64 63 51 62 48 44 58
SCC SCC SCC SCC AS ACa ACa ACa AcCa Amelo SCC
2b 2b 2b 3b 3b 3a 4a 2b 2b 2b 2b
Conventional denture Conventional denture Standard implant Standard implant Refused rehabilitation Refused rehabilitation Conventional denture Refused rehabilitation Refused rehabilitation Refused rehabilitation Refused rehabilitation
SCC: squamous cell carcinoma; AS: angiosarcoma; Aca: adenocarcinoma; AcCa: adenoidcystic carcinoma; and Amelo: ameloblastoma.
Fig. 3. Closer view of the branch to the serratus anterior muscle, after the latissimus dorsi muscle had been retracted.
V. Ilankovan et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) 53–57
55
Fig. 4. Line drawing showing the composite flap in the thoracodorsal system.
usually inset with one plate 1.5 mm thick and 6 mm screws at the contralateral premaxilla. If further stabilisation was required, an identical plate was used at the malar bone. We are able to achieve excellent postoperative facial and intraoral appearances (Figs. 6 and 7).
Results All the flaps were successful. Two patients died from metastatic disease 12 and 18 months postoperatively. Five patients were given prosthetic rehabilitation, two of whom were provided with implant-retained dentures, and three with conventional dentures. Six patients refused any form of prosthetic rehabilitation. None of the successful patients had aspiration seen on videofluoroscopy, which was done 10 days postoperatively. All patients had normal speech. The mean duration of operation was 9 h 43 min (range from 6 h to 12 h 30 min). The donor site scars healed well with no cosmetic asymmetry. No patients complained of any difficulty in shoulder function.
Fig. 6. Appearance of the face 6 weeks postoperatively (reproduced with the patient’s permission).
Fig. 7. Intraoral appearance 6 weeks postoperatively.
Discussion
Fig. 5. Harvested flap with serratus anterior muscle and angle of the scapula.
The average anterior height of an adult maxilla is 4 cm. The hemiarch is a maximum of 6 cm, and the anteroposterior width from the incisor edge to the midline of the hard palate is 5 cm. The average volume of the maxillary sinus is 15 ml. The volume of bony defect of a hemimaxilla varies from 4 to 6 cm3 . The required volume to reconstruct a large hemimaxillary defect is therefore about 20 to 25 ml. The missing
56
V. Ilankovan et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) 53–57
components after the tumour has been resected are a combination of hard and soft tissue, namely the anterior wall of the maxilla, the hard palate, and the alveolar bone, with soft tissue required to fill and line the defect. Sometimes the facial skin may need to be reconstructed simultaneously. The roof of the maxillary sinuses, floor of the orbit, and further extension into the orbital defect would add another 5 to 6 ml of volume requirement. When one is faced with such a complex defect, therefore, the role of anatomical classification in selecting a suitable graft is questionable. It is apparent from the published reports that a classification to describe a complex defect itself would be complicated; they show that it is impossible to provide an algorithm for free-tissue-based reconstruction of maxillary defects. The free flaps used are rectus abdominis,6,7 radial forearm free flap,8–11 a composite flap based on the deep circumflex iliac artery and vein (DCIA),12–14 a composite fibular free flap,15–21 and a composite scapular flap.22–24 The requirements of the free tissue to fill these defects are: adequate dimension of bone to maintain the anteroposterior, vertical, and transverse dimensions, and muscle to line and fill the defects. If there is dead space it could compromise the success of the flap. A radial forearm free flap, either fasciocutaneous or composite, will fall short as a suitable flap. A soft tissue flap on its own, for example the rectus abdominis, will fall short in providing stability to the palatal component of the defect, as it does not provide height, though on its own it can fill the defect in volume. A fibular free flap will provide good bony dimension, sometimes more than required, but has a short pedicle and does not have enough muscular volume to fill a large dead space. The DCIA with internal oblique, and scapula with serratus anterior flaps, have many similar properties. The volume of the internal oblique muscle may be difficult to adjust because of the position of the vascular access. The hip provides an excellent source of bone, but the lack of mobility between it and bone in a composite flap is restricting. In addition, the length of the pedicle is shorter. The benefit here is that a two-team approach is feasible. With the scapular flap, the angle can provide adequate palatal support as well as the anterior projection. The volume of serratus anterior harvested can be varied to match the soft tissue defect. The versatility of this flap is in its mobility between bone and soft tissue components and the length of the pedicle. The main disadvantage, however, is that the patient needs to be turned, which precludes a simultaneous two-team approach. In the reconstructive phase the requirement for skin in the palatal aspect merits discussion. A muscle flap epithelialises and contracts, and in our opinion gives better stability and is a superior denture-bearing surface than the flabby skin component. This is where the radial forearm and fibular flaps fall short in their suitability as donor flaps. In a rectus flap one does not have to use the perforator skin component to line the palatal surface. Preoperative quantifying of the maxillary defect with the help of three-dimensional evaluation would aid in planning
the harvesting of the required bone and muscle. The biting force in patients who have been rehabilitated is nothing like that of patients who have not been operated on.25 An implant-retained prosthesis is therefore not always required for rehabilitation. A mucosal retained denture should provide adequate masticatory support, articulation, and aesthetics. In summary, there is no satisfactory published algorithm for reconstructing maxillary defects. The reconstructive head and neck surgeon is familiar with many techniques and, therefore, we think that classification of the defects has limited clinical use. Just being able to quantify the required volume preoperatively is in itself valuable in deciding which method of reconstruction to use. Skin on the palatal surface is not a good denture-bearing surface. Epithelialisation of muscle gives a better functional and restorative outcome. The biting force in the reconstructed palate/maxilla is not equal to that in the unoperated sites, and hence an implant-retained prosthesis is not always a requirement. If implants are desired, the required bony thickness of the angle of the scapula and lateral border range from 6 to 10 mm, which is sufficient to allow their placement. The mobility between the different tissues relative to each other in a composite reconstruction is desirable. Anastomosis in the neck close to the internal jugular vein provides the best chance of success and so a longer pedicle is preferable for composite flaps. The simultaneous two-team approach is ideal if possible. Extensive manipulation and increased unpredictable soft tissue volume can compromise tissue perfusion. In our experience the angle of the scapula with varied bony dimensions harvested with serratus anterior of different volumes, provides the ideal tissue for the reconstruction of orbital maxillary defects, giving excellent aesthetics and a functional denture base.
References 1. Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 2000;105:2331–46. 2. Rogers SN, Lowe D, McNally D, Brown JS, Vaughan ED. Health-related quality of life after maxillectomy: a comparison between prosthetic obturation and free flap. J Oral Maxillofac Surg 2003;61:174–81. 3. Sarukawa S, Sakuraba M, Asano T, et al. Immediate maxillary reconstruction after malignant tumour extirpation. Eur J Surg Oncol 2007;33:518–23. 4. Brown JS, Rogers SN, McNally DN, Boyle M. A modified classification for maxillectomy defect. Head Neck 2000;22:17–26. 5. Spiro RH, Strong EW, Shah JP. Maxillectomy and its classification. Head Neck 1997;19:309–14. 6. Olsen KD, Meland NB, Ebersold MJ, Bartley CP, Garrity JA. Extensive defects of the sino-orbital region: results with microvascular reconstruction. Arch Otolaryngol Head Neck Surg 1992;118:828–33. 7. Pribaz JJ, Morris DJ, Mulliken JB. Three dimensional folded free flap reconstruction of complex facial defects using intraoperative monitoring. Plast Reconstr Surg 1994;93:285–93. 8. Cordeiro PG, Bacilious N, Schantz S, Spiro R. The radial forearm osteocutaneous “sandwich” free flap for reconstruction of the
V. Ilankovan et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) 53–57
9.
10.
11.
12.
13. 14. 15.
16.
17.
bilateral subtotal maxillectomy defect. Ann Plast Surg 1998;40: 397–402. Duffy Jr FJ, Gan BS, Israeli D, Tantillo MB, Yaremchuk MJ. Use of bilateral folded radial forearm flaps for reconstruction of a midface gunshot wound. J Reconstr Microsurg 1998;14:89–96. Hatoko M, Harashina H, Inouc T, Tanaka I, Imai K. Reconstruction of the palate with radial forearm flap: a report of three cases. Br J Plast Surg 1990;43:350–4. MacLeod A, Morrison W, McCann JH, Thistlethwaite S, Vanderkolk CA, Ryan AD. The free radial forearm flap with and without bone for closure of large palatal fistulae. Br J Plast Surg 1987;40:391–5. Brown JS. Deep circumflex iliac artery free flap with internal oblique muscle as a new method of immediate reconstruction of maxillectomy defect. Head Neck 1996;18:412–21. Coleman III JJ. Osseous reconstruction of the midface and orbits. Clin Plast Surg 1994;21:113–24. Schusterman MA, Reece GP, Miller MJ. Osseous free flaps for orbit and midface reconstruction. Am J Surg 1993;166:341–5. Anthony JP, Foster RD, Sharma AB, Kearns GJ, Hoffman WV, Pogrel MA. Reconstruction of a complex midfacial defect with a folded fibula free flap and osseointegrated implants. Ann Plast Surg 1996;37:204–10. Freije JE, Campbell B, Yousif NJ, Matloub HS. Reconstruction after infrastructure maxillectomy using dual free flaps. Laryngoscope 1997;107:694–7. Nakayama B, Matsuura H, Hasegawa H, Ishihara O, Matega I, Torii S. Functional reconstruction of a bilateral maxillectomy defect using a
18.
19.
20.
21. 22.
23.
24.
25.
57
fibula osteocutaneous flap with osseointegrated implants. Plast Reconstr Surg 1995;102:141–6. Nakayama B, Matsuura H, Hasegawa V, Ishihara O, Hasegawa H, Torii S. New reconstruction for total maxillectomy with a fibula osteocutaneous free flap. Br J Plast Surg 1994;47:247–9. Reece GP, Lemon JC, Jacob RF, Taylor TD, Weber RS, Garden AS. Total midface reconstruction after radical tumour resection: a case report and overview of the problem. Ann Plast Surg 1996;36:551–7. Sadove RC, Powell LA. Simultaneous maxillary and mandibular reconstruction with one free osteocutaneous flap. Plast Reconstr Surg 1993;92:141–6. Yim KK, Wei FC. Fibula osteoseptocutaneous free flap for mandible reconstruction. Microsurgery 1994;15:353–7. Clark JR, Vesely M, Gilbert R. Scapular angle osteomyogenous flap in post maxillectomy reconstruction: defect, reconstruction, shoulder function and harvest technique. Head Neck 2008;30: 10–20. Granick MS, Ramassary SS, Newton ED, Solomon MP, Hanna DC, Kaltman S. Reconstruction of complex maxillectomy defects with the scapular-free flap. Head Neck 1990;12:377–85. Swartz WM, Banis JC, Newton ED, Ramasastry SS, Jones NF, Acland R. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 1986;77:530–45. Curtis DA, Plesh O, Miller AJ, et al. A comparison of masticatory function in patients with or without reconstruction of the mandible. Head Neck 1997;19:287–96.
British Journal of Oral and Maxillofacial Surgery 49 (2011) 53–57
Reconstruction of maxillary defects with serratus anterior muscle and angle of the scapula V. Ilankovan ∗ , P. Ramchandani, S. Walji, R. Anand Poole Hospital, Longfleet Road, Poole, Dorset BH15 2JB, UK Accepted 28 October 2009 Available online 26 March 2010
Abstract Large maxillary defects ideally require reconstruction with a free flap. Varied classifications have been reported to describe maxillary/orbital defects. We describe our experience of free flaps in large maxillary defects using composite tissue of serratus anterior muscle and the angle of the scapula. Eleven patients (6 men and 5 women, age range 42–69 years) were studied retrospectively and the outcome was recorded. We conclude that the composite flap is versatile enough to reconstruct maxillary defects of various sizes. © 2010 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons. Keywords: Maxillectomy; Scapula flap; Composite tissue
Introduction Different techniques have been described for reconstruction and rehabilitation of maxillary/orbital defects,1 including obturators, alloplastic implants, pedicled flaps, free flaps, or a combination. As in any protocol for treatment of the head and neck, it is impossible to compare different methods and come to an agreed algorithm. The maxillary/orbital defects are reconstructed surgically with pedicled and free flaps, and it is increasingly accepted among head and neck reconstructive surgeons that large maxillary/orbital defects are better repaired with a free flap than any other way.2 The argument that the maxillary defect should be kept patent for detection of recurrence lost its battle a long time ago.3 Obturators are therefore reserved for patients who are not able to withstand major surgery, or where reconstruction has failed. There are published classifications that describe the degree of maxillary/orbital defects.1,3–5 The proponents for classifi∗
Corresponding author. Tel.: +44 01202 442576; fax: +44 01202 448005. E-mail addresses: [email protected], [email protected] (V. Ilankovan).
cation argue that the defect should be described in a unified fashion so that the outcome of different units can be compared in a rational way. Classifications have also tried to guide the type of tissue required for the repair, but so far nobody has put the benefit of this classification to the test for knowledge, information, and comparison of outcome. The various maxillectomy defects result in loss of hard and soft palate and alveolar bone, the buttress that gives stability to the midface, maxillary sinus, lateral wall of the nose, orbital floor, and sometimes the orbital contents and overlying skin. The ideal requirement for reconstruction of these defects should consist of bone of suitable dimensions; enough soft tissue bulk; and mobility between the tissues of the composite flap. It should also be able to provide stability to the midface and a denture-bearing surface. Maxillectomy defects create a three-dimensional aesthetic problem, mainly the loss of anteroposterior, vertical, and transverse dimensions. The functional disabilities as a result of the resection are creation of an oronasal fistula, velopharyngeal incompetence, and difficulty in nasal breathing. We think that the defects should be planned before resection, assessed after resection, and a reconstructive technique should be chosen that restores the three-dimensional aesthetics and lost functions. A donor site that filled all these
0266-4356/$ – see front matter © 2010 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
doi:10.1016/j.bjoms.2009.10.034
54
V. Ilankovan et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) 53–57
Fig. 1. Patient positioned laterally with the composite tissue harvested from the right scapula marked.
Fig. 2. The anterior border of the latissimus dorsi muscle and branch of serratus anterior identified and marked with an arrow.
requirements should be considered as the ideal reconstructive tool. We use a serratus anterior muscle with an angle of the scapula as a composite flap to reconstruct various large maxillary defects, and here report our experience with aesthetics and function.
A skin incision is made from the midpoint of the axilla to the midpoint between the anterior superior iliac spine and the posterior superior iliac spine. Sharp dissection allows the anterior border of the latissimus dorsi muscle to be identified (Fig. 2). The areolar fatty tissue is dissected and branches to the serratus anterior muscles are identified (Fig. 3). The required volume of serratus anterior muscle is harvested. The thoracodorsal system is identified by proximal dissection from the branches to the serratus anterior. The angular artery is identified and is followed to the angle of the scapula. Dissection deep to the latissimus dorsi releases the medial supraspinatus attachments to the scapula to mobilise the angle of the scapula. The desired shape of the scapular bone is cut with a combination of saw and drill. Once the segment is completely mobilised, the thoracodorsal system is traced to the axilla. The harvested flap will have a serratus anterior section with its blood supply, angle of the scapula with its blood supply, and a long thoracodorsal pedicle (Figs. 4 and 5). If a portion of the latissimus dorsi and the overlying skin is required, it is mobilised as a separate pedicle of the composite flap. The mean length of the pedicle was 12 cm (range 8–14 cms). The facial artery and facial vein were the main recipient vessels. The flap was
Patients and methods Only those patients who required reconstruction of maxillary defects with free flaps were included in the study. Eleven patients, 6 men and 5 women, age range 42–69 years, were studied retrospectively. Their diagnoses were squamous cell carcinoma (n = 5), adenocarcinoma (n = 3), and adenoid cystic carcinoma, angiosarcoma, and ameloblastoma (n = 1 each), and all the patients required composite free tissue transfer. Clinical and personal details are shown in Table 1. Surgical technique The patient is placed in the lateral decubitus position with the arm extended and rotated forwards (Fig. 1). Table 1 Details of patients. Case
Age (years)
Diagnosis
Classification4
Outcome
1 2 3 4 5 6 7 8 9 10 11
61 55 61 54 64 63 51 62 48 44 58
SCC SCC SCC SCC AS ACa ACa ACa AcCa Amelo SCC
2b 2b 2b 3b 3b 3a 4a 2b 2b 2b 2b
Conventional denture Conventional denture Standard implant Standard implant Refused rehabilitation Refused rehabilitation Conventional denture Refused rehabilitation Refused rehabilitation Refused rehabilitation Refused rehabilitation
SCC: squamous cell carcinoma; AS: angiosarcoma; Aca: adenocarcinoma; AcCa: adenoidcystic carcinoma; and Amelo: ameloblastoma.
Fig. 3. Closer view of the branch to the serratus anterior muscle, after the latissimus dorsi muscle had been retracted.
V. Ilankovan et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) 53–57
55
Fig. 4. Line drawing showing the composite flap in the thoracodorsal system.
usually inset with one plate 1.5 mm thick and 6 mm screws at the contralateral premaxilla. If further stabilisation was required, an identical plate was used at the malar bone. We are able to achieve excellent postoperative facial and intraoral appearances (Figs. 6 and 7).
Results All the flaps were successful. Two patients died from metastatic disease 12 and 18 months postoperatively. Five patients were given prosthetic rehabilitation, two of whom were provided with implant-retained dentures, and three with conventional dentures. Six patients refused any form of prosthetic rehabilitation. None of the successful patients had aspiration seen on videofluoroscopy, which was done 10 days postoperatively. All patients had normal speech. The mean duration of operation was 9 h 43 min (range from 6 h to 12 h 30 min). The donor site scars healed well with no cosmetic asymmetry. No patients complained of any difficulty in shoulder function.
Fig. 6. Appearance of the face 6 weeks postoperatively (reproduced with the patient’s permission).
Fig. 7. Intraoral appearance 6 weeks postoperatively.
Discussion
Fig. 5. Harvested flap with serratus anterior muscle and angle of the scapula.
The average anterior height of an adult maxilla is 4 cm. The hemiarch is a maximum of 6 cm, and the anteroposterior width from the incisor edge to the midline of the hard palate is 5 cm. The average volume of the maxillary sinus is 15 ml. The volume of bony defect of a hemimaxilla varies from 4 to 6 cm3 . The required volume to reconstruct a large hemimaxillary defect is therefore about 20 to 25 ml. The missing
56
V. Ilankovan et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) 53–57
components after the tumour has been resected are a combination of hard and soft tissue, namely the anterior wall of the maxilla, the hard palate, and the alveolar bone, with soft tissue required to fill and line the defect. Sometimes the facial skin may need to be reconstructed simultaneously. The roof of the maxillary sinuses, floor of the orbit, and further extension into the orbital defect would add another 5 to 6 ml of volume requirement. When one is faced with such a complex defect, therefore, the role of anatomical classification in selecting a suitable graft is questionable. It is apparent from the published reports that a classification to describe a complex defect itself would be complicated; they show that it is impossible to provide an algorithm for free-tissue-based reconstruction of maxillary defects. The free flaps used are rectus abdominis,6,7 radial forearm free flap,8–11 a composite flap based on the deep circumflex iliac artery and vein (DCIA),12–14 a composite fibular free flap,15–21 and a composite scapular flap.22–24 The requirements of the free tissue to fill these defects are: adequate dimension of bone to maintain the anteroposterior, vertical, and transverse dimensions, and muscle to line and fill the defects. If there is dead space it could compromise the success of the flap. A radial forearm free flap, either fasciocutaneous or composite, will fall short as a suitable flap. A soft tissue flap on its own, for example the rectus abdominis, will fall short in providing stability to the palatal component of the defect, as it does not provide height, though on its own it can fill the defect in volume. A fibular free flap will provide good bony dimension, sometimes more than required, but has a short pedicle and does not have enough muscular volume to fill a large dead space. The DCIA with internal oblique, and scapula with serratus anterior flaps, have many similar properties. The volume of the internal oblique muscle may be difficult to adjust because of the position of the vascular access. The hip provides an excellent source of bone, but the lack of mobility between it and bone in a composite flap is restricting. In addition, the length of the pedicle is shorter. The benefit here is that a two-team approach is feasible. With the scapular flap, the angle can provide adequate palatal support as well as the anterior projection. The volume of serratus anterior harvested can be varied to match the soft tissue defect. The versatility of this flap is in its mobility between bone and soft tissue components and the length of the pedicle. The main disadvantage, however, is that the patient needs to be turned, which precludes a simultaneous two-team approach. In the reconstructive phase the requirement for skin in the palatal aspect merits discussion. A muscle flap epithelialises and contracts, and in our opinion gives better stability and is a superior denture-bearing surface than the flabby skin component. This is where the radial forearm and fibular flaps fall short in their suitability as donor flaps. In a rectus flap one does not have to use the perforator skin component to line the palatal surface. Preoperative quantifying of the maxillary defect with the help of three-dimensional evaluation would aid in planning
the harvesting of the required bone and muscle. The biting force in patients who have been rehabilitated is nothing like that of patients who have not been operated on.25 An implant-retained prosthesis is therefore not always required for rehabilitation. A mucosal retained denture should provide adequate masticatory support, articulation, and aesthetics. In summary, there is no satisfactory published algorithm for reconstructing maxillary defects. The reconstructive head and neck surgeon is familiar with many techniques and, therefore, we think that classification of the defects has limited clinical use. Just being able to quantify the required volume preoperatively is in itself valuable in deciding which method of reconstruction to use. Skin on the palatal surface is not a good denture-bearing surface. Epithelialisation of muscle gives a better functional and restorative outcome. The biting force in the reconstructed palate/maxilla is not equal to that in the unoperated sites, and hence an implant-retained prosthesis is not always a requirement. If implants are desired, the required bony thickness of the angle of the scapula and lateral border range from 6 to 10 mm, which is sufficient to allow their placement. The mobility between the different tissues relative to each other in a composite reconstruction is desirable. Anastomosis in the neck close to the internal jugular vein provides the best chance of success and so a longer pedicle is preferable for composite flaps. The simultaneous two-team approach is ideal if possible. Extensive manipulation and increased unpredictable soft tissue volume can compromise tissue perfusion. In our experience the angle of the scapula with varied bony dimensions harvested with serratus anterior of different volumes, provides the ideal tissue for the reconstruction of orbital maxillary defects, giving excellent aesthetics and a functional denture base.
References 1. Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 2000;105:2331–46. 2. Rogers SN, Lowe D, McNally D, Brown JS, Vaughan ED. Health-related quality of life after maxillectomy: a comparison between prosthetic obturation and free flap. J Oral Maxillofac Surg 2003;61:174–81. 3. Sarukawa S, Sakuraba M, Asano T, et al. Immediate maxillary reconstruction after malignant tumour extirpation. Eur J Surg Oncol 2007;33:518–23. 4. Brown JS, Rogers SN, McNally DN, Boyle M. A modified classification for maxillectomy defect. Head Neck 2000;22:17–26. 5. Spiro RH, Strong EW, Shah JP. Maxillectomy and its classification. Head Neck 1997;19:309–14. 6. Olsen KD, Meland NB, Ebersold MJ, Bartley CP, Garrity JA. Extensive defects of the sino-orbital region: results with microvascular reconstruction. Arch Otolaryngol Head Neck Surg 1992;118:828–33. 7. Pribaz JJ, Morris DJ, Mulliken JB. Three dimensional folded free flap reconstruction of complex facial defects using intraoperative monitoring. Plast Reconstr Surg 1994;93:285–93. 8. Cordeiro PG, Bacilious N, Schantz S, Spiro R. The radial forearm osteocutaneous “sandwich” free flap for reconstruction of the
V. Ilankovan et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) 53–57
9.
10.
11.
12.
13. 14. 15.
16.
17.
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