,B 1993 The Bnmh Assocmtion of Plasr~c Surpeonr

TIC SURGERY

New reconstruction for total maxillectomy defect with a fibula osteocutaneous free flap

B. Nakayama, H. Matsuura. Y. Hasegawa, 0. Ishihara, H. Hasegawa and S. Torii

Departwent of Head arld Neck Surgery, Aichi Cancer Center Hospital and Department @Plastic arld Reconstructive SurgerJy, NagoJw University- Hospital, Nago)>a, Japan

SUMMA R Y. The osteocutaneous fibula free transfer with three segments of bone and the peroneal flap was used to reconstruct a total unilateral maxillectomy defect. Satisfactory restoration of three-dimensional facial structure, orbital support, and prosthesis wearing was achieved.

The fibula osteocutaneous free flap is a very useful alternative for reconstructing a maxillectomy defect.

Microvascular free flap transfer has brought great advances in reconstruction after cancer ablation of the head and neck.

However reconstruction for total maxillectomy de- fects has been a challenging problem for plastic surgeons, requiring internal lining in addition to three- dimensional bone reconstruction.

The deltopectoral flap with the clavicle’ and scapu- lar free flap2s3 which have previously been reported, meet the above requirements, but both donor sites have had significant limitations. The former needs multi-stage operations and the length and number of bone segments is not adequate. The latter has a problem with the donor-site location. As the patient must be turned intraoperatively, tumour resection and flap elevation cannot be done simultaneously, thus adding to the operative time.

The free osteocutaneous fibula graft overcomes these shortcomings. The fibula flap was first used for mandibular reconstruction4 in the head and neck area.

We describe our experience using the osteo- cutaneous fibula flap for reconstruction of the maxilla. This procedure can provide the required three- dimensional bone structure as well as internal lining for the cheek and orbital floor, and allows the patient to wear a dental prosthesis.

Case report

A 53-year-old man with squamous cell carcinoma of the right maxillary sinus invading the anterior wall of the maxilla had the entire right maxilla, the zygomatic body, the hard palate, the pterygoid process, the orbital floor to the optic canal and the surrounding soft tissues, except the cheek skin, excised. The eyeball was preserved.

We designed a fibula flap which had three bone segments and two skin paddles (Fig. 1). The distal bone segment became the orbital floor, the middle segment the infraorbital margin, and the proximal segment the zygomatic arch (Fig. 2). A 2 cm gap between the middle bone segment and the distal segment was left to allow for mobility when recon- structing the orbital rim and floor. The distal skin paddle lined the inner surface of the cheek and the other paddle

covered the orbital floor. Each skin paddle was fed by a perforator derived from the peroneal vessels. marked with a Doppler flowmeter preoperatively. The flap pedicle was anastomosed to the superficial temporal vessels. Finally, the cheek skin was replaced. The donor site skin defect was closed with a skin graft.

The postoperative course was uneventful. The patient was fitted for his dental prosthesis, which completely separated the new nasal and oral cavity (Fig. 3). Speech was sat- isfactory with this. The prosthesis also supported the contour of the upper lip. His appearance was remarkably good (Fig. 4).

Discussion

In the case of a total maxillectomy defect extending to the body of the zygoma and the lateral orbital wall and floor, mid-facial deformity is extremely severe. Inferior-lateral eyeball displacement, or exposure of bone can occur. To resolve these problems, three dimensional bone reconstruction is essential and a skin flap transfer is necessary to cover the transferred bone and to prevent cicatricial contracture of the cheek skin. A skin graft cannot prevent cicatricial con- tracture of the cheek. The fibula osteocutaneous flap has a number of characteristics that make it an attractive alternative for maxillary reconstruction.

The periosteum of the fibula is supplied by the peroneal artery in the form of multiple circumferential branches around the shaft. Its blood supply is abun- dant and also a good length of bone is available permitting multiple osteotomies wherever necessary along the length of the transfer.“,’ The framework of the maxillary and zygomatic complex can be recon- structed using a combination of such bone segments in three dimensions (Fig. 5). We believe these bone segments help produce a normal appearance of the mid-face and prevent double vision.

A dental prosthesis can be fitted to separate the new nasal cavity from the oral one, restoring natural speech and giving better appearance. If a dental prosthesis cannot be worn, there is the possibility of osseo-

248 British Journal of Plastic Surgery

Fig. 1

arch

Fig. 2

Fig. 3 Fig. 4

Figure l-The flap was designed on the right lateral leg. Skin Flap: Flap 1 and 2. Flap Sizes: Flap 1-8 x 5 cm. Flap 2211 x 7 cm. Bone Segments: Bone 1. 2 and 3. Bone Length: Bone 1 and 2-5 cm. Bone 3-3 cm. Figure 2-Illustration of alignment for bone reconstruction. A: Bone 1. B: Bone 2. C: Bone 3. Figure %-The dental prosthesis fits well. Figure &Postoperative appearance with the dental prosthesis.

integrated implants into the opposite maxilla and the reconstructed orbital floor. Implantation into a trans- ferred fibula’ was reported recently. On removal of the prosthesis, the cavity is easy to clean and allows for detection of any local recurrence.

There are some problems that may be encountered with the osteocutaneous fibula flap transfer. When radiation or intra-arterial chemotherapy is used pre- operatively, the recipient vessels of the microvascular anastomotic site may be damaged. If the superficial temporal vessels are not adequate, a vein graft may be

necessary. Mild ectropion may occur due to facial palsy. In order to prevent this condition, we over- corrected the height of the lower eyelid with the transferred middle bone segment, which was set superior to the original level of the orbital rim. However, this was still not enough to prevent ectropion completely.

In the case of reconstructing a bilateral total maxillectomy defect, which is a much more com- plicated procedure, bone reconstruction is essential to create a site for osseointegrated implants in order to

Oste :ocutaneous Fibula Free Transfer for Total Maxillectomy Defect

Figm

Fig. 5

re %The 3-D image demonstrates the facial bone structure rebuilt by the vascularised fibula transfer.

accommodate a large prosthesis. The fibula osteo- cutaneous flap, which has a long and a strong cortical bone could be used, if necessary in combination with other flaps.

References

1. Konno A, Togawa K, Iizuka K. Primary reconstruction after total or extended total maxillectomy for maxillary cancer. Plast Reconstr Surg 1981; 67: 44&8.

2. Granick MS, Ramasastry SS, Newton ED. Solomon MP, Hanna DC, Kaltman S. Reconstruction of complex maxil- lectomy defects with the scapular-free flap. Head Neck Surg 1990: 12: 377-85.

3. 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.

4. Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg 1989; 84: 71-9.

5. Berggren A, Weiland AJ. Ostrup LT. Dorfman H. Micro- vascular free bone transfer with revascularization of the medullary and periosteal circulation or the periosteal circulation alone. J Bone Joint Surg 1982; 64A: 73-87.

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6. Wei FC, Chen HC. Chuang CC, Noordhoff MS. Fibular osteoseptocutaneous flap: anatomic study and clinical ap- plication Plast Reconstr Surg 1986; 78: 191-9.

7. Zlotolow MI. Osseointegrated implants and functional pros- thetic rehabilitation in microvascular fibula free flap recon- structed mandibles. Am J Surg 1992; 164: 677781.

The Authors

Bin Nakayama, MD, Staff Surgeon. Department of Head and Neck Surgery, Aichi Cancer Center Hospital, I- 1 Kanokoden. Chikusa- ku, Nagoya 464, Japan.

Hidehiro Matsuura, MD, Director, Department of Head and Neck Surgery, Aichi Cancer Center Hospital.

Yasuhisa Hasegawa, MD, Staff Surgeon, Department of Head and Neck Surgery, Aichi Cancer Center Hospital.

Osamu Ishihara, DDS, Resident. Department of Head and Neck Surgery. Aichi Cancer Center Hospital.

Hiroshi Hasegawa, DDS, Resident. Department of Head and Neck Surgery, Aichi Cancer Center Hospital.

Shuhei Torii, MD, Professor of Plastic and Reconstructive Surgery, Nagoya University Hospital, Nagoya, Japan.

Requests for reprints to Dr B. Nakayama.

Paper received 9 August 1993. Accepted 20 December 1993, after revision