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Iliac Crest Internal Oblique Osteomusculocutaneous Free Flap Reconstruction of the Postablative Palatomaxillary Defect
Eric M. Genden, MD;
Derrick Wallace, MD;
Daniel Buchbinder, DDS, MD;
Devin Okay, DDS;
Mark L. Urken, MD
Arch Otolaryngol Head Neck Surg. 2001;127:854-861.
ABSTRACT
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Background Traditionally, restoration of extensive palatomaxillary defects have
been achieved by prosthetic restoration, often with suboptimal functional
results. More recently, vascularized bone-containing free flaps have been
used for this purpose.
Objective To describe 6 patients who underwent palatomaxillary reconstruction
using the composite iliac crest–internal oblique osteomusculocutaneous
free flap.
Methods Six cases of iliac crest osteomusculocutaneous free flap reconstruction
of extensive postablative palatomaxillary defects were retrospectively reviewed
with clinical follow-up. We reviewed these cases for pathologic findings,
defect size, dental restoration, oral rehabilitation, and speech.
Results Pathologic findings included squamous cell carcinoma (n = 4), osteogenic
sarcoma (n = 1), and sinonasal hemangiopericytoma (n = 1). Mean follow-up
was 14.5 months (range, 10-25 months). Four patients underwent resection and
reconstruction primarily and 2 underwent reconstruction secondarily. Two patients
required reconstruction of a cutaneous defect using the iliac skin paddle.
The hard palate and lateral nasal wall were reconstructed in all 6 patients,
and the orbital rim and zygomatic body were reconstructed in 4. One patient
underwent reconstruction with an orbital prosthesis supported by osseointegrated
implants. There was 1 donor site complication and 1 recipient site infection,
which was treated successfully with oral antibiotics. Four patients were rehabilitated
with osseointegrated implants, and all 6 patients maintain an unrestricted
oral diet. All 6 patients have normal speech without velopharyngeal or oronasal
insufficiency.
Conclusion For extensive palatomaxillary defects, the iliac crest–internal
oblique osteomusculocutaneous free flap offers a reliable method of primary
reconstruction, allowing for complete orodental rehabilitation without the
use of a prosthetic obturator.
INTRODUCTION
THE 3-DIMENSIONAL architecture of the maxillary skeleton serves functional
and aesthetic roles. Functionally, the palate provides an occlusal surface
for the mandible during mastication and supports the globe, the nasal airway,
and the pharyngeal musculature essential to initiation of deglutition. Aesthetically,
the maxilla serves as a scaffold that is responsible for projection of the
nose, the cheek, and the anterior midface. As a result of this complex interaction
between form and function, defects in the palatomaxillary complex can lead
to devastating functional as well as cosmetic consequences. Prosthetic obturation,
local soft tissue flaps, free bone grafts, pedicled soft tissue flaps, and,
more recently, vascularized bone-containing free flaps (VBCFFs) have all played
a role in the evolution of palatomaxillary restoration.
In the past, tissue-borne prosthetic obturation was the only option
for orodental rehabilitation of postablative palatomaxillary defects. Although
prosthetic obturation has several advantages, including immediate dental restoration
without the need for further surgery, it is also associated with a variety
of shortcomings, most notably, instability and poor retention. A breakdown
in the oronasal prosthetic-tissue seal, characteristic of prosthetic instability,
might lead to oronasal insufficiency manifest as oronasal regurgitation and
compromised speech. These shortcomings are accentuated in edentulous patients,
irradiated patients, and those who have undergone extensive resections. In
an effort to achieve improved prosthetic stabilization and retention, the
surgeon and the prosthodontist have been encouraged to work together to develop
surgical and nonsurgical measures for achieving functional success.
Conventional surgical considerations for prosthetic rehabilitation have
focused on placement of a split-thickness skin graft within a palatomaxillary
defect and on formation of tissue undercuts to aid in the creation of fibrous
scar bands. When it is possible, surgical cuts should be made adjacent to
canine or molar teeth. Characteristically, these teeth have superior root
form and can be clasped by the obturator framework to enhance prosthetic stability.
Nonsurgical considerations have focused on enhancing the favorable biomechanical
forces and deemphasizing the counterproductive lever forces placed on the
obturator. Several publications1-5
have been devoted to techniques aimed at minimizing the destabilizing forces.
However, as the amount of residual palate diminishes, and the palatal defect
enlarges, the cantilever forces2 become overwhelming,
leading to prosthetic instability and a poor functional result.
Large defects adversely affect prosthetic retention in 2 ways. In such
defects, less dentition is available to clasp, and the diminished retentive
surface area results in greater cantilever forces over the defect. As a result,
the prosthesis tends to tip toward the defect. In smaller defects, the fulcrum
is positioned across 2 stable teeth, usually the canine and the third molar.
Each has characteristically strong root form and will support clasping. In
addition, the dentition oriented perpendicular to the fulcrum line can be
securely clasped. However, techniques to neutralize these counterproductive
forces become obsolete in extensive palatal defects because the retentive
mechanisms, such as dentition, palatal surface area, and bony undercuts, are
diminished. To stabilize prosthetic restoration of large palatal defects,
the surgeon must supplement bone to increase the area of the palatal arch.
This can be achieved by the addition of vascularized or nonvascularized bone
into which osseointegrated implants can be placed and a stable fulcrum line
reestablished.
In an effort to achieve successful implant stability through osseointegration,
a variety of techniques have been used to restore bone to the maxilla. Free
iliac bone,6 vascularized rib with latissimus
dorsi and periosteal flaps,7 and vascularized
cranial bone flaps6 were used in the 1980s.
Although these methods provided bone to the region, they were often insufficient
for implant placement, and the soft tissue was commonly too bulky to permit
retention of tissue-borne dentures.
Application of microvascular reconstruction to the head and neck has
greatly impacted the surgeon's approach to defect restoration and functional
rehabilitation. Superior functional results in mandibular reconstruction using
VBCFFs8-9 led to application of
the osteocutaneous scapular free flap,10 followed
by a variety of publications describing fibular-containing11-12
and iliac bone–containing13-14
free flaps for maxillary reconstruction. Vascularized bone-containing free
flaps offer several benefits for primary maxillary reconstruction over traditional
palatomaxillary obturation. This technique permits the single-staged transfer
of vascularized soft tissue and bone, which is capable of separating the oral
and nasal cavities as well as providing bone adequate for the placement of
osseointegrated implants. This technique eliminates the limitations of vascular
pedicle length associated with regional flap reconstructions. The mobility
of the skin paddle relative to the bone flap permits the restoration of complex
3-dimensional defects of the palatomaxillary complex that otherwise require
prosthetic restoration. Probably, the most significant advantage of free tissue
reconstruction is the ability to rehabilitate extensive palatomaxillary defects.
The biomechanical forces placed on a palatomaxillary obturator, particularly
in extensive defects in which the retentive surface is diminished, leads to
a cascade of destabilizing forces. Reconstruction with autologous bone and
soft tissue restores a permanent soft tissue seal, preserving oronasal competence,
restoring nasal lining, and providing a fixed segment of bone ideal for dental
rehabilitation.
We retrospectively reviewed 6 cases of palatomaxillary reconstruction
using the iliac crest VBCFF combined with the internal oblique muscle. In
this series, we evaluated our ability to achieve a separation between the
oral and nasal cavities, dental rehabilitation, intelligible speech, a patent
nasal airway, and satisfactory cosmetic restoration.
PATIENTS AND METHODS
The study population consists of 6 consecutive patients who presented
to The Mount Sinai Medical Center, a tertiary referral center for otolaryngology
in New York, NY, with either a malignancy of the palatomaxillary complex or
a palatomaxillary defect as a result of a previous ablative surgery. All 6
patients were offered the option of surgical or prosthetic reconstruction,
and all were explained the risks and benefits of each method of orodental
rehabilitation.
Each case was retrospectively reviewed for the patient's ability to
maintain intelligible speech, orodental rehabilitation, a patent nasal airway,
and a satisfactory cosmetic result. Oronasal separation and a patent nasal
airway were assessed by direct examination. Intelligible speech and oral rehabilitation
were assessed by a licensed speech pathologist.
After the maxillary resection, an iliac crest–internal oblique
VBCFF was harvested in the manner previously described by Urken et al.9 In all cases, the internal oblique muscle, based on
the ascending branch of the deep circumflex iliac artery and vein, was harvested
with the vascularized bone graft. Skin paddle overlying the iliac crest was
harvested in cases in which a cutaneous defect existed. After the free flap
was removed from the donor site, the iliac bone flap was contoured using a
reciprocating saw, which allowed for the fashioning of a piriform aperture
and orbital rim. Additional bone was used for restoration of the prominence
of the zygomatic body, which was performed by placing a free on-lay bone graft
onto the vascularized iliac bone. The bone graft was fixed with 2 titanium
lag screws. The internal oblique muscle was sutured to the cut edge of the
remaining palatal mucosa and then used to resurface the lateral nasal wall
(Figure 1). The distal edge of the
internal oblique was sutured to the superior aspect of the remaining nasal
and ethmoid bones by making drill holes in the bone. The internal oblique
served to resurface the palate and the lateral nasal wall, and in the case
of a previous orbital exenteration, the orbital cavity. Once the bone was
properly fashioned and the internal oblique was sutured to reline the neopalate
and the lateral nasal wall, the iliac bone graft was fixed to the remaining
maxilla, zygoma, and nasal bones using titanium miniplates. The vascular pedicle
was delivered through a subcutaneous tunnel made along the cheek. In all cases,
the facial artery and vein were used without a vein graft as recipient vessels.
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Figure 1. Right hemimaxillectomy with resection
of the orbital rim, the orbital floor, and the body of the zygoma.
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RESULTS
Six consecutive patients underwent palatomaxillary reconstruction using
the iliac crest–internal oblique VBCFF. Patients were followed up after
surgery for an average of 14.5 months (range, 10-25 months). The patient population
consisted of 5 men and 1 woman, ranging in age from 42 to 63 years (mean,
52 years). Four patients had squamous cell carcinoma of the maxillary sinus,
1 had an osteogenic sarcoma of the maxillary sinus, and 1 had a hemangiopericytoma
of the lateral nasal wall that had invaded the adjacent sinus (Table 1). Five patients underwent surgical therapy and primary reconstruction
at The Mount Sinai Medical Center. One patient underwent primary surgical
therapy and postoperative external beam radiation at another institution and
subsequently presented to The Mount Sinai Medical Center for secondary reconstruction.
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Palatomaxillary Reconstruction*
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Five of 6 defects involved at least half of the hard palate, the orbital
rim, and the body of the zygoma (Table 1). One patient underwent an infrastructure maxillectomy involving
half of the palate without ablation of the orbital rim or zygoma. Patient
4 presented for a secondary reconstruction after a previous resection involving
the hard palate, the orbital rim, and the body of the zygoma as well as an
orbital exenteration and resection of the skin of the cheek (case presentation
2). This patient had undergone concomitant radiation therapy and chemotherapy.
At the time of presentation, the patient had also developed osteoradionecrosis
of the medial margin of the hard palate. The cutaneous defect was reconstructed
using a combination of the iliac skin paddle and a split-thickness skin graft
placed over the distal tip of the internal oblique muscle. A second patient
sustained a cutaneous defect of the lateral cheek that was reconstructed using
only the iliac skin paddle.
All 6 patients underwent successful reconstruction with an iliac crest
VBCFF. There were no intraoperative complications. After surgery, patient
2, who had sustained a cutaneous defect of the lateral cheek, required leech
therapy early in the postoperative course for the successful treatment of
transient venous congestion that involved only the cutaneous portion of the
composite flap. One patient sustained a postoperative donor site abdominal
hernia that was repaired successfully secondarily. Two patients underwent
placement of Marlex mesh in the primary closure of the iliac crest donor site,
and all 6 patients were ambulatory by postoperative day 5.
Four patients underwent primary placement of osseointegrated dental
implants (Table 1). One patient
underwent secondary placement of osseointegrated implants, and 1 did not undergo
implant placement. Five of 6 patients rehabilitated with implant-borne dentures
are currently eating an unrestricted oral diet. One patient did not undergo
implant placement because of financial limitations; however, this patient
currently manages a soft diet. Patient 4 underwent placement of osseointegrated
implants in the native superior orbital rim and iliac bone graft for retention
of an orbital prosthesis.
All 6 patients have successful permanent separation of the oral and
nasal cavities and excellent speech quality, with no evidence of oronasal
escape or velopharyngeal insufficiency. Five of 6 patients are currently free
of disease. Patient 2 is presently being treated for locally recurrent disease.
CASE PRESENTATIONS
Case 1
The patient is a 59-year-old man with no significant past medical history
who presented with complaints of right maxillary sinus pressure and epiphora.
Computed tomography demonstrated a right maxillary sinus mass with invasion
into the right lateral nasal wall.
A right hemimaxillectomy and resection of the inferior orbital rim and
body of the zygoma was performed after a transnasal biopsy, which was interpreted
as fibrosarcoma (Figure 1). An iliac
crest–internal oblique osteomusculocutaneous free flap was harvested
without a skin paddle. The iliac crest was fashioned to recreate the nasal
piriform aperture and the inferior orbital rim (Figure 2 and Figure 3).
The vascularized iliac bone flap was fixed to the adjacent maxilla, the remaining
lateral nasal bones, and the remnant of the zygoma using titanium miniplates.
The internal oblique muscle was used to reline the palate and resurface the
ipsilateral lateral nasal wall. Free bone grafts were lag screwed to the anterior
surface of the iliac bone to restore the prominence of the body of the zygoma
(Figure 4). The iliac bone was oriented
with the crest along the inferior border to restore the new maxillary alveolus.
Osseointegrated dental implants were primarily placed into the neoridge of
the iliac bone. A subcutaneous tunnel was made along the cheek, and a separate
incision was made inferior to the ipsilateral mandibular ramus. The facial
artery and vein were isolated as recipient vessels for the microvascular anastomoses,
which were performed without vein grafts.
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Figure 2. Intraoperative photograph demonstrating
the iliac crest osteomusculocutaneous free flap rigidly fixed to the adjacent
maxilla, the lateral orbital rim, and the nasal bone.
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Figure 3. A, Iliac crest osteomusculocutaneous
free flap with the internal oblique muscle. The bone is fashioned to accommodate
the piriform aperture and the inferior orbital rim. B, Miniplates are used
for rigid fixation. The internal oblique muscle is drawn to the adjacent palatal
edge and sutured superiorly to recreate the lateral nasal wall. The vascular
pedicle is directed posterior and inferior through a subcutaneous tunnel in
the cheek.
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Figure 4. Computed tomographic scan demonstrating
free bone grafts secured to the vascularized iliac graft using titanium lag
screws to recreate the malar eminence.
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Subsequently, the neopalate mucosalized and the patient underwent the
fabrication and placement of an implant-borne denture (Figure 5). He currently tolerates an unrestricted oral diet. He
has achieved an acceptable cosmetic result with near normal midface contour
(Figure 6).
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Figure 5. A, Osseointegrated implant within
the vascularized iliac bone graft. The reconstructed neopalate has mucosalized
and regained a normal contour. B, Maxilla after dental restoration with an
implant-borne denture.
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Figure 6. Postoperative photograph 3 months
after surgery.
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Case 2
This patient is a 53-year-old man with a history of squamous cell carcinoma
of the right maxillary sinus. The patient underwent a right radical maxillectomy
with orbital exenteration and postoperative external beam radiation at another
hospital. Several failed attempts had been made to fabricate a prosthesis
for a combined orbital-palatal-cutaneous defect. The patient presented with
a cutaneous lateral cheek defect, chronic purulent drainage from the orbital
exenteration site, and osteoradionecrosis of the remaining palatal margin
(Figure 7).
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Figure 7. Preoperative photograph demonstrating
an orbital exenteration cavity and a cutaneous defect with direct communication
with the nasoantral cavity and oral cavity.
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Nonvital bone was excised from the residual palate and orbit, and an
iliac crest–internal oblique osteomusculocutaneous free flap was harvested
from the ipsilateral hip. The iliac bone was fashioned to reconstruct the
palatal alveolus, the inferior orbital rim, and the nasal piriform aperture
(Figure 8). Miniplates were used
to secure the iliac bone to the remaining palate. The internal oblique muscle
was used to reline the palate, the lateral nasal wall, and the orbital exenteration
site. A split-thickness skin graft was sutured to the underlying muscle in
the orbit, and the iliac skin paddle was used to restore the lateral cheek
defect.
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Figure 8. Rigid fixation of the vascularized
iliac bone graft. The bone graft has been contoured to accommodate the inferior
orbital rim and the lateral orbital rim. The internal oblique muscle has been
used to reline the neopalate, the lateral nasal wall, and the orbital cavity.
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Osseointegrated dental implants were primarily placed into the neoalveolus
and along the native superior orbital rim and the newly created inferior orbital
rim for future placement of an orbital prosthesis. This patient's postoperative
course was complicated by a minor wound infection, which was successfully
treated with oral antibiotics. Three months after surgery the implants were
uncovered and the patient was orally rehabilitated with an implant-borne dental
prosthesis and an orbital prosthesis (Figure
9). A 3-dimensional computed tomographic scan demonstrates the position
of the iliac crest relative to the native maxilla (Figure 10). Currently, the patient tolerates an unrestricted regular
diet.
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Figure 9. Postoperative photograph with
the orbital prosthesis in place. The cutaneous defect has been resurfaced
and the contour restored to the midface.
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Figure 10. Three-dimensional computed tomographic
scan demonstrating the bony portion of the maxillary reconstruction.
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COMMENT
Although prosthetic obturation or adjacent tissue transfer offers equivalent
functional results for smaller defects, debate still exists with regard to
the optimal method of reconstruction of more extensive defects.15-16
Some researchers have advocated the prosthetic restoration of all hemipalatectomy
defects,2, 5 whereas others believe
that such defects, in which the unfavorable biomechanical forces lead to an
unstable or nonretentive prosthesis, are overwhelming and are best rehabilitated
using a VBCFF.16-17
In the typical hemipalatectomy defect, the anterior abutment tooth is
either the central or lateral incisor. Retention is not uncommonly provided
by framework designs, where clasps to the incisor are provided in an effort
to distribute the load. Such clasps often splint 2 or more adjacent teeth.
However, despite these load-sharing designs, the inadequate root form of the
incisors make stabilization of the prosthesis difficult. Furthermore, the
hemipalatectomy defect shifts the fulcrum line to an unfavorable position,
leading to increased tipping forces. As a result, obturated patients often
have difficulty with mastication. The unfavorable forces are a particular
problem in the edentulous patient or in previously irradiated patients whose
teeth are absent or poorly suited to withstand the stresses of a clasp.
Soft tissue flaps are effective for relining the oral cavity and separating
the oral and nasal cavities. However, placement of a soft tissue flap obliterates
the maxillectomy cavity and eliminates the retentive properties of the mucocutaneous
scar band and the medial palatal shelf, thereby adversely affecting the prognosis
for a stable tissue-borne dental prosthesis. Furthermore, the absence of bone
will prevent the placement of osseointegrated implants. As a result, patients
are left without the opportunity for dental rehabilitation. Several attempts
to combine a fasciocutaneous flap18-20
or a temporalis flap21-22 with
free bone grafts have been used to address this problem. Choung et al19 advocated using a parietal osteofascial flap with
vascularized cranial bone grafts for maxillary reconstruction, and, more recently,
Cordeiro et al18 reported the wrapping of nonvascularized
bone grafts in a radial forearm free flap. Although cranial bone grafts can
be stacked and wrapped in vascularized tissue to increase the bone stock and
therefore accommodate osseointegrated implants, success with this technique
is limited because of poor bone graft vascularization and resultant bone resorption.
Furthermore, reconstruction of extensive defects is limited by the amount
of available donor bone.
The goal of palatomaxillary reconstruction is to achieve a level of
function and cosmesis similar to the predisease state. To achieve this goal,
2 broad aims must be accomplished: first, to shift the fulcrum line away from
the midline, thereby decreasing the tipping forces and improving the equal
distribution of masticatory forces, and, second, to address the vertical component
of the defect, namely, the orbital rim/floor and the body of the zygoma. Defects
of the zygomatic body are extremely difficult to rehabilitate using a prosthesis.
Reconstruction of the hemipalatectomy defect using VBCFF offers several unique
advantages to orodental rehabilitation that cannot be realized with other
forms of prosthetic or soft tissue reconstruction. Most important, free tissue
transfer allows for the bony restoration of the absent maxillary alveolus.
Placement of osseointegrated implants, and subsequent fitting of an implant-borne
denture, offers patients an excellent orodental rehabilitation without the
inconvenience or instability associated with prosthetic devices. Although
the pure hemipalatectomy defect (an infrastructure maxillectomy) can be adequately
managed with either prosthetic rehabilitation or bone-containing free flaps,
the unique advantage of a VBCFF is realized in defects that involve the vertical
component of the palatomaxillary complex, specifically, the orbital rim, the
body of the zygoma, and cutaneous defects.
Palatomaxillary defects involving the orbital rim and/or the zygomatic
body are particularly difficult to reconstruct prosthetically. Resection of
the orbital floor, the orbital rim, and/or the globe itself represents a functional
and aesthetic problem. The bony architecture of the orbit acts to support
the globe and provide midface form. Vertical orientation of the iliac bone–containing
free flap provides a bony rim that might serve as a shelf to secure an orbital
floor reconstruction, or in the case of an orbital exenteration, provide bone
for the placement of implants for a future prosthetic globe.
Extensive resections might involve the lateral orbital rim, the zygoma,
and, in some cases, the skin of the lateral cheek. Reconstruction of the zygoma
will often require the placement of free bone grafts, which can be secured
using lag screws placed directly into the iliac bone.
The scapula, fibula, and iliac crest bone–containing free flaps
have all been described for palatomaxillary reconstruction12-14;
however, we believe that each donor site has a well-defined role that is largely
determined by the nature of the defect. Each donor site offers a unique source
of bone and associated soft tissue and muscle. As a result, choosing the most
appropriate donor site requires a preoperative assessment of the anticipated
defect.
During the past 2 decades, the iliac crest became a popular donor site
for the reconstruction of complex composite oromandibular defects. The addition
of the internal oblique muscle based on the ascending branch of the deep circumflex
iliac artery and vein provides a unique tripartite design consisting of vascularized
bone and skin based on a single vascular pedicle. Initially described by Ramasastry
et al23 for extremity reconstruction, the iliac
crest–internal oblique VBCFF was subsequently modified by Urken et al9, 24-25 and used extensively
in oromandibular reconstruction. Subsequently, Brown14
described using the iliac crest–internal oblique composite flap as a
method of palatomaxillary reconstruction. Brown reported 3 cases using the
iliac crest–internal oblique muscle VBCFF to immediately reconstruct
a low central defect, a moderate lateral defect, and a high complex defect
with an orbital exenteration. Brown oriented the iliac bone horizontally in
2 defects and vertically in 1. One of the 3 patients was successfully rehabilitated
with osseointegrated dental implants, and 1 patient who had undergone an orbital
exenteration was scheduled for the future placement of osseointegrated implants
for an orbital prosthesis. None of the patients in the series by Brown required
reconstruction of a cutaneous defect.
In this series, we found that the iliac crest free flap offers an ideal
source of tissue for the reconstruction of subtotal defects of the palatomaxillary
complex. In particular, defects that involve a vertical component of the maxilla
can be appropriately managed by orienting the bone flap vertically. This allows
the internal oblique muscle to serve as a neopalate and lateral nasal wall.
The tremendous flexibility of the internal oblique muscle based on its axial
blood supply in 80% of cases provides the necessary mobility of the soft tissue
flap relative to the bone, which is critical for restoring the complex 3-dimensional
anatomy of the midface region. Similarly, the vertically oriented bone graft
can be fashioned to duplicate the piriform aperture and the orbital rim. Palatomaxillary
reconstruction of complex defects can be achieved with the fibular26 and the scapular10
donor sites; however, the ability to contour the hearty bone stock associated
with the iliac crest uniquely allows for the restoration of the horizontal
and vertical components of these defects. Although the scapular donor site
has been used in adult10 and pediatric27 populations for maxillary rehabilitation, the ability
to reconstruct the 3-dimensional buttress system of the maxilla is limited.
All 6 patients included in this review had a patent nasal airway. The
internal oblique muscle was used to reline the nasal airway, and, after several
weeks, the denervated muscle atrophied and mucosalized. Two patients sustained
mild epiphora as a result of lacrimal duct stenosis despite placement of a
lacrimal stent at the time of surgery. Secondary procedures were necessary
to correct this condition. The neopalate resulted from mucosal ingrowth over
the atrophied, denervated internal oblique muscle, resulting in an arched
hemipalate that simulated the appearance of the intact native palate. None
of the patients had oronasal escape or velopharyngeal insufficiency. As a
result, all 6 patients had normal speech and articulation.
Vertical orientation of the iliac bone graft serves to reconstruct the
orbital rim, which is often difficult to accomplish with scapula or fibula
VBCFFs. Titanium mesh or free cortical bone grafts can be fixed to the neo-orbital
rim to provide support for the globe. Four of 6 patients reviewed in this
series have normal globe position relative to the contralateral eye. One patient
had a previous orbital exenteration, and another patient did not require resection
of the orbital floor. All 6 patients achieved facial symmetry after reconstruction
of the zygoma with free bone grafts; however, 1 patient required secondary
revision surgery. Similarly, 2 patients required a revision dacrocystorhinostomy
for epiphora.
Five patients underwent placement of osseointegrated implants, followed
by implant-borne dental rehabilitation. Patients rehabilitated with implant-borne
dentures are maintaining an unrestricted diet and deny any problem with mastication
of solid food. The single patient who was not rehabilitated with implant-borne
dentures is maintaining a soft diet without difficulty. We found that patients
who undergo maxillary reconstruction and orodental rehabilitation have a significantly
improved functional prognosis relative to patients who undergo mandibular
reconstruction and orodental rehabilitation. This is likely because the tongue
is unaffected in palatomaxillary carcinoma. Therefore, the onus of restoring
the oral phase of deglutition and mastication is more easily achieved using
palatomaxillary resection or reconstruction.
Although this review demonstrates the high level of orodental rehabilitation
that can be achieved with iliac crest VBCFF reconstruction of the extensive
palatomaxillary defect, a prospective evaluation comparing prosthetic and
VBCFF reconstruction is necessary to elucidate the impact of this technique
on function, form, and quality of life. We are currently conducting a 2-arm
outcomes study in an effort to examine these factors.
CONCLUSIONS
The goals of palatomaxillary reconstruction are to support the orbital
contents, separate the oral cavity and nasal cavity, reconstruct the palatal
surface, reconstruct the lacrimal apparatus, provide facial symmetry, and
achieve dental rehabilitation. The iliac crest–internal oblique VBCFF
offers an excellent source of tissue to achieve these goals. It has become
evident through the course of this review that patients with extensive defects
of the palatomaxillary complex profoundly benefit from iliac crest VBCFF reconstruction.
The addition of vascularized bone to the midface allows for the equal distribution
of forces associated with chewing. The bone stock provides an excellent scaffold
for the placement of osseointegrated implants for the retention of dental
and orbital prostheses. Furthermore, cutaneous defects of the lateral cheek,
which are poorly managed by prosthetic reconstruction, are effectively treated
using the iliac skin paddle.
AUTHOR INFORMATION
Accepted for publication January 18, 2001.
Presented at the annual meeting of the American Head and Neck Society,
Fifth International Conference on Head and Neck Cancer, San Francisco, Calif,
August 1, 2000.
Corresponding author: Eric M. Genden, MD, Department of Otolaryngology–Head
and Neck Surgery, Box 1189, The Mount Sinai School of Medicine, One Gustave
L. Levy Place, New York, NY 10029.
From the Departments of Otolaryngology–Head and Neck Surgery
(Drs Genden, Wallace, and Urken) and Oral Maxillofacial Surgery and Dentistry
(Drs Buchbinder and Okay), The Mount Sinai Medical Center, New York, NY.
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