Free Rectus Abdominis Myocutaneous Flap With Anterior Rectus Sheath to Provide the Orbital Support in Globe-Sparing Total Maxillectomy

Abstract

Reconstruction after total maxillectomy with preservation of the orbital contents is technically more challenging than when the maxillectomy is combined with orbital exenteration. It results in severe complications if the orbital content is not supported. We would like to introduce a new technique using free rectus abdominis myocutaneous (RAM) flap with anterior rectus sheath to support the orbital content in a patient who underwent globe-sparing total maxillectomy. The large resection of the recurrent maxillary peripheral nerve sheath tumor was performed in a 34-year-old male patient. Right free RAM flap was harvested simultaneously with the tumor resection. The anterior sheath of upper portion of the rectus muscle was also incorporated into the flap. The free edge of the upper anterior rectus sheath was anchored to three different points: Lateral rim, medial rim and the posterior remnant of the bony orbital floor with non-absorbable suture. Consequently, orbital support was achieved with well-vascularized, thin, strong fascia with smooth surface. Right facial artery and vein were chosen as recipient vessel. Duration of the operation was 5.5 hours. Postoperative period was uneventful. Six months after the surgery, the right eye was in good position without inferior dystopia. Eyeball movement could be done without restriction. The patient also denied diplopia. Reconstruction of globe-sparing total maxillectomy defects with free RAM flap with anterior rectus sheath has several advantages that enable the reconstructive surgeon to solve the multiple complex reconstructive task with one flap: 1) elimination of the secondary donor site morbidity; 2) more simply addressing the challenging task of the eye support than the other techniques; 3) obliterating the maxillectomy defect and closing the palate; 4) restoring the large skin defect; and 5) reducing the operation time. It is difficult to conclude that this technique is the best choice in such cases based on a report of the single case. However, presented technique should be kept in mind as a practical and effective reconstructive option in cases that have underwent the total maxillectomy with the preservation of the orbit.

Reconstruction of an inferior orbital rim and cheek defect with a pedicled osteomyocutaneous submental flap

“…Reconstruction of the inferior orbital rim has been accomplished with free tissue flap with or without bone and titanium mesh with varying outcomes. The osteomyocutaneous submental flap provides an excellent alternative to free flaps.…”

Management of orbital complications in palatomaxillary reconstruction: A review of preemptive and corrective measures

“…[18][19][20][21][22][23] While these techniques still carry a risk of infection and implant exposure, this is further minimized by full implant coverage, adequate obliteration of maxillary cavity dead space, and watertight closure of the oral cavity component of the surgical defect. [18][19][20][21][22][23] While these techniques still carry a risk of infection and implant exposure, this is further minimized by full implant coverage, adequate obliteration of maxillary cavity dead space, and watertight closure of the oral cavity component of the surgical defect.…”

Maxillary reconstruction: Current concepts and controversies

“…[Figure 5a–d]. Provision for orbital floor support has been attempted by several methods[68] including use of prolene mesh, facial or musculofacial slings,[69] titanium mesh in combination with other flaps,[3538] free bone grafts along with soft tissue flaps,[70] pedicled calvarial[71] and coronoid flaps[4041] and free bone flaps. The free bone flaps suitable in these cases include fibula,[72] Scapula,[50] DCIA[5254] and TFL-IC flap.…”