Vascular Iliac Crest With Inner Table of the Ilium as an Option in Maxillary Reconstruction

Abstract

Reconstruction of large maxillary defects has been a long-standing challenge to the reconstructive surgeon. Total maxillary reconstruction is desirable but often not possible; ideally, this would provide all the anatomical structural support, function, and esthetics missing because of the defect. A case is presented in which all the criteria for total maxillary reconstruction have been fulfilled. The patient is a 60-year-old man who had wide excision of his maxilla for ameloblastoma, followed by temporal bone flap reconstruction, which failed. He presented to our institution for further evaluation and possible treatment options; these were discussed with the patient and the multidisciplinary team that deals with congenital and acquired deformities in the head and neck area. An iliac crest free flap that included the inner table of the ilium based on the deep circumflex iliac artery was used for the reconstruction. The procedure is described, including restoration of a nasal lining. Osseointegrated implants were used for dental rehabilitation. Ameloblastoma is briefly discussed. The goals of maxillary rehabilitation and obstacles to obtaining those goals are presented. Options available for maxillary reconstruction are discussed, along with some of their advantages and disadvantages, as is the reason why the iliac crest free flap with the inner table of the ilium was chosen. An iliac crest free flap with microvascular anastomosis to facial vessels was used to reconstruct a large maxillary defect. Osseointegrated implants were used to facilitate dental rehabilitation. Our patient has excellent restoration of oronasal function with a satisfactory esthetic result.

The Microvascular Corticocancellous Femur Flap for Reconstruction of the Anterior Maxilla in Adult Cleft Lip, Palate, and Alveolus Patients

“…It can be used to cover local soft tissue defects (Schö n et al, 2002). The main disadvantage of bone flaps is that many of these flaps cannot easily be shaped precisely to the defect without damaging their vascularization (Kelly et al, 2004;Smolka and Iizuka, 2005).…”

“…The soft tissue surrounding the bone flap also can be used for soft tissue coverage (Schö n et al, 2002). In comparison with free grafting, the main problem of microvascular bone flaps is the difficulty in correctly shaping them to the defect without damaging the vascular pedicle and therefore being able to keep the bone vascularized (Kelly et al, 2004).…”

An intraoral anastomosing technique for microvascular bone flaps in alveolar ridge reconstruction

“…In penetrating bony defects of the maxilla, and in cases of severely atrophic edentulous alveolar ridges showing poor regenerative potential combined with poor soft tissues, microvascular bone reconstruction is sometimes the only safe technique for bony reconstruction 12,20 . Microvascular flaps do not depend on the regenerative potential of the transplant bed as they have their own independent blood supply to the transplant bed.…”

“…With the intraoral approach, the vessels were long enough in every case. No interpositional vein graft was necessary 12,24,25 .…”

“…Several microvascular bone transfer techniques have been described that make individualized coverage of defects possible 8,12,20 . In maxillofacial surgery, most of these microvascular techniques are used for covering extended defects after tumour surgery 7,13,23 .…”