Functional Reconstruction of Maxilla with Free Latissimus Dorsi-Scapular Osteomusculocutaneous Flap

Abstract

Restoration of oral and nasal function together with facial appearance is still challenging in maxillary reconstruction. Use of a composite flap transfer merely to fill the defect results in unsatisfactory functional and aesthetic outcomes. The authors present a reconstructive procedure for complex maxillary defects using the latissimus dorsi-scapular rib osteomusculocutaneous flap. Some modifications for the reconstruction of the nasal cavity and the hard palate contributed to excellent postoperative functions. Five cases of extended maxillary defect were reconstructed using a novel procedure between February of 1997 and October of 2000. The hard palate was reconstructed with a vascularized scapular angle. The infraorbital rim was reconstructed with a vascularized rib if it was required. A prop bone graft, replacing the zygomatic buttress, was added between the infraorbital rim and the hard palate. The latissimus dorsi muscle flap, which was supported by a skeletal framework and obliterated the remaining cavities around the bone grafts, was left exposed into the nasal cavity, and an 8-French (no. 10) nasal airway tube was placed as a stent in the nasal meatus for 3 weeks after surgery. A skin graft was applied on the scapular angle to reconstruct the oral side of the hard palate. If required, facial skin defect was repaired with a latissimus dorsi musculocutaneous flap or scapular flap. No major complications at the recipient or the donor sites occurred postoperatively in any of the five cases. In cases in which the eyeballs were preserved, almost normal facial appearance was obtained and an orbital extirpation case showed an acceptable postoperative appearance. All five patients returned to an unrestricted diet and their speech was assessed as normal by a speech test. Nasal breathing through the re-epithelialized meatus was possible in all cases. The reconstructed nasal cavity was maintained for more than 6 months in all cases and for more than 2 years in one early case. Rhinometry demonstrated normal function, and histologic findings of the re-epithelialized mucosa over the muscle flap in the nasal cavity revealed a nearly normal architecture. This technique simplifies the reconstructive procedure of massive maxillary defects, including those in the lateral wall of the nasal cavity. It also improves the postoperative oral and nasal functions of the patients.

Scapula osteocutaneous free flap reconstruction of the head and neck: Impact of flap choice on surgical and medical complications

“…[10][11][12][13] Urken et al 8 noted advantages of the scapula free flap over other free flaps including its ability to allow early ambulation, its lack of impact on gait that is encountered with the lower extremity donor sites, the lack of atherosclerotic changes in vascular pedicle in patients with peripheral vascular disease, and the vast options of tissue components that have easy maneuverability for highly complex defects.…”

Vascularized bone grafts in trauma and reconstructive microsurgery, part 1

“…32,33 Similar to the iliac crest, the vascularized scapular graft is a cortico-cancellous graft with limited applications because of its shape. Although the majority of applications of both iliac crest and scapula grafts are for mandibular reconstruction, 34 there are some sporadic reports that describe the use of vascularized scapular grafts in the extremities. 35 The rib is a weak, membranous bone with curved shape.…”

18 Reconstruction of the Mandible

“…[30][31][32][33][34] In case of failure A detailed understanding of the microvascular architecture and physiology is necessar y to understand the management of this flap and its components in the event of vascular compromise. In its normal state, the primary blood supply to the fibula i.e., two-thirds of cortical supply is via the medullary cavity in a centrifugal pattern of flow.…”