Sequential chimeric fibula‐gracilis flap to salvage a complex orbitomaxillary defect: A case report

Abstract

Extended maxillectomies with orbital exenteration and facial soft tissue resection need careful planning to achieve satisfactory functional and esthetic outcomes. Only a few solutions provide enough hard and soft tissue on a single pedicle, and only some reconstructive goals might be achievable with a single flap. This paper describes an original inset of the gracilis muscle free flap, used in a vessels depleted patient to salvage a partially failed multi-flap reconstruction after an extensive maxillectomy. A 55-years old man underwent a surgical intervention for a fibrosarcoma of the right maxilla. Due to the disease extension, the resection included right maxilla and palate, the overlying facial soft tissues (including the paranasal, cheek, and infraorbital regions), and the entire orbital content (orbital exenteration). A double flap reconstruction-a free fibula flap and a deep circumflex iliac artery flap-was carried out primarily. However, an intraoperative complication caused a partial flap loss, resulting in a complex tridimensional defect of the orbit and the oral cavity. Therefore, a 18 cm long gracilis muscle free flap was used to fill the defect and save the remaining bony reconstruction. The muscle was inset behind the transplanted bone to seal both the orbit and the oral cavity. No complications occurred after the salvage surgery, with a stable result at the 6-months follow-up. The designed gracilis muscle free flap proved a reliable option for this salvage surgery. However, it could be helpful also in the primary reconstruction of extended maxillectomies in combination with another composite free flap.

Advances in Microvascular Reconstruction of the Orbit and Beyond: Considerations and a Checklist for Decision-Making

“…One weakness of their reconstruction was the little bone stock available for dental rehabilitation, as observed by Eskander [13]. To overcome the limitation of a single bone flap, in selected patients, the senior author favors a composite double bone flap reconstruction to simultaneously address periorbital and zygomatic aesthetics, support for the globe (if preserved), and dental rehabilitation [20][21][22].…”

“…At the authors' institution, Brandtner et al joined the DCIA and an MFC flap in a chimeric flap to reconstruct the maxilla and the orbit [21]. De Cicco reported a case of orbitomaxillectomy reconstructed with a double composite flap (osteocutaneous fibula and DCIA with internal oblique muscle) where the fibula skin paddle underwent partial necrosis with suture breakdown and the reconstruction salvaged with a third free flap, a gracilis muscle anastomosed to the fibula in a sequential chimeric flap [22]. Bottini et al described a retrospective case series on microvascular reconstruction of the orbit and adjacent regions where combinations of DCIA and MFC or DCIA with saphenous artery perforator flap were used for orbitomaxillectomies [20].…”