Iliac Crest Free Flap for Maxillary Reconstruction

Abstract

Reconstructing defects after maxillary resections presents a challenge for the reconstructive surgeon because of the critical role played by the maxillary skeleton in facial function and esthetics. Obturation, local or locoregional flaps, and soft tissue free flaps are good options for maxillary reconstruction; however, the lack of bone reconstruction often leads to ptosis of the facial tissues, particularly of the nasal base and columella, under the effects of gravity and makes it impossible to place osseous implants for dental rehabilitation. We present our experience with the iliac crest free flap for maxillary reconstruction, focusing on the advantages of this technique and particularly on flap positioning, which is dependent on defect site and size. Finally, 2 representative cases will be presented. Between January 1, 1996, and January 1, 2008, 14 patients were treated for maxillary reconstruction with an iliac crest free flap. In 6 patients, the floor of the orbit was included in the resection. In 5 patients, we performed reconstructions using bone grafts harvested from the iliac crest, whereas in the remaining patient a titanium mesh was used. All flaps were harvested and transposed. Minor complications included wound dehiscence in 2 cases, ectropion in 2, and nasal airway obstruction in 1. No major complications or donor site morbidity occurred. No oronasal communication or swallowing impairments developed in any patient. Seven patients completed oral rehabilitation with dental implant placement; the remaining 7 refused the treatment because of financial problems, and 4 patients were rehabilitated with a mobile prosthesis. The iliac crest free flap is an optimal method for maxillary defect reconstruction. The main advantages of the flap are the large amount of bone provided, its height, and the possibility of including the internal oblique muscle. Flap insetting is the key part of the procedure, and whether to use vertical or horizontal placement of the flap is the main consideration. Finally, the low rate of donor site morbidity reported in our patients, as in the recent literature, makes this flap even more safe and reliable.