Modifications of the deep circumflex iliac artery free flap for reconstruction of the maxilla

Abstract

The deep circumflex iliac artery (DCIA) free flap remains underused in maxillectomy reconstruction. A number of surgical techniques have been described however, maxillary defects vary greatly and modifying techniques to account for such variation can be challenging. This article presents the first standardized approach to DCIA free flap modification for maxillary reconstruction where graded modifications are made to a standard procedure based on defect grade. A review of 11 cases that underwent maxillectomy reconstruction with this technique is presented. Defect complexity is stratified according to the Brown Classification System and graded modifications of increasing complexity are made to a standard harvest and flap inset technique. Modifications include increasing the depth of the harvested iliac crest bone to correspond to the height of the anterior maxillary wall defect, addition of a titanium mesh plate to reconstruct the orbital floor and harvest of the internal oblique muscle to fill the orbital cavity. Short and long-term outcomes and complications of 11 cases that underwent maxillectomy reconstruction according to this technique were documented. Defects ranged from Brown Class I-IV, b-c. All but two patients had malignant diagnoses with squamous cell carcinoma (n = 5) being the most prevalent. Short-term flap related complications were neck cellulitis (n = 1) and donor site haematoma (n = 2) whilst long-term flap related complications were mild trismus (n = 1) and donor site pain (n = 1). There were no reported problems with speech, swallowing or vision. This stepwise approach to DCIA free flap modification for maxillectomy defect reconstruction may be used as a guide for future maxillary reconstruction.