Journal of Cranio-Maxillofacial Surgery (2001) 29, 337–343 r 2001 European Association for Cranio-Maxillofacial Surgery doi:10.1054/jcms.2001.0253, available online at http://www.idealibrary.com on Repair of composite zygomatico-maxillary defects with free bone grafts and free vascularized tissue transfer Dennis Rohner,1,2 Bien-Keem Tan,1 Colin Song,1 Vincent Yeow,1 Beat Hammer2 1 Department of Plastic Surgery (Head: Dr. Kok Chai Tan), Singapore General Hospital, Singapore; Department of Reconstructive Surgery (Head: Prof. Dr. Dr. Joachim Prein), University Hospital Basel, Basel, Switzerland 2 SUMMARY. Introduction: Three-dimensional repair of the zygomatico-maxillary defect calls for an elaborate technique to achieve facial symmetry and correct globe position. We present a technique, which combines the use of a free vascularized soft tissue flap and free bone grafts for repair of composite zygomatico-maxillary defects. Patients: Three patients that underwent radical resection of the maxilla and the zygoma have undergone facial reconstruction using this technique. The mean follow up was 9 months. Methods: The key points of this technique are: (1) precise reconstruction of the zygomatico-maxillary complex including the orbit; (2) creation of a skeletal framework for canthopexy and suspension of the free flap; (3) repair of through-and-through soft tissue defects with a folded musculocutaneous free flap; and (4) simultaneous harvesting and reconstruction using two surgical teams to reduce the duration of surgery. Results: Reconstruction of the zygomatico-maxillary complex could be successfully accomplished in a single surgical procedure. Conclusion: This paper presents a method of repairing zygomaticomaxillary defects with free bone grafts and vascularized soft tissue. However, this concept has yet to be reviewed in the long term. r 2001 European Association for Cranio-Maxillofacial Surgery maxilla using split rib grafts (Obwegeser 1973; Brown et al., 1978). But only Brown et al. (1978) used bone grafts in combination with a free vascularized omentum flap: Two recent reports highlighted the advantages of using free calvarial bone grafts in combination with free flaps: Cordeiro et al. (1998) described primary repair of maxillectomy defects using free bone grafts in combination with a free rectus abdominis myocutaneous flap. Posnick et al. (1992) presented a case of free vascularized radial forearm flap and free calvarial bone grafts for the reconstruction of the zygomatico-maxillary complex. The purpose of our report is to describe our technique of reconstructing the zygomatico-maxillary complex using free bone grafts in combination with a myocutaneous free flap. The key points of our technique are: (1) precise reconstruction of the malar prominence, orbital walls and orbital floor to maintain facial symmetry and globe position; (2) creation of a skeletal framework for canthopexy and suspension of the free flap; and (3) adequate soft tissue replacement for bulk, skin cover, and oro-nasal lining. INTRODUCTION Various classifications exist for maxillectomy defects (Brown et al., 2000; Cordeiro and Santamaria, 2000; Spiro et al., 1997). These defects range from minor, such as those following limited resection of the alveolus, to major defects following total maxillectomy. Total maxillectomy defects may be divided into those sparing the globe and those with orbital exenteration. We have classified our patients with maxillary defects according to the horizontal and vertical extents of resection (Table 1) as described by Brown et al. (2000). Zygomatico-maxillary defects are complex following resection of tumours of the maxilla and zygoma. They may be associated with loss of bone, skin, oronasal lining, and soft tissue depending on the tumour. Reconstruction must address all aspects including the skeleton and soft tissue (skin, bone and mucosa). The aims of skeletal reconstruction are to restore correct facial dimensions (facial width and malar projection) and to provide support for the globe. Soft tissue reconstruction involves replacement of skin and oronasal lining. Soft tissue bulk must be adequate to obliterate dead space and to anticipate post-irradiation contracture. Most reports describe one-stage reconstruction using microvascular composite tissue transfer (Brown 1996; Browne and Burke, 1999; Cordeiro et al., 1998; Foster et al., 1997; Granick et al., 1990; Jortay et al., 1994; Kazaoka et al., 1999; Kyutoku et al., 1999; Lee et al., 1999; Nakayama et al., 1994; Schusterman et al., 1993; Yamada et al., 1996; Yamamoto et al., 1987). Two reports describe reconstruction of the PATIENTS AND METHODS Between March and August of 2000, three patients underwent radical resection of the maxilla and zygoma. The primary diagnoses were Ewing’s sarcoma, adenoidcystic carcinoma, and poorly differentiated squamous cell carcinoma (Table 2). Resection of the orbital floor was carried out preserving the orbital contents. Due to tumour involvement, the 337 338 Journal of Cranio-Maxillofacial Surgery Table 1 – Maxillectomy classification from Brown et al., 2000 Vertical Horizontal 1 Maxillectomy without oro-antral fistula 2 Low maxillectomy 3 High maxillectomy a unilateral alveolus of maxilla and hard palate less than or equal to the midline b resection crossing the midline c entire alveolus of maxilla and hard palate 4 Radical maxillectomy resections included skin, oral and nasal linings. The head and neck surgeon or maxillofacial surgeon performed tumour extirpation. All resection margins were subjected to frozen section analysis before proceeding with repair. Reconstruction was undertaken by two teams working simultaneously – the plastic surgeons who harvested the free flap and the maxillofacial team who assembled the orbitozygomatic complex. Technical aspects Skeletal reconstruction was carried out in patients 2 and 3 with free split calvarial bone grafts harvested through limited coronal approaches using the technique described by Jackson et al. (1986) and Frodel et al. (1993). Six pieces of bone, each measuring 1  4  0.3 cm, were sufficient to reconstruct the medial and lateral orbital walls, lateral orbital rim, orbital floor, infraorbital rim and zygomatic arch. For patient 1 who was in the paediatric age group, the 7th and 8th ribs were harvested from the right chest, split and cut into six pieces to create the zygomatic skeletal framework (Fig. 1). The bone grafts were fixed to the base of the zygomatic arch, supraorbital rim, residual medial and lateral orbital walls and the cranial base, lateral to the pterygoid fossa by means of titanium miniplates (Synthess, Mathys Medical, Bettlach, Switzerland). Miniplates (1.5 mm) were used for orbital reconstruction, 2.0 mm plates were employed at the base of the zygomatic arch and for the zygomatic body for greater rigidity. The medial orbital wall bone graft was fixed to the remaining part of the wall. In cases where the medial wall had been completely resected, it was secured to nasion and glabella. The posteromedial wall and orbital floor were reconstructed with a single bone graft attached to the base of the middle cranial fossa. Upon completion, the position of the globe was checked by comparison with the opposite side. Medial and lateral canthopexies were performed by attaching the respective canthal ligaments to the newly created framework with non-resorbable sutures. A free musculocutaneous flap was used to reconstruct the through-and-through cheek defect. To create outer and inner linings, the flap was folded on itself and its central portion de-epithelialized. The intraoral portion was first inset to establish a seal. The muscle and fascia of the flap were then sutured to the reconstructed orbital rim for suspension. Likewise, the skin and subcutaneous tissue at the upper border of the flap were anchored to the bone grafts to prevent traction on the lower eyelid. Case report This 74-year-old patient (patient 3) had a poorly differentiated squamous cell carcinoma of the left maxilla (Fig. 2). The resection was a type 3a maxillectomy including the body of the zygoma, cheek skin and oral mucosa. The globe was spared. Because of neural invasion, the facial nerve and its branches were sacrificed. Reconstruction of the zygomatico-maxillary complex was acomplished with free calvarial bone grafts, soft tissue reconstruction with a folded anterolateral thigh flap, suspended from the bone graft scaffold (Fig. 3). Healing was uneventful and the patient commenced radiotherapy 6 weeks postoperatively. Postoperative CT scans revealed slight overcorrection of the zygoma, which was necessary for soft tissue support (Fig. 4). Clinical assessment showed good facial symmetry and malar projection; there was no ectropion (Fig. 5). RESULTS The flap survival was complete in all three cases. Reconstruction of the bone framework was successful and healed uneventful. Two patients (patients 1 and 3) underwent radiotherapy without complications. The donor sites were closed in all three patients primarily. The function of the lower limb from patients 2 and 3, and of the upper limb and shoulder from patient 1 did not show any impairment in comparison to the contralateral side at 3 months. The function of the involved eye was not impaired and none of the patients experienced double vision. The mean follow up was 9 months (7–11 months). Patient 2 needed some debulking of the soft tissue flap in a secondary surgical procedure 4 months after the primary reconstruction. Table 2 – Patient records Patient Age (Years) Diagnosis Location Resection Reconstruction 1 2 3 5 49 74 Ewing’s sarcoma Adenoidcystic carcinoma Poorly differentiated squamous cell carcinoma Left maxilla Right maxilla Left maxilla 3b+zygoma 3a+zygoma 3a+zygoma RG+LD SCG+ALT SCG+ALT RG – free rib graft; SCG=split calvarial graft; LD=latissimus dorsi free flap; ALT – anterolateral thigh free flap. Repair of composite zygomatico-maxillary defects 339 Fig. 1 – Cadaveric demonstration. (A) Reconstruction starts at base of the zygomatic arch (1). The natural curvature of the graft reproduces the shape of the zygomatic arch. For adequate globe support, the posterior orbital floor is reconstructed with a graft secured to the cranial base (2). (B) The bone graft attached to the remnant of the medial orbital wall or to the orbital roof (3) to reconstruct the orbital wall. The frontozygomatic buttress reconstructed with a bone graft joined at right angles to the zygomatic arch (4). This graft creates the malar prominence. Overcorrection is desirable to overcome the effects of soft tissue shrinkage. (C) Fixation of the infraorbital bone graft (5) completes the zygomaticomaxillary complex. Additional bone grafts may be placed to create the lateral orbital wall (6) and to augment the floor (7). (D) Oblique view of the complete zygomatico-maxillary complex. DISCUSSION Extended ablative surgery of the midface results in disfigurement and functional disability. Even with the latest techniques, satisfactory reconstruction of the total zygomatico-maxillary complex is a formidable challenge, particularly in cases where there is associated soft tissue loss. To date, there are no reports focusing exclusively on the repair of throughand-through zygomatico-maxillary defects (i.e. oronasal lining, bone and skin). Techniques for maxillectomy reconstruction may be broadly divided into three categories: (1) free vascularized soft tissue flap without skeletal reconstruction (Browne and Burke, 1999; Yamamoto et al., 1987); (2) free bone grafts in conjunction with free vascularized tissue (Cordeiro et al., 1998; Pollice and Frodel 1998); and (3) osteocutaneous/osteomyocutaneous free flaps (Brown, 1996; Foster et al., 1997; Granick et al., 1990; Holle et al., 1996; Igawa et al., 1998; Kazaoka et al., 1999; Kyutoku et al., 1999; Lee et al., 1999; Nakayama et al., 1994; Schusterman et al., 1993; Yamada et al., 1996). Bone grafts in conjunction with free vascularized tissue were employed in our three patients who all had composite zygomatico-maxillary defects. The advantages of this approach are: Firstly, a precise reconstruction of the orbitozygomatic complex can be accomplished with bone grafts. Based on Gruss’ principles (Gruss and Mackinnon 1986), malar projection and facial width are restored by recreating the zygomatico-maxillary and nasomaxillary buttresses using rigid fixation techniques (Manson et al., 1980). Soft tissue cover is achieved 340 Journal of Cranio-Maxillofacial Surgery Fig. 2 – Patient no 3. (A & B) Coronal and axial CT scans depicting maxillary squamous cell carcinoma occupying the entire antrum and invading the orbital floor and cheek. (C) Preoperative view. Fig. 3 – Intraoperative views (patient no. 3). (A) Completed zygomatico-maxillary buttress. (B) Posterior orbital floor reconstruction; bone graft secured to cranial base with a miniplate (arrow). (C) Anterolateral thigh flap based on the descending lateral circumflex femoral vessels. Fig. 4 – Postoperative CT scans (patient no. 3). (A) Axial view demonstrating skeletal asymmetry. (B) Maxillary region completely filled with muscle to vascularize calvarial grafts and to obliterate dead space. (C) Anterior view; overcorrection of orbital floor to prevent enophthalmos. Repair of composite zygomatico-maxillary defects 341 Fig. 5 – Two weeks postoperatively (A) Symmetrical facial contour despite facial nerve resection. Suspension of the free flap from the orbital rim prevented ectropion and sagging of the cheek. (B) Globe position maintained; no enophthalmos. with a free musculocutaneous flap draped over the bony scaffold. Cordeiro et al. (1998) reported a series of maxillectomy repairs employing bone grafts and free vascularized soft tissue. The authors favoured this technique because bone and soft tissue could be independently inset without compromising the microvascular aspects of the reconstruction. In contrast, one limitation of composite free flaps (e.g. fibula osteocutaneous flap, scapula osteocutaneous flap, rectus abdominis myocutaneous flap with costal cartilage) is the inability to reconstruct the orbitozygomatic skeleton precisely because of soft tissue attachments to bone maintained for osseous vascularity. Free vascularized soft tissue alone is unlikely to be adequate due to the absence of skeletal support. Yamamoto et al. (1987) described the use of a single osteomyocutaneous free flap to reconstruct the zygomatico-maxillary, naso-maxillary and pterygomaxillary buttresses in a maxillectomy defect. However, the procedure was simplified by the presence of intact skin, allowing the authors to focus entirely on reconstruction of skeletal structure and oral lining. Even so, an additional scapula bone graft was necessary for orbital floor reconstruction. Similarly, Nakayama et al. (1994) used a fibula osteocutaneous flap for reconstruction of the maxilla in a case without skin defect. The bone was osteotomised into three segments to reconstruct the infraorbital rim, orbital floor and zygomatic arch. Secondly, the technique allows precise placement of calvarial bone grafts for globe support. To prevent enophthalmos or other dystopia, attention is focused on key areas such as the posteromedial orbital wall and lateral orbital wall (Hammer, 1995). Fine adjustment to the position of the globe can be effected by layering grafts. Foster et al. (1997) highlighted the difficulty of fabricating the entire orbitozygomatic complex with a single composite free flap for midface reconstruction. The authors proposed the fibula flap for complex midfacial defects, but qualified this by stating that the orbital floor required additional support with bone grafts or titanium mesh. Granick et al. (1990) preferred the osteocutaneous scapular flap, but also conceded that support for the posteromedial wall of the orbit was problematic without separate pieces of bone graft. Thirdly, the assembled skeletal framework provides anchoring points for soft tissue support and suspension. To prevent telecanthus and lower lid laxity, medial and lateral canthopexies are performed by reattaching the respective canthal ligaments to predetermined points on the orbital rim (Hammer, 1995). Additionally, the free flap is suspended from the orbital rim to prevent sagging and traction on the lower eyelid. Granick et al. (1990) reported a case of postoperative ectropion due to its unsupported weight when using an osteocutaneous scapular flap. Controversies exist concerning the use of free bone grafts for facial reconstruction following tumour ablation. Since most patients require postoperative radiotherapy, there is concern regarding the risk of infection, extensive resorption and osteoradionecrosis (Coleman, 1994; Kyutoku et al., 1999; Lee et al., 1999). Nevertheless, several animal studies showed that rational radiotherapy after insertion of a bone graft did not endanger the graft survival (DeSantis et al., 1990; Roy-Camille et al., 1981; Schwartz et al., 1986). Cordeiro et al., (1998) reported good tolerance of bone grafts to radiation when the grafts were used in conjunction with free flaps for reconstruction of the maxilla. Ten of 14 patients received postoperative radiotherapy. Over a mean follow-up of 21 months all primary bone grafts survived and the authors did not detect any bone resorption or infection. We 342 Journal of Cranio-Maxillofacial Surgery believe that the key to bone graft preservation is bone revascularization. When placing the flap, care is taken to ensure that the entire bony framework is enveloped by vascularized muscle, since direct muscle-bone contact promotes vascularization of the free bone grafts. This phenomenon was demonstrated by Fisher and Wood (1987) in a pig model when free bone grafts embedded in a muscle flap acquired medullary circulation within 4 weeks. These results could explain why rabbit bone grafts irradiated 4 weeks after surgery were less affected by irradiation than those irradiated during the first 4 weeks, because the grafts achieved sufficient new vascularity within 4 weeks (Morales et al., 1987). In our hospitals, radiotherapy is usually administered 6 weeks postoperatively, a time interval which is probably sufficient for osseous revascularization. The second controversial issue relates to bone graft resorption with time. In general, the rate of bone resorption depends on bone vascularity and quality. Several authors describe a high resorption rate of free bone grafts when compared with vascularized grafts (Antonyshyn et al., 1987; Fukuta et al., 1992; Gosain et al., 1999). Fukuta et al., (1992) observed that pedicled bone flaps in pigs retained their original volumes, whereas free skull grafts lost approximately 50% of the initial volume after 3 months. Gosain et al., (1999) observed a 15% loss in thickness of nonvascularized grafts over one year, compared with vascularized grafts which maintained their initial thickness over the same time period. With regard to bone quality, Ozaki and Buchman (1998) noted that cortical grafts maintained their volumes significantly better than cancellous grafts. Furthermore, Motoki and Mulliken (1990) demonstrated that membranous bone (e.g. calvarial bone) underwent less resorption and revascularized at a faster rate when compared with endochondral bone (e.g. iliac crest). In our technique, we favour calvarial bone grafts because of their large cortical component, which confers mechanical strength and resistance to resorption. To overcome the problem of resorption due to nonvascularity, the bone grafts are maintained in contact with the flap, for reasons alluded to in the previous section. Finally, some technical refinements are worth noting: K To achieve an aesthetic outcome, overcorrection of the contour of the zygoma is recommended. Overcorrection helps to counterbalance the effects of soft tissue shrinkage. K The infraorbital rim is positioned 3–4 mm higher than the opposite side for lower eyelid and flap support. K Overcorrection of the orbital floor and posteromedial wall with bone grafts is essential to prevent enophthalmos. Apart from the question of bony repair of the defect there is still the discussion about the choice of the soft tissue flap. Whilst there may be different soft tissue flaps that can be chosen, depending on the location and size of the defect, we have chosen the anterolateral thigh flap because it is extremely versatile in design and composition with multiple advantages like adequate tissue volume, minimal donor site morbidity, potential for reinnervation, large and long pedicle and the feasibility of the two team approach. Two minor disadvantages of this flap are the high incidence of hairy skin in that area in male patients and donor site scars associated with the use of skin grafts in large defects (Demirkan et al., 2000). The major problem may be the variation in the origin and course of the supplying perforators, which is present in 12–18% of patients (Demirkan et al., 2000; Kimata et al., 1998). However, the anterolateral thigh flap is a good choice for reconstruction of any type of defects after tumour resection in the head and neck area. CONCLUSION We describe the reconstruction of through-andthrough zygomaticomaxillary defects using free bone grafts and a free vascularized soft tissue flap. This technique was successful in three patients with a mean follow up period of 9 months. The advantage of this technique was on the one hand the precise reconstruction of the orbitozygomatic complex with free bone grafts, which could be accomplished independently from the free vascularized soft tissue flap. One the other hand the reconstruction of the oral lining and the repair of the skin defect could be performed with a folded soft tissue flap draped over the bony orbitozygomatic scaffold. The simultaneous two team approach is another advantage for reducing the time of surgery. 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Microsurgery 17: 141–145, 1996 Yamamoto K, Takagi N, Miyashita Y, Hirabayashi M, Goto A: Facial reconstruction with latissimus dorsi myocutaneous island flap following total maxillectomy. J CranioMaxillofac Surg 15: 288–90, 1987 Dennis Rohner, MD, DMD Department of Reconstructive Surgery Clinic of Maxillofacial Surgery University Hospital Basel Spitalstrasse 21 CH-4031 Basel, Switzerland Tel: +41 61 265 7344 Fax: +41 61 265 7458 E-mail: dennisrohner@hotmail.com Paper received 8 November 2000 Accepted 25 September 2001