Maxillary reconstruction using

rectus abdominis free flap and
bone grafts.

INDIAN DENTAL ACADEMY

Leader in continuing dental education
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INTRODUCTION
The reconstruction of maxilla after massive
excisions has been described using prostheses,soft
tissue,and osseous pedicled flaps,etc

Clinically and radiologically when no infiltration of
orbital fat and extrinsic muscles by tumor ,it is
essential to preserve the orbital contents .

A comb. Of nonvascularised bone graft and rectus
abdominus free flap is safe and relaiable.

Free flaps are used only when alveolar ridge is to
be reconstructed to add stability to the prostheses.
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ADVANTAGES
Rectus abdominus :
• Reliable
• Versatile
• Easy to harvest
• Has a long pedicle
• Large diameter vessels
• Good blood supply
• Possibility of shaping the skin paddle to the required
form
• Two surgical teams can work simultaniously coz of
remote donor site.
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PATIENTS & METHOD
Between jan1996 and Nov2003,22 pts underwent
microsurgical reconstrucion using R.A free flaps
and bone grafts after total or extended total
maxiilectomy.
14-squamous cell carcinoma
1-Anaplastic carcinoma
4-Anaplastic carcinoma
4-Adenoid cystic carcinoma
1-Mets from renal carcinoma
1-Melanoma
1-Condrosarcoma
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• In all the cases orbital floor was resected
and the orbital contents preserved.

• Only two pts were given preoperative
radiotherapy

• Reconstruction was with iliac bone grafts
and rectus abdominis myocutaneous free
flaps in 19 cases, and rectus abdominus
osteomyocutaneous free flaps in 3.
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• The bone that was harvested was monocortical
and was used in two or three pieces,fixed to
each other with plates for the floor and resected
orbital walls.

• Care was taken to envelop the bone with in the
vascularised muscle,as bone muscle contact
promotes vascularisation and protects the
healing bone.
• The graft ,even though was largely resorbed
,maintained the globe in proper position even
after radiation.
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• Donor site was harvested by a second surgical
team and the length of the pedicle allowed the
vessels to those in the neck for anastamosis.

• Pedicle of the flap was taken to the neck through
the tunnel in the cheek.

• Anastamosis was done with facial vessels but
the length of the pedicle would allow
anastamosis with Jugular vein and Thyroid
artery.
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• Good vascularisation of the flap allowed to
design multiple skin paddels with what
ever shape and orientation required.

• In19 pts –Two skin paddles were used
,one for the palate and one for lining the
nose.

• 3pts –required paddles for replacement of
facial skin but the inability to match color
and texture resulted in poor aesthetic.
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DISCUSSION
• Reconstruction of defects after
maxillectomy with preservation of orbital
contents is a challenging problem coz of
the key role of the orbital floor in
suspension of the globe and binocular
vision

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OTHER TECHNIQUES
• Obturators
• Alloplastic prostheses
• Skin grafts
• Temporal and nasal flaps.
• Palatal obturators are bulky and cannot be
possible to support eyeball resulting in poor
functional results.
• Use of alloplastic materials is contraindicated in
irradiated pts.Temporal flaps is not ideal for
orbital suspension.

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• More recently some authors have
described reconstructions of orbital floor
and maxilla with osseous-
osteomyocutaneous free flaps
{scapula,fibula,iliac crest }.


• But the disadvantage is the morbidity of
the donor site and difficulty in inserting the
flap,shaping.
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• Reconstruction of orbital part requires
more cephalic portion of the flap and need
for the vessels to reach vessels in the
neck,with a high risk of thrombosis.

• In our experience ,bone grafts for the iliac
crest for reconstruction of orbital floor have
good long term results ,even after
postoperative radiotherapy.

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• When resection of zygoma results in the need
for malar reconstruction we usually harvest a
composite rectus abdominis
osseomyocutaneous free flap.
• In these 3pts ,bone grafts were used for
reconstruction of orbital floor and vascularised
costocondral component was positioned from
nasal to zygomatic areas,reestablishing the
normal facial contour.
• In our experience ,malar reconstruction with
nonvascularised bone grafts associated with a
vascularised soft tissue flapsresulted in total or
subtotal resorption ,particularly after
radiotherapy.
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• The longterm aesthetic results are good even
after radiotherapy.Despite muscular atrophy ,the
subcutaneous fat maintains enough volumes to
prevent depression of the cheek and dislocation
of nasal alar cartilage.


• An important point during reconstruction is to put
in an excess of tissue to account for atrophy of
denervated muscle,and to suspend the flap to
skeletal frame work to prevent ptosis of the
cheek,prolapse of the flap into the
mouth,resulting in impairment of prosthetic
rehabilitation.

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THANK YOU
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