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2 Int. J. Oral Maxillofac. Surg. 2007; 36: doi: /j.ijom , available online at Technical Note Reconstructive Surgery Reconstruction of a palatomaxillary defect with vascularized iliac bone combined with a superficial inferior epigastric artery flap and zygomatic implants as anchorage Y. J. Hu 1,a, A. Hardianto 1,2,a, S. Y. Li 1, Z. Y. Zhang 1, C. P. Zhang 1 1 Department of Oral and Maxillofacial Surgery, Shanghai Ninth People s Hospital, School of Stomatology, Shanghai Jiao Tong University, Shanghai , China; 2 Department of Oral and Maxillofacial Surgery, Dr. Hasan Sadikin General Hospital. Faculty of Dentistry, Padjadjaran University, Bandung, Indonesia Y. J. Hu, A. Hardianto, S. Y. Li, Z. Y. Zhang, C. P. Zhang: Reconstruction of a palatomaxillary defect with vascularized iliac bone combined with a superficial inferior epigastric artery flap and zygomatic implants as anchorage. Int. J. Oral Maxillofac. Surg. 2007; 36: # 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. Here is described a modified technique of palatomaxillary reconstruction that combines the use of a free vascularized bone graft by osteotomy, soft-tissue flap, zygomatic implant as an anchorage and two standard implants simultaneously. The patient presented with deformity in the left face after subtotal maxillectomy (Brown 2b classification). Preoperative work up was performed by a rapid prototyping model using computer-aided manufacturing technology. The purpose of this model is to provide accurate measurements of the defect. The palatomaxillary three-dimensional buttress system can be managed by orienting the bone graft vertically and horizontally. Reconstruction of the palatomaxillary defect was successfully accomplished in a single surgical procedure. Dental implant restoration achieved good osseointegration without any significant resorption. This new modification represents a significant contribution to palatomaxillary reconstruction using zygomatic implants as anchorage. Key words: vascularized iliac bone; zygomatic implant; superficial inferior epigastric artery; palatomaxillary defects; CAD/CAM. Accepted for publication 27 April 2007 Available online 5 July 2007 Clinical report A 26-year-old male patient was referred with the diagnosis of an epitheloid sarcoma in the left palate. The tumour had been completely resected 2 years earlier (Fig. 1). The patient was classified as having maxillary defects according to a These authors contributed equally to this work / $30.00/0 # 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

3 Fig. 1. The facial appearance 24 months after subtotal maxillectomy. (Left) Frontal view of the patient. (Right) Lateral view showing the left maxillary defects. the horizontal and vertical extents of resection. Resection of the maxillary defect was carried out preserving the orbital floor. Due to tumour involvement, the resections through the midline and the left posterior margin of the soft palate included palatine tonsil and uvula (Class 2b, Maxillectomy defect classification as described by BROWN et al. 3 ). A staged work up (magnetic resonance imaging, MRI; computerized tomography, CT) revealed no evidence of recurrence and metastasis. The resection margins were subjected to frozen section analysis before proceeding with reconstruction. In preliminary three-dimensional CT, computer-aided design (CAD) was used to fit the contour of the maxilla, and automatically transform it into the computer-aided manufacturing process (CAM), in order to prototype the maxillary defect. This guaranteed the position and direction of the zygomatic implant and vascularized iliac bone graft. The Weber Ferguson approach involves an extension of the lateral rhinotomy incision that includes splitting the upper lip. Vascularized iliac crest with internal oblique muscle without a skin paddle and a superficial inferior epigastric artery (SIEA) perforator flap were harvested (Fig. 2). The vascularized iliac bone was osteotomized into two segments using CAD/ CAM prototyping as a reference model; the vertical segment allowed for the fashioning of the anterior maxilla, nasal piriform aperture and infraorbital rim. The horizontal segment was fashioned for Reconstruction of a palatomaxillary defect 855 the posterior maxilla. The internal oblique muscle was then sutured to reline the neopalate and the lateral nasal process. The vertical segment of the bone graft was fixed with two titanium miniplates and the horizontal segment was anchored by a zygomatic implant. In the same session, two standard endosseous implants were placed in the posterior maxillary region into the neoridge of the iliac bone (Fig. 3). The vascular pedicle of iliac bone was delivered through a subcutaneous tunnel made along the cheek. In this case, the facial artery and vein were used without a vein graft as recipient vessel. The superior thyroid artery and vein were used for the SIEA flap. This flap was designed to the exact measurement of the palatal defect including soft palate, and the fascial portion of the flap was harvested to provide a neoridge of iliac bone lining. Patient follow-up was at 1, 3, 6 and 12 months. He underwent formal speech evaluation at 6 months and 1 year after reconstructive surgery. The patient has resumed Fig. 2. (Left) The donor site was prepared for two sources of free flap. (Right) A vascularized iliac bone internal oblique muscle flap with SIEA flap was elevated. Fig. 3. Intra-operative photo shows the vascularized iliac bone has been osteotomized and contoured. Vertical segment to accommodate the infraorbital rim, nasal piriform aperture and anterior maxilla. Horizontal segment to accommodate posterior maxilla. Vertical segment was fixed by two mini-plates whereas horizontal segment was anchored by zygomatic implant. The internal oblique has been used to reline the neopalate and lateral nasal process.

4 856 Hu et al. Fig. 4. The facial and lateral appearance 6 months after surgery was judged as good, without dental prothesis. The implant-supported dental restoration was fabricated 3 weeks later. non-vascularized bone grafting, such as postoperative infection and resorption 7. The ability to contour the iliac bone uniquely allows for restoration of the horizontal and vertical segments of defects. Reconstruction of the three-dimensional buttress system of the maxilla is limited 6. The present technique to repair palatomaxillary defects (class 2b) involved osteotomy of the vascularized iliac bone internal oblique muscle into two segments, in conjunction with a SIEA flap and zygomaticus implant. An additional free bone graft was used for restoration of the prominence of the zygomatic body, which was performed by placing a free inlay bone graft into the space between two segments of vascularized iliac bone. Osteotomy of the vascularized iliac bone offers an ideal source of tissue for reconstruction of the palatomaxillary threedimensional buttress system. There are normal phonation, with no evidence of oronasal escape or velopharyngeal insufficiency. Some debulking was required of the soft-tissue flap in a secondary surgical procedure 6 months after the primary reconstruction. The implant-supported dental restoration was fabricated 3 weeks later (Figs. 4 and 5). At 12 months, CT/MRI and clinical examination showed no evidence of recurrent disease. The dental implant restoration has achieved good osseointegration without any significant resorption. The patient has achieved an acceptable cosmetic result with near normal mid-face contour (Fig. 6). Discussion There are many possible techniques to repair palatomaxillary defects. In small defects of Classes 1 and 2a, local flaps with or without bone grafts 4 and a zygomatic implant with obturator 1 are often sufficient. Pedicled flaps based on the temporalis muscle or the superficial temporal vessels have been described. Some good results can be achieved with these techniques, but cranial bone stock is limited for high maxillectomies (class 3 and 4), and transfer of the temporalis muscle can leave an unsightly defect at the donor site 3.Most palatomaxillary defects (Classes 2b, 2c, 3 and 4) need advanced reconstructions 5. Useful flaps are composite grafts consisting of a vascularized soft-tissue flap combined with a free bone graft 10, iliac crest with internal oblique muscle 3, scapula 14, radial forearm 15 or fibula free flaps 9. The transfer of vascularized bone helps to avoid common complications associated with Fig. 5. Postoperative 6 months. Frontal (left) and lateral (right) cephalometric radiographs showing the neoridge iliac bone, zygomatic implant and two standard implants. Fig. 6. Postoperative 12 months. (Left) The dental restoration has been fabricated with good osseointegration and without any significant resorption. (Right) The dental relationship was judged as good occlusion.

5 Reconstruction of a palatomaxillary defect 857 advantages and disadvantages to the use of this flap as discussed by BROWN 2. The zygomaticus implant is a product of the remote bone anchorage concept and originally was developed for use in patients with challenging palatomaxillary defects 11. In the present report, the vascularized iliac bone was osteotomised into two segments, the vertical segment being fixed by two mini-plates and the horizontal segment anchored by a zygomatic implant. In the horizontal segment, it is not possible for the bone graft to share the load, or perhaps only minimally. A typical situation in which load sharing is not possible is a vertical segment of iliac bone graft where the plate must support all the forces applied to the bone. In such a situation, a zygomatic implant represents an alternative anchorage in the rehabilitation of a palatomaxillary defect. It offers a solid and extended anchorage in the left posterior maxilla region. Considering the biomechanical aspects of prosthetic reconstructions on zygomatic implants, it is well known that when connecting two standard implants and a zygomatic implant, the masticatory load in the posterior region is transferred to the bony support situated in the zygoma. The technique used here clearly creates a load-bearing situation (Fig. 3). The SIEA flap has been described for different reconstructions including abdominal wall, head neck and limb reconstruction 12,13. The SIEA flap was applied as an abdominal dermofat graft, the length of the pedicle varying from 8 to 15 cm. Most frequently, the origin of the SIEA was observed at a common pedicle with the superficial circumflex iliac artery (SCIA) (47%) or directly from the common femoral artery (36.5%). The SIEA flap is based on direct perforators that pierce only the deep fascia. Discussions continue as to whether or not the SIEA flap is a true perforator flap because the pedicle does not perforate the muscle. The important vascular system is the SCIA 8. The choice of donor site must be made with the patient s best interest in mind. As known from anatomical study, the superficial epigastric artery has a common origin with the SCIA from the femoral artery. From this donor site it is possible to harvest two free flaps at the same session, with only one donor site defect. The operative sessions can be reduced, which is cost effective. With the development of a vascularized composite autograft using a microsurgical technique in conjunction with a rapid prototyping model based on CAD/CAM, direct visualization of the full threedimensional context of the structures involved in the surgery can be achieved. Precise pre-surgical planning minimizes the duration and thus risks of the surgical procedure, resulting in a reduction in morbidity as well as cost. In conclusion, the overall result provided exceptional function including a satisfactory aesthetic appearance. This new modification represents a significant contribution to palatomaxillary reconstruction using zygomatic implants as anchorage. References 1. Blondeel PN, Morris SF, Hallock GG, Neligan PC. Perforator flaps anatomy, technique and clinical applications Vol. 1. St. Louis, Missouri: Quality Medical Publishing, Inc. 2006: pp Brown JS. Deep circumflex iliac artery free flap with internal oblique muscle as a new method of immediate reconstruction of maxillectomy defect. Head Neck 1996: 18: Brown JS, Jones DC, Summerwill A, Rogers SN, Howell RA, Cawood JI, Vaughan ED. Vascularized iliac crest with internal oblique muscle for immediate reconstruction after maxillectomy. Br J Oral Maxillofac Surg 2002: 40: Cheung LK, Samman N, Tideman H. Reconstructive options for maxillary defects. Ann R Australas Coll Dent Surg 1994: 12: Davison SP, Sherris DA, Meland NB. An algorithm for maxillectomy defect reconstruction. Laryngoscope 1998: 108: Genden EM, Wallace D, Buchbinder D, Okay D, Urken ML. Arch Otolaryngol Head Neck Surg 2001: 127: Muzaffar AR, Adams Jr WP, Hartog JM, Rohrich RJ, Byrd HS. Maxillary reconstruction: functional and aesthetic considerations. Plast Reconstr Surg 1999: 104: Parel SM, Branemark PI, Ohrnell LO, Svensson B. Remote implant anchorage for the rehabilitation of maxillary defects. J Prosthet Dent 2001: 86: Rohner D, Bucher P, Kunz C, Hammer B, Prein J, Schenk RK. Treatment of severe atrophy of the maxilla with the prefabricated free vascularized fibula flap. Clin Oral Implants Res 2002: 13: Schliephake H. Revascularized tissue transfer for the repair of complex midfacial defects in oncologic patients. J Oral Maxillofac Surg 2000: 58: Schmidt BL, Pogrel MA, Young CW, Sharma A. Reconstruction of extensive maxillary defects using zygomaticus implants. J Oral Maxillofac Surg 2004: 62(Suppl. 2): Stern HS, Nihai F. The versatile superficial inferior epigastric artery free flap. Br J Plast Surg 1992: 45: Stevenson TR, Hester TR, Duus EC, Dingman RO. The superficial inferior epigastric artery flap for coverage of hand and forearm defects. Ann Plast Surg 1984: 12: Urken ML, Bridger AG, Zur KB, Genden EM. The scapular osteofasciocutaneous flap: a 12-year experience. Arch Otolaryngol Head Neck Surg 2001: 127: Villaret DB, Futran NA. The indications and outcomes in the use of osteocutaneous radial forearm free flap. Head Neck 2003: 25: Address: Zhang Chenping Department of Oral and Maxillofacial Surgery Ninth People s Hospital affiliated Shanghai Jiao Tong University Shanghai China Tel: x5157 Fax: h9mfsl@online.sh.cn