Second reconstruction of the posterior maxilla with a free latissimus dorsi muscle flap
R. W, Williams 1, B. Speculand 1, P. E. Robin 2, M. Simms 3 1Department of Oral and Maxillo-facial Surgery, Dudley Road Hospital, Birmingham, UK; 2Department of Oto-rhinolaryngology, Dudley Road Hospital, Birmingham; 3Department of Surgery, Selly Oak Hospital, Birmingham
Case report R. W. Williams, B. Speculand, P E. Robin, M. Simms: Second reconstruction o f the posterior maxilla with a free latissimus dorsi muscle flap. Case report. Int. J. Oral Maxillofac. Surg. 1992; 21: 284-286. Abstract. This paper reports a case in which a latissmus dorsi free muscle flap was used for a second reconstruction following resection of a maxillary ameloblastoma when the ipsilateral temporalis muscle flap had already been used. The case illustrates the dilemma of immediate versus delayed reconstruction following excision of maxillary tumours.
The surgical resection of maxillary tumours continues to pose problems postoperatively with regard to aesthetics, feeding, sight, and speech. These problems include oro-antral fistula, velopharyngeal incompetence, and loss of cheek and orbital support. Surgical closure of such a space is often an attractive proposition for the patient, as it negates the need for an obturator, which requires frequent adjustment. The main argument against surgical closure is that it prevents examination of the cavity and hence early identification of recurrent disease. Surgical repair of maxillary defects has been widely reported, and approaches to the problem vary, depending largely on the size of the defect. For small defects, local mucosal flaps 5 or the buccal fat pad 9, can be used, while temporalis muscle has been advocated for slightly larger defects 3'7. Where total or near total maxillectomy has been necessary, a large bulk of tissue is required for reconstruction. Initially, pedicled myocutaneous flaps, such as pectoralis major flaps, were used 1. Recently, free muscle flaps, such as the latissimus dorsi flap 2, have become more common. Although free flaps are more complex to undertake, they are useful in reconstruction when local flaps are not available because of radiotherapy or previous surgery. This paper illustrates such a case where a free latissimus dorsi muscle flap
was used for maxillary reconstruction following resection of a maxillary ameloblastoma and where the ipsilateral temporalis muscle flap had already been used.
Case report A 52-year-old Caucasian man was referred by his dentist for a suspicious ulcer in the left posterior maxilla which had been present for an unknown period of time. His medical history included hypertension controlled with nifedipine. Examination revealed a 1-cm diameter, shallow ulcer with slightly raised edges on the left maxillary tuberosity (Fig. 1). The neck was clear. An orthopantomogram showed evidence of osteolysis of the left maxillary tuberosity (Fig. 2). An incisional biopsy was taken. The histopathology report stated that there were groups of basaloid epithelial cells apparently invading the underlying tissue; this suggested that the lesion was either a peripheral ameloblastoma or a basal cell carcinoma.
Key words: latissimus dorsi; free flap; maxillary reconstruction; ameloblastoma. Accepted for publication 14 July 1992
The patient was admitted for an intraoral posterior maxillectomy and repair of defect with a temporalis muscle flap. At operation, the lesion was larger than anticipated and a wider excision was necessary. However, the defect was closed successfully with a temporalis muscle flap. He made a rapid and uneventful recovery. Histopathologic examination confirmed that the lesion was an ameloblastoma, but there was doubt whether the pterygoid region was clear of tumour. Because of the risk of the tumour's spreading into the cranial base and the relatively young age of the patient, a second operation was deemed necessary to clear the infratemporal fossa and pterygopalatine fossa, even at the risk of negative findings. Surgical access to the pterygopalatine fossa and infratemporal fossa was gained by the
Fig. 2. Orthopantomogram showing evidence Fig. 1. View of shallow ulcer on left maxillary tuberosity.
of osteolysis in left maxillary tuberosity region (arrowed).
Second maxillary reconstruction with free latissimus dorsi
285
Fig. 5. Intraoral view of muscle flap 1 month postoperatively.
Fig. 3. View of axilla showing long vascular pedicle of thoracodorsal vessels.
method described by OBWEGESER6. A bicoronal flap was raised and the zygoma and mandibular condyle exposed. The zygoma was then freed by osteotomy and hinged downwards on the masseter muscle. The defect was repaired with a free latissimus dorsi muscle flap from the same side, anastomosed with the facial vessels. The latissimus dorsi was dissected off its bed along with its main vessels, the thoacodorsal vessels, as far as their junction with the supraseapular vessels (Fig. 3). Access to the facial vessels was gained via a submandibular incision. A subcutaneous tunnel was made from the zygomatic arch over the parotid to communicate with the submandibular incision. The muscle flap was then placed in the defect, and the vessels pedicled down through the subcutaneous tunnel and anastomosed with the facial vessels (Fig. 4). The patient made an uneventful recovery and was discharged 6 d postoperatively. Histopathologie examination of this second specimen showed no evidence of the tumour. One month postoperatively, the flap was healing satisfactorily and there was little aesthetic disturbance (Figs. 5 and 6).
m a t i o n a b o u t clearance o f the margins. Use o f a t e m p o r a r y o b t u r a t o r , for perh a p s a 6 - m o n t h period, m a y have avoid-
Discussion
Fig. 4. View of top end of latissimus dorsi muscle flap spread out over temporal bone and thoracodorsal vessels pedicled downwards subcutaneously over parotid gland and anastomosed with facial vessels.
This case illustrates the difficulty which m a y follow p r i m a r y closure of a defect in the maxilla w i t h o u t definite infor-
ed the s u b s e q u e n t sacrifice of the temporalis muscle flap used in the first repair. T h e temporalis muscle remains the first choice for m a n y m a j o r maxillary defects. Smaller defects m a y be closed with a buccal fat p a d flap 9, while free flaps such as the latissimus dorsi provide either a last resource or greater bulk for larger defects. TANSINI8 w a s the first to use a superiorly b a s e d flap o f the skin a n d latissimus dorsi muscle, in 1895, after which it was used as a pedicled flap for breast r e c o n s t r u c t i o n where two-thirds of the muscle was t r a n s f e r r e d to the a n t e r i o r chest wall to replace the breast. The use of latissimus dorsi muscle as a free flap for oral r e c o n s t r u c t i o n was first described by MARUYAMA 4.
Fig. 6. Facial appearance 1 month postoperatively.
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Williams et al.
Its use as a free flap h a s b e c o m e comm o n because o f the ease of elevation, its long a n d relatively large (2.5 m m ) vascular pedicle, a n d the low incidence o f d o n o r site morbidity. There are some disadvantages to its use, as the p a t i e n t has to be repositioned d u r i n g o p e r a t i o n a n d there is a slight winging o f the scapula postoperatively. However, it h a s p r o v e d to be a very reliable muscle flap a n d is n o w extensively used for h e a d a n d neck reconstruction. In the case described, the latissimus dorsi flap was used as a b a c k u p for the temporalis muscle flap which h a d to be sacrificed d u r i n g the second operation. O u r experience highlights the d i l e m m a o f p r i m a r y r e c o n s t r u c t i o n versus delayed reconstruction, especially in relatively small defects in the maxilla.
Acknowledgments. Thanks are due to the Department of Clinical Photography, Dudley Road Hospital.
References
1. AR1YAN S. The pectoralis major myocutaneous flap. Plast Reconstr Surg 1979: 63:73-81. 2. BAKER SR. Closure of large orbitalmaxillary defects with free latissimus dorsi myocutaneous flap. Head Neck Surg 1984: 6: 828. 3. BRADLEY P, BROCKBANK J. The temporalis muscle flap in oral reconstruction. J Oral Maxillofac Surg 1981: 9: 139. 4. MARUYAMAY, NAKAJIMA H, FOSSATI E, FUJINO T. Free latissimus dorsi myocutaneous flaps in dynamic reconstruction of cheek defects: a preliminary report. J Microsurg 1979: Nov/Dec: 231. 5. OBWEGESER HL. Late reconstruction of large maxillary defects after tumour resection. J Maxillofac Surg 1973: 1: 19. 6. OBWEGESER HL. Temporal approach to the T.M.J., the orbit and retromaxillary-
infracranial region. Head Neck Surg 1985: 7:185 99. 7. PHILLIPS JG, PECK~TT NS. Reconstruction of the palate using bilateral temporalis muscle flaps: a case report. Br J Oral Maxillofac Surg 1988: 26: 32~5. 8. TANSINII. Nuovo processo per l'amputazione della mammella per canine. La Reforma Medica 12: 3. Reprinted in Langenbeck's Archiv ffir klinische Chirurgie, 1896. 9. TIDEMANH, BOSANQUETA, SCOTT J. Use of the buccal fat pad as a pedicled graft. J Oral Maxillofac Surg 1986: 44: 435-40. Address:
B. Speculand Department of Oral and Maxillo-facial Surgery Dudley Road Hospital Birmingham B18 7QH UK
R. W, Williams 1, B. Speculand 1, P. E. Robin 2, M. Simms 3 1Department of Oral and Maxillo-facial Surgery, Dudley Road Hospital, Birmingham, UK; 2Department of Oto-rhinolaryngology, Dudley Road Hospital, Birmingham; 3Department of Surgery, Selly Oak Hospital, Birmingham
Case report R. W. Williams, B. Speculand, P E. Robin, M. Simms: Second reconstruction o f the posterior maxilla with a free latissimus dorsi muscle flap. Case report. Int. J. Oral Maxillofac. Surg. 1992; 21: 284-286. Abstract. This paper reports a case in which a latissmus dorsi free muscle flap was used for a second reconstruction following resection of a maxillary ameloblastoma when the ipsilateral temporalis muscle flap had already been used. The case illustrates the dilemma of immediate versus delayed reconstruction following excision of maxillary tumours.
The surgical resection of maxillary tumours continues to pose problems postoperatively with regard to aesthetics, feeding, sight, and speech. These problems include oro-antral fistula, velopharyngeal incompetence, and loss of cheek and orbital support. Surgical closure of such a space is often an attractive proposition for the patient, as it negates the need for an obturator, which requires frequent adjustment. The main argument against surgical closure is that it prevents examination of the cavity and hence early identification of recurrent disease. Surgical repair of maxillary defects has been widely reported, and approaches to the problem vary, depending largely on the size of the defect. For small defects, local mucosal flaps 5 or the buccal fat pad 9, can be used, while temporalis muscle has been advocated for slightly larger defects 3'7. Where total or near total maxillectomy has been necessary, a large bulk of tissue is required for reconstruction. Initially, pedicled myocutaneous flaps, such as pectoralis major flaps, were used 1. Recently, free muscle flaps, such as the latissimus dorsi flap 2, have become more common. Although free flaps are more complex to undertake, they are useful in reconstruction when local flaps are not available because of radiotherapy or previous surgery. This paper illustrates such a case where a free latissimus dorsi muscle flap
was used for maxillary reconstruction following resection of a maxillary ameloblastoma and where the ipsilateral temporalis muscle flap had already been used.
Case report A 52-year-old Caucasian man was referred by his dentist for a suspicious ulcer in the left posterior maxilla which had been present for an unknown period of time. His medical history included hypertension controlled with nifedipine. Examination revealed a 1-cm diameter, shallow ulcer with slightly raised edges on the left maxillary tuberosity (Fig. 1). The neck was clear. An orthopantomogram showed evidence of osteolysis of the left maxillary tuberosity (Fig. 2). An incisional biopsy was taken. The histopathology report stated that there were groups of basaloid epithelial cells apparently invading the underlying tissue; this suggested that the lesion was either a peripheral ameloblastoma or a basal cell carcinoma.
Key words: latissimus dorsi; free flap; maxillary reconstruction; ameloblastoma. Accepted for publication 14 July 1992
The patient was admitted for an intraoral posterior maxillectomy and repair of defect with a temporalis muscle flap. At operation, the lesion was larger than anticipated and a wider excision was necessary. However, the defect was closed successfully with a temporalis muscle flap. He made a rapid and uneventful recovery. Histopathologic examination confirmed that the lesion was an ameloblastoma, but there was doubt whether the pterygoid region was clear of tumour. Because of the risk of the tumour's spreading into the cranial base and the relatively young age of the patient, a second operation was deemed necessary to clear the infratemporal fossa and pterygopalatine fossa, even at the risk of negative findings. Surgical access to the pterygopalatine fossa and infratemporal fossa was gained by the
Fig. 2. Orthopantomogram showing evidence Fig. 1. View of shallow ulcer on left maxillary tuberosity.
of osteolysis in left maxillary tuberosity region (arrowed).
Second maxillary reconstruction with free latissimus dorsi
285
Fig. 5. Intraoral view of muscle flap 1 month postoperatively.
Fig. 3. View of axilla showing long vascular pedicle of thoracodorsal vessels.
method described by OBWEGESER6. A bicoronal flap was raised and the zygoma and mandibular condyle exposed. The zygoma was then freed by osteotomy and hinged downwards on the masseter muscle. The defect was repaired with a free latissimus dorsi muscle flap from the same side, anastomosed with the facial vessels. The latissimus dorsi was dissected off its bed along with its main vessels, the thoacodorsal vessels, as far as their junction with the supraseapular vessels (Fig. 3). Access to the facial vessels was gained via a submandibular incision. A subcutaneous tunnel was made from the zygomatic arch over the parotid to communicate with the submandibular incision. The muscle flap was then placed in the defect, and the vessels pedicled down through the subcutaneous tunnel and anastomosed with the facial vessels (Fig. 4). The patient made an uneventful recovery and was discharged 6 d postoperatively. Histopathologie examination of this second specimen showed no evidence of the tumour. One month postoperatively, the flap was healing satisfactorily and there was little aesthetic disturbance (Figs. 5 and 6).
m a t i o n a b o u t clearance o f the margins. Use o f a t e m p o r a r y o b t u r a t o r , for perh a p s a 6 - m o n t h period, m a y have avoid-
Discussion
Fig. 4. View of top end of latissimus dorsi muscle flap spread out over temporal bone and thoracodorsal vessels pedicled downwards subcutaneously over parotid gland and anastomosed with facial vessels.
This case illustrates the difficulty which m a y follow p r i m a r y closure of a defect in the maxilla w i t h o u t definite infor-
ed the s u b s e q u e n t sacrifice of the temporalis muscle flap used in the first repair. T h e temporalis muscle remains the first choice for m a n y m a j o r maxillary defects. Smaller defects m a y be closed with a buccal fat p a d flap 9, while free flaps such as the latissimus dorsi provide either a last resource or greater bulk for larger defects. TANSINI8 w a s the first to use a superiorly b a s e d flap o f the skin a n d latissimus dorsi muscle, in 1895, after which it was used as a pedicled flap for breast r e c o n s t r u c t i o n where two-thirds of the muscle was t r a n s f e r r e d to the a n t e r i o r chest wall to replace the breast. The use of latissimus dorsi muscle as a free flap for oral r e c o n s t r u c t i o n was first described by MARUYAMA 4.
Fig. 6. Facial appearance 1 month postoperatively.
286
Williams et al.
Its use as a free flap h a s b e c o m e comm o n because o f the ease of elevation, its long a n d relatively large (2.5 m m ) vascular pedicle, a n d the low incidence o f d o n o r site morbidity. There are some disadvantages to its use, as the p a t i e n t has to be repositioned d u r i n g o p e r a t i o n a n d there is a slight winging o f the scapula postoperatively. However, it h a s p r o v e d to be a very reliable muscle flap a n d is n o w extensively used for h e a d a n d neck reconstruction. In the case described, the latissimus dorsi flap was used as a b a c k u p for the temporalis muscle flap which h a d to be sacrificed d u r i n g the second operation. O u r experience highlights the d i l e m m a o f p r i m a r y r e c o n s t r u c t i o n versus delayed reconstruction, especially in relatively small defects in the maxilla.
Acknowledgments. Thanks are due to the Department of Clinical Photography, Dudley Road Hospital.
References
1. AR1YAN S. The pectoralis major myocutaneous flap. Plast Reconstr Surg 1979: 63:73-81. 2. BAKER SR. Closure of large orbitalmaxillary defects with free latissimus dorsi myocutaneous flap. Head Neck Surg 1984: 6: 828. 3. BRADLEY P, BROCKBANK J. The temporalis muscle flap in oral reconstruction. J Oral Maxillofac Surg 1981: 9: 139. 4. MARUYAMAY, NAKAJIMA H, FOSSATI E, FUJINO T. Free latissimus dorsi myocutaneous flaps in dynamic reconstruction of cheek defects: a preliminary report. J Microsurg 1979: Nov/Dec: 231. 5. OBWEGESER HL. Late reconstruction of large maxillary defects after tumour resection. J Maxillofac Surg 1973: 1: 19. 6. OBWEGESER HL. Temporal approach to the T.M.J., the orbit and retromaxillary-
infracranial region. Head Neck Surg 1985: 7:185 99. 7. PHILLIPS JG, PECK~TT NS. Reconstruction of the palate using bilateral temporalis muscle flaps: a case report. Br J Oral Maxillofac Surg 1988: 26: 32~5. 8. TANSINII. Nuovo processo per l'amputazione della mammella per canine. La Reforma Medica 12: 3. Reprinted in Langenbeck's Archiv ffir klinische Chirurgie, 1896. 9. TIDEMANH, BOSANQUETA, SCOTT J. Use of the buccal fat pad as a pedicled graft. J Oral Maxillofac Surg 1986: 44: 435-40. Address:
B. Speculand Department of Oral and Maxillo-facial Surgery Dudley Road Hospital Birmingham B18 7QH UK
