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

Background: 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.

Purpose: 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.

Methods: 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.

Results: 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.

Conclusions: This stepwise approach to DCIA free flap modification for maxillectomy defect reconstruction may be used as a guide for future maxillary reconstruction.