ABSTRACT
BACKGROUND: The maxilla is the functional and aesthetic keystone of the midface. However, because of the irregularity and complexity, the functional reconstruction of large maxillary defect is a significant challenge.OBJECTIVE: To set up a new method for maxillary reconstruction by distraction osteogenesis of zygoma and free fibula composite flap.DESIGN: Case observation.SETTING: Department of Stomatology, the 252 Hospital of Chinese PLA.PARTICIPANTS: A patient who suffered from right total maxillectomy and left subtotal maxillectomy. The subject was proved by the Department of Stomatology, the 252 Hospital of Chinese PLA in November 2005. The procedure and consequences of the treatment were told to the patient and his wife before the operation. They greed and signed on the consent book.METHODS: The bilateral internal curve distraction osteogenesis of zygoma (first stage) and transfer of free fibula composite flap (second stage) were performed on the patient. First stage: Following the total maxillectomy, the distraction osteogenesis of zygoma was performed. First, the complete osteotomy was performed on the biliteral remaining zygoma with oscillating saw and osteotome. The transport disks distal to the defect about 10 mm in length were made. Then the internal curve distractors were installed with titanium screws bilaterally and the pedicled buccal fat pad was used to cover the right distractor and separate it from oral and nasal cavities. Due to the skin grafting had been undertaken in the former surgery, no special measure was needed in the left side. After irrigation with normal saline, the wounds were closed with the distraction activator exiting through the soft tissue in the temporal region. Distraction began after a week and proceeded at 0.2 mm twice per day for 21 consecutive days in the right side and 16 days in the left. Consolidation was fixed for eight months. Second stage: By the original Weber's incision, distractors were exposed and released. With new bone formed well in the distracted gap, the bony support was founded in the low position of maxilla. The free fibula composite flap was harvested and the medial-mandibular tunnel was made as described by hidalgo and Peng. After that, the flap was transferred to the recipient site with the pedicle through the tunnel into the neck, then with the help of surgical plate, the fibula bone was remodeled as maxillary arch and fixed to the "bony support" with titanium plates. Following that, the microvascular anastomoses were performed. By the measure, the maxillary cavity was filled by peroneus longus muscle and the maxillary alveolar process was rebuilt by fibula bone. During the procedure, the condition of the distractors and fibula flap, the effect of osteogenesis and the reconstruction was checked by general observation and panoramic film.MAIN OUTCOME MEASURES: The general condition of the distractors and the flap;the effect of osteogenesis and reconstruction.RESULTS: The distractors were in good condition and fibula healed well. By the distraction osteogenesis of zygoma, bony support was set up in the low position of maxilla, the midfacial appearance was restored and the defects was reduced. By the transfer of free fibula composite flap, the defect was restored, the maxillary alveolar process was rebuilt, the oronasal communication was closed, and the contour of upper lip was reestablished.CONCLUSION: The distraction osteogenesis of zygoma and free composite fibula flap can be used together for the reconstruction of large maxillary defects. A new method is set up for functional reconstruction of large maxillary defects.