Maxillary Reconstruction with Iliac Crest Free Flap, Using Vascular Loops and Intraoral Anastomosis.

According to the principle of replacing “like with like”, our preferred choice for reconstruction for complex upper palatal-maxillary defects is the iliac crest free flap. This flap provides an ideal shape, thickness and vertical high for Osseo-Integrated implant-based rehabilitation. Furthermore, the  internal oblique muscle  included in the flap gives support to the cheek and nose and minimizes dead space. Fibula flap is used for this kind of recontruction by most of microsurgeons because it is easier to perform,  however the shape of the transplanted bone is far from ideal.

Iliac crest free flap has a relatively short pedicle that makes its positioning challenging. This is even more difficult when the pedicle has to be placed posteriorly. To overcome these challenges, we create a temporary arteriovenous loop using a venous graft that is anastomosed to de facial vessels (in most of the cases). This loop is then passed thought the cheek and its distal end is placed in the posterior vestibule. Finally this loop is divided and the distal end is anastomosed with iliac crest vessels. 

Materials and Methods: We present a series of seven cases of maxillary reconstruction with iliac crest  free flap, using vein grafts and intraoral anastomosis. 

Results: Adequate oral diet was achieved by all of the patients after 3 weeks postoperative. The average follow-up period was 13 months. There was no evidence of arterial or venous thrombosis. No major complications were encountered. 

Conclusion:  Although Iliac crest free flap is an excellent flap choice for complex maxillary reconstruction, this flap has a small pedicle, though a tension-free anastomosis is difficult to perform, especially when flap vessels are placed towards the posterior vestibule.  Using vascular loops and intraoral anastomosis represent useful strategies to overcome these challenges and to achieve adequate results with consistent flap survival.