Radial Fasciocutaneous Free Flap “Wrap-Around” Iliac Bone Graft for Hard Palate–Premaxilla–Nasal Septum Reconstruction

Sir: A 48-year-old healthy man presented with an advanced squamous cell carcinoma at the maxillary labial sulcus, expanding into the premaxilla and palate. There was no neck or distant metastasis. Surgery was staged over 2 consecutive days. Tracheostomy and extirpation of the tumor were performed first. Excision included the premaxillary alveolus, the hard palate and the adjacent labial sulcus mucosa, the nasal septum, and the lateral nasal walls, leaving a skeletal and soft-tissue defect measuring 5 × 5 × 3 cm (Fig. 1). The next day, the patient underwent bilateral supra-omohyoid neck dissections and reconstruction of the defect.Fig. 1.: The defect after bilateral subtotal maxillectomy.An en bloc segment of the iliac crest and the adjacent gluteal surface of the ilium were harvested as a nonvascularized bone graft. The ilium was burred down to a thin sheet of cortical bone to replace the bony hard palate. The iliac crest component was to become the alveolar process. A separate bone fragment, also from the crest, was fashioned to imitate the vomer component of the septum. This new “septum” was stabilized to the new “hard palate” using metal wires. This iliac bone graft was wrapped in a radial forearm fasciocutaneous free flap and oriented so the fascia of the flap would become the nasal lining and the skin paddle would replace the oral mucosa of the palate. This composite flap-graft was inset using wires (Fig. 2). The radial artery and cephalic vein were anastomosed with the facial artery and vein using 9-0 nylon.Fig. 2.: Design of the radial fasciocutaneous free flap wrapped around the reconstructed hard palate and nasal septum.Postoperative recovery was uncomplicated (Fig. 3). The final staging was a T4N1M0 premaxillary squamous cell carcinoma. Six months postoperatively, the patient developed a recurrence and is presently undergoing palliative chemotherapy.Fig. 3.: View of the patient 3 weeks postoperatively, before radiotherapy.Palatal reconstruction is challenging. Traditionally, obturators are the mainstay of reconstruction. Autologous tissues are preferred and result in better cosmetic and functional outcomes. Local flaps and regional flaps are frequently inadequate and multistaged, and leave poor secondary defects.1 Hatoko et al. first described the use of the radial forearm free flap for palatal reconstruction.2 Other free flaps are available, but all are too bulky.3–5 We found no example of simultaneous palatal and nasal septum reconstruction in the literature. Our technique is a good option for a large premaxilla, hard palate, and nasal septum defect. The forearm skin is a reasonable oral lining. The fascia is thin, provides revascularization of the bone graft, and becomes mucosalized. The “wrap-around” technique improves the bone graft’s take. Septum reconstruction is important to prevent nasal deformity. The iliac crest has sufficient bulk to support dental prostheses or implants. The relative ease of molding and shaping of this technique provides flexibility in design. Good oral function was achieved with no early fistulas; speech was intelligible and aesthetically excellent. The disadvantages are long operative time and high personnel demand. In summary, we were able to reconstruct the premaxilla, hard palate, and nasal septum simultaneously using a radial forearm fasciocutaneous free flap wrapped around a composite nonvascularized iliac bone. We believe that this is a good option to meet the structural, functional, and aesthetic needs of this complex defect. Tam Dieu, F.R.A.C.S. Ram Silfen, M.D. Laura Chin-Lenn, M.B., B.S. Michael Schenberg, F.R.A.C.D.S., F.D.S.R.C.S. James Leong, F.R.A.C.S. Department of Plastic and Reconstructive Surgery and Hand Surgery Southern Health Melbourne, Victoria, Australia