The deep circumflex iliac artery flap using intraoral anastomosis for delayed reconstruction after partial maxillectomy: a case report

Precise Reconstruction of Mandibular Angle Defects Using Digital Technology-Assisted Vascularized Iliac Crest Flap Combined With Nonvascularized Iliac Bone Graft.

Background/Objectives: The deep circumflex iliac artery (DCIA) free flap with internal abdominal oblique muscle (IAOM) is a well-known method of reconstruction used in cases of oral cavity neoplasms. Because the IAOM can be insufficient for extensive defects after removal of advanced carcinomas of the tongue, floor of the mouth, or gingiva, the additional preparation of a perforator-supported external abdominal oblique (EAOM) muscle flap can be useful. The aim of this study was to introduce the use of a DCIA flap with an IAOM and EAOM island in the reconstruction of oral cavity compound defects. Methods: A retrospective analysis was performed involving eight patients who underwent reconstruction using a DCIA free flap with IAOM and perforator-supported EAOM island. Patients underwent the operation between June 2021 and February 2025 in the Department of Maxillofacial Surgery of the Rydygier Hospital in Kraków, Poland. Results: A group of eight patients underwent an operation due to squamous cell carcinoma of the oral cavity. The most common primary subsite of disease was the floor of the mouth (n = 4, 50%), followed by the lower gingiva (n = 2, 25%) and retromolar area (n = 2, 25%). All patients required resection involving part of the mandible, the floor of the mouth, and part of the tongue simultaneously with reconstruction using a DCIA free flap with IAOM and perforator-supported EAOM island. Osteotomies were performed in two flaps (one single osteotomy, one double osteotomy). Reconstruction was successfully performed in seven out of eight patients (overall success rate 88%). Conclusions: The DCIA free flap with IAOM and perforator-supported EAOM flap is a reliable method for compound soft tissue and bone defects in maxillofacial reconstruction. The use of IAOM and EAOM can be helpful in cases of three-dimensional soft tissue defects of the lower gingiva, the floor of the mouth, and the tongue. The lower gingiva and floor of the mouth can be reconstructed with IAOM, while the more mobile part of the tongue can be reconstructed with a perforator-supported EAOM island.

With the increasing use of dental implants in patients undergoing extensive mandibular reconstructions, it is crucial to understand how soft tissues react in different implantation contexts. The aim was to compare the behavior of the soft tissues surrounding zirconia implants to that of the soft tissues surrounding natural teeth in terms of cytokine levels in patients who had undergone various microvascular flap procedures for jaw reconstruction. Due to anatomical deviations after flap surgery, such as thick skin paddles, the possibility of fixed implant dentures in patients with bony flaps is rare. Therefore, these patients are often treated with removable dentures. In this prospective observational study ten patients with a total of six fibula flaps and four deep circumflex iliac artery (DCIA) flaps underwent reconstruction in the lower and upper jaws using vascularized bone flaps, and were treated with a total of 41 zirconia implants. The cytokine levels in the crevicular fluid were analyzed in terms of the interleukin-1 beta (IL-1b) and matrix metalloproteinase-8 (MMP-8) levels up to one-year follow-up. The implant survival and success rates were also investigated up to one year. No significant differences in IL-1b were found between natural teeth and ceramic implants. After six months, MMP-8 levels of the natural teeth of a patient treated with DCIA flaps were once significantly lower when compared to the ceramic implants inserted into fibula flaps (p = 0.001). The overall survival and success rates were 100 and 76.83%, respectively. For the fibula group, the survival and success rates were 100 and 72.55%, respectively, and for the DCIA group, they were 100 and 81.12%. Zirconia implants and natural teeth showed comparable cytokine levels in the crevicular fluid. Nevertheless, implant treatment with extensive microvascular jaw reconstructions affected the success rates in the present study.

Unleashing the potency of multi-segmental DCIA flap in mandibular reconstruction with the aid of virtual surgery- A retrospective cohort study.

Carcinoma of oral cavity requires resection followed by reconstruction. For the carcinoma of alveolus, lower gingivo-buccal sulcus or gingivo-lingual sulcus of middle 3rd bony reconstruction is required. Generally free fibula flap is preferred. But free fibula cannot be harvested if there is peripheral vascular disease. Here we present a case of carcinoma alveolus of mandible middle 3rd in a case of peripheral vascular disease. Deep circumflex illiac artery used instead of free fibula flap. Patient had a very good outcome, facial cosmesis was good, no hernia in the donor site.

BackgroundThe medial approach for minimally invasive harvesting of a deep circumflex iliac artery (DCIA) flap is described for reconstruction of the jaw. The associated preservation of the crest of the ilium prevents the raising of the abdominal internal oblique muscle (IO) in a standard fashion. However, reconstructive surgery of composite mandibular defects includes bone and soft tissue. To achieve this goal, we combined this technique with a new perforator-based raising of the IO for reconstruction of intraoral soft tissue.MethodsIn this study, we present eight cases of patients with composite mandibular defects who underwent the myo-osseous DCIA flap procedure with an IO perforator. Virtual surgical planning was employed to preplan the size and configuration of the graft. Cutting guides were made using CAD/CAM technology. The surgical procedure followed the described medial approach for minimally invasive harvesting, leaving the iliac crest, spine, and skin intact. In addition, we completely cut and isolated the IO with its sole attachment being the ascending branch of the DCIA. We used either a surgical guide with a slot to lead through both the transverse branch of the bone and the ascending branch of the IO or a surgical guide consisting of 2 parts.ResultsIn all instances, the flap successfully survived with a 100% success rate. There were no signs of infection, wound opening, or bleeding in either patient. Furthermore, the patients did not exhibit permanent complications related to the donor site. The internal oblique perforator flap exhibited remarkable integration in all patients and underwent rapid transformation. Notably, the flap developed keratinized mucosa (KM) that closely resembled the attached gingiva.ConclusionOur study demonstrated the effectiveness of a medial approach for harvesting a newly designed more flexible chimeric myo-osseous deep circumflex iliac artery flap. By incorporating virtual surgical planning and custom-made cutting guides for obtaining deep circumflex iliac artery flaps through the medial route along with an internal oblique perforator flap, we have established a highly promising method for the rehabilitation of patients with composite mandibular defects. This approach not only improves functional outcomes, but also enhances aesthetic results to maintain patients’ quality of life.

Background: Mandibular reconstruction remains challenging in oral and maxillofacial surgery due to its complex anatomy and functional requirements. While Deep Circumflex Iliac Artery (DCIA) flaps offer advantages in bone height and natural contour, their application with computer-aided surgical planning remains limited. Aim: This preliminary study aimed to evaluate the accuracy and clinical outcomes of mandibular reconstruction using DCIA free flaps with patient-specific surgical guides and customized plates. Materials and Methods: A pilot study of five patients who underwent mandibular reconstruction using DCIA free flaps was conducted. Virtual surgical planning was performed using Cone-Beam Computed Tomography (CBCT) and pelvic Computed Tomography (CT) data to design patient-specific cutting guides and reconstruction plates. All surgeries were performed by a single experienced surgeon using standardized techniques. Results: The mean deviation between the virtual planning and actual surgical outcomes was 0.73 ± 0.23 mm, with maximum deviations ranging from 3.87 to 7.83 mm. All flaps achieved 100% survival, with one case (20%) experiencing screw loosening that required plate removal. This complication led to the modification of the plate design to include six or more holes in subsequent cases. Conclusions: Despite limitations including the small sample size and short follow-up period, our preliminary results demonstrate that computer-aided surgical planning with patient-specific devices can significantly improve the accuracy and predictability of DCIA flap mandibular reconstruction, even in challenging revision cases. Further studies with larger patient cohorts are needed to validate these findings.

Background/Objectives: Computer-assisted mandibular reconstruction requires sophisticated technical expertise alongside surgical knowledge. This study aims to establish and validate an efficient collaborative protocol between oral and maxillofacial surgeons and bioengineers for virtual surgical planning in mandibular reconstruction. Methods: We developed a structured protocol with four sequential phases: (1) generation of 3D models from CT data, (2) virtual resection planning, (3) reconstruction design, and (4) surgical guide fabrication. Protocol efficiency was assessed through seven simulation trials measuring planning duration and required revisions. Clinical validation was performed in four mandibular reconstruction cases. Accuracy was evaluated by comparing virtual surgical plans to postoperative outcomes using 3-matic 13.0 software analysis. Results: Protocol implementation showed consistent efficiency across simulations with a mean planning duration of 2.86 working days (SD = 1.35). Only two of seven simulations required design revisions. Clinical application in four cases (three ameloblastomas, one odontogenic myxoma) demonstrated high precision with a mean virtual-to-actual discrepancy of 0.90 mm (SD = 0.34). Successful reconstructions were achieved across varying defect spans (29–53 mm) using both bicortical deep circumflex iliac artery (DCIA) flaps and monocortical iliac block bone grafts. The collaborative workflow resulted in optimized surgical guide design, reduced planning iterations, and improved surgical precision. Conclusions: The established surgeon–bioengineer collaborative protocol enhances the efficiency and accuracy of computer-assisted mandibular reconstruction while making advanced surgical planning techniques more accessible. While initial results are promising, future studies with larger patient cohorts and extended follow-up periods are needed to fully validate the protocol’s long-term benefits and broader applicability.

Reconstruction of extensive mandibular defects using deep circumflex iliac artery flap surgery and 3D-printed guides: a case report

Follow-up results of modern zirconia implants inserted in fibula free and deep circumflex iliac artery (DCIA) flaps with fixed dentures are scarce. This study aimed to evaluate crestal bone changes and the survival rate of zirconia implants for up to 1.5 years of prospective follow-up. Ten patients with six fibula and four DCIA flaps underwent reconstruction in the lower and upper jaws using vascularized composite flaps and were treated with zirconia implants. Peri-implant bone resorption was measured using radiographic images that were taken immediately after implant surgery (T1) and after three (T2), 12 (T3), and 18 months (T4). Between the day of operation and T3, a significant increase in distance was recorded for the fibula flaps. After occlusal loading (T2) of 41 zirconia implants for up to 1.5 years, no significant bone loss in each flap was observed overall. An overall survival rate of 96.56% was reported. When comparing both composite flaps, no significant difference in periimplant bone levels was measured between the same timepoints. For fixed dentures, modern zirconia implants can be used in the DCIA and fibula flaps, however further long-term data is necessary.

A generalizable procedure for Brown's class Ⅱ and Ⅲ defects reconstruction with deep circumflex iliac artery flap using computer-assisted technique

BackgroundTumorous diseases of the jaw demand effective treatments, often involving continuity resection of the jaw. Reconstruction via microvascular bone flaps, like deep circumflex iliac artery flaps (DCIA), is standard. Computer aided planning (CAD) enhances accuracy in reconstruction using patient-specific CT images to create three-dimensional (3D) models. Data on the accuracy of CAD-planned DCIA flaps is scarce. Moreover, the data on accuracy should be combined with data on the exact positioning of the implants for well-fitting dental prosthetics. This study focuses on CAD-planned DCIA flaps accuracy and proper positioning for prosthetic rehabilitation.MethodsPatients post-mandible resection with CAD-planned DCIA flap reconstruction were evaluated. Postoperative radiograph-derived 3D models were aligned with 3D models from the CAD plans for osteotomy position, angle, and flap volume comparison. To evaluate the DCIA flap’s suitability for prosthetic dental rehabilitation, a plane was created in the support zone and crestal in the middle of the DCIA flap. The lower jaw was rotated to close the mouth and the distance between the two planes was measured.Results20 patients (12 males, 8 females) were included. Mean defect size was 73.28 ± 4.87 mm; 11 L defects, 9 LC defects. Planned vs. actual DCIA transplant volume difference was 3.814 ± 3.856 cm³ (p = 0.2223). The deviation from the planned angle was significantly larger at the dorsal osteotomy than at the ventral (p = 0.035). Linear differences between the planned DCIA transplant and the actual DCIA transplant were 1.294 ± 1.197 mm for the ventral osteotomy and 2.680 ± 3.449 mm for the dorsal (p = 0.1078). The difference between the dental axis and the middle of the DCIA transplant ranged from 0.2 mm to 14.8 mm. The mean lateral difference was 2.695 ± 3.667 mm in the region of the first premolar.ConclusionThe CAD-planned DCIA flap is a solution for reconstructing the mandible. CAD planning results in an accurate reconstruction enabling dental implant placement and dental prosthetics.

Bone-flap-harvest-related donor site morbidity in reconstructive jaw microsurgery: Retrospective analysis based on 220 patients over a ten-year period

BackgroundThis study aimed to identify outcome predictors with the GEM microvascular coupler system (GEM Coupler) in a series of patients undergoing free flap reconstruction for head and neck defects.MethodologyIn this retrospective chart review of 218 consecutive microvascular procedures performed on 204 patients at an academic tertiary care center, demographics, comorbidities, surgical data, and outcomes were retrieved. The endpoints for the analysis were microvascular revision surgery and flap survival.ResultsThe study included 142 (70.2%) males and 62 (29.8%) females, with a mean age of 56 years, primarily treated for malignancy (76%). The anterolateral thigh and fibula were the most commonly used flaps (40.4% and 27.1%, respectively). In 21 (9.6%) cases, a double venous anastomosis was performed. There were nine flap failures requiring microvascular revision surgery; the flap was salvaged in four of these cases yielding an overall success rate of 97.7%. Factors associated with total flap loss included a history of a thrombotic or embolic event (p = 0.017), deep circumflex iliac artery flap (p < 0.001), and absence of monitoring skin paddle (p < 0.001).ConclusionsProthrombotic conditions, buried flaps, and flap type are outcome predictors in patients undergoing microvascular reconstruction with GEM Coupler.

Background: Defects of the ascending ramus of the mandible, including the condylar head and neck or the whole temporomandibular joint (TMJ), are difficult to reconstruct. Reconstruction is mainly based on the use of alloplastic joint prosthesis, costochondral grafting, distraction osteogenesis of the dorsal part of the mandibular ramus, or osseous microvascular flaps of various origin. With the objective of developing a method that overcomes the restrictions of these methods, we recently introduced a sequential chimeric flap consisting of a lateral femoral condyle flap (LFC) and deep circumflex iliac artery flap (DCIA) for reconstruction of up to half of the mandible and the condylar head and neck. Methods: The chimeric flap was used in four patients with the following diagnoses: therapy-refractory osteomyelitis, extended recurrent odontogenic keratozyst, Goldenhar syndrome, and adenocarcinoma of the parotid gland. After a diagnostic workup, LFC and DCIA flaps were harvested in all patients and used in a sequential chimeric design for the reconstruction of the mandibular body and condylar head and neck. Results: Follow-up from at least 24 months up to 70 month after surgery showed a successful reconstruction in all four patients. The LFC provided a cartilaginous joint surface, allowing for a satisfactory masticatory function with a stable occlusion and unrestricted mouth opening and preserved or regained lateral and medial excursions in all patients. The DCIA allowed for a bony reconstruction anatomically resembling a non-atrophied mandibular body. No flap-related complications were observed. Conclusions: The sequential chimeric LFC and DCIA flap is an appropriate method for reconstructing up to half of the mandible and the condylar head and neck. It is suitable in cases where alloplastic joint replacement cannot be used or where other methods have failed. Due to the necessity of harvesting two flaps, the burden of care is increased, and a careful indication is required. The technique is reserved for maxillofacial surgeons who have already gained significant experience in the field of microsurgery.

Retrospective study of the deep circumflex iliac artery flap and the vascularized fibula free flap for maxillary defect repair

PurposeThe deep circumflex iliac crest flap (DCIA) is used for the reconstruction of the jaw. For fitting of the transplant by computer-aided planning (CAD), a computerized tomography (CT) of the jaw and the pelvis is necessary. Ready-made cutting guides save a pelvic CT and healthcare resources while maintaining the advantages of the CAD planning.MethodsA total of 2000 CTs of the pelvis were divided into groups of 500 by sex and age (≤ 45 and > 45 years). Three-dimensional (3D) pelvis models were aligned and averaged. Cutting guides were designed on the averaged pelvis for each group and an overall averaged pelvis. The cutting guides and 50 randomly selected iliac crests (10 from each group and 10 from the whole collective) were 3D printed. The appropriate cutting guide was mounted to the iliac crest and a cone beam CT was performed. The thickness of the space between the iliac crest and the cutting guide was evaluated.ResultsOverall the mean thickness of the space was 2.137 mm and the mean volume of the space was 4513 mm3. The measured values were significantly different between the different groups. The overall averaged group had not the greatest volume, maximum thickness and mean thickness of the space.ConclusionReady-made cutting guides for the DCIA flap fit to the iliac crest and make quick and accurate flap raising possible while radiation dose and resources can be saved. The cutting guides fit sufficient to the iliac crest and should keep the advantages of a standard CAD planning.

There is limited information regarding implant and prosthetic survival after osseous microvascular free flap (OMFF). This case series aims to describe the placement of short and extra short implants in osseous microvascular free flaps to support prostheses, and present an up to 40-month retrospective follow-up. Short and extra short dental implants were placed in six fibula free flaps (FFF) and in two microvascular deep circumflex iliac artery (DCIA) flaps. In total, 27 short and extra short dental implants have been placed into two different types of free flaps. Kaplan-Meyer (K-M) survival analyses were performed to evaluate the survival and success outcomes of implants and prostheses. Out of the eight patients reconstructed with free flap, five were rehabilitated with prostheses, one patient has a temporary prosthesis, and two patients are in the process of prosthetic rehabilitation. Twenty-seven implants were followed up for up to 40 months, and K-M analyses showed 100% implant survival probability (95% confidence interval: 100%), while the implant success probability was 91.0% (95% confidence interval: 68.6-97.7%). Short and extra short dental implants placed in OMFF presented high survival and success rates in a retrospective case series after up to 40 months.

Mandibular reconstruction using an iliac bone flap with perforator-supported external oblique abdominal muscle island: a pilot study