Iliac Crest Free Flap Research Articles

Axial split step osteotomy of free iliac crest flaps for mandible reconstruction: Preliminary results.

Vascularized bone grafting (VBG) is preferred for mandibular reconstruction post-tumor ablation. Although various bone-free flaps are used, their application is compromised by limitations including insufficient bone volume and poor shape. Here, we report mandibular reconstruction using axial split-step osteotomy with an iliac crest-free flap. Over December 2018-November 2020, 12 patients underwent mandibular reconstruction via axial split osteotomy using a free iliac-crest flap. The preoperative iliac-crest length was 5.7-9.5 mm (median, 7.5 cm); the mean post-axial split-osteotomy iliac-crest length increased to 9.59 mm (range, 6.34-15.15 mm). All patients presented with initial healing 2 weeks postoperation; good bone healing was achieved in all grafted flaps by the third month of follow-up. We propose a new axial split-step osteotomy technique using free iliac-crest flaps for mandibular reconstruction. We demonstrated this novel technique's reliability for safe and effective bone lengthening and establishing a reliable occlusal relationship.

A staged approach to oromandibular reconstruction using the iliac crest free flap in the setting of bilateral failed fibula free flaps.

While a single-stage free-flap reconstruction is the preferred approach for oromandibular defects, a multistaged approach may be necessary in rare cases. These patients can still be effectively restored with functional and aesthetic improvements. We report two cases with a history of bilateral failed fibula free flaps. We detail the multistaged reconstruction to repair these complex defects and discuss the considerations when planning such procedures. Both patients successfully underwent a staged reconstruction with an iliac crest osteocutaneous flap following either a rectus abdominis or pectoralis major myocutaneous flap. Oromandibular reconstruction is an expected outcome in the contemporary management of oral cavity cancer and osteoradionecrosis. However, complications do occur and can be devastating. In cases of bilateral failed fibula free flaps, a staged approach is a favorable option. Moreover, the iliac crest provides an important reconstructive option with the documented potential for implant born dental rehabilitation.

Microsurgical reconstruction of the mandible part II: new classification system and algorithm

BackgroundVarious classifications of mandibular defects have been attempted, but no universally accepted system exists. After 25 years of experience, the senior author idealized a new mandibulectomy classification which could give a more detailed anatomical description leading to a more precise algorithm for reconstruction.MethodsA new classification of mandibular defects is proposed: class I (anterior arch), class II (body), class III (ascending ramus), class IV (hemimandibulectomy), and class V (extended mandibulectomy). Each class is further subdivided into those that preserve or resect intra- and/or extraoral soft tissues (ABCD). This classification takes in account four factors that need to be thought when planning mandibular reconstruction: location/specificity of the defect, osteotomies, and bone and soft tissue requirements.ResultsA total of 218 defects were classified according to this new classification. Nearly 40% of the cases were classified as a class I defect followed by class IV (36,7%), class II (16%), class V (6,8%), and class III (0,5%). The authors also created an algorithm for reconstruction. In cases of an “only-bone” defect, the free iliac crest flap is the preferable choice, especially in class I and IV. When intra- or extraoral soft tissue is needed (types B and C), the fibula flap is our choice of excellence. In cases of extensive defects (type D), the fibula flap and the sequentially linked flow through flap are the preferred options.ConclusionsOptimizing mandibular defect classification with better integration of data-driven information along with clinicopathological evidences and related experience allows for better clinical judgment and choices. We believe that our new classification system and algorithm for reconstruction can be a valuable guiding tool for dealing with complex mandibular reconstruction.Level of evidence:Level III, therapeutic study

P-068 A NOVEL TECHNIQUE TO REDUCE RECURRENCE IN PATIENTS WITH DONOR SITE HERNIAS IN ILIAC CREST BONE GRAFTS

Abstract Introduction Iliac crest bone grafts (ICBG) are commonly used to heal non-union fractures in orthopaedic and maxillofacial surgery. The most common complications are pain, haematoma, neurovascular injury and scarring however one complication that is mentioned less frequently is herniation of abdominal contents. We emphasise the importance of this complication, and describe a technique that can be used to repair this when there is herniation. Case A 76 year old gentleman developed squamous cell carcinoma of the right mandible in 2019. The right mandible was resected, followed by an iliac crest free flap from the left side with a prophylactic prolene mesh which was performed in 2020. The patient then received adjuvant chemotherapy. Shortly thereafter, the patient developed a lump which became increasingly painful. The patient was referred onto the general surgical team after a CT scan showed herniation of colon and small bowel loops at the donor site. The patient underwent a hernia repair in November 2022 and is recovering well. Discussion and conclusion Herniation of abdominal contents following ICBG are rare and potentially dangerous complication that can lead to significant morbidity and even mortality. Here we present an open repair of a recurrent hernia, using a pre-peritoneal mesh. A pre-peritoneal plane was developed all around to ensure there is good overlap of the mesh and was anchored to a mini-plate that was fixed to the iliac bone. Pre-peritoneal meshes should be preferred to fix hernia defects caused from ICBGs, which otherwise can cause significant morbidity in patients with ICBGs.

Application of digital guide plate with drill-hole sharing technique in the mandible reconstruction

With the development of computer-assisted surgery, digital guide plate was widely used in vascularized bone flap grafts for mandibular reconstruction. The purpose of this study was to design and manufacture a digital guide plate with drill-hole sharing for mandibular reconstruction and assess for surgical accuracy. 17 patients that required mandibular reconstruction using fibula free flap or iliac crest free flap were included in the study. The computed tomography (CT) data of the patient's mandible and pelvis or fibula were acquired preoperatively. A surgical simulation was then performed using computer-aided surgical simulation (CASS) technology based on above date, which allowed the design of two cutting guide and a repositioning guide for mandibular reconstruction. After surgery, the accuracy of reconstruction was evaluated by superimposing the postoperative image onto the preoperative image of mandible, recording the linear and angular deviation of landmarks, measuring the differences between the planned and actual outcomes. The osteotomy and repositioning of fibula or iliac crest segments were successfully performed as planned using surgical guides. The digital guide plate with drill-hole sharing showed excellent accuracy, When the iliac crest or the fibula free flap were used for mandibular reconstruction, the largest mean differences between the preoperative and postoperative were 1.11mm and 2.8° or 1.3mm and 3.87°. The digital guide plate with drill-hole sharing designed preoperatively provides a reliable method of for the mandibular reconstruction. This can assist surgeons in accurately performing osteotomy and repositioning fibula or iliac crest segments during the mandibular reconstruction.

Maxillary Ossifying Fibroma Managed Using Cosmetically Acceptable Facial Degloving Approach with Iliac Bone Graft Reconstruction.

Ossifying fibroma is benign, slowly expansile, painless, well defined fibro-osseous tumour composed of calcified products such as bone, cementum, or both [1]. We opted for a novel approach for the management of ossifying fibroma of maxillary region through scarless midfacial degloving approach with iliac bone graft reconstruction. A 20 years old young female presented with left sided facial swelling involving anterior wall of maxilla and lifting the ala of nose. CT and FNAC suggested a benign lesion. Surgery was performed to remove the tumour completely and managed with scarless midfacial degloving approach with iliac bone graft reconstruction. The iliac crest free flap is an optimal method for maxillary defect reconstruction. The main advantages of the flap are the large amount of bone provided, its height, and the possibility of including the internal oblique muscle [2].

Handgrip Strength Predicts Poorly the Surgical Outcome or Length of Hospitalization in Patients With Surgically Operated Oral Cancer.

Handgrip strength has been used to evaluate the potential of elderly patients to survive different medical conditions or procedures, or to predict the nutritional status and length of hospitalization. The aim of this study was to evaluate the use of handgrip strength as a predictor of the length of hospitalization and need for prolonged intensive care in patients with oral malignancies requiring surgical resection and simultaneous primary reconstruction with microvascular free flap. This is a retrospective study of 37 head and neck carcinoma patients operated between 2012 and 2014 who had undergone a handgrip force test. The microvascular free flaps used were: radial forearm flap (n=23), anterolateral thigh flap (n=10), and iliac crest free flap (n=4). Average stay at the hospital was 13.3 days after the operation and there was a 2.9-days need for intensive care. Handgrip strength did not predict susceptibility to complications, duration of hospitalization, or 12-month survival in the study population. Other anamnestic and medical factors and not handgrip strength should be considered when evaluating operability of the patient or their individual risks for microvascular reconstruction.

Fibular Free Flap and Iliac Crest Free Flap Mandibular Reconstruction In Patients With Mandibular Ameloblastomas.

Ameloblastoma (AM) is the most common, locally aggressive odontogenic tumor. It comprises about 1% of all head and neck neoplasms. It occurs mainly in young adults in their 3rd and 4th decade of life. It localizes in the mandible in about 80% of the cases. According to the 2017 WHO classification, 4 types of ameloblastoma can be distinguished: ameloblastoma (previously referred to as solid/multicystic-SMA; the "conventional type" AM), unicystic (AM-UA), extraosseous/peripheral (AM-PA), and malignant/metastatic (AM-MA). Solid, multicystic is the most common type. It is characteristic for its aggressiveness and high risk of recurrence. Radical resection with consecutive reconstruction is the treatment of choice of mandibular ameloblastomas.In this study, the authors present their experience in the surgical treatment of mandibular ameloblastomas with vascularized free flap reconstructions. They discuss new technological possibilities that could improve the precision of the reconstructive procedure and therefore result in the better aesthetic outcome.The retrospective study of a group of 21 patients suffering from mandibular ameloblastoma who underwent segmental man-dibulectomy with simultaneous microvascular free flap reconstruction was conducted. A thorough clinical analysis with various aspects was performed. Tumors resected before 2017 were double checked patomorphologically and assigned to the corrected subtype group.Seven patients were admitted to the department due to recurrent ameloblastoma. The most common localization of the tumor was the mandibular body ( n = 6) andbodywith ramus of the mandible ( n = 6). A total amount of 10 iliac crest free flaps and 12 fibular free flaps were performed. Complications were reported in 4 patients. A purulent oro-cutaneus fistula occurred in 3 patients. There was a flap failure in each reconstructive group. The virtual surgical planning with intraoperative cone-beam computed tomography was used in 3 patients. Dentition implantation was conducted in 4 patients (3 simultaneously, 1 postponed). The mean follow-up was 5 years and 8 months.Radical resection that covers radical segmental mandibulect-omy with immediate microvascular free flap reconstruction is a first-line and only effective treatment of mandibular ameloblas-tomas, that eliminates the risk of recurrence. The extent of surgical margins seems not to influence the recurrence rate, yet further investigation with statistical analysis should be performed. The choice of the adequate free flap must be adapted to dimensions and localization of the tumor and to each patient individually.New technologies such as virtual surgical planning with 3D models and intraoperative cone-beam computed tomography can make the reconstruction more accurate, improving patient's quality of life.

Differences in free flaps' reconstructions with and without coupling device for venous anastomosis.

<br><b>Introduction:</b> Introduction of the coupler devices for anastomoses of neck vessels changes planning and performance of the surgical procedures. The Rigid ring of the coupling devices keeps a vein open and less prone to occlusion. Therefore, this should improve the flap survival rate and surgery duration.</br> <br><b>Aim:</b> The aim of the study was to point out the differences in surgery planning between couplers and sutures for venous microsurgical anastomoses.</br> <br><b>Methods:</b> The medical records of 209 patients who underwent 212 microvascular free flap reconstructions from January 2011 till December 2017 were retrospectively analyzed; 103 received radial forearm free flap (RFFF); 43 - anterolateral thigh flap (ALTF); 51 - fibula free flap (FFF); 15 - iliac crest free flap (ICFF). In 189 cases, reconstruction was performed simultaneously with tumor resection and in 23 cases, reconstruction was secondary, after previous oncological treatment. Among 443 anastomoses, suturing was used for 212 arteries and 127 venous anastomoses, while coupling was used for 104 venous anastomoses.</br> <br><b>Results:</b> The mean surgery duration for suturing was 452.82 min vs 358.88 min for coupling (P<0.05). Differences in flap survival and partial necrosis rates between coupling and suturing groups were not statistically significant (P>0.05). Donor vessel distribution in the neck was significantly different in both groups. Estimated costs of the surgical procedures performed with and without coupler devices were not equal.</br> <br><b>Conclusions:</b> The use of couplers for venous anastomosis in free flap head and neck reconstructions impacts the surgery process by shortening surgery duration which leads to cost reduction.</br&gt.

Iliac crest free flap: a reappraisal of indications and donor site complications

Iliac crest free flap: a reappraisal of indications and donor site complications

Pediatric mandible reconstruction using free iliac crest flap with growth center: flap growth assessment after long-term follow-up

Pediatric mandible reconstruction using free iliac crest flap with growth center: flap growth assessment after long-term follow-up

Maxillary reconstruction with free iliac crest flap in a pediatric patient: long-term results

Maxillary reconstruction with free iliac crest flap in a pediatric patient: long-term results

A retrospective study on mandibular reconstruction using iliac crest free flap

PurposeTo assess the availability, success rate and complications of microvascular iliac crest free flap for reconstruction of mandibular segmental defects. MethodsIn this retrospective-descriptive study, we report patients who had undergone segmental mandibular resection for pathologic lesions and received reconstruction with iliac crest microvascular free flap between 2016 and 2019. Clinical and demographic data of all the cases were collected. Success was regarded as complete consolidation of the bone graft in panoramic radiograph. Postoperative complications were defined as major or minor based on the need for intervention. T-test, Kolomogorov_Smirnov, and multivariate analysis were used and the p-value<0.05 was considered to be statistically significant. ResultsOf all 30 patients, 16 were women and 14 were men with an average age of 27.2 years (range 14–40). Patients were followed for 12–60 month (mean: 38.4). One flap was lost due to unsalvageable venous thrombosis. Six other cases had post-op complications while smoking and diabetes were associated with more complications (P = 0.036). Twenty-three patients received primary reconstruction which was more successful than secondary ones (P = 0.003). Osteogenic sarcoma was associated with greater risk of complications (P < 0.01). ConclusionsThe results of this study suggest that iliac crest microvascular free flap serves as a promising option for the reconstruction of mandibular defects, providing excellent contour and acceptable success rate with low donor site morbidity. Future studies will focus on the role of systemic diseases in post-op complications and flap failures.

Postoperative Imaging Appearance of Iliac Crest Free Flaps Used for Palatomaxillary Reconstructions.

The osteomyocutaneous iliac crest free flap is a reconstructive option for segmental mandibular or complex palatomaxillary defects. Familiarity with the radiographic appearance of free flaps such as the iliac crest is necessary for the postoperative evaluation of patients after mandibular, maxillary, or palatal reconstructions because it allows radiologists to properly monitor and interpret the appearance of the flap over time. This study presents a retrospective review of 5 patients who underwent palatomaxillary reconstruction with an iliac crest free flap at our institution. The imaging appearances of the 5 patients were analyzed to determine the key radiographic characteristics of a healthy and successful iliac crest free flap. Radiographic fluency with the imaging appearance of the iliac crest free flap, as well as the new anatomy of the region in the postoperative period, will allow for better interpretation of the flap appearance on imaging and will prevent false identification of tumor recurrence.

Interest and outcomes of alveolar distraction osteogenesis for dental implant rehabilitation following mandibular reconstruction

Introduction: Alveolar distraction osteogenesis (ADO) is one of vertical bone augmentation technique used to restore the vertical bone discrepancy between the transplanted graft and the residual alveolar bone after mandibular reconstruction. The aim of this article is to present the clinical outcomes of ADO applied to reconstructed mandible for three patients. Observation: Three patients underwent alveolar distraction osteogenesis procedure on mandibula reconstructed by fibula free flap (n = 2) or iliac crest free flap (n = 1). The mean bone height increase was 11 mm. 16 implants have been placed in all patients, with a success rate of 100% and a mean follow-up of 25 months. Two complications occurred without compromising the final outcome of the procedure: one fracture of the basal bone and one bony interference, both during activation phase. Commentaries: ADO can be performed on reconstructed mandible with free flap to restore alveolar height. An acceptable implant-to-crown ratio allows an optimal supported implant prosthesis. The particular antecedent of our patients can lead to uncommon complications such as basal bone fracture, but doesn't seem to compromise implant placement with good success rate. Conclusions: ADO performed on reconstructed mandible allows appropriate dental implant rehabilitation, achieving good esthetics and occlusal outcomes.

Twelve-year experience in mandibular reconstruction using osteo-muscular dorsal scapular pedicled flaps

Primary mandibular reconstruction after tumor removal or osteoradionecrosis treatment is a standard procedure. The most common reconstruction techniques are fibula, scapula, and iliac crest free flaps. Nevertheless, all patients are not eligible for microsurgery.In this study, we assess 12 years of mandibular reconstruction using an osteo-muscular dorsal scapular pedicled flap (OMDS). We included 40 patients operated on using an OMDS flap. We collected parameters such as length of hospital stay, recurrence risk, and need for secondary flap for oral cutaneous fistula (OCF) treatment. Flap bone volume was assessed by segmenting the scapula on postoperative CT-scans using dedicated software.Forty patients were included. Indications for OMDS flaps were severe cardiovascular history (27%), preoperative radiotherapy with a radiation neck and potentially unreliable blood vessel sutures (20%), previous fibula free flap failure (15%), and patient refusing free tissue transfer (8%). Aside from these medical indications, OMDS flaps were performed in 30% of cases due to organizational concerns. The mean flap length was 73±16 mm, with a maximum of 109 mm. Flap bone volume was stable over time, with negligible resorption (p = 0.761). Secondary pedicled flaps were used to treat OCF in 5 patients (12%). Secondary esthetic procedures were performed in 9 patients (22%). None of the 40 flaps were removed. None of the patients had long-term scarring complications in donor sites.OMDS flaps merit consideration for mandibular reconstruction when free tissue transfer is contraindicated or impossible due to organizational issues.

Rehabilitacja implantoprotetyczna pacjeta w obrębie przeszczepu kości z talerza biodrowego po częściowej resekcji kości żuchwy z powodu szkliwiaka

Rehabilitacja implantoprotetyczna pacjeta w obrębie przeszczepu kości z talerza biodrowego po częściowej resekcji kości żuchwy z powodu szkliwiaka

Time and cost-analysis of virtual surgical planning for head and neck reconstruction: A matched pair analysis

ObjectivesVirtual surgical planning (VSP) uses patient-specific modelling of the facial skeleton to provide a tailored surgical plan which may increase accuracy and reduce operating time. The aim of this study was to perform a time and cost-analysis comparing patients treated with and without VSP-technology. Material and methodsA retrospective analysis of 138 patients undergoing microvascular free flap mandible (76.8%) or maxillary (23.2%) reconstruction between 2010 and 2018 was performed. The cohort was divided into two groups according to reconstruction-approach: non-VSP and proprietary-VSP (P-VSP). Cost-analysis was performed comparing non-VSP and P-VSP by matching patients according to site, bone flap, indication, complexity and age. ResultsFibula, scapula and iliac crest free flaps were used in 92 patients (66.7%), 33 patients (23.9%) and 13 patients (9.4%), respectively. Eight patients (5.8%) required revision of the microvascular anastomosis, of which four flaps were salvaged giving a 2.9% flap failure rate. P-VSP was associated with shorter median length of stay (LOS) (10.0 vs 13.0 days, p = 0.009), lower mean procedure time (507.38 vs 561.75 min, p = 0.042), and similar median total cost ($34939.00 vs $34653.00, p = 0.938), despite higher complexity (2.0 vs 1.0, p = 0.09). In the matched-series, P-VSP was associated with a similar median LOS (10.5 vs 11 days), lower mean procedure time (497 vs 555 min, p = 0.231), lower mean total cost ($35,493 v $37,345) but higher median total cost ($35504.50 vs $32391.50, p = 0.607), although not statistically different. ConclusionVSP-technology represents a helpful surgical tool for complex reconstructions, without adversely impacting on the overall-cost of treatment.

Microsurgical reconstruction of complex oromandibular defects: An update

Free flaps are the gold standard for reconstruction of the mandible, tongue and floor of the mouth. Free fibular flaps are the most preferable option for reconstruction of complex mandibular defects, as well as for tongue and mouth floor reconstruction, since they are harvested easily, present excellent sculptability and good functional outcomes. Alternative options for bone reconstruction include the fibular and iliac crest free flap, and for soft tissue reconstruction include the anterolateral thigh, the radial forearm free flap, and the nasolabial island flap. The principles of the surgical approach include resection of the mandibular segment, intraoperative evaluation of the defect, and various surgical manipulations of the flap on site to reconstruct the defect. Advances in computerized preoperative planning have allowed virtual simulation of the defect and fabrication of an individualized stereolithic mandibular model. This short review discusses the current trends of bone and soft tissue flaps for complex oromandibular reconstructions aiming to present a comprehensive review that the readers would find interesting and informative.

Intraosseous microdialysis for bone free flap monitoring in head and neck reconstructive surgery: A prospective pilot study.

BackgroundAlthough some researchers have positioned microdialysis catheters in the soft tissue surrounding bone, the results did not accurately reflect bone metabolism. The present study's objective was to establish the feasibility of microdialysis with a catheter positioned directly in bone.MethodsThirty‐four patients (19 males, 15 females; median age: 59) were included in a prospective, nonrandomized clinical trial in the Department of Maxillofacial Surgery at Amiens‐Picardie University Hospital (Amiens, France). Fibula or iliac crest free flaps were used in reconstructive head and neck surgery (for cancer, osteoradionecrosis, trauma, or ameloblastoma) and monitored with microdialysis catheters positioned in a hole drilled into the bone. Glucose, lactate, pyruvate, and glycerol concentrations were analyzed for 5 days.ResultsAll catheters were positioned successfully, and thrombosis did not occur during the monitoring. In two patients, an increase in the lactate concentration and a glucose level close to 0 were associated with signs of flap necrosis, with removal on Days 9 and 50. In viable flaps, the mean glucose level was 2.02 mmol/L, the mean lactate level was 8.36 mmol/L, and the mean lactate/pyruvate ratio was 53. Forty percent of the glucose values were below 1 mmol/L, and 50% of the lactate/pyruvate ratio values were above 50—suggesting a specific metabolic pattern because these values would be considered as alert values in soft tissue.ConclusionMonitoring bone free flaps with intraosseous microdialysis is feasible. This technique specifically assesses bone viability, and further studies are now necessary to define the alert values in bone.