Experience with free composite tissue transplantation based on the deep circumflex iliac vessels

Eight free iliac osteocutaneous flaps and three vascularized iliac bone grafts based on the deep circumflex iliac vessels were transferred in 11 cases of large skin and bone or bone defects. Seven of the eight osteocutaneous flaps took successfully. The eighth demonstrated partial necrosis. There was complete bone union in ten cases, and no union in one case as a result of persistent infection. Based on this experience, we conclude that free osteocutaneous flaps based on the deep circumflex iliac vessels have the following advantages over free osteocutaneous flaps based on the superficial circumflex iliac vessels: the pedicle is long (5 to 7 cm); the nutrient vessels are large (artery: 2.2 mm; vein: 2.5 mm); the anatomic course of the vessels is constant; and there is a large amount of bone available.     

Mandibular reconstruction with free osteocutaneous iliac crest flap based on the deep circumflex vessels

Summary Mandibular reconstructions using free osteocutaneous iliac crest composite flaps based on the deep circumflex iliac vessels have been completed successfully in seven patients. The advantages of the method include reliability of the blood supply to the bone, long and good size of the vascular pedicle and the possibility of taking bone pieces as required for a hemiandible or medial segment reconstruction. The method should be reserved for the very difficult cases of mandibular replacement where more conventional approaches are contraindicated.     

Surgical anatomy of the internal oblique muscle: a practical approach

In recent years pedicled and microvascular free muscle flaps, myocutaneous flaps, and vascularized bone grafts have become well accepted reconstructive techniques in the management of complex defects. The deep circumflex iliac artery-based internal oblique muscle pedicle flap, internal oblique free muscle pedicle flap, internal oblique free muscle flap, and the internal oblique-iliac crest microvascular free flap are the latest additions to the reconstructive surgeons' armamentarium. This report describes the surgical anatomy of the internal oblique muscle and the deep circumflex iliac artery from a practical viewpoint with particular emphasis on the vascular basis of the above mentioned flaps.     

带旋髂深血管的游离髂骨瓣移植修复胫骨骨不连

目的：探讨应用带旋髂深血管的游离髂骨瓣移植修复胫骨骨不连的临床疗效。方法2003-2013年对30例胫骨骨不连患者,治疗组15例应用带旋髂深动静脉的髂骨瓣或髂骨皮瓣移植修复,对照组15例采用单纯髂骨移植。结果长期随访发现,治疗组的髂骨瓣均成活,胫骨骨不连骨性愈合时间最早6个月;对照组移植骨再生时间最早9个月,骨髓腔再通时间最早1年。结论采用显微外科技术吻合带旋髂深血管的游离髂骨瓣修复胫骨骨不连,对比单纯髂骨移植,愈合时间明显缩短,疗效可靠。     

Arterial supply of the deep circumflex iliac artery (DCIA) flap

The main constituents of the deep circumflex iliac artery (DCIA) flap are a rim of iliac crest and an overlying paddle of skin. Taylor et al. believed that both constituents were adequately supplied by the DCIA, but in some of our recent DCIA flaps, the bone has survived while the skin has undergone necrosis. We believe that this is because the skin is supplied mainly by the superficial circumflex iliac artery (SCIA). To test this hypothesis, three DCIA flaps, with both the DCIA and SCIA, were raised from three unembalmed cadavers. The DCIA pedicle was injected with a mass of black latex, while the SCIA was injected with a mass of green latex. The flaps were rendered transparent using the Spalteholz method. In each flap, black latex filled vessels close to the rim of bone. Green latex filled vessels in the skin paddle. No black latex was seen in the skin paddle, nor was green latex seen in the bone segment. There was no apparent anastomosis between the two systems. The DCIA mainly supplies the bone and the SCIA the skin, but the DCIA is not always adequate to supply both. When raising a flap of bone and skin from the iliac crest region, surgeons should consider raising both the deep and superficial circumflex arteries.     

Deep circumflex iliac artery (DCIA) free flap without DCIA: report of a unique case

The iliac crest free flap is a reliable source of cancellous bone, muscle, and skin. The vascularization of this flap arises from the deep circumflex iliac artery (DCIA) which allegedly is always present. The authors report a unique case of successful microvascular transplantation of an iliac crest osteomyocutaneous free flap in a patient in whom the DCIA and DCIV were absent.     

Variants in the deep circumflex iliac artery: clinical considerations in raising iliac osteocutaneous free flaps

Anomalies of the deep circumflex iliac artery do occur, although they are uncommon. Recently, two cases of these anomalies were encountered by the authors during elevation of iliac osteocutaneous free flaps. In the first case, the deep circumflex iliac artery was absent, and the nourishing artery of the flap was instead connected to the large iliolumbar artery. In the second case, the ascending branch, deriving from the deep circumflex iliac artery as usual, had a separate takeoff directly from the external iliac artery, and provided blood supply to the overlying skin as a musculocutaneous perforator that transversed the three muscle layers of the abdominal wall. This ascending branch was assumed to be a duplication of the deep circumflex iliac artery. Ascertaining the divergence of the deep circumflex iliac artery from the external iliac artery before beginning to raise the flap, and careful dissection of the artery, are essential for minimizing problems in flap transfer.     

Clinical anatomy of the internal oblique muscle

In recent years microvascular free tissue transfer has become a well accepted reconstructive technique. The current trend in flap research seems to be the development of more refined flaps to meet specific needs with minimal donor site morbidity. The internal oblique muscle provides a broad, thin, well-vascularized flap which is ideally suited for restoration of contour with excellent aesthetic results. In addition, the iliac crest may be raised in continuity based on the same vascular pedicle, i.e. the deep circumflex iliac vessels. The purpose of this article is to describe the anatomic details necessary for the clinical application of this versatile flap. Thirty specimens of the internal oblique muscle flap were dissected and studied using Microfil injection techniques, including xerograms. In about 80 percent of the flaps, a single ascending branch of the deep circumflex iliac artery (DCIA) enters the undersurface of the muscle, arborizing within the muscle. In the remaining 20 percent, two or three branches enter the muscle separately, originating on the DCIA. The arc of rotation extends into the ipsilateral groin for coverage of exposed femoral vessels, along the pubis and the anterior perineum. The length of the vascular pedicle is to 6 to 7 cm and the vessel diameter is 2.0 to 3.0 mm, making the flap suitable for free tissue transfer.     

A new vascularized bone graft transferred by microvascular anastomosis as a free flap

We describe a new, versatile bone and soft tissue compound free flap which may be transferred quickly and simply and describe its use in the treatment of compound fracture of the tibia and fibula with non-union due to loss of bone. The iliac crest and overlying soft tissue is transferred to the leg in one stage by microvascular anastomosis of the deep circumflex iliac vessels to vessels in the leg.     

旋髂深血管蒂骨膜瓣与旋股外血管蒂阔筋膜张肌髂骨瓣复合移植治疗成人股骨头缺血性坏死

目的观察旋髂深血管蒂骨膜瓣与旋股外侧血管蒂阔筋膜张肌髂骨瓣复合移植治疗成人股骨头缺血性坏死的疗效。方法采用旋髂深血管蒂骨膜瓣与旋股外侧血管蒂阔筋膜张肌髂骨瓣复合移植至4例坏死塌陷的股骨头内重建病变的股骨头。结果按髋关节功能Harris评分标准进行评价，对4例进行2-3年随访，优3例，良1例。结论本复合骨瓣对重建股骨头坏死的血运是可靠的方法。     

山羊血管化骨髓移植的解剖学基础研究

目的通过对山羊股骨、髂骨、胸骨、肋骨4个较为常见的血管化骨髓移植供区部位相关结构的测量观察,从移植手术的角度,分析其解剖特点,为下一步建立山羊血管化骨髓移植模型提供一定的解剖依据。方法取6只（共12侧）体质量相当的山羊做活体解剖研究。观测4个供区血液供应情况,并对比4种移植物体质量、体积、骨髓干细胞密度等因素。结果髂骨可见主要滋养血管为髂内动脉及其分支,另外紧贴骨面的臀部肌肉也会有细小动脉进入骨膜,髂内血管为较理想的血管蒂;股骨的主要滋养动脉有3条：股深动脉、旋股外侧动脉及膝降动脉,取髂外血管为血管蒂;双侧胸廓内动脉及伴行静脉为胸骨的主要滋养血管,双侧胸廓内动静脉的近端可作为游离血管蒂;肋骨以第7肋为例,其肋间后动脉及其伴行静脉为主要滋养血管,可以取到一定长度的游离血管蒂。结论山羊的髂骨及股骨是较为理想的血管化骨髓移植术供区,其游离血管蒂长度及其动静脉外径均可满足异体移植术的需求。     

Free combined anterolateral thigh flap and vascularized iliac bone graft with double vascular pedicle

Although free vascularized iliac bone graft has been successfully used for the reconstruction of large bone defect with microvascular surgery, there is a serious problem of how to repair in one-stage, those cases having a large bone defect with a very wide skin defect. A free combined anterolateral flap and vascularized iliac bone graft with double vascular pedicles seems to be a most suitable method for cases having both large bone and skin defects. Two case reports are presented in which this flap was used. Based on the authors' cases, the advantages of this flap are its thinness and the extreme wideness of the skin territory. The anatomy of the pedicle vessels is large and long, and the donor scar can be made in an unexposed area. This flap can be considered for use in one-stage reconstructions of both large bone and skin defects in the oral and leg regions.     

Microsurgical reconstruction of the irradiated mandible with deep iliac circumflex flap]

From 1979 to 1988, 30 osteomuscular or osteomyocutaneous free flaps of the iliac crest (revascularized by the deep circumflex pedicle) were used to reconstruct 28 mandibles severely compromised by radiotherapy exceeding 66 Grays. In addition to a perfect graft raising and microsurgical technique, perfect closure of the mucosal plane appears to be an essential factor of success. Over the years, this iliac crest flap appears to improve the radiological appearance of the bone stumps on either side. The procedure therefore appears to be particularly useful in the treatment of advanced radiation osteonecrosis.     

A new flap model in rats: iliac osteomusculocutaneous flap

Although osteomusculocutaneous flaps are used frequently in clinical practice to repair defects involving soft tissue and bone, there are still many questions that remain to be answered regarding their basic physiology. To accomplish such basic science studies, simple and reliable animal osteomusculocutaneous flap models are needed. The purpose of this study was to describe a new flap model in rats--namely, the iliac osteomusculocutaneous flap. Thirty adult Wistar rats weighing 200 to 250 g were used in this experiment. In 15 rats, the vascular anatomy of the iliolumbar vessels and their relation with adjacent soft tissues and the iliac bone was determined by anatomic dissection. Based on this anatomic study, the iliac osteomusculocutaneous flap model was created in rats. The flap is comprised of a skin island (3 x 3 cm) in the flank region, a 1 x 1-cm segment of iliac bone, and an abdominal wall muscle cuff. In 10 rats, the flap was raised as an island flap based on its vascular pedicle of iliolumbar vessels, and was replaced in situ. In the remaining 5 rats, the flap was transferred to the groin region as a free flap. Direct observation on postoperative day 7 revealed that the skin island of all the flaps was completely viable. Bone scintigraphy performed on postoperative day 3 in free flaps demonstrated radionuclide uptake, indicating viability of the bony segment. The dye injection study revealed ink staining within blood vessels of the bone, confirming its viability. Microangiography of the flap demonstrated vascularity of each component of the flap by the iliolumbar vessels, including a distinct branch to the iliac bone. The authors conclude that the iliac osteomusculocutaneous flap of the rat is a simple and reliable flap model that offers the following advantages: (1) It is a true osteomusculocutaneous flap, (2) it can be used as a free flap without the need for an isogeneic rat, (3) the vascular pedicle is consistent, and (4) it is harvested from a small-animal species.     

Pseudoaneurysm of the deep circumflex iliac artery: a rare complication at an anterior iliac bone graft donor site

STUDY DESIGN: The formation of a pseudoaneurysm of the deep circumflex iliac artery after the harvesting of an anterior iliac bone graft for spinal fusion is reported. OBJECTIVE: To describe a rare complication at an iliac bone graft donor site. SUMMARY OF BACKGROUND DATA: The iliac bone is a common site for harvesting bone for spinal surgery. Although many complications have been reported, vascular injuries associated with this procedure are rare. To the authors' knowledge, deep circumflex iliac artery injury has not been reported as a complication. METHODS: A 70-year-old man with cervical myelopathy underwent anterior cervical decompression and fusion with an anterior iliac bone graft. Fracture displacement of the anterior superior iliac spine at the donor site was noted 1 week after a second operation, which was performed to reduce the displaced grafted bone. Five months after the second operation, he reported pain and swelling at the donor site. Removal of a hematoma was attempted, which led to massive bleeding that was difficult to control. RESULTS: Angiography demonstrated a pseudoaneurysm of the deep circumflex iliac artery. Selective embolization of the artery was performed, and the bleeding was arrested. CONCLUSIONS: Vascular injury after anterior iliac bone harvesting is rare but can occur. Selective arterial embolization was an effective solution.     

Acetabular roof reconstruction with pedicled iliac graft

Reconstruction of the acetabular roof in patients with hip dysplasia shows disappointing mid-term results due to insufficient incorporation and collapse of the bone graft. We have developed a new reconstructive method using a pedicled iliac graft. We simulated surgical reconstruction of the acetabular roof in ten cadaver specimens. The purpose was to evaluate whether the deep circumflex artery was long enough to allow transfer of the graft without requiring micro-vascular anastomosis. In all cadavers, the length of the pedicle was sufficient to reach any desired position of the acetabular roof. The use of such a pedicled structural graft may provide good primary stability and allow local bony remodelling and incorporation under load.     

The Pararectus approach provides secure access to the deep circumflex iliac vessel for harvest of a large sized and vascularized segment of the iliac crest

BackgroundThe feasibility of harvesting a vascularized iliac crest utilizing the Pararectus approach was assessed in cadavers and then this new technique was implemented in a clinical case.MethodsBilaterally in five cadavers the branches of both external iliac arteries were injected with colored silicone to assess their position to each other and to harvest a bone graft vascularized by the deep circumflex iliac artery (DCIA) through the Pararectus approach. This technique was implemented in a 68-years-old female patient, initially admitted to a level-I-trauma center after sustaining multiple injuries by falling from great height. For definitive treatment of a severely contaminated medially open (Gustilo-Anderson Type 3A) calcaneal luxation fracture (Sanders type IIIBC) in this patient a vascularized iliac crest autograft harvest by the Pararectus approach was used for reconstructive surgery.ResultsThe DCIA and the deep inferior epigastric vessels (DIEV: vascularizing the rectus abdominis muscle and main pedicle of the inferiorly based rectus abdominis myocutaneous flap) are very close on the lateral and medial border of the external iliac artery, respectively. As a consequence, the retrograde dissection of the DIEV towards the DCIA through the Pararectus approach made the dissection of the vascularized iliac crest more amenable, preserving both the lateral femoral cutaneous and the genitofemoral nerves. Four months after the surgery the patient was able to fully weight-bear in orthopedic shoes. Radiographs and CT scans showed correct hind foot alignment and bony integration of the vascularized iliac crest graft into the residual calcaneal body.ConclusionThe Pararectus approach allowed for secure collection of large vascularized iliac grafts. The presented technique was successful as a salvage procedure in a clinical case with substantial bone loss after an open calcaneal fracture.     

髂骨皮瓣修复手掌部毁损伤

目的 探讨应用吻合旋髂深动脉的髂骨皮瓣一期修复手掌部毁损伤所致多根掌骨复合组织缺损的疗效.方法 1996年以来,对8例手掌部毁损伤所致多根掌骨复合组织缺损,采用吻合旋髂深动脉的髂骨皮瓣重建手掌,并一期修复肌腱、神经.其中2根掌骨缺损3例,3根3例,4根2例.6例肌腱、神经缺损在2～3cm以内,通过短缩植骨,获得肌腱、神经的直接缝合;1例2～5掌骨缺损通过一期"y"形截骨,增加骨承载面,减小了骨瓣切取宽度;1例通过传统骨移植单独重建第一掌骨.获得了拇指单独活动功能;2例合并掌骨头缺损者一期行掌指关节成形术.结果 8例骨皮瓣全部存活.7例伤口 I期愈合,1例因术后皮瓣肿胀,拆除部分缝线,获得Ⅱ期愈合.术后随访1～3年.临床骨愈合时间为3～5周,全部获得骨性愈合.供区无明显并发症.术后手功能评定:优1例,良5例,可1例,差1例;优良率为75%.结论 应用吻合旋髂深动脉的髂骨皮瓣移植重建手掌,并一期修复肌腱和神经,可以较好地恢复手的外形和功能,是手掌毁损伤修复重建的一种有效治疗方法.     

Osteonecrosis of femoral head: Treatment by core decompression and vascular pedicle grafting

Background:

Femoral head-preserving core decompression and bone grafting have shown excellent result in preventing collapse. The use of vascularized grafts have shown better clinical results. The vascular pedicle bone graft is an easy to perform operation and does not require special equipment. We analyzed and report a series of patients of osteonecrosis of femoral head treated by core decompression and vascular pedicle grafting of part of iliac crest based on deep circumflex iliac vessels.

Materials and Methods:

The article comprises of the retrospective study of 31 patients of osteonecrosis of femoral head in stage II and III treated with core decompression and vascular pedicle grafting by using part of iliac crest with deep circumflex iliac vessels from January 1990 to December 2005. The young patients with a mean age 32 years (18–52 years) with a minimum follow-up of five years were included for analysis. Sixteen patients had osteonecrosis following alcohol abuse, 12 patients following corticosteroid consumption, 3 patients had idiopathic osteonecrosis. Nine patients were stage IIB, and 22 patients were stage IIIC according to ARCO''s system. The core decompression and vascular pedicle grafting was performed by anterior approach by using part of iliac crest with deep circumflex iliac vessels.

Results:

Digital subtraction arteriography performed in 9 patients at the end of 12 weeks showed the patency of deep circumflex artery in all cases, and bone scan performed in 6 other patients showed high uptake in the grafted area of the femoral head proving the efficacy of the operative procedure. Out of 31 patients, only one patient progressed to collapse and total joint replacement was advised. At the final follow up period of 5–8 years, Harris Hip Score improved mean ± SD of 28.2 ± 6.4 (p < 0.05). Forty-eight percent of patients had an improvement in Harris Hip Score of more that 28 points.

Conclusion:

The core decompression and vascular pedicle grafting reduces the intraosseous tension to achieve early revascularization of ischemic femoral head. The high percentage of marrow and osteogenic cells survive within a vascularized pedicle graft, which helps in early vascularization and we have been able to achieve good outcome.     

Microvascular myocutaneous flaps in the lumbosacral area using the iliac artery and vein as recipient vessels.

Lumbosacral tissue defects are usually closed with local flaps. Sometimes in large high-situated defects free microvascular flaps are used. However, finding a suitable recipient vessel for microvascular anastomosis in this region is difficult. In large soft-tissue defects high in the lumbar area, closure with a free flap using the iliac artery and vein as recipient vessels channelled from the pelvic cavity to the back through a drill canal in a bone presents an alternative option where other vessels are damaged by radiotherapy or infection. This has been used successfully in two cases.