single osteotomized iliac crest free flap in anterior mandible reconstruction

SINGLE OSTEOTOMIZED ILIAC CREST FREE FLAP IN ANTERIORMANDIBLE RECONSTRUCTION

OMER OZKAN, M.D.*

While the iliac crest flap provides a natural contour for the lateral segment of the mandible, for the anterior segment en bloc, the use of the iliacgraft, even harvested in a V shape, fails to yield a three-dimensional natural-shaped reconstruction. In this report, we present our experiencewith reconstruction of the anterior segment of the mandible using a single osteotomized free iliac crest flap in 5 patients. The study comprised4 male patients and 1 female patient, their ages ranging between 34�82 years. In all patients, composite iliac osteomusculocutaneous flapswere harvested based on the deep circumflex iliac artery in the standard manner, and the bony segment of the flap was divided into twosegments, performing a single osteotomy. The fixation of bone segments was performed in new positions, sliding the segments in differentplanes to provide the original shape of the resected mandible segment, and in a manner appropriate to the defect. The overall flap successrate was 100%. In no cases were wound infections or hematomas observed. X-rays showed bone healing without resorption. In conclusion,the use of a single osteotomy for an iliac crest flap in the reconstruction of the anterior segment of the mandible is a simple and safeprocedure, and provides a natural and acceptable jaw appearance. The risk of devascularization is quite low when compared with the multipleosteotomy procedure, and it does not need to be fixed with complex devices such as reconstruction plates or external fixators. ª 2006 Wiley-Liss, Inc. Microsurgery 26: 93�99, 2006.

The most reliable soft-tissue coverage and bonyreconstruction for the mandible are provided by freeflaps, which allow most reconstruction needs to be metwithout restriction. Osteocutaneous flaps, includingvascularized ilium, scapula, radius, and fibula flaps,promote optimal configuration for solving specificcomposite tissue defects with acceptable aesthetic andfunctional results.1�6

The vascularized iliac bone graft, based on the deepcircumflex iliac artery, has been used for jaw recon-struction since 1979.7 A sequence of modifications hasbeen proposed to improve the consistency of the pedicle,the ability to reconstruct three-dimensional defects, thebulk of the bony segment and soft-tissue component,and donor-site morbidity.8�11

In order to improve the contour of the recon-structed jaw in large resections, the transferred boneusually needs to be osteotomized.2,6,8,9,12�16 Althoughmultiple segmental osteotomies for the fibula flap canbe safely performed depending on its segmental bloodsupply,4�6,15,16 there have been few reports to dateregarding the bicortical osteotomized vascularized iliacflap.2,8,9,12 While the iliac crest flap provides a naturalcontour for the lateral segment of the mandible, forthe anterior segment en bloc, the use of the iliac graft,even harvested or designed in a V shape,3 fails to yield

a three-dimensional natural-shaped reconstruction. Inthe case of donor-area selection for the flap by pa-tients, and of the surgeon having experience with theflap, the iliac crest flap could be the first choice formandible reconstruction.3,8,9,14,17,18 Since its manipu-lation is not easy and the periosteal branches to thebone are not macroscopically obvious, using multipleosteotomies to divide the bone into multiple smallsegments in the iliac crest flap may not be as safe as inthe fibula flap. In this report, we present our experi-ence with the reconstruction of the anterior mandibleusing a single osteotomized free iliac crest flap in aseries of five patients. After modification in the inset ofthe flap using only a single osteotomy, the bone per-mitted more natural contouring to the shape of theanterior mandible defect.

MATERIALS AND METHODS

Between 2001�2004, surgery was performed on atotal of 5 patients with defects of the anterior mandible(Table 1). There were 4 male patients and 1 femalepatient, whose ages ranged from 34�82 years (meanage, 58 years). Of these, 3 patients had defects afterresection due to a primary mandible tumor, one haddefects after wide resection due to invasive lip cancer,and the remaining patient had defects after crush injurydue to a close-range gunshot wound. In all cases, theiliac crest flap was used for osteomusculocutaneouscomposition. In most cases, basic elements influencedthe decision to use the iliac crest flap, i.e., the prefer-ence of the patients mainly based on the well-concealednature of donor site, and our experiences with the flap.In all patients, the bony segment of the iliac crest flapwas divided into two segments, performing a single

Department of Plastic and Reconstructive Surgery, Faculty of Medicine,Akdeniz University, Antalya, Turkey

Grant sponsor: Akdeniz University Scientific Research Projects Unit.

*Correspondence to: Dr. Omer Ozkan, Plastik ve Rekonstruktif Cerrahi Ana-bilim Dal, Akdeniz Universitesi Hastanesi, B Blok Kat 5, 07059 Antalya,Turkey. E-mail: [email protected]

Received 27 March 2005; Accepted 12 July 2005

DOI: 10.1002/micr.20182

ª 2006 Wiley-Liss, Inc.

osteotomy. While 3 flaps were used for anterior defectsof the mandible, 2 flaps were used to reconstructanterior defects laterally extended to the mandible an-gle that could not be reconstructed with a straight-shaped bone.

In all cases, composite iliac osteomusculocutaneousflaps were harvested based on the deep circumflex iliacartery in the standard manner. The size of the bony partwas measured, and a paper template was used to per-form the osteotomy. The size of each segment was cal-culated, and the site for the osteotomy was identified. Inthis location, the periosteum of the inner cortex wasstripped at an approximately 10-mm length. A small,malleable retractor was installed to protect the perios-teum and the vascular pedicle, and a vertical osteotomywas performed using an oscillating saw. Before the fix-ation of the osteotomized segments in their new posi-tions, in order to allow good contact and a smoothsurface between these segments, a small wedge excisionis required (Fig. 1). It is better to perform these wedgeexcisions gradually, and to check the shape of the boneby comparing this with the template. The fixation ofbone segments was performed in new positions, slidingthe segments in different planes to provide the originalshape of the resected mandible segment, in a mannerappropriate to the defect (Fig. 1). In 3 patients, platesand screws were used to fix the segments. In theremaining 2 patients, interosseous wires were used forthis purpose, depending on the economical situation ofthe patients. Active bleeding from the osteotomizededges of the bone immediately after performing theanastomoses was considered confirmation of the vas-cularity of all segments. The facial artery was used as therecipient artery in 4 patients, and the superior thyroidartery was used in the remaining one. The concomitantveins of these arteries, the external jugular vein, andbranches of the internal jugular vein were the recipientvein sources in different cases, based on the recipientartery used and the number of veins available in the flap.All anastomoses were performed without using any in-terpositional vein grafts. Postoperatively, patients werefollowed up clinically, and panorex radiographs weretaken.

PATIENT REPORTS

Patient 3

An 82-year-old man presented with a squamous-cellcarcinoma of the lower lip, which involved the anteriorfloor of the mouth with an extension to the mandible(Fig. 2A). There were multiple palpable mobile lymph-adenopathies of less than 1 cm in the neck bilaterally.The patient had chronic obstructive lung disease andhypertension. Because the patient refused neck dissec-

Table 1. Patient Summary

Patient Age Sex Cause Length of segments Complications

1 59 M Mandible tumor 5 cm, 3 cm None2 51 F Mandible tumor 6 cm, 4 cm None3a 82 M Lower-lip tumor 5 cm, 3 cm Pulmonary insufficiency, prolonged ventilator support4 64 M Mandible tumor 6 cm, 4 cm None5a 34 M Close-range gunshot wound 7 cm, 4 cm None

aCases described in text.

Figure 1. Schematic representations of single full-thickness osteo-

tomized iliac bone of iliac crest flap. Note that single vertical wedge

osteotomy and fixation of bone in different planes provide natural

three-dimensional shape and smooth contour. Arrows show rotation

routes of osteotomized bone segments.

Microsurgery. DOI 10.1002/micr

94 Ozkan

Figure 2. An 82-year-old man with squamous-cell carcinoma of lower lip, which involved anterior floor of mouth with extension to mandible.

A: Preoperative view. B: Intraoperative view after excision. C: Harvested iliac osteomusculocutaneous flap. D: Postoperative anterior-

posterior view at 6 months. E: Postoperative right lateral view at 6 months. F: Panorex radiograph 45 days after surgery.


Single Osteotomized Iliac Crest Free Flap 95

t-


Figure 3. A 34-year-old patient who suffered close-range gunshot blast injury. A: Intraoperative view. B: Iliac crest flap based on its vascular

pedicle. C: Immediate postoperative view. D: X-ray of mandible 1 month postoperatively. E: Anterior view after revisional procedures for lower

lip, including upper-lip switch flap at 12 months. F: Postoperative lateral view at 12 months.

96 Ozkan

ion, only a radical excision of the lesion, including thetotal lower limb and an 8-cm segment of the anteriormandible, was performed (Fig. 2B). The defect wasreconstructed with an iliac osteomusculocutaneous flap(Fig. 2C). The bone was osteotomized into 5-cm and 3-cm segments, and was replaced in the resected man-dibular gap. A skin paddle was inset to resurface theanterior floor of the mouth and lower chin. The patientdeveloped pulmonary insufficiency in the early postop-erative period that resulted in prolonged ventilatorysupport. He remained in the intensive care unit for 5days, and was then observed in a ward, on a broad-spectrum antibiotic regimen. Mobilization and ambu-lation with chest physiotherapy were provided as soonas possible. Eventually, he recovered and was dischargedon postoperative day 20. The flap healed without anyresorption, and yielded an acceptable cosmetic andfunctional outcome (Fig. 2D�F). The patient under-went postoperative radiation therapy for the neck re-gion. Eight months later, the patient suffered an attackof esophagitis and laryngitis due to the radiation ther-apy, finally dying from pulmonary complications.

Patient 5

A 34-year-old man was admitted to our clinic withextensive composite-tissue defects of the lower facecaused by a close-range gunshot blast following a sui-cide attempt. The patient was evaluated in the emer-gency room and remained conscious and alertthroughout. The skeletal structure of the central seg-ment of the mandible was lost. The anterior part of themouth floor and the entire lower lip were defective.First, a tracheostomy was performed, and debridement

of the wound was provided at the time of the initialtriage. One week later, the patient underwent surgery fordefinitive treatment. The wound was redebrided, andboth the soft-tissue and bone defects were exposed (Fig.3A). The right facial artery and vein, and the externaljugular vein, were prepared as recipient vessels. Theright iliac osteomusculocutaneous flap was harvestedwith an 8 · 12 cm skin paddle on its vascular pedicle(Fig. 3B). A transverse osteotomy was made, dividingthe bone into 7-cm and 4-cm segments, based on thecentral mandibular defect, which was 11 cm in length.The shape of the bone was adjusted to the defect bysliding the osteotomized segments into the proper po-sition. The iliac bone was subsequently secured withrigid miniplate fixation, bridging the mandibular defectfor the anterior segment after appropriate debridementof the mandibular edges and periosteal stripping of thefree iliac flap edges. The deep circumflex iliac vessels ofthe iliac flap were anastomosed to the facial vessels. Theskin island of the flap was used to cover the oral floorand lower lip defects (Fig. 3C). Postoperative recoverywas uneventful. Three months later, in order to preventdrooling and to provide a proper shape for the lower lip,flap revision was performed, using an upper-lip switchflap (Abbe flap). Thirteen days later, the flap was di-vided, and revision was completed. An acceptable cos-metic appearance and mouth opening, preventingdrooling, were achieved simultaneously (Fig. 3D,E).Bone healing was uneventful (Fig. 3F).

RESULTS

One flap required reoperation due to vascular com-promise, and this was salvaged with an arterial anasto-mosis revision. Thus, the overall flap success rate was100%. In all cases, the bony segment was used toreconstruct the mandible. The soft tissue was used toreconstruct the tissue defect of the mental region in 3patients, and to reconstruct the entire lower lip, mentalregion, and anterior part of the mouth floor in others.The lengths of bone segments that were osteotomizedranged from 3�7 cm (mean, 4.7 cm). In no cases werewound infections, hematomas, or donor-site herniasobserved. X-rays showed bone healing without resorp-tion. In consideration of economical problems, in noneof the cases were dental implants used. During the fol-low-up periods, ranging from 7 months to 2 years, sec-ondary revisional procedures were performed for 1 case.In all cases, complete healing of the bones was obtainedusing panorex radiographs. One patient developedesophageal and pulmonary complications due to radia-tion therapy and died 8 months postoperatively. An-other patient died because of tumor metastasis 18months later.


Figure 3. Continued.


DISCUSSION

With the introduction of and improvements in clin-ical microvascular tissue transfer, a number of donorsites and their flaps have been proposed for mandibularreconstruction.1�6 The choice of which tissues to usedepends on several factors: location and extension,including the composition of the defect; characteristicsof the flaps in terms of the bone, soft tissue, and pediclebeing reliable and appropriate to the defect; and thesurgeon’s experience with the flap.

Since the first report by Taylor et al. in 1979,7 thefree vascularized iliac osteocutaneous flap based on thedeep circumflex iliac artery has become one of the mostcommonly used flaps for reconstruction of the mandible.Its anatomy, and a sequence of refinements and modi-fications to the techniques, were introduced by severalauthors.8�11 The dominant blood supply of the iliacbone is provided by the deep circumflex iliac artery.7,10

The flap has gained popularity because it has a reliablecutaneous area, and a consistent vascular pedicle with asuitable vessel diameter with acceptable donor-sitemorbidity.3,8�10,14,17�20

The deep circumflex iliac artery originates from theexternal iliac artery immediately proximal to the ingui-nal ligament. The artery courses along the concavity ofthe inner ileum, and emanates muscular, musculocuta-neous, and a series of segmental periosteal bran-ches.2,7,10,17 These periosteal branches enter the iliacbone medially and supply serial vascular territories. Bymeans of this vascular arrangement, it is possible to usethe inner-cortex iliac crest without fear of vascularcompromise. This modification was shown to be usefulin reducing the incidence of hernia and improving pelviccontour by preserving the outer lamella, and in pro-viding a size match between the breadth of the split-cortex bony segment and the intact part of the recon-structed mandible.

Osteotomy of a bone graft in oromandibularreconstruction is of particular importance in improvingthe functional and structural outcome of a recon-struction.2,6,8,12�16 Allowing multiple segmental oste-otomies by means of its segmental vascular supply, thefibular osteocutaneous flap has become widely used forthis purpose.2,4,15,16 Although there are a few reportsregarding osteotomized radial forearm21,22 and scapu-lar ostocutaneous flaps,23 the bone quality of the radialform flap is inferior to that of both the fibular flap andthe iliac crest flap. While the fibular flap can be usedfor mandible reconstruction using multiple osteoto-mies, in terms of patient preference, especially regard-ing the flap donor area (whose location permits easyconcealment) and the experience of the surgeon withthe flap, the iliac crest flap can also be safely and

reliably used as an alternative in mandible reconstruc-tion.3,8,9,14,17,18

Segments of the mandible that help to managereconstruction are classified according to the locationand extension of the defect.3,8,13 In general, anteriormandibular defects are located extending from angle toangle, including symphysis defects. Because of the clearand direct appearance of this segment, its reconstruc-tion requires special attention. Although the iliac boneprovides a natural appearance for the lateral segmentwithout necessitating an osteotomy procedure, its usein the anterior segment requires some manipulations.In the anterior segment, although it seems to possess agood natural appearance of V-shaped bone, this shapeusually provides a contour in the sagittal plane.3 Inorder to obtain a three-dimensional configuration, it isusually necessary to perform a vertical osteotomy toprovide anterior projection. It is obvious that with theosteotomy procedure, the medullary blood supply isdisrupted.21 However, its segmental vascular supplyfrom the main vascular pedicle allows this modificationto be employed safely, as in the fibular flap. In addi-tion, by means of its already curved structure, it issufficient to perform a single osteotomy to obtain anacceptable projection and contour of the anteriormandible, while this can only be achieved with at leasttwo sequential osteotomies in the fibula flap because ofits straight structure. In the literature, in order toachieve an acceptable mandibular contour with theiliac crest flap, multiple closing-wedge osteotomies wereused by several authors.2,6,8,9,12�14 This type of multi-ple osteotomy, involving breaking the bone into aseries of small segments, can potentially damage theblood supply to the bone. Since the periosteal bloodsupply of the bone of the iliac crest flap is not ascertain and macroscopically obvious as that of thebone in the fibular flap, small segments of bone ob-tained after multiple osteotomies of the iliac bone canbe devascularized and act as a nonvascularized graftinstead of vascularized bone. Using only a single os-teotomy, the risk of devascularization of bone seg-ments can be reduced by means of preserving the largesegments that may have a high chance of periostealsupply, minimalizing surgical trauma and manipula-tions and any undue trauma over the bone.

The single closing-wedge osteotomy has already beendescribed for symphysis reconstruction, fixing the bonesegments on the same single plane.3 However, the bestresults for the anterior segment can be obtained byconsidering a three-dimensional view, arranging theosteotomized bones in different planes. Moreover, thebeneficial effect of providing a smooth curve will bemore obvious for defects extending beyond the sym-physis.


98 Ozkan

Reports regarding the fibula,15,16 radius,21,24 andrib25 flaps used as osteotomized flaps showed no detri-mental effects of osteotomy on bone union. The singleosteotomized bone does not require a reconstructionplate, a necessity for multiple osteotomized bones,which represents a particular economic advantage. Nobone-healing problems, including resorption, nonunion,and infection, were encountered in any of our cases.This confirms the finding that any method of fixationyields consistently good results in vascularized bonegrafts.26,27

In conclusion, the use of a single osteotomy for theiliac crest free flap in the reconstruction of the anteriorsegment of the mandible provides a safe and naturalacceptable jaw appearance. Arranging the type of wedgeosteotomy and fixting the bone in a new plane, thenatural curved contour of the iliac crest bone yields asufficient cosmetic outcome without necessitating addi-tional osteotomies and the use of a reconstruction plate,and reduces the risk of devascularization of the bone. Itobviates the many drawbacks in both structural andsurgical dissatisfaction and morbidity that may occur innonosteotomized or multiple osteotomized iliac crestflaps.

ACKNOWLEDGMENTS

This study was supported by the Akdeniz UniversityScientific Research Project Unit. We thank them fortheir support.

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single osteotomized iliac crest free flap in anterior mandible reconstruction

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