microvascular flaps used in reconstruction of head and neck

1. GOOD morning

3. Contents
 Introduction
 History
 Advantages and disadvantages
 Planning- instrument setup, vessel preparation
 vascular anastomosis technique
 Anostomosis failure and its treatment
 Recent advances
 Microvascular flaps
 conclusion
 References

4. Introduction
 With the introduction of micro vascular tissue transfer in
the early 1970s, a new universe of reconstructive
possibilities was opened.
 Meanwhile, this technique has proven to be one of the
most important developments for our patients.
 Reconstruction of congenital, developmental, or acquired
head and neck defects remains a significant challenge for
the oral and maxillofacial surgeon.
 In no other anatomic location is the quality of both form
and function of the reconstructed part more critically
appraised by the patient, surgeon, and society.

5.  Reconstruction of head and neck defects was previously
limited by the paucity of local tissues available to
reconstruct complex wounds.
 The development of pedicled flaps during the 1970s and
1980s (deltopectoral, pectoralis major)changed head and
neck surgery and quickly became the workhorse
procedures of the reconstructive surgeon.

6. History
1950Jacobsen and Suarez—
anastomoses in animals
1959 Seidenberg– free jejunum segments to
repair pharyngoesophageal defects.
1973 Daniels and Taylor– “free flap” First free cutaneous
flap
1976 Baker and Panje– first free flap in head and neck cancer
reconstruction Groin flap pedicled on the circumflex iliac
artery

7. Advantages of free tissue
transfer
 Two team approach
 Improved vascularity and wound healing
 Low rate of resorption
 Defect size of little consequence
 Potential for sensory and motor innervation
 Permits use of osseointegrated implants

8.  Wide variety of available tissue types
 Large amount of composite tissue
 Tailored to match defect
 Wide range of skin
characteristics
 More efficient use of
harvested tissue
 Immediate reconstruction

9. THE ADVANTAGES OF MICROVASCULAR FREE FLAPS
Includes:
(1) predictable composite tissue transfer
from a variety of donor sites at a single stage
(immediate reconstruction);
(2) radiation tolerance; and
(3) minimal donor site morbidity.
 It has been shown to carry success rates of greater than 90%
in experienced hands
Oral Maxillofacial Surg Clin N Am 20 (2008) 521–526

10. The shortcomings of Pedicled flaps :
(1) the pedicled transfer of bone-containing soft
tissue flaps is unpredictable and limited because
of extreme arcs of rotation;
(2) large, axial pattern rotational flaps, such as the
pectoralis major myocutaneous flap, commonly
result in unsightly contours and an unfavorable
donor site defect; and
(3) the use in midface and upper facial reconstruction is
limited.

12. General consideration
 Includes:
1. Patient age,
2. Tobacco use,
3. Diabetes,
4. Prior radiation, and
5. prior operative procedures.

13. PLANNING FOR MICROVASCULAR
SURGERY
1. Vascular status: selection of proper artery and vein: may
require angiographic imaging/Duplex colour-flow Doppler
2. Wide exposure: Microsurgery is extremely difficult to
perform deep in the neck without adequate access
3.Donor site: functional and cosmetic morbidity
4. Patient: Medical and oncologic status

14. INSTRUMENT SETUP :
Baby satinsky
vascular clamp

15. VESSEL PREPARATION
 Arteries need to have strong pulsatile flow—cut until
it flows.
 Cut back beyond branches or ligate them if sufficiently
distant from the anastomosis site.
 Intimal inspection
 Dilation
 Removing the adventitia

16. IRRADIATED VESSELS
 Technically more difficult—effects appear specific
to arteries
 Vessel wall fibrosis, increased wall thickness, more
intimal dehiscence
 No reported difference in outcome of microvascular
anastomoses (Nahabedian MY, et al., 2004, Kroll SS, et
al 1998)
 Microvascular anastomoses tolerate XRT well long-
term (Foote RL., et al., 1994)
 Require careful handling, cut off clot (teasing
thrombi may denude vessel wall—”sticky” walls),
smaller suture, needle introduced from lumen to
outside wall (to pin intima to wall)

17. MICROVASCULAR ANASTOMOSIS
 Prepare vessels
 Evaluate vessel geometry
 Trim, irrigate, dilate
 Partial flap insetting (bony cuts and plating
done at donor bed, if necessary)
 Arterial vs. venous anastomosis first with
early or delayed unclamping of first vessel
showed no difference. (Braun, et al., 2003)
 Anastomosis of remaining vessel
 Complete flap insetting

18. MICROVASCULAR SURGICAL
TECHNIQUE
 Trim adventitia
 2-3mm
 Gentle handling (no full-
thickness)
 Trim free edge, if needed
 Dissect vessels from
surrounding tissues
 Irrigate and dilate
 Heparinized saline
 Mechanical dilation (1 ½
times normal –paralyses
smooth muscle)
 Chemical dilation, if
necessary
 Suturing

19. MICROVASCULAR SUTURE
TECHNIQUE 3 guide sutures (120 degrees
apart)
 Perpendicular piercing
 Entry point 2x thickness of
vessel from cut end
 Equal bites on either side
 Microforceps in lumen vs.
retracting adventitia
 Pull needle through in
circular motion
 Surgeon’s knot with guide
sutures, simple for others
 Avoid backwalling—2
bites/irrigation

20. SUTURE TECHNIQUE

21. Vessel size mismatch
 Laminar flow vs. turbulent flow
 <2:1 – dilation, suture technique
 >2:1, <3:1 – beveling or spatulation (no more than
30 degrees to avoid turbulence)
 >3:1 – end-to-side

22. End-to-end vs. End-to-side
 Recent reports indicate end-to-side without
increase in flap loss or blood flow rate.
 End-to-side overcomes size discrepancy, avoids
vessel retraction, and IJ may act as venous siphon.
 End-to-side felt best when angle is less than 60
degrees (minimize turbulence)
 Vessel incision should be elliptical, not slit
 Can use continuous suture technique

23. End-to-side Anastomosis

24. Continuous suture technique
 May significantly narrow anastomosis
 May be used on vessels >2.5 mm
 Decreases anastomosis time by up to 50%
 Decreases anastomosis leakage
 Most commonly used for end-to-side anastomoses
with large vessels

25. MECHANICAL ANASTOMOSIS Devices
 Clips
 Coupler
 Laser
 Results
 Increased efficiency and speed,
use in difficult areas
 Patency rates at least equal to
hand-sewn (Shindo, et al 1996, De
Lorenzi, et al 2002)
 Can be used for end-to-end or
end-to-side (DeLacure, et al 1999)
 Poorer outcome with arterial
anastomosis—20-25% failure
(Shindo, et al 1996, Ahn, et al 1994)

27. VEIN GRAFTS
 Used in situation where pedicle is not long enough for
tension-free anastomosis
 Usually harvested from lower extremity (saphenous
system)
 Valve orientation is necessary
 Avoid anastomosis at level of vein valve
 Keep clamps in place until both anastomoses sewn
 Prognosis for success controversial (Jones NF, et al., 1996,
German, et al. 1996)

28. Anastomotic failure
 93-95% success rate expected
 Venous thrombosis:Arterial thrombosis 4:1,
ateriovenous loop, tobacco use significant factors
(Nahabedian M., et al, 2004) Tobacco use as contribution
controversial (4/5 failures in Nahabedian study - venous
thrombosis)
 Age, prior irradiation, DM (well-controlled), method of
anastomosis, timing, vein graft, and specific
arteries/veins not felt to contribute to failure rate

29. Anastomotic Failure--timeline
 15-20 minutes
 <72 hours
 5-7 days
 >8 days
 Thin vs. thick flaps

30. Thrombus formation
 Injury to endothelium and media of vessel
 Mechanical vs. thermal
 Error in suture placement
 Backwall or loose sutures
 Edges not well-aligned (most common in veins—most
common site of thrombus)
 Intimal discontinuity with exposure of media
 Oblique sutures, large needles, tight knots
 Infection

31. VESSEL SPASM
 Causes
 Trauma
 Contact with blood
 Vasoconstrictive drugs
 Phenylephrine--dose causing 30% increase in arterial
pressure shows no effect on flap circulation (Banic A, et al.,
1999)
 Nicotine
 Temperature, drying
 Treatment
 Warmth
 Xylocaine
 Papavarine, thorazine
 Volume repletion

32. Treatment for anastomotic failure
 Revision of anastomoses
 Exploration of wound
 Wound care
 Statistics
 Revisions successful in 50%
 Revisions less successful after first 24-48hr
 >6 hrs of ischemia leads to poor survival
 12 hrs of ischemia leads to “no-flow” phenomenon
 After 5 days almost all flaps in rabbit model survived with loss of
artery or vein (but not both)—this is rational for other modalities
after 48 hours

33. Post-operative care
 Attention to wound care
 Flap monitoring
 Nothing around neck that might compress pedicle
 Antibiotics
 No pressure/cooling of flap

34. Flap monitoring
 Clinical –”flap checks”
 Most commonly used
 Warmth
 Color
 Pin prick
 Wound monitoring (hematoma, fistula)
 Mechanical
 Doppler
 Implanted vs. external vs. color flow

35. Clinical flap monitoring
 Normal exam:
 Warm, good color, pinprick slightly delayed with bright
red blood
 Venous occlusion (delayed):
 Edema, mottled/purple/petechiae, tense
 Pinprick – immediate dark blood, won’t stop
 Arterial occlusion (usually <72hr):
 temperature, turgor
 Pale
 Pinprick—little bleeding, very delayed

36. Mechanical flap monitoring
 Doppler
 External
 Implanted
 Buried flaps
 80-100% salvage
(Disa J, et al 1999)
 Color flow

37. Recent Advances in
Microsurgery

38. TOMS-Three Dimensional On-Screen Microsurgery
System
 It facilitates three dimensional visualization of (micro)
surgical field on a video monitor, without need to visualize
physically through the microscope.
 It provides a clear stereoscopic view with accurate sense of
depth perception.
HDTV single camera 3D system
 This involves a high definition television attached to the
microscope which enables three dimensional visualization
and documentation as well.

39.  SUPERMICROSURGERY
 The highly challenging task of anastomosis of very small vessels
(<0.3 mm) is now possible with the assistance of modern optical
equipments. This is known as supermicrosurgery.
 It has been used in the anastomosis of perforator flaps.
TRANS ORAL LASER MICROSURGERY (TLM)
 It is a recent type of minimally invasive surgery for oral
cancers, especially in laryngeal cancer.
 It employs CO2 laser via endoscopic approach.
 TLM follows an incisional resection technique under microscopic
guidance.
 The dissection proceeds gradually bit by bit allowing the operator
to precisely follow the anatomical interface between tumor and
normal tissue.
 It thus facilitates a greater preservation of normal tissue structure
and function .

40. ELECTROMICROSURGERY
 This modality is used in cosmetic procedures like the destruction
of feeding vessels in a skin tag, warts, and spider naevi.
 In it under the guidance of a magnifying lamp, the tip of the finest
smallest probe possible, about the size of an eyelash is introduced
along the line of a capillary and a tiny energy current is
discharged.
MOHS MICROGRAPHIC SURGERY
 This is a highly specialized surgical technique to treat certain
types of skin cancers. In it, the skin cancer is removed a thin
layer at a time with a very small margin of healthy skin around it.
 The resected specimen is immediately evaluated under
microscope to find out positive margins.
 The corresponding area of apparently healthy skin is then
resected.
 The entire process is repeated until no residual tumor is left
behind .

44. RADIAL FOREARM FLAP
 In 1978, a fasciocutaneous free flap from the volar aspect of
the forearm and pedicled on the radial artery was first used
in China. When this so called “Chinese flap”, was originally
described by Yang et al. in 1981
 Cheng used this flap for tongue reconstruction
 Hatoko et al. and Chen et al. favored the forearm flap for
defect coverage of the hard and soft palate and thus
proposed this flap for rehabilitation of the cleft lip and
palate patient.
 The forearm flap was used as a tubed flap to reestablish
phonation ability or deglutition by inserting it in defects of
the hypopharynx, trachea, or esophagus.

45. FLAP RAISING
 Preoperative management:
 performed to assess the adequacy of the circulation of the
hand (especially the thumb) through the ulnar artery alone
after sacrifice of the radial artery. (allen test)

50. -distal flap border is placed 3 cm proximal to the wrist
-the ulnar margin of the flap is outlined over the flexor carpi ulnaris muscle
-radial flap margin is placed over the brachioradialis muscle
-For exposure of the proximal vascular pedicle, a wavy-line incision helps to reduce
postoperative scar shrinkage.

52. -To prevent using a false dissection plane above the fascia, incise the fascia until
the underlying muscle becomes clearlyvisible.
-Do not dissect deep to the flexor carpi ulnaris muscle to prevent injury of the
ulnaris artery.
-As a variation, the ulnaris artery can run superficial to the muscle (the ulnaris
pulse can be palpated).
-If the ulnar artery is violated, raise an ulnaris flap instead of using the radial
vessels.

53. Do not remove the paratenon completely because this will lead to wound-healing
disturbances.
Fascia and paratenon can best be separated using a sharp scalpel.

54. the strong tendon of the flexor carpi radialis muscle is reached
and subsequently isolated from the forearm fascia in its distal
portion.

55. Directly radial to this tendon, the radial artery is palpated, which runs into the septum
between the flexor carpi radialis and brachioradialis muscle.
this septum is opened and a short segment of the radial artery is exposed.
the superficial branch of the radial nerve is identified over the tendon of the
brachioradialis muscle and preserved

56. The radial artery is divided at the distal border of the flap

57. In this step ,Injuring the superficial branch of the radial nerve is easily possible.
In slim patients, the location of the nerve can be palpated through the skin.
Including the cephalic vein can lead to damage of the superficial branch of the radial nerve
with subsequent numbness at the dorsum of the thumb and index finger.

58. Injuring the vascular pedicle is possible in this step; retract the brachioradialis muscle
for dissection of the pedicle.
The fascia is incised, keeping a safe distance from the radial artery, and the tendon of the
brachioradialis muscle is exposed and retracted laterally.
The intermuscular septum containing the radial artery is separated from the
brachioradialis muscle.

60. For dissection of the pedicle, the skin incision is made at the proximal border of the
flap
A wavy skin incision is made to expose the proximal segment of the vascular
pedicle

61. The forearm fascia is now incised between the bellies of the brachioradialis and flexor
Digitorum muscles, and the vascular pedicle is exposed by retracting the
brachioradialis muscle

62. The vascular pedicle is traced proximally so that sufficient length for a safe
anastomosis is obtained.

67. Advantages
 thin, pliable, and mostly hairless fasciocutaneous flap,
having great value for reconstructions in the head and neck
region, especially in the oral cavity.
 high caliber of the vessels (artery 2–3 mm, cephalic vein 3–4
mm, deep veins 1–3 mm) and the long vascular pedicle and
variability in flap perfusion (ortho- and retrograde flow,
venous drainage via the superficial or deep system) are of
considerable help when constructing anastomoses.

68. Disadvantages
 Blood supply to the thumb and index finger can totally
depend on the integrity of the radial artery if two
anatomical variations coexist:
 (1) if there are no branches of the superficial palmar arch to
the index finger and thumb,
 (2) if there is no anastomosis between the deep and
superficial palmar arch ( allen test to be performed)
 The appearance of the donor site, which is located in an
esthetically exposed region
 Edema formation, reduced strength and extension of the
hand, loss of sensation because of injury of the superficial
branches of the radial nerve, and cold intolerance.

70.  Using the tibia of sheep, Meland and coworkers have
found considerable weakness and loss of stability of
the bone even if only small amounts of the cortical
bone have been removed .
 Therefore and because other flaps are available that
provide much more bone material to be raised, the
osteocutaneous forearm flap cannot be considered a
method of first choice for mandible reconstruction.

77. Lateral arm flap

78. introduction
 The first septocutaneous flap was originally introduced
in 1982 by Song and coworkers and 2 years later was
described in more detail by Katsaros et al.
 Similar to the radial forearm flap, the lateral upperarm
flap is relatively thin, but limited in width and can be
transferred together with a segment of bone, muscle,
or sensory nerves.
 The flap, which is raised at the lateral aspect of the
upper arm, is perfused by the terminal branches of the
profunda brachii artery.

79. Patient Positioning
 The upper arm is disinfected completely from the
shoulder and axilla down to the distal forearm and
brought into an abduced position.
 The elbow is moderately flexed. In this position, flap
raising can be carried out simultaneously to tumor
resection in the head and neck area.
 No specific preoperative measures are necessary for
elevating the lateral arm flap, and there is no need to
use a tourniquet.

80. Standard Flap Design
 The flap dimensions vary between 7 and 12 cm in
length and 5–6 cm in width. The central axis of the
skin island lies over the septum between the brachial
and triceps muscle (lateral intermuscular septum),
which is represented by the interconnection of the
lateral epicondyle and the insertion of the deltoid
muscle.
 The skin paddle covers the brachial and part of the
biceps muscle anterior and the lateral head of the
triceps muscle posterior to the septum with a
maximum width of 7 cm.

84. For most indications, the flap dimensions vary between 7 and 12 cm in ength and 5–
6 cm in width.
The central axis of the skin island lies over the septum between the brachial and
triceps muscle

85. the skin incision is made perpendicularly through the subcutaneous fatty tissue until
the brachial fascia is reached.

87. the dissection proceeds bluntly in an anterior direction until the lateral intermuscular
septum is reached.
This septum separates the triceps from the brachial muscle

89. In the subfascial plane, the flap is now undermined until the anterior aspect of the
lateral intermuscular septum has been reached.

91. -Before the septum is incised distally, the strong radial nerve is palpated anterior to
the septum between the brachioradial and brachial muscle.
-The nerve is exposed at the distal third of the upper arm by careful and blunt
separation of the muscle fibers.

92. The intermuscular septum is perpendicularly incised at the distal flap
pole to the level of the periosteum

97. ADVANTAGES
 good color match and similar texture, the flap is
suitable for defect coverage in the face and neck
DISADVANTAGES
limited length of the pedicle and the small diameter of
the vessels, so that anastomoses can be difficult,
especially following radical neck dissection

101.  The first microvascular bone transfer was performed
by Taylor and coworkers, who used a vascularized
myoosseous segment of the fibula for treatment of a
post-traumatic defect of the tibia in 1975.
 Since this first description, the primary indications for
the fibular bone flap have been reconstructions of
extended bone defects in the extremities by using a
posterior approach for flap harvesting.

102.  Whereas these first transfers of the fibula were performed
without including a skin paddle, Chen and Yan were the
first to report an osteocutaneous fibula flap in 1983
 This extension of flap raising became possible following
the proposal of Gilbert to use a lateral approach for
harvesting the bone flap, which was easier to perform and
allowed for visualization of the cutaneous branches of the
peroneal artery.
 A valuable extension of the indicational spectrum of the
fibular flap was achieved by Hidalgo, who performed the
first lower-jaw reconstruction in 1989 using osteotomies to
mimic the shape of nearly a whole mandible .
 By inclusion of the soleus muscle, which then was
connected to motor branches at the recipient site,
restoration of motor function was achieved.

103. Typical MR angiogram of
bilateral lower extremities
used as preoperative
screening to identify any
vascular
anomalies.

104. procedure
 The lateral approach to the fibula for free flap harvest was
described by Gilbert in 1979 and reiterated by Flemming and
colleagues in 1990.
 The donor leg should be prepped and draped circumferentiall
from the toes to the hip and the knee flexed at a 90 angle.
 The lateral epicondyle of the ankle and the fibular head are
palpated and marked, and a line between these points is draw
that approximates the position of the posterior crural septum.
 The proximal and distal 6 to 7 cm of the fibula are identified to
be preserved.

109.  incision is made in the skin along the peroneus longus
muscle, keeping a distance of 2 cm from the posterior
intermuscular septum, which easily can be palpated
posterior to the muscle.

110. carefully separating the fascia from the peroneal muscles and blunt dissection in
the posterior direction.
Once the perforator is identified, the peroneal muscles are retracted anteriorly,
and the lateral margin of fibula is palpated

112.  the posterior intermuscular septum is incised sharply
along the lateral margin of the fibula.

113.  strong attachment of the soleus and flexor hallucis
muscle to the fibula is divided carefully with scissors
proximal to the skin paddle.

114.  muscular branches of the peroneal vessels are exposed.

115.  Dissection must be performed carefully to prevent any
bleeding from the peroneal vessels.
 In the perfused leg, the artery can easily be palpated at
the posterior aspect of the fibula

116.  A vessel loop is placed around the peroneal vessels, and
the branches to the surrounding muscles and the fibular
bone are clipped and transected.

117. The distal osteotomy is now
performed with an oscillating
saw, keeping a distance of 8 cm
to the ankle.
proximal osteotomy is carried
out in the same fashion. The
longer the bone segment built
for reconstruction, the shorter
the vascular pedicle.
In the standard situation, at
least 10 cm of pedicle length is
obtained using this technique.

119.  After dividing the interosseous membrane completely, the
bone segment can be retracted laterally, and the peroneal
vessels are exposed by bluntly separating the fibers of the
tibialis posterior muscle at the distal osteotomy.

120.  The tibialis posterior muscle is divided where the V-like
fibers meet at the midline, so that a cuff of muscle is left
attached to the fibular bone segment.

121.  To obtain access to the flexor hallucis longus muscle from both
sides, the skin paddle is now circumcised to the level of the
crural fascia, which is included in the skin paddle to protect the
perforating vessel.
 The fascia is circumcised using scissors, keeping a safe distance
from the cutaneous vessel.

124.  The flap is now ready for microvascular transfer.
 Direct wound closure in the distal third of the lower leg
is achieved if the width of the skin flap does not exceed 3
cm; in all other cases, a split-thickness skin graft is used
to cover the donor-site defect.

128. Advantages
 The fibula is the longest bone flap available and can be
transferred as a bone flap or in combination with one or
two skin paddles.
 to replacement of the whole mandible, including closure of
large perforating defects of the oral cavity.
 The quality of the thin and pliable skin paddle is
comparable to the radial forearm skin, and the 3–5 cm
broad septum provides good flexibility to the skin island,
which can be brought into the oral cavity for lining without
tension.

129.  The fibula is a non–weight-bearing bone. The entire
length of the fibula can be harvested except for the
most proximal and distal 6 to 7 cm to preserve the
integrity of the knee and ankle joints.
 This harvest usually provides 22 to 25 cm of bone with
an average diameter of 14 to 15 mm.

130. disadvantage
 The unreliability of the skin,supplythe variability of
the cutaneous perforating vessels and the limited size
of the skin island.
 Loss of the skin island must be considered in 7–9 % of
the cases.

140. Introduction
 The possibility of transferring bone blocks of the ileum as
parts of composite flaps from the groin donor site was
described in anatomical studies by Taylor et al. in 1979.
 Whereas the blood supply of the SCIA was excellent to the
skin, the bone blocks of the iliac crest were only perfused
marginally by these vessels.
 The first transfer of the iliac crest bone, using the deep
circumflex iliac artery (DCIA) as the vascular pedicle.

141.  Since these first reports, the iliac crest has proved to be a
useful and reliable donor site, and because of its
anatomical shape it is ideally suited for the harvest of bone
flaps to reconstruct defects of up to half a mandible.
 As a result of the high amount of bone available,
enosseous dental implants can be inserted without
problems, making the iliac crest the donor site of first
choice for functional masticatory reconstruction of the
mandible and maxilla.
 In addition to the decreased bulk, covering the iliac crest
with the internal oblique muscle is advantageous for
prosthetic rehabilitation following the insertion of
enosseous dental implants.

142. DEEP CIRCUMFLEX ILIAC ARTERY
 The most reliable periosteal and endosteal blood supply
to the iliac bone is from the deep circumflex iliac artery
and vein (DCIA and DCIV).
 The DCIA originates from the external iliac artery
cephalad to the inguinal ligament and courses toward
the ilium between the transversalis and iliacus fascia to
a point 10 cm posterior to the Anterior Superior Iliac
Spine (ASIS).
 Along this path it gives off the ascending branch and
osseous perforators

144. the incision is outlined 2 cm superior to the
connection of the pubic tubercule and the
ASIS, starting just lateral to the pulse of the
femoral artery.
the incision is drawn directly above the
curvature of the iliac crest far enough
distally to allow for easy detachment of
the gluteus muscles.

145. The internal oblique muscle is transected
with scissors 2 cm superior to the
connection of the ASIS and the pubic
tubercule, and loose fatty tissue become
visible, covering the thin transversalis fascia.
A vessel loop is placed around the artery,
which is accompanied by two veins, and the
pedicle is dissected along its course to the
ASIS.

147.  Once the vascular pedicle has been isolated just medial to
the ASIS, the skin incision is continued along the iliac crest
to the level of the external oblique muscle.

148.  The lateral rim of the iliac crest is palpated, and the
muscles are now transected at the gluteal aspect of the
pelvis.

150.  Keeping a distance of 2 cm to the inner rim of the iliac crest,
the abdominal muscles are transected with scissors from a
caudal to a cranial direction, and further muscular branches to
the internal oblique muscle are cauterized or ligated.
 The pulse of the DCIA is palpated at the inner surface of the
pelvic curvature 1–3 cm inferior to the inner rim and therefore
can easily be preserved during transection of the muscles.

152.  The course of the DCIA is palpated in the groove formed
by the transversus and iliacus muscle, and the iliacus
muscle is sharply transected to the periosteum about 1–2
cm below the artery.

153.  Muscular detachment is continued at the ASIS, where the
sartorius muscle is transected directly at its origin from the
bone.
 The vascular pedicle, which is enveloped in the fascia
between the iliacus and transversus muscle, must be carefully
protected in the region of the ASIS when transecting the
muscles.

154.  Osteotomy begins distally at the iliac crest after
transection of the abdominal muscles covering the bone.
 The vascular pedicle is transected and ligated at the distal
osteotomy.

155.  If a mandibular angle and ramus has to be built, the
osteotomy is continued parallel to the anterior rim of the
pelvis up to a depth of 6–8 cm.

156.  The osteotomized bone segment is elevated, and
residual muscle fibers are transected.

158.  First, the iliacus muscle is attached to the transversus muscle
using multiple and deep sutures, which additionally can be
placed through drill holes along the cut margin of the pelvic
bone.
 Next, the internal and external oblique muscles are
approximated to the tensor and gluteus muscles.
 Finally, the subcutaneous fatty tissue and the skin are closed in
layers.

161. Advantage
 Because of the extensive amount of bone and the various
possibilitiesfor designing the bone flap, the iliac crest is
supposed to be the ideal donor site for mandible
reconstruction; moreover, the flap has the potential to be
used for other osseous defects at the maxilla, skull
base, tibia, metacarpus, and many other parts of the
skeleton.
 the donor-site morbidity normally is low, even if extensive
bone flaps have been removed, including the ASIS.

162.  The length of the vascular pedicle is limited to about 7
cm, sometimes making anastomosis difficult,
especially after radical neck dissection.
 In these cases, interpositional vein grafts have to be
used to lengthen the pedicle.

163. conclusion

164. conclusion
 Microvascular free bone flaps are a modern means of restoring
bone-containing composite defects of the maxillofacial region.
The techniques are simple and reliable.
 The results are reproducible and offer significant advantages over
staged mandibular reconstruction. In particular, these
techniques decrease costs and provide a means of rapid
definitive reconstruction.
 Patients avoid multiple surgical procedures with immediate
reconstruction that allows them to return to productive lives in
society. Proper selection of an appropriate donor site and
appropriate preoperative planning facilitate application of these
techniques in an expedient manner.
 Microvascular free bone flap reconstruction should be
considered for all patients with composite bone-containing
defects of the maxillofacial region.

165. References
 K.-D. Wolff · F. Hِ lzle Raising of Microvascular Flaps-A Systematic Approach
 Atlas Oral Maxillofacial Surg Clin N Am 15 (2007) 13–22: The Fibula Free Flap in
Maxillary Reconstruction
 Atlas Oral Maxillofacial Surg Clin N Am 14 (2006) 185–189: The Anterolateral Thigh
Flap in Mandibular Reconstruction
 Atlas Oral Maxillofacial Surg Clin N Am 14 (2006) 143–150: Fibula Free Flap in
Mandibular Reconstruction Rui Fernandes, DMD, MD
 Atlas Oral Maxillofacial Surg Clin N Am 14 (2006) 161–170 : Iliac Crest Grafting for
Mandibular Reconstruction
 Atlas Oral Maxillofacial Surg Clin N Am 14 (2006) 151–159 : Deep Circumflex Iliac
Artery Free Flap in Mandible Reconstruction
 Atlas Oral Maxillofacial Surg Clin N Am 13 (2005) 151–171 : Microvascular Free Bone
Flaps
 Craniofacial Surgery. Vol. 2, No. 6-1, 2014, pp. 1-5. Vascularized free fibula flap for
reconstruction of mandibular defects

166.  Turrà et al. BMC Surgery 2013, 13(Suppl 2):S27: Microvascular
free-flap transfer for head and neck reconstruction in elderly
patients
 J Oral Maxillofac Surg 63:220-224, 2005: The Use of Free
Fibular Flap for Functional Mandibular Reconstruction.
 British Journal of Oral and Maxillofacial Surgery 53 (2015) 49–
53: Surgical planning and microvascular reconstruction of the
mandible with a fibular flap using computer-aided design, rapid
prototype modelling, and precontoured titanium reconstruction
plates: a prospective study
 Atlas Oral Maxillofacial Surg Clin N Am 15 (2007) 7–12 :
Reconstruction of Maxillary Defects with the Radial Forearm
Free Flap