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Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al. | ||
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| The deep circumflex artery has now been used as the supplying vessel for the free transfer of iliac bone and overlying skin in 70 patients and for the supply of a free myocutaneous skin flap in another 3 patients. This osteocutaneous graft has been used to reconstruct composite defects of the lower jaw in 42 patients and of the tibia in another 19, as well as to reconstruct the foot in 3, the pelvis in two, the femur in 2, and the hand and humerus in 1 patient each.
When designed on the deep circumflex iliac vessels, the osteocutaneous graft has many attractions. 1. A vast amount of ilium is supplied from its medial cortex by a series of small nutrient branches that enter the bone just below the inner lip of the iliac crest and by a rich lattice of periosteal vessels that drape the iliac fossa. This pattern of supply enables the outer cortex to be removed and shaped without compromise to the blood supply, only the inner cortex to be taken as the graft where desired, and various osteotomies to be performed (directed from the outer cortex) to alter the curvature of the graft to satisfy recipient-site requirements. In this last instance, the blood supply to the distal bone segment is retained by preserving intact the medial periosteum and the soft-tissue attachments along the iliac crest. 2. A large skin flap is provided that is nourished by a series of musculocutaneous perforators. The mobility of the subcutaneous and muscle pedicles allows the skin-flap axis to be rotated to a right angle with respect to the underlying iliac crest. To date, the largest skin flap has measured as 33 x 12 cm. |
3. The pedicle is long (5 to 8 cm) and the vessels are large (1.5 to 4 mm); both facilitate an easy vascular repair and ensure a high patency rate. 4. Soft tissues other than skin can be included in the graft design to reconstruct muscle and ligamentous attachments. This advantage has particular application in repair of the mandible. 5. The donor site is relatively inconspicuous and the hip-contour deformity is remarkably small, considering the large amounts of bone that have been harvested. The main disadvantages of this graft are its color match and its bulk, especially in obese or muscular patients. The skin or subcutaneous tissues, however, can be omitted where appropriate and the attached muscle sealed with a split-thickness skin graft. Alternatively, the skin flap can be thinned at a later stage. In each case, the donor site has been closed as a linear scar. The potential problems are inclusion of too much muscle with the graft and incorrect placement of the axis of the skin flap. It must be remembered that the skin perforators emerge in a row just above the inner lip of the iliac crest. The largest of these, which is usually the termination of the DCIA, usually appears 6 to 8 cm beyond the anterior superior iliac spine. |
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