A new surgical technique for dissecting iliac bone flap with deep iliac circumflex vessel—retrograde anatomical method / 中华显微外科杂志

Objective:To introduce a new surgical procedure for harvesting an iliac bone flap with deep iliac circumflex vessels—"retrograde anatomical method", and report the effect of preliminary application with this procedure.Methods:From June 2018 to May 2021, 15 patients who admitted in the Department of Hand and Microsurgery, Xiangya Hospital of Central South University received surgeries of iliac bone flap with deep iliac circumflex artery by "retrograde anatomical method". During the surgery, appropriate cutaneous perforators or muscular branches were found near the medial side of the iliac bone of iliac tubercle. The branches were dissected from surface inwards to the starting point of deep circumflex iliac blood vessel with microsurgery and micro Schlieren forceps. The iliac bone flap was chiselled out, inserted into femoral head, and then anastomosed with the transverse branches of deep circumflex iliac blood vessel and lateral circumflex femoral blood vessel. All patients were included in the postoperative follow-up at the outpatient clinic to evaluate the preliminary effect of this procedure. Harris scores before and after surgery were assessed with paired t test. P<0.05 was considered statistically significant. Results:The length of iliac bone flap was at 3.0-5.0(4.0±0.5) cm, and the length of vascular pedicle was at 4.0-7.0(5.3±1.0) cm. The time of iliac bone flap harvest was 35-55(45.0±6.1) minutes. During the operation, the success rate of harvesting iliac bone flap with deep iliac circumflex artery was 100%, and blood had oozed out of bone surface before the pedicle of all iliac bone flaps was cut-off. The volume of intraoperative autologous blood transfusion was 100-400(226.7±78.2) ml. One patient suffered from traction injury of lateral femoral cutaneous nerve in the operation. The numbness of anterolateral thigh area occurred on the 1st day after the surgery, and relieved 4 months later. Other 14 patients did not suffer from postoperative numbness in the area of anterolateral thigh. The amount of drainage from donor site for the iliac bone flap was 50-70 ml[(62.7±7.5) ml in average] after surgery. Incisions at the donor sites of iliac bone flap healed in stage I. Postoperative follow-up lasted between 3 months and 3 years. There was no incision hernia and other complication in the donor sites of the iliac bone flap. There was a significant difference in Harris scores between at 9, 12 and 18 months after surgery and that before the surgery, respectively( P<0.05). After 18 months, Harris score were at a better level. Conclusion:The "retrograde anatomical method" can quickly determine the nutrient vessels of an iliac bone flap with deep circumflex iliac vessels. The surgical procedure is relatively simple with safe and reliable anatomy. Donor site damage and postoperative complications are greatly minimised. This surgical technique can be considered to be applied clinically.

Simultaneous innervated and vascularized iliac bone flap for reconstructing mandible and nerve defects / 口腔疾病防治

@#The functional reconstruction of large maxillofacial defects is a major issue in oral and maxillofacial surgery, and autologous bone transplantation is the main method. However, bone is readily absorbed following an autologous bone transplant. Even with vascular anastomosis, spontaneous osteoporosis of transplanted bone is still serious, which affects dental implantation and functional recovery. Therefore, osteoporosis of the grafted bone has become one of the main complications of jaw reconstruction, and there is no preventive measure. The problem that autologous bone with sufficient blood supply cannot avoid osteoporosis suggests that systemic factors such as nerves, which have been neglected in traditional methods, may regulate the internal environment of the transplanted bone. Based on previous studies on the regulation of mesenchymal stem cells by the neural microenvironment, we initiated a new surgical procedure for innervated and vascularized iliac bone flaps based on animal model and cadaver studies. In the innervated and vascularized iliac bone flap, vascular microanastomosis was performed in conjunction with microneuronal anastomosis between the simultaneously harvested ilioinguinal nerve (which innervates the iliac bone and is usually sacrificed and neglected in the conventional vascularized iliac bone flap) and the inferior alveolar nerve proximally and with the mental nerve distally. By conducting clinical retrospective studies and prospective randomized controlled trials, we proved that the novel method of simultaneous innervated iliac bone transplantation can not only prevent bone resorption but also restore the sensation of adjacent soft tissues such as the lip. This may solve the key problems of sensory loss and osteoporosis after mandibular reconstruction, ensure the success of dental implant dentures, and put forward the new concept of "blood supply + innervation" bi-system bone transplantation.

Application of digital surgery in the reconstruction of mandibular composite defects with chimeric deep circumflex iliac artery perforator flap / 口腔疾病防治

Objective@#The purpose of this study was to explore the application value of digital surgery in the reconstruction of mandibular composite defects with a chimeric deep circumflex iliac artery perforator flap (DCIAPF).@*Methods@# Six patients with complex defects within half of the mandible underwent reconstruction using DCIAPF from January 2019 to January 2020 in Shenzhen People’s Hospital. Doppler was used to locate the deep iliac circumflex artery, the range of mandibular osteotomy was designed, and DCIAPF was used to repair the mandibular composite under the guidance of the guide plate during the operation. Twelve months postoperatively, the facial shape, jaw height, and occlusal relationship were evaluated@*Results@#DCIAPF was harvested successfully in 6 patients, and the heights of all alveolar ridges and occlusal function of patients were significantly restored, without pain or snapping in the temporomandibular joint area.@*Conclusion @#The blood supply of DCIAPF is rich, and soft-bone tissue is sufficient for the reconstruction of mandibular composite defects. Combined with digital surgery, the accuracy and safety are improved.

Application of ilioinguinal chimeric perforator bone flap to repair the bone and soft tissue defect of limbs / 中华显微外科杂志

Objective To evaluate the method and clinical efficacy of utilizing ilioinguinal chimeric perforator bone flap to repair bone and soft tissue defects of limb.Methods From May,2004 to February,2018,there were 11 patients who were diagnosed as bone and soft tissue defect in the upper or lower extremities,7 of which were repaired by chimeric perforator bone flap with the superficial circumflex iliac artery and 4 of which were repaired by chimeric perforator bone flap with the deep circumflex iliac artery.The size of bone flap ranged from 2.5 cm×2.0 cm× 2.0 cm to 6.0 cm×3.0 cm×2.0 cm,and the flap sizes ranged from 5.0 cm×3.0 cm to 17.0 cm×13.0 cm.The donor sites of the flap were directly sutured.Nine patients were implemented by postoperative followed-up visit in hospital.And the appearance,texture,color,shallow sensation of flaps,fracture healing,limb's function and donor site were observed.Results Postoperative followed-up ranged from 3 to 18 months.All flaps survived.The flaps had satisfactory appearance,texture and color.Osseous tissue of defects healed.The function of injury limb was restored well,which metacarpo-phalangeal joint and carpometacarpal joint's movement with metacarpal defect recovered,and gait were normal without pain.As for the donor sites,1 case had hyperplastic scar while the other only had linear scars.Abdominal hernia and numbness with lower extremities were disappeared.Conclusion Ilioinguinal chimeric perforator bone flap can be designed with different pedicles based iliac bone flap according to the size of bone defects.The donor site is concealed with less trauma and less healing time.The operation position is easy to operate,and clinic efficacy is satisfactory.

Digital assisted chimeric deep circumflex iliac artery perforator flap in the reconstruction of mandibular composite defects / 中华显微外科杂志

To evaluate the clinical effect of digital assisted chimeric deep circumflex iliac artery perforator flap (DCIAPF) in the reconstruction of mandibular composite defects. Methods From January, 2018 to January, 2019, 6 cases of mandibular tumor patients with postoperative defect within side were treated. Preoperative CTA was used to evaluate the deep branches of spin iliac artery.Digital simulation software and 3D printing technolo-gy was taken, vascularized iliac flap of the design guide of bone was made, and the rebuilding effect was simulated. DCIAPF was used to repair the defect of lower jawbone. The donor sites were sutured directly. The patients were fol-lowed-up in outpatient department for 3-6 months to evaluate the recovery of the patient′s shape, jaw height and oc-clusal function, as well as the complications in the donor area. Results Postoperation pathological examination re-sults: ameloblastoma in 2 cases, 4 cases of gingival cancer. The length of cut out ilium was 6.0-13.0 cm, carrying the flap area of 3.0 cm×1.0 cm-6.0 cm×5.0 cm.Six cases of DCIAPF and iliac bone flap survived.The shape, mandibular height and occlusal function were satisfactory.And no obvious complications were found in the donor area. Conclu-sion The blood supply of DCIAPF is rich with enough bone mass and height. The position of terminal skin perfora-tors is invariant. The complications of donor sites is less. With the help of digital technology, the accuracy of mandibular defect repair and the 3-dimensional wound repair can be realized, and provides an advantage condition for subsequent dental implant.It is one of the ideal method of reconstruction of mandibular defect.

Application of deep circumflex iliac artery based iliac-internal oblique musculofascial chimeric flaps in reconstruction of complex oromandibular defects / 中国修复重建外科杂志

Objective: To evaluate the reliability and effectiveness of a deep circumflex iliac artery based iliac-internal oblique musculofascial chimeric flap (DCIA-IIOF) in reconstruction of complex oromandibular defect. Methods: Between January 2010 and December 2015, DCIA-IIOFs were used to repair complex oromandibular defects in 11 patients. There were 8 males and 3 females, with an age of 27-75 years (median, 56 years). Original disease was lower gingival squamous cell carcinoma in 7 cases (T 3N 1M 0 in 2 cases, T 3N 2M 0 in 1 case, T 4N 0M 0 in 2 cases, and T 4N 2M 0 in 2 cases), osteoradionecrosis after radiotherapy for nasopharyngeal carcinoma in 2 cases, central mandibular squamous cell carcinoma in 1 case (T 4N 0M 0), and mandibular malignant fibrous histiocytoma in 1 case. The length of mandibular bone defects ranged from 7 to 10 cm (mean, 8 cm), and the area of the mucosal defects ranged from 5 cm×3 cm to 7 cm×4 cm. Preoperative ultrasonic identification of the DCIA and its ascending branch was routinely performed. The DCIA-IIOF was harvested by using an anterograde dissection technique, of which the iliac island was used for segmental mandibular defect repair and the musculofascial island for soft tissue and mucosal defect repair. Results: All 11 cases were followed up 15-75 months (median, 37 months). All flaps survived after operation, without necrosis of both iliac island and oblique internal musculofascial island. One patient had a mild submandibular infection which healed after wound drainage and intravenous antibiotics. At 1 month after operation, the color and texture of the musculofascial island were similar to oral mucosa without contracture, and the occluding relation was good for all patients. At 6 months after operation, the mouth opening hardly improved in 2 patients who had osteoradionecrosis; 1 patient who underwent postoperative radiotherapy had restriction of mouth opening; the remaining 8 patients had normal month opening and normal diet. Three patients died of cancer recurrence, 2 patients died of other diseases (encephalorrhagia in 1 case and myocardial infarction in 1 case), and the others survived without recurrence during follow-up. No patient developed abdominal hernia during follow-up. Conclusion : DCIA-IIOF is a reliable flap in reconstruction of complex oromandibular defects. The occluding relation after operation is good and the mucosal lining is soft. This technique provides an effective option for moderate complex oromandibular defects repair.

Herniation after deep circumflex iliac artery flap: two cases of rare complication / 대한악안면성형재건외과학회지

Herniation after harvesting of deep circumflex iliac artery (DCIA) flap is a known but not a common complication. It occurs about 2.8 to 9 % according to the literatures and can proceed to a more severe complication such as bowel obstruction. There are several factors that exacerbate the risk: surgical factors, operator factor, and patient factors. Surgical factors include large anatomical defect and denervation of related muscles. Operator factor stands for unpunctual suture technique. Patient factors represent obesity, diabetes, pulmonary disease, smoking habits, and so on. Thus, herniation might occur regardless of meticulous suture. Herein, we would like to report two cases of herniation after DCIA flap harvesting and repaired by Lichtenstein tension-free hernioplasty with literature review.

Clinical application of repairing donor site of abdomen flap by V-Y flap pedicled with deep circumflex iliac artery perforator musculocutaneous / 中华显微外科杂志

Objective To research the clinical outcomes of repairing donor site of abdomen flap by V-Y flap pedicled with deep circumflex iliac artery perforator musculocutaneous.Methods Nine cases with skin defects of hand were treated with lower abdomen flap from December, 2011 to March, 2013, abdominal donor sites could not be directly sutured, and pedicled with deep circumflex iliac artery perforator musculocutaneous.The flap was 8 cm × 16 cm-12 cm × 24 cm in size.Results The average healing time of the V-Y flap pedicled with deep circumflex iliac artery perforator musculocutaneous was 17 days.The patients were followed-up for 3 months to 18 months, averaged of 9 months.The appearance and the texture of the flaps were good.Abdominal wound healing was flat, with no significant depression and navel no significant skew.Patients were satisfied with function and appearance.Conclusion This procedure is easy and effective.The treatment result is satisfactory.It is improvement for repairing donor site of tradition abdomen flap.

Vascularized chimerical perforator flaps of deep circumflex iliac artery repairing bone and soft tissue defects of limbs / 中华显微外科杂志

Objective To explore the clinical effect and experience of separating deep circumflex iliac artery osteocutaneous perforator flap (DCIAP) from the bone flap.Methods According to local applied anatomy of groin,vascularized chimerical flaps of deep iliac circumflex artery was designed and applied.From May,2008 to June,2012,12 patients who combined bone and composite skin and soft-tissue defects were positioned by color dopplar ultrasound before operation and treated with vascularized chimerical flaps of deep iliac circumflex artery.The deep circumflex iliac perforator flaps was 8 to 19 cm in length and 2 to 6 cm in width,and the iliac bone grafts ranged from 5 to 8 cm in length.Results All flaps were fully survival.After 8-10 months postoperative followed-up,all the bone defect gained healing.The function and appearance of cutaneous flaps were satisfactory.There was no serious complication in donor sites of groin.The average time of healing was 9 (8-10) months.Conclusion Vascularized iliac bone graft and a perforator flap are nourished by the same deep circumflex iliac artery.There is more mobile scope and only 1 blood vessel between the bone graft and skin flap,which should be called chimeric perforator flap based on the deep iliac circumflex artery,and is a kind of good method to repair bone and soft-tissue defects of limbs.

Considerations and Protocols in Virtual Surgical Planning of Reconstructive Surgery for More Accurate and Esthetic Neomandible with Deep Circumflex Iliac Artery Free Flap / 대한악안면성형재건외과학회지

PURPOSE: The reconstruction of mandibular defects poses many difficulties due to the unique, complex shape of the mandible and the temporomandibular joints. With development of microvascular anastomosis, free tissue transplantation techniques, such as deep circumflex iliac artery (DCIA) flap and fibular free flap (FFF), were developed. The DCIA offers good quality and quantity of bone tissue for mandibular segmental defect and implant for dental rehabilitation. Virtual surgical planning (VSP) and stereolithography-guided osteotomy are currently successfully applied in three-dimensional mandibular reconstruction, but most use FFF. There are only a few articles on reconstruction with the DCIA that assess the postoperative results. METHODS: Three patients admitted during a five month period (April of 2013 to August of 2013) underwent resection of mandible and DCIA musculo-osseous reconstruction using a VSP and stereolithographic modeling and assessment of outcomes included technical accuracy, esthetic contour, and functional outcomes. RESULTS: This technique yielded iliac bone segment with excellent apposition and duplication of the preoperative plan. Flap survival was 100 percent and all patients maintained preoperative occlusion and contour. CONCLUSION: Based on our experience, we offer considerations and logically consistent protocols by classification of mandibular defects, and demonstrate the benefits in VSP and stereolithographic modeling of mandibular reconstructive surgery with DCIA flap.

Unusual branches of femoral artery in the femoral triangle: a case report / Ramas inusuales de la arteria femoral en el triángulo femoral: reporte de caso

Femoral artery is the major artery of the lower limb. It shows some variations in its branching pattern. One of the rare but clinically important variations is the origin of deep circumflex iliac and inferior epigastric arteries from it instead of from external iliac artery. We report here the origin of inferior epigastric and deep circumflex iliac arteries from the femoral artery bilaterally. Both the arteries passed up deep to the inguinal ligament and had a normal course and distribution after crossing the inguinal ligament. Knowledge of these variations is of importance in plastic surgery, anterior approach to the hip joint, draining psoas abscess or reducing a femoral hernia.

La arteria femoral es la principal arteria del miembro inferior. Se observan algunas variaciones en su patrón de ramificación. Una variante rara, pero clínicamente importante es el origen común de las arterias circunfleja iliaca profunda y epigástrica inferior no desde la arteria ilíaca externa. Presentamos el origen bilateral de las arterias epigástricas inferiores y circunfleja ilíaca profunda desde la arteria femoral. Ambas arterias pasaron profundas al ligamento inguinal y tuvieron un curso y distribución normal después de cruzar el ligamento inguinal. El conocimiento de estas variaciones son de importancia en la cirugía plástica, en el acceso anterior a la articulación de la cadera, el drenaje absceso del músculo psoas mayor o para reducir una hernia femoral.

Nerocutneous vessels enlarges the survival area of perforator flap: an experimental study / 中华显微外科杂志

Objective To study the effects of nerocutneous vessels on perforator flap blood supply and survival area. Methods Thirty SD rats were randomly divided into 3 groups. The study of the vasculature and nerve disposition of rat dorsum was performed with 10 rats of one group. According to the study,a distal rectangle neurocutaneous flap based on deep circumflex iliac artery perforator, 10 cm long and 3 cm in the width, was elevated on the rest rats, and sutured back to the original situation. The axis of the experimental group's flap paralleles the posterior median line,while the control group flap's angulated about 30° with it. The blood flow of the flap was assessed by fluorescein angiography on the 1st and 7th day after surgery. The surviving rate and the capillary density of flap were assessed on the 7th day after surgery. Results The rat deep circumflex iliac perforator artery was a constant perforator artery, with an nutrition area about 4 cm× 3 cm. The dorsal cutaneous nerves run along the dorsomedian line, nourished by rich vessels. The blood perfusion 1st day after surgery was 42.85% in the experimental group, 37.94% in the control group(P ＞ 0.01 ).On the 7th day, it was 84.07% in the experimental group, 58.55% in the control group (P＜ 0.01). The mean survival rate of the experimental group was 83.93%, higher than control group's 59.95% (P＜0.01),and the density of the blood vessels was higher in experimental group than control group's. Conclusion The neurocutaneous vessels can improve the flap survival condition, which make the perforator flap bigger and safer.

An Unexpected Huge Hematoma after Iliac Artery Injury as a Rare Complication at an Anterior Iliac Bone Graft Donor Site: A Case Report

Even through there are many reported complications of the iliac bone donor site during anterior cervical spine surgery, vascular injuries are very rare, especially deep circumflex iliac artery(DCIA) injury encountered after harvesting of a bone graft. A 68-year-old female was presented with neck pain and recent progressive weakness due to dislocation and instability of C5/6 with cord compression. Corpectomy and inter-body fusion from C5 to 7 was done without any definite perioperative complications including the iliac donor site. On the 2nd post-operative day, a huge hematoma and active bleeding at the retroperitoneal site was found by computed tomography and angiography revealed bleeding from DCIA. The authors report a case of massive bleeding due to DCIA injury that was difficult to control and managed by selective arterial embolization.

Esthetic reconstruction of iliac crest donor deffect with tow titanium plates after harvesting a dcia composite free flap

DIGITAL ANATOMY OF THE DEEP CIRCUMFLEX ILIAC ARTERY OSTEOCUTANEOUS PERFORATOR FLAP / 解剖学报

Objective To determine the anatomical basis of an algorithm to safely elevate the deep circumflex iliac artery osteocutaneous perforator(DCIAP) flap. Methods 1.Six unfixed corpses underwent whole body gelatine/lead oxide injection.Specimens were dissected by layers.Angiography and photography were used to document the precise course,size,location,and type of individual perforators in the lateral lumbar region.The surface areas of cutaneous territories and perforator zones were measured and calculated with Photoshop and Scion Image.2.One specimen also underwent whole body carboxymethylcellulose/lead oxide injection,CT scan and 3D-Reconstrution. Results An average of 1.6 DCIA perforators with a diameter of 0.7mm was present in 92% of specimens.Perforators were located 5～10 cm posterior to the anterior superior iliac spine,12～35mm above the crest,with a perforator zone of 31 cm~2.The DCIA reliably perfused the medial aspect of the iliac crest.Conclusion The DCIA reliably perfused the medial aspect of the iliac crest and lateral lumbar region.It offers a large quantity of bone on a pedicle of large diameter.The mobility of the skin component allows better tissue positioning during complex reconstructions.