The Iliac Crest Osteomuscular Flap for Bony Reconstruction: Beast or Beauty? A Reassessment of the Value and Donor Site Morbidity in the CAD/CAM Era

Abstract

Background The iliac crest bone flap (ICBF), based on the deep circumflex iliac artery, has a bad reputation regarding donor site morbidity. However, the ICBF has an ideal curvature and shape for occlusion-based hemimandibular reconstructions with rapid dental rehabilitation and for vertical class III maxillary reconstructions that require bony support and muscular bulk to fill cavities and to provide intraoral lining. Is this notorious donor site reputation still valid with modern flap procurement using computer aided design/computer aided manufacturing (CAD/CAM) and recipient-site closure techniques? Materials and Methods We performed a literature search of the public databases PubMed, Cochrane, Google Scholar, and Web of Science for papers using mesh keywords related to donor site morbidity of the ICBF. We report three illustrative case reports using our current protocols for oncologic bony resection and reconstruction, using in-house CAD/CAM and three-dimensional printing to procure a tight-fit ICBF and minimizing donor site morbidity. Results We found 191 articles in the PubMed database of which we considered 176 nonrelevant. Cochrane Library and Google Scholar database searches resulted in the inclusion of 11 additional papers. The second search resulted in 172 articles of which we used five after excluding nonrelevant papers. Accurate preoperative (CAD/CAM) planning, preservation of the anterior superior iliac spine (ASIS), and paying attention to thoroughly donor site closure make the ICBF a very valuable option for accurate maxillofacial reconstructions with very acceptable comorbidities. This corresponds with our clinical findings. Conclusion Dogma never is a good teacher; it remains elementary that routine “knowledge” is (re)questioned. Donor site morbidity of the ICBF is comparable to other bone flaps. The shape and bone stock of the ICBF is ideal and often may be first choice. In combination with CAD/CAM planning, the ICBF is an excellent option for specific maxillofacial reconstructions.

Orthopedic rehabilitation after computer assisted surgical reconstruction of the mandible using deep circumflex iliac artery grafts – a cross sectional study

“…In the last two years, three systematic reviews were published summarizing the ndings regarding donorsite morbidity after head and neck reconstruction of the last 20 years 20,28,29 . Despite the abundance of existent publications, 21,34,38−50 only few studies are available, which investigate the impact of graft volume on donor-site morbidity after mandibular reconstruction using DCIA grafts 34,51,52 .…”

“…18,19 The DCIA graft provides anatomically shaped bone with su cient vertical height resembling the anatomical form of the mandibular body. 20 Additionally, it offers excellent conditions for subsequent placement of osseointegrating dental implants. 21,22 Due to its favorable characteristics some authors even proposed the DCIA graft as transplant of choice for reconstruction of the mandible.…”

“…Chronic pain, gait disturbances and neurosensory de cits are only a few of the known adverse effects described in the context of DCIA graft reconstructions. 20,28,29 However, to date only few studies investigate donor-site morbidity after CAD/CAM driven DCIA graft harvesting. As CAD/CAM techniques have been in routine clinical use for only a decade and OSCC patients face limited long-term survival rates, data investigating the donor-site morbidity by physical follow-up is di cult to acquire.…”

“…As CAD/CAM techniques have been in routine clinical use for only a decade and OSCC patients face limited long-term survival rates, data investigating the donor-site morbidity by physical follow-up is di cult to acquire. 20 This study aimed to assess the importance of the graft volume and incision length on postoperative donor-site morbidity in patients receiving a CAD/CAM-driven DCIA graft reconstruction of the mandible. For this purpose, thorough chart review, evaluation of imaging data and postoperative physical examination was performed.…”

The Versatility of the DCIA Free Flap: A Forgotten Flap? Systematic Review and Meta-Analysis

“…20,[31][32][33] The cortical bone of the ilium can be inset to replace the superior or inferior alveolar process, providing the necessary robustness to accommodate osseointegrated implants for full dental rehabilitation. 13,16,20,[34][35][36][37][38][39] Additionally, the internal oblique or the iliacus muscle can be preserved so the flap inset orientation allows for medial pulling of the muscle to assist for neo-mandible or palate coverage, or to fill the dead space following ablation of the orbital content. 20,40 In this setting, muscle is advantageous as it is epithelialized in 2 to 3 weeks and undergoes substantial atrophy over a period of 8 to 24 weeks, providing an exceptional appearance with minimal bulk.…”