A retrospective study on mandibular reconstruction using iliac crest free flap.

PURPOSE: To assess the availability, success rate and complications of microvascular iliac crest free flap for reconstruction of mandibular segmental defects. METHODS: In this retrospective-descriptive study, we report patients who had undergone segmental mandibular resection for pathologic lesions and received reconstruction with iliac crest microvascular free flap between 2016 and 2019. Clinical and demographic data of all the cases were collected. Success was regarded as complete consolidation of the bone graft in panoramic radiograph. Postoperative complications were defined as major or minor based on the need for intervention. T-test, Kolomogorov_Smirnov, and multivariate analysis were used and the p-value<0.05 was considered to be statistically significant. RESULTS: Of all 30 patients, 16 were women and 14 were men with an average age of 27.2 years (range 14-40). Patients were followed for 12-60 month (mean: 38.4). One flap was lost due to unsalvageable venous thrombosis. Six other cases had post-op complications while smoking and diabetes were associated with more complications (P = 0.036). Twenty-three patients received primary reconstruction which was more successful than secondary ones (P = 0.003). Osteogenic sarcoma was associated with greater risk of complications (P < 0.01). CONCLUSIONS: The results of this study suggest that iliac crest microvascular free flap serves as a promising option for the reconstruction of mandibular defects, providing excellent contour and acceptable success rate with low donor site morbidity. Future studies will focus on the role of systemic diseases in post-op complications and flap failures.

Assessing the Anatomical Variability of Deep Circumflex Iliac Vessels in Harvesting of Iliac Crest-Free Flap for Mandibular Reconstruction.

In this study, the authors' aims were to measure the length and location of branching of the pedicle from iliac artery, to describe the anatomical variability of iliac crest free flap with deep circumflex iliac (DCI) artery pedicle. Fourteen patients with ameloblastoma, osteosarcoma, and squamous cell carcinoma underwent mandibular resection and iliac crest-free flap reconstruction in one-step surgery. During surgery and before harvesting the deep circumflex iliac artery vascular pedicle, the location, origin, and the branching pattern of the pedicles were studied. Then, the pedicle length was measured and the data was analyzed using χ and independent samples t test. In all patients, the DCI vascular pedicles were separated with a common trunk from the external iliac artery and vein and the DCI arteries were posterior and lateral to the veins. Also after branching from the external iliac artery, all vascular DCI pedicles traveled upward and medially along the Iliacus muscle and the iliac fascia. The mean pedicle length was 21.78 mm for men and 19 mm for women. No statistically significant relationship was observed between the patient's age and the vascular pedicle length or number of branches. There are great variations in the anatomy of this vascular pedicle. According to the finding of this study, the length of the vascular pedicle is 2.78 mm higher in men which might help to increase the feasibility and success rate of this operation. No significant correlation was found between other variables.

Ventral tongue myomucosal flap: a suitable choice for shaved lower vermilion border reconstruction.

Squamous cell carcinoma (SCC) or verrocous carcinoma (VC) occurs frequently on the border of the lower lip and surgical excision is the mainstay of treatment. The vermilion border area is difficult to reconstruct and is very complex both morphologically and anatomically. Various reconstructive approaches for defects of the vermilion border have been described. However, for esthetics, reconstruction of the vermilion border defect by tissue of normal texture and color is paramount.We used a ventral myomucosal tongue flap for reconstruction of the vermilion border after radical excision of squamous cell carcinomas of the lip in 15 patients with labial carcinoma. The tumor was resected with a safe margin (1 cm in SCC and 0.5 cm in VC) in an approximately rectangular shape. Free-border confirmation was done using frozen section. A longitudinal strip of the free border of the tongue nonkeratinized mucosal layer with submucosal muscular layers of the tongue including the terminal branch of the lingual artery was raised. This strip extended to the angles of the mouth to cover the defect. The mucosal or myomucosal flap of the ventral tongue is designed according to the shape and size of a vermilion defect. The vermilion and subcutaneous tissue are incised, and the specimen is sent for histopathological free-border confirmation by frozen section. The flap is sutured in 2 layers, joining the mucosal border of the tongue and the upper border of the skin. The tongue flap pedicle was cut off after 3 weeks, and the oral side of the vermilion was sutured. The donor site of the tongue was closed primarily. Application of moisturizing cream for at least 2 months after surgery would be continued. In all 15 cases, the reconstructed vermilion with a tongue flap was ideal and with almost no disturbance in the patients' speaking, swallowing or taste with satisfactory cosmetic results. The ventral tongue flap is a suitable choice for vermilion border reconstruction. This flap is useful because the procedure does not require complicated surgery, and preservation of the orbicularis oris muscle and mental artery and nerve is possible.

Nasal reconstruction: experience using tissue expansion and forehead flap.

PURPOSE: The forehead is acknowledged to be one of the best, if not the best, donor sites for reconstruction of postoperative nasal defects after ablation in cancer patients. The versatility, color match, and texture are among the benefits of this flap. However, it has 2 major disadvantages: 1) it is stiff, flat, and thicker than normal nasal skin, and thus molding from a 2-dimensional to a 3-dimensional shape is difficult, and 2) there is a donor-site defect that requires coverage using a split-thickness skin graft. PATIENTS AND METHODS: In this 5-year study (2004-2009), we modified the 2-stage technique and added an operation before tissue transfer and pedicle division in 48 patients with nasal defects. During the first stage, the tumor was completely excised, and a tissue expander was inserted in the subgaleal plane. After 3 weeks, expansion was initiated. The second operation was performed 12 weeks later. A full-thickness forehead flap was elevated and transposed with primary closure of the donor site. In a third or final stage 3 weeks later, the pedicle was divided. Patient satisfaction and donor site scar was evaluated. RESULTS: Over the past 5 years, 48 reconstructions for nasal defects were performed using this technique. Nasal defects of the dorsum, alar, tip, columella, and septum were successfully treated. Graft take was successful in all patients. CONCLUSIONS: The forehead flap technique, in conjunction with tissue expander for nasal repair, has both advantages and disadvantages. The esthetic benefits of this technique must be weighed against the disadvantages.