A combined superficial inferior epigastric artery flap and vascularized iliac crest flap in the reconstruction of extended composite defects of the posterior mandible and adjacent soft tissue: first clinical results


The technique of posterior facial reconstruction using a combination of a superficial inferior epigastric artery (SIEA) flap and a microvascular iliac crest flap (deep circumflex iliac artery (DCIA) flap) is described. 12 cases are reported. The patients had unilateral squamous cell carcinoma of the posterior mandible affecting parts of the soft palate and tonsil region or the posterior cheek. In all patients unilateral neck dissection, resection of the posterior and lateral mandible, was performed. Reconstruction was carried out during primary surgical therapy, followed by postoperative radiotherapy. A flap combination of a SIEA and a DCIA flap was used. There were no problems with pedicle length or anastomoses. There was no flap loss or severe postoperative complications. All patients had good aesthetic and functional results. One patient had distant metastases 2 years postoperatively. All other patients were free of tumour relapse or metastases within 12–58 months of follow up. The SIEA flap and vascularized iliac bone flap combination is useful in reconstructing the posterior face. The iliac bone flap is well suited for posterior mandible reconstruction and the SIEA flap for reconstruction of the soft palate, lateral pharyngeal wall and cheek. Both flaps are harvested from the same donor site.

Extended defects of the face caused by tumour resections are often covered by microvascular flaps during single stage surgery. The reconstruction is performed to allow patients to achieve functional and aesthetic rehabilitation within a short time period postoperatively . The free transfer of flaps from a distant donor site makes coverage of the defect with individual soft and hard tissue configuration possible, compared with techniques of local tissue transposition from the head or neck and pedicled island flaps from the chest or shoulder . The composite defects caused by a loss of bone, muscles and skin may be covered by transplants consisting of the same components of tissue . In many cases these composite flaps can be harvested from one donor site and the reconstruction can be carried out with a composite flap perfused by one vascular pedicle. If defects of the mandible have to be covered, microvascular fibula , iliac crest , scapula , rib or radius flaps are used most often . These flaps may be used as osseous, osteocutaneous or osteomyocutaneous transplants to make individual tissue transfer possible, depending on the components to be reconstructed. In some cases of extended defects of the face, one flap is not enough and a combination of two or more flaps becomes necessary . In cases of complex reconstruction of the floor of the mouth and tongue, the mandible, and other adjacent soft tissue components, double or triple flap reconstruction is sometimes used to achieve the best possible function and aesthetic result . If combined multi-flap surgery is used, the best morphological result for every component (bone and soft tissue) of microvascular reconstruction is required .

In this study, initial experiences with a combination of an iliac crest bone flap (deep circumflex iliac artery flap (DCIA flap)) and a superficial inferior epigastric artery (SIEA) flap for the reconstruction of the posterior face are described and discussed.

Patients and methods

The 12 patients had a unilateral squamous cell carcinoma of the posterior lateral mandible also affecting the floor of the mouth, tongue, soft palate, tonsil region or cheek. All patients were classified as T4/N2a/M0. There were nine men and three women; their mean age was 61 years.

In all patients, unilateral neck dissection and en bloc resection of the posterior and lateral mandible, posterior floor of the mouth, posterior lateral part of the tongue, tonsil, soft palate region and parts of the cheek were performed. An R0 resection was achieved in every case.

Reconstruction was carried out during primary surgical therapy, followed by postoperative radiotherapy. After resection, reconstruction was performed with a double flap technique using a microvascular DCIA flap to reconstruct the mandible. For intraoral soft tissue reconstruction a microvascular SIEA flap was used.

The run of the superficial epigastric artery was identified by Doppler ultrasound examination. The planed size and form of the soft tissue flap was transduced to the inguinal region keeping the marked pedicle central to the flap ( Fig. 1 a ). The planned dimension of the flap was registered. The length of the flap was defined as the largest diameter in the pedicle direction and the width as the largest diameter at right angles to the flap axis ( Table 1 ). The lateral part of the SIEA flap was incised and the superficial inferior epigastric artery and vein were prepared down to their origin/emission from the femoral or superficial circumflex iliac artery and vein ( Fig. 1 b). After pedicle preparation, the medial, cranial and caudal parts of the flap were incised and the SIEA flap was isolated on its pedicle. The pedicle length was registered ( Table 1 ).

Fig. 1
(a) Clinical situation after marking the superior anterior iliac spine, inguinal ligament, the femoral artery, the planed SIEA flap design, and the SIEA crossing the inguinal ligament. (b) The SIEA flap during harvesting. The pedicle crosses over the inguinal ligament 1–2 cm lateral to its midpoint. (c) The DCIA flap and SIEA flap after isolation on their pedicle. (d) The DCIA flap. The ascending branch is prepared to a length of 4 cm.

Table 1
Flap data of all patients.
Patient [initials] Sex [f/m] DCIA-flap SIEA-flap
Age [years] Height [cm] Length [cm] Pedicle length [cm] Ascending branch length [cm] Length [cm] Widths [cm] Pedicle length [cm]
H.T. m 61 3.5 6.5 7.0 4.0 8.0 5.0 5.0
D.E. f 58 3.0 6.0 6.0 4.5 6.5 5.0 4.0
O.G. m 57 4.5 8.5 7.5 4.5 6.0 5.5 4.5
K.J. m 67 4.0 8.0 6.5 4.0 7.5 4.5 4.0
F.J. m 68 4.5 7.0 8.0 3.5 7.5 6.0 4.0
S.F. m 65 3.5 8.5 6.0 4.0 5.5 5.0 4.5
S.G. m 60 5.0 7.5 6.5 4.0 5.0 4.0 4.0
Z.F. m 68 4.5 7.0 6.5 4.0 6.0 3.5 3.5
L.F. m 52 5.0 9.0 8.0 5.0 8.0 5.5 4.5
W.G. m 65 3.5 8.0 6.5 4.0 7.0 4.5 5.0
O.A. f 59 4.0 6.5 5.0 4.0 5.0 3.5 5.5
P.H. f 55 4.5 7.5 6.0 4.0 6.0 5.0 4.0

Following SIEA flap preparation, the iliac bone flap was harvested in the conventional way deflecting the SIEA flap downwards and medially. The DCIA and deep circumflex iliac vein (DCIV) were identified via the supra-inguinal approach. The ascending branch of the DCIA and DCIV was identified, followed upwards, and preserved to a length of 4–5 cm. The ascending branch was clipped and dissected. The preparation of the iliac bone flap was completed only leaving a small pad of the abdominal wall muscles connected to the iliac bone flap to avoid later soft tissue excess in the submandibular area. After clipping the pedicle distally the osteotomy was performed as planned and the iliac bone flap was isolated on its pedicle ( Fig. 1 c). The maximum length and height of the iliac bone flap, the pedicle length, and length of the prepared ascending branch were measured ( Table 1 ). The pedicle was clipped proximally and the bone flap was transferred to the recipient site ( Fig. 1 d). The bone flap was banded according to the defect and was fixed to the reconstruction plate ( Fig. 2 a ). The anastomoses between the DCIA and the superficial thyroid artery (end-to-end-anastomoses) and the DCIV and the internal jugular vein (end-to-side anastomoses) or one branch of the internal jugular vein (end-to-end anastomoses) were performed under the operation microscope.

Fig. 2
(a) Intraoperative photo after resection of the posterior mandible, cheek, floor of the mouth and soft palate after placement of the iliac crest transplant for coverage of the bone defect. (b) Intraoperative photo after fixation of the SIEA flap for intraoral soft tissue defect coverage.

After achieving reperfusion in the DCIA flap the SIEA flap pedicle was clipped and the flap transferred to the recipient site. It was sutured to the soft tissue defect ( Fig. 2 b). The reconstruction plate was loosened to gain access to the ascending branch of the DCIA flap. The SIEA and superficial inferior epigastric vein (SIEV) were anastomosed to the ascending branch vessels of the DCIA flap under the operating microscope ( Fig. 3 ). After revascularization of both flaps, the iliac bone flap was refixed to the reconstruction plate and wound closure was completed.

Fig. 3
Intraoperative situation after anastomoses. (A) Anastomoses between the DCIA/DCIV and the superior thyroid artery/jugular vein. (B) Anastomoses between the ascending branch of the DCIA/DCIV and the SIEA/SIEV.

After 2 weeks of treatment, all patients left hospital. They had radiotherapy 6 weeks after surgery (62 Gray local doses, 52 Gray LNN Lymph nodes doses at mean). 6 months after irradiation, 20 dental implants were placed for later prosthetic treatment in eight patients. Four patients were treated with conventional prostheses without implant-based superstructures. The patients were followed up clinically once a month during the first 6 months and every 3 months for the following years. Ultrasound examination of the neck was performed every 3 months postoperatively and a magnetic resonance tomography (MRT) or positron emission tomography-computed tomography (PET-CT) check-up was carried out every 6 months. The follow-up period was 12–58 months. All patients were followed up for relapse, functional results, such as lip competence, speech, eating and swallowing, peri-implant conditions, and donor site complications at every check-up.

Lip competence was examined by testing lip strength and closure. The patients were tested for the possibility and strength of fixing using a standardized small stick at four lip positions (paramedian and lateral on each side). For comparison of strength, the operated side was compared with the non-operated side. For speech examination, nasality and comprehension of speech was registered by a logopaedic examination. The patients were asked what type of food they could eat, to determine restrictions during eating and swallowing and signs of aspiration. The maximum interincisal distance during mouth opening was registered 12 months after surgery.

For registration of peri-implant conditions, all patients were examined every 6 months after implant placement for peri-implant bleeding on probing, peri-implant probing depth and peri-implant bone loss. Peri-implant probing was performed mesially, distally, buccally and lingually on every implant. The highest value was registered. For examination of peri-implant bone loss, dental X-rays and panoramic X-rays were taken and compared with the X-rays taken directly after implant placement. The highest value of bone loss was registered ( Table 2 ).

Table 2
Results of periimplant examination 6 months after implant placement.
Patient [initials] Sex [f/m] Age [years] Number of implants Periimplant probing depths (highest value) [mm] Positive periimplant bleeding [implant number] Periimplant bone loss (radiologic examination) [mm]
H.T. m 61 3 2 0 0
D.E. f 58 2 3 0 0
O.G. m 57 2 2 0 0
K.J. m 67 3 2 0 0
F.J. m 68 0
S.F. m 65 2 3 0 0
S.G. m 60 0
Z.F. m 68 3 2 1 0
L.F. m 52 0
W.G. m 65 3 3 0 0
O.A. f 59 0
P.H. f 55 2 2 0 0
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Feb 7, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on A combined superficial inferior epigastric artery flap and vascularized iliac crest flap in the reconstruction of extended composite defects of the posterior mandible and adjacent soft tissue: first clinical results
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