Surgical oncology and reconstruction
Developments in Image-Guided Deep Circumflex Iliac Artery Flap Harvest: A Step-by-Step Guide and Literature Review

https://doi.org/10.1016/j.joms.2013.06.219Get rights and content

Purpose

The deep circumflex iliac artery (DCIA) flap has evolved significantly over time in the intricacies of flap design and breadth of surgical application. This has been facilitated by advances in preoperative imaging and planning, in particular, computed tomographic angiography. Studies have highlighted that advanced imaging modalities and other technologies such as image-guided stereolithographic biomodeling can substantially improve flap planning, flap harvest, and operative outcomes.

Patients and Methods

The present report comprises a combined literature review and clinical cohort study of 20 consecutive patients to assess the modern technologies applied to DCIA flap planning and harvest. We have also described a step-by-step guide for the implementation of these techniques into clinical practice.

Results

The protocol for a single, standardized technique of computed tomographic angiography scanning is presented and was applied to a range of techniques in the preoperative planning of DCIA flaps. These include 1) bony and vascular imaging analysis of both donor and recipient sites, 2) stereolithographic “biomodeling” of both donor and recipient bony and vascular anatomy, and 3) the use of preoperative “virtual surgery” with image-guided stereotactic navigation. The application and role of each technique was explored.

Conclusions

Modern imaging and stereolithographic techniques are innovations that can substantially improve surgical outcomes in DCIA flap surgery, such as has been highlighted in our clinical experience and in published studies. Notably, few outcome studies have been reported, and the need for larger case series and comparative studies is apparent.

Section snippets

Patients and Methods

Our clinical approach as described was based on implementation of these techniques in a cohort of 20 consecutive patients (12 men and 8 women) who underwent DCIA flap reconstruction for an oncologic defect. The patients had an age range of 39 to 75 years and a range of body habitus (Table 1). All patients provided written informed consent for inclusion, and their cases were deemed clinically appropriate for DCIA flap surgery, with no exclusions. The technique described was based on a

Results

CTA and stereolithographic models were performed and made for 20 consecutive patients undergoing DCIA reconstruction (Table 1). All patients had clear oncologic clearance. Intraoperative adjustments of the resections were all within 1 cm of the preoperatively planned models. All patients underwent successful dissection and elevation of their DCIA flap, and no complete flap failures occurred. The concordance between the imaging and operative findings of the pedicle was 95%, with 100% concordance

Discussion

The iliac crest has long been recognized to be an excellent source of bone graft material and was widely used as a nonvascularized graft as early as World War I, with poor results.22, 23 It was not until the 1970s, with the developments in microsurgery and vascularized transfers, that surgeons were able to markedly improve the iliac bone graft survival rate. The vascularized DCIA flap was popularized in association with an inconspicuous donor scar and low donor site morbidity.24, 25, 26 In

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