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Title : The Anatomical Basis of the Deep Circumflex Iliac Artery Perforator Flap Authors: Leonard Bergeron, MD, Maolin Tang, MD, Steven F. Morris, MD, MSc Introduction: In 1979, Taylor described the classic iliac crest osteomusculocutaneous flap[1,2] (Figure 1) based on the Deep Circumflex Iliac Artery (DCIA). It includes a segment of iliac crest, a skin paddle, and an “obligatory muscle cuff”. This muscle cuff is a full thickness segment of the abdominal wall harvested in order to protect the DCIA cutaneous perforators. Advantages of this flap include a large segment of vascularized bone, similarity between the shape of the iliac crest and the mandible, and a vascular pedicle of large caliber and adequate length. Disadvantages for oromandibular reconstruction include the bulk occupied by this “obligatory muscle cuff”, and the tethering of tissue components caused by it. Safak[3] and Kimata[4,5] have had limited success at designing a DCIA perforator flap. Only 7 successful cases are reported. The anatomical descriptions of the DCIA perforators are conflicting and insufficient to dissect a perforator flap. The goals of this project are to define the anatomy of the DCIA perforator flap (Figure 2) and to describe the optimal method to dissect the flap. Methods: Six fresh cadavers were systemically injected with a lead oxide and gelatine preparation[6]. The lateral lumbar area was subsequently dissected. All cutaneous perforators were labelled with radio-opaque markers. Photography, dissection notes, and angiography were used to document the course and origin of each perforator. Internal vessel diameter measurements were made on the original angiograms. Angiograms were digitalized and assembled with Adobe Photoshop CS (Adobe Systems Incorporated, San Jose, California, USA). Surface measurements were made with Scion Image Beta 4.02 (Scion Corporation, Frederick, Maryland, USA). Results: A total of 3000 angiograms and photographs were analyzed to reconstitute the angiosomes of the hemitrunk and determine DCIA perforator(s) characteristics (Table 1). One or two perforators are usually found in a 5x4 cm zone along the superior aspect of the iliac crest, 5 cm posterior to the anterior superior iliac spine (ASIS) (Figure 1). Discussion: Based on these dissections and angiographic studies, the following dissection algorithm has been prepared. Dissection algorithm. The ASIS and the superior border of the iliac crest are identified. The DCIA perforator(s) are located with a Doppler in a 5x4 cm zone along the iliac crest, 5cm posterior to the ASIS. The dissection of the skin paddle proceeds from superior to inferior. Perforators traveling with a nerve can be divided as they are intercostal or lumbar perforators. In case of the presence of an iliolumbar perforator in proximity to the flap, it can be identified by spreading the external oblique muscle fibres. A posterior origin indicates that the iliolumbar artery is the source artery, whereas an anterior origin confirms that it is from the DCIA. The rest of the dissection is similar to that of the classic DCIA osteomusculocutaneous flap. The DCIA perforator flap offers a reliable skin paddle which can be harvested in continuity with a large segment of iliac crest suitable for mandibular reconstruction. One or two perforators of significant size are usually located along the iliac crest, 5-10cm posterior to the ASIS. In case of absence or injury to the DCIA perforator(s), the SCIA could provide an alternative rescue pedicle for the cutaneous component. The exclusion of abdominal wall musculature, along with a split iliac crest [7,8] design will likely reduce donor site contour deformity, facilitate donor site closure and diminish the incidence of hernias. It should also allow much better positioning of the skin paddle during complex oromandibular reconstructions, and diminish flap bulk. Conclusion: This study defines the anatomical properties of the DCIA perforator flap and suggests a dissection algorithm based on these findings. The DCIA perforator flap with iliac crest offers a significant skin paddle and bony component perfused by a single vascular pedicle of large diameter. Possible applications include reconstruction of the mandible, and other osteocutaneous deficits such as open tibial fractures. The cutaneous component could be raised without the iliac crest and be used as an alternative donor site for breast reconstruction (Rubens flap [9]). Table 1. Characteristics of the DCIA perforators Value Range/Comments Presence of perforator(s) 92% Absent in one dissection Average number of perforators 1.6 0-5 • 1-2 in general • 5th is aberrant (excluded) Average perforator internal diameter 0.7mm 0.5-1.75mm 2 Angiosome surface 54cm 26-69cm2 Perforator zone* 31cm2 13-68cm2 DCIA pedicle length to iliac crest 5cm 4-8cm DCIA pedicle length to perforator 12cm 9-15cm DCIA internal diameter 2mm 1.25-2.75mm *Cutaneous territory supplied by a single perforator. Figure 1. Angiogram of the DCIA perforator flap with split iliac crest. Note the relation of the superficial circumflex iliac artery (SCIA) and the DCIA. Vascularization of the medial cortex is through periosteal circulation from the DCIA. (Black dotted line: skin staining obtained by ink injection of the DCIA. Solid black line: DCIA anatomical angiosome. White dotted line: skin staining obtained by ink injection of the SCIA. Solid white line: SCIA anatomical angiosome.) References: 1. Taylor, G.I., Townsend, P., and Corlett, R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Clinical work. Plast Reconstr Surg. 64: 745, 1979. 2. Taylor, G.I., Townsend, P., and Corlett, R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Experimental work. Plast Reconstr Surg. 64: 595, 1979. 3. Safak, T., Klebuc, M.J., Mavili, E. et al. A new design of the iliac crest microsurgical free flap without including the "obligatory" muscle cuff. Plast Reconstr Surg. 100: 1703, 1997. 4. Kimata, Y. Deep circumflex iliac perforator flap. Clin Plast Surg. 30: 433, 2003. 5. Kimata, Y., Uchiyama, K., Sakuraba, M. et al. Deep circumflex iliac perforator flap with iliac crest for mandibular reconstruction. Br J Plast Surg. 54: 487, 2001. 6. Tang, M., Geddes, C.R., Yang, D. et al. Modified lead oxide-gelatin injection technique for vascular studies. Chin J Clin Anat. 1: 73, 2002. 7. Taylor, G.I., and Daniel, R.K. Aesthetic aspects of microsurgery: composite tissue transfer to the face. Clin Plast Surg. 8: 333, 1981. 8. Shenaq, S.M. Refinements in mandibular reconstruction. Clin Plast Surg. 19: 809, 1992. 9. Elliott, L.F., and Hartrampf, C.R., Jr. The Rubens flap. The deep circumflex iliac artery flap. Clin Plast Surg. 25: 283, 1998.