Download The Anatomical Basis of the Deep Circumflex Iliac Artery Perforator

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.