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A Revised Approach for Mandibular Reconstruction with the Vascularized Iliac Crest Flap by Virtual Surgical Planning

2012; Lippincott Williams & Wilkins; Volume: 129; Issue: 3 Linguagem: Inglês

10.1097/prs.0b013e3182419b42

1529-4242

Yi Shen, Jian Sun, Jun Li, Tong Ji, Meimei Li,

Anatomy and Medical Technology

Sir:FigureWith the development of computer software technology, virtual surgical planning can help the surgeon to improve the accuracy of mandibulectomy and mandibular reconstruction and to save operating time. At present, virtual surgical planning is often performed in mandibular reconstruction with the vascularized fibula flap to help shape the neomandible,1–5 although it also can be used in mandibular reconstruction with the vascularized iliac crest flap. We have performed mandibular reconstruction with the vascularized iliac crest flap guided by computer simulation and stereo modeling in 12 patients since June of 2009. In virtual surgical planning preoperatively, the contralateral unaffected mandible was mirrored about the central plane to enable symmetry as the reference position of reconstruction. Then, bilateral iliac crests were automatically superimposed on the mirror mandible to choose the optimal matching donor region in shape and geometry (Fig. 1). This design was different from the conventional option of ipsilateral iliac crest. If no matching donor region was found, various virtual osteotomies of the iliac crest were simulated to select the best bone-splitting line and repositioning angle and to determine the removed bone stock. Once the virtual surgical planning was approved, the stereo models, including the reconstructive mandibular model, the resection guide template, and the iliac crest cutting and osteotomy guide templates, were manufactured by a bioengineer. Approval for the study was obtained from the research ethics committee of our hospital.Fig. 1: The contralateral iliac crest is chosen automatically for reconstruction of the defect in the right mandibular ramus in virtual surgical planning.In harvesting the vascularized iliac crest flap, the lateral femoral cutaneous nerve was first identified and protected before identifying and dissecting the deep circumflex iliac vessels because the vessels passed crossing the nerve. After dissection of the deep circumflex iliac vessels was completed, harvesting of the iliac crest was performed using the cutting guide template according to preoperative virtual planning. (See Video, Supplemental Digital Content 1, which shows a revised approach for harvesting a vascularized iliac crest with the internal oblique muscle flap, https://links.lww.com/PRS/A466. In harvesting the vascularized iliac crest flap, the lateral femoral cutaneous nerve was first identified and protected. Once the nerve was identified, the deep circumflex iliac vessels were then easily identified and dissected near the nerve because the vessels always passed crossing the nerve. After dissection of the deep circumflex iliac vessels was completed, harvesting of the iliac crest was performed using the cutting guide template according to preoperative virtual planning.) For the patient with extensive soft-tissue defects, the internal oblique muscle was harvested simultaneously to form a vascularized iliac crest with the internal oblique muscle flap. Then, mandibular reconstruction was performed guided by stereo models to replicate the preoperative virtual planning intraoperatively. Comparison of actual reconstruction with virtual surgical planning showed that actual results were basically in accordance with virtual planning in all patients (Fig. 2).Video: Supplemental Digital Content 1 shows a revised approach for harvesting a vascularized iliac crest with the internal oblique muscle flap, https://links.lww.com/PRS/A466. In harvesting the vascularized iliac crest flap, the lateral femoral cutaneous nerve was first identified and protected. Once the nerve was identified, the deep circumflex iliac vessels were then easily identified and dissected near the nerve because the vessels always passed crossing the nerve. After dissection of the deep circumflex iliac vessels was completed, harvesting of the iliac crest was performed using the cutting guide template according to preoperative virtual planning.Fig. 2: Comparison of virtual surgical planning (brown) with actual reconstruction result (green).Although the lateral femoral cutaneous nerve may lie deep or superficial to the deep circumflex iliac vessels, it occasionally lies between the artery and vein of the vascular pedicle. In harvesting the vascularized iliac crest flap, we first identified and protected the lateral femoral cutaneous nerve. Once the nerve was identified, the deep circumflex iliac vessels were then easily identified and dissected near the nerve because the vessels always passed crossing the nerve. We thought this approach for harvesting the vascularized iliac crest flap was feasible in addition to the conventional procedures to identify the iliac vessels first or to identify the ascending branch of the deep circumflex iliac vessels first. In our experience, harvesting the vascularized iliac crest flap was not too complex, and few donor-site complications were observed. Therefore, it is feasible that virtual surgical planning for mandibular reconstruction with the vascularized iliac crest flap and identification of the lateral femoral cutaneous nerve be applied before dissecting the deep circumflex iliac vessels in harvesting the flap. Yi Shen, M.D., D.D.S. Jian Sun, M.D., D.D.S. Jun Li, D.D.S. Tong Ji, D.D.S. Department of Oral and Maxillofacial Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology Mei-mei Li, M.E. Materialise China Shanghai Office, Shanghai, People's Republic of China ACKNOWLEDGMENT This work was supported by the Science and Technology Commission of Shanghai (08DZ2271100). DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.