ABSTRACT
The iliac crest osseocutaneous free flap, based on the deep circumflex iliac artery
and vein, was a landmark contribution to head and neck reconstruction. Two major problems
associated with this flap are the lack of flexibility in placement of the skin paddle
with relation to the bone graft, and the excessive thickness of the skin paddle when
used in the oral cavity. The scapular osseocutaneous flap has achieved recent popularity
for mandibular reconstruction based, in part, on its thin skin paddle that is easily
positioned in three dimensions with relation to the bone graft. However, the segment
of bone that can be harvested from the iliac crest is superior to that of the lateral
border of the scapula because of its increased length, thickness, and natural contour.
In 1984 the internal oblique free muscle flap based on the ascending branch of the
deep circumflex iliac artery was described for use in reconstruction of the extremities
only. The authors introduce the application of the internal oblique-iliac crest osseomyocutaneous
free flap for mandibular reconstruction. The mobility of the internal oblique muscle
with relation to the iliac bone graft has permitted its use for inner mucosal defects
or outer cutaneous defects when covered with a skin graft. Following denervation atrophy,
the muscle component becomes a thin, pliable piece of tissue that easily conforms
to three-dimensional defects of the head and neck. This increased flexibility, the
established benefits of the iliac bone, and the ease of intraoperative positioning
for a two-team approach make this composite flap an outstanding tool for mandibular
reconstruction. Two representative cases and a detailed description of flap harvesting,
insetting, and donor-site closure are presented.
